Effects of home-based respiratory muscle training in children and adolescents with chronic lung disease

Inspiratory muscle training in children with neuromuscular disorders

Background

Progressive respiratory muscle weakness and ineffective cough contribute to morbidity and mortality in children with neuromuscular disorders (NMD). Inspiratory muscle training (IMT) aims to preserve or improve respiratory muscle strength and reduce respiratory morbidity. This study aimed to determine the safety and efficacy of IMT in children with NMD.

Methods/design

A randomised cross-over study compared a 3-month intervention (IMT) with control periods (no IMT). Children diagnosed with NMD (5 years - 18 years) performed 30 breaths (at 30% of maximum inspiratory mouth pressure [Pimax]) with an electronic threshold device, twice daily. During the control period, participants did not perform any IMT.

Discussion

Twenty three children (median [interquartile range {IQR}] age of 12.33 [10.03-14.17] years), mostly male (n = 20) and non-ambulant (n = 14) participated. No adverse events related to IMT were reported. No difference in median patient hospitalisation and respiratory tract infection (RTI) rates between non-training and intervention periods (p = 0.60; p = 0.21) was found. During IMT, Pimax and peak cough flow improved with a mean ± standard deviation (s.d.) of 14.57 ± 15.67 cmH2O and 32.27 ± 36.60 L/min, compared to 3.04 ± 11.93 cmH2O (p = 0.01) and -16.59 ± 48.29 L/min (p = 0.0005) during the non-training period. Similar to other studies, spirometry did not show a significant change.

Conclusion

A 3-month IMT programme in children with NMD appears safe and well-tolerated, with significant improvement in respiratory muscle strength and cough efficacy.

Clinical implications

Inspiratory muscle training could be considered a cost-effective adjunct to respiratory management in children with NMD.

Trial Registration

Pan African Clinical Trial Registry, PACTR201506001171421, https://pactr.samrc.ac.za.

Feasibility of Home-Based Pulmonary Rehabilitation of Pediatric Patients with Chronic Respiratory Diseases

BACKGROUND AND OBJECTIVE

Chronic respiratory diseases in children deteriorate their daily life due to dyspnea and reduced lung function. We aimed to evaluate the feasibility of home-based pulmonary rehabilitation in pediatric chronic respiratory diseases.

METHODS

This prospective, single-arm, cohort study included children with chronic lung disease. They were instructed to perform home-based pulmonary rehabilitation 30 min/session, three sessions/week for three months. Pulmonary function test (PFT) using spirometry, respiratory muscle strength (RMT), cardiopulmonary exercise test (CPET), 6 min walk test (6MWT), dyspnea questionnaires, speech evaluation, and pediatric quality of life inventory (PedsQL) were assessed pre- and post-pulmonary rehabilitation. Compliance and satisfaction of the program were also evaluated.

RESULTS

Twenty children (mean age: 11.2 ± 3.1 years) with chronic respiratory diseases without cardiopulmonary instability participated. The overall compliance was 71.1% with no related adverse events. After pulmonary rehabilitation, forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), RMT, 6MWT, dyspnea questionnaire, speech rate, and PedsQL (child) significantly improved (p < 0.05), particularly better in the FEV1 < 60% group than in the FEV1 ≥ 60% group and in the high-compliance group (compliance ≥ 50%) than in the low-compliance group (compliance < 50%).

CONCLUSIONS

Home-based pulmonary rehabilitation for children with chronic lung disease was feasible with high compliance and effective in terms of objective functions, subjective dyspnea symptom, and quality of life.

The effect of respiratory muscle training on children and adolescents with cystic fibrosis: a systematic review and meta-analysis

BACKGROUND

Cystic fibrosis is a chronic genetic disease that can affect the function of the respiratory system. Previous reviews of the effects of respiratory muscle training in people with cystic fibrosis are uncertain and do not consider the effect of age on disease progression. This systematic review aims to determine the effectiveness of respiratory muscle training in the clinical outcomes of children and adolescents with cystic fibrosis.

METHODS

Up to July 2023, electronic databases and clinical trial registries were searched. Controlled clinical trials comparing respiratory muscle training with sham intervention or no intervention in children and adolescents with cystic fibrosis. The primary outcomes were respiratory muscle strength, respiratory muscle endurance, lung function, and cough. Secondary outcomes included exercise capacity, quality of life and adverse events. Two review authors independently extracted data and assessed study quality using the Cochrane Risk of Bias Tool 2. The certainty of the evidence was assessed according to the GRADE approach. Meta-analyses where possible; otherwise, take a qualitative approach.

RESULTS

Six studies with a total of 151 participants met the inclusion criteria for this review. Two of the six included studies were published in abstract form only, limiting the available information. Four studies were parallel studies and two were cross-over designs. There were significant differences in the methods and quality of the methodology included in the studies. The pooled data showed no difference in respiratory muscle strength, lung function, and exercise capacity between the treatment and control groups. However, subgroup analyses suggest that inspiratory muscle training is beneficial in increasing maximal inspiratory pressure, and qualitative analyses suggest that respiratory muscle training may benefit respiratory muscle endurance without any adverse effects.

CONCLUSIONS

This systematic review and meta-analysis indicate that although the level of evidence indicating the benefits of respiratory muscle training is low, its clinical significance suggests that we further study the methodological quality to determine the effectiveness of training.

TRIAL REGISTRATION

The protocol for this review was recorded in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023441829.

Aerobic exercise capacity, cough strength, posture, and depression in primary ciliary dyskinesia

INTRODUCTION

Assessment of exercise capacity is important for information about lung function and prognosis in primary ciliary dyskinesia (PCD). In addition, deterioration in the pulmonary system may affect cough efficiency, posture, and thoracoabdominal mobility. In turn, this deterioration may also disturb the psychological function of patients with PCD. Therefore, this study aimed to compare exercise capacity, cough strength, thoracoabdominal mobility, posture, and depression in children with PCD and healthy peers.

METHODS

Twenty-seven patients with PCD and 28 healthy peers were included. Aerobic exercise capacity (3-min step test), cough strength (peak expiratory flow meter), thoracoabdominal mobility (upper chest, lower chest, and abdomen), posture (Corbin postural assessment scale), and depression (Children's Depression Inventory) were evaluated.

RESULTS

Patients' number of steps completed, cough strength, and thoracoabdominal mobility were significantly decreased; total posture and depression scores were higher compared with healthy controls (p< 0.05). There was a significant relationship between cough strength and maximal expiratory strength (r = 0.541, p= 0.004) and total number of steps (r = 0.509, p= 0.007) in the patients.

CONCLUSION

Aerobic exercise capacity, cough strength, and thoracoabdominal mobility were impaired, posture was deteriorated, and depression perception elevated in children with PCD compared to healthy peers. Furthermore, aerobic exercise capacity and maximal expiratory strength are related to cough strength in these patients. Rehabilitation programs including aerobic and resistive exercise training, deep breathing and postural exercise, and nutrition counseling may improve these results and better be investigated. Trial registration: Clinicaltrials.gov: NCT03370029; December 12, 2017.

Effect of expiratory muscle training on peak cough flow in children and adolescents with cystic fibrosis: A randomized controlled trial

BACKGROUND

Cough is an important defense and airway clearance mechanism for removing thick and viscous secretions in cystic fibrosis (CF). The primary aim of this study was to investigate the effect of expiratory muscle training (EMT) on peak cough flow (PCF) and secondly on respiratory muscle functions, functional exercise capacity, and quality of life (QoL) in CF.

METHODS

Thirty patients were randomized as training and sham groups. Both groups were trained with the EMT protocol, which involved twice per day for at least 5 days per week for 6 weeks. The training intensity in the training group was 30% of the maximal expiratory pressure (MEP). In the sham group, it remained at the lowest pressure (5 cmH₂ O). The primary outcome was PCF. The secondary outcomes were MEP, maximal inspiratory pressure (MIP), spirometric measures, six-minute walking distance (6MWD), and QoL (Cystic Fibrosis Questionnaire-Revised).

RESULTS

Twenty-eight patients completed the study. Changes in PCF (p = .041) and MEP (p = .003) were higher in the training group than the sham group. Also, treatment burden (p = .008), digestive symptoms (p = .019), and vitality (p = .042) in QoL were more improved in the training group. MIP (p = .028) and 6MWD (p = .035) changed significantly only in the training group. Spirometric measurements did not change (p > .05).

CONCLUSIONS

The results of the study show that EMT could improve PCF, MEP, treatment burden, digestive symptoms, and vitality domains of QoL in patients with CF. Moreover, MIP and functional exercise capacity improved in the training group with EMT.

Exercise and Cystic Fibrosis

Cystic fibrosis (CF) is an autosomal recessive, inherited congenital disease caused by the mutation of the family autosomal CF gene, with cumulative exocrine secretion characterized by inflammation, tracheal remodeling, and mucus accumulation. With the development of modern medical technology, CF patients are living longer lives and receiving more and more treatments, including traditional drugs, physical therapy, and gene therapy. Exercise is widely used to prevent and treat metabolic diseases such as cardiovascular diseases, obesity, diabetes, and metabolic syndrome. Regular exercise is beneficial to aerobic capacity and lung health. Exercise therapy has been of great interest since people realized that CF can be affected by exercise. Exercise alone can be used as an ACT (airway clearance technique), which promotes the removal of mucosal cilia. Exercise therapy is more easily accepted by any society, which helps to normalize the lives of CF patients, rather than placing a psychological burden on them. In this chapter, we will review the latest research progress about exercise in CF.

Training, detraining, and retraining: Two 12-week respiratory muscle training regimens in a child with infantile-onset Pompe disease

BACKGROUND

Respiratory muscle weakness is a primary cause of morbidity and mortality in patients with Pompe disease. We previously described the effects of our 12-week respiratory muscle training (RMT) regimen in 8 adults with late-onset Pompe disease [1] and 2 children with infantile-onset Pompe disease [2].

CASE REPORT

Here we describe repeat enrollment by one of the pediatric participants who completed a second 12-week RMT regimen after 7 months of detraining. We investigated the effects of two 12-week RMT regimens (RMT #1, RMT #2) using a single-participant A-B-A experimental design. Primary outcome measures were maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP). Effect sizes for changes in MIP and MEP were determined using Cohen's d statistic. Exploratory outcomes targeted motor function.

RELEVANCE

From pretest to posttest, RMT #2 was associated with a 25% increase in MIP and a 22% increase in MEP, corresponding with very large effect sizes (d= 2.92 and d= 2.65, respectively). Following two 12-week RMT regimens over 16 months, MIP increased by 69% and MEP increased by 97%, corresponding with very large effect sizes (d= 3.57 and d= 5.10, respectively). MIP and MEP were largely stable over 7 months of detraining between regimens. Magnitude of change was greater for RMT #1 relative to RMT #2.

Respiratory muscle training in children and adults with neuromuscular disease

BACKGROUND

Neuromuscular diseases (NMDs) are a heterogeneous group of diseases affecting the anterior horn cell of spinal cord, neuromuscular junction, peripheral nerves and muscles. NMDs cause physical disability usually due to progressive loss of strength in limb muscles, and some NMDs also cause respiratory muscle weakness. Respiratory muscle training (RMT) might be expected to improve respiratory muscle weakness; however, the effects of RMT are still uncertain. This systematic review will synthesize the available trial evidence on the effectiveness and safety of RMT in people with NMD, to inform clinical practice.

OBJECTIVES

To assess the effects of respiratory muscle training (RMT) for neuromuscular disease (NMD) in adults and children, in comparison to sham training, no training, standard treatment, breathing exercises, or other intensities or types of RMT.

SEARCH METHODS

On 19 November 2018, we searched the Cochrane Neuromuscular Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. On 23 December 2018, we searched the US National Institutes for Health Clinical Trials Registry (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform, and reference lists of the included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, of RMT in adults and children with a diagnosis of NMD of any degree of severity, who were living in the community, and who did not need mechanical ventilation. We compared trials of RMT (inspiratory muscle training (IMT) or expiratory muscle training (EMT), or both), with sham training, no training, standard treatment, different intensities of RMT, different types of RMT, or breathing exercises.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 studies involving 250 randomized participants with NMDs: three trials (N = 88) in people with amyotrophic lateral sclerosis (ALS; motor neuron disease), six trials (N = 112) in Duchenne muscular dystrophy (DMD), one trial (N = 23) in people with Becker muscular dystrophy (BMD) or limb-girdle muscular dystrophy, and one trial (N = 27) in people with myasthenia gravis.Nine of the trials were at high risk of bias in at least one domain and many reported insufficient information for accurate assessment of the risk of bias. Populations, interventions, control interventions, and outcome measures were often different, which largely ruled out meta-analysis. All included studies assessed lung capacity, our primary outcome, but four did not provide data for analysis (1 in people with ALS and three cross-over studies in DMD). None provided long-term data (over a year) and only one trial, in ALS, provided information on adverse events. Unscheduled hospitalisations for chest infection or acute exacerbation of chronic respiratory failure were not reported and physical function and quality of life were reported in one (ALS) trial.Amyotrophic lateral sclerosis (ALS)Three trials compared RMT versus sham training in ALS. Short-term (8 weeks) effects of RMT on lung capacity in ALS showed no clear difference in the change of the per cent predicted forced vital capacity (FVC%) between EMT and sham EMT groups (mean difference (MD) 0.70, 95% confidence interval (CI) -8.48 to 9.88; N = 46; low-certainty evidence). The mean difference (MD) in FVC% after four months' treatment was 10.86% in favour of IMT (95% CI -4.25 to 25.97; 1 trial, N = 24; low-certainty evidence), which is larger than the minimal clinically important difference (MCID, as estimated in people with idiopathic pulmonary fibrosis). There was no clear difference between IMT and sham IMT groups, measured on the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALFRS; range of possible scores 0 = best to 40 = worst) (MD 0.85, 95% CI -2.16 to 3.85; 1 trial, N = 24; low-certainty evidence) or quality of life, measured on the EuroQol-5D (0 = worst to 100 = best) (MD 0.77, 95% CI -17.09 to 18.62; 1 trial, N = 24; low-certainty evidence) over the medium term (4 months). One trial report stated that the IMT protocol had no adverse effect (very low-certainty evidence).Duchenne muscular dystrophy (DMD)Two DMD trials compared RMT versus sham training in young males with DMD. In one study, the mean post-intervention (6-week) total lung capacity (TLC) favoured RMT (MD 0.45 L, 95% CI -0.24 to 1.14; 1 trial, N = 16; low-certainty evidence). In the other trial there was no clear difference in post-intervention (18 days) FVC between RMT and sham RMT (MD 0.16 L, 95% CI -0.31 to 0.63; 1 trial, N = 20; low-certainty evidence). One RCT and three cross-over trials compared a form of RMT with no training in males with DMD; the cross-over trials did not provide suitable data. Post-intervention (6-month) values showed no clear difference between the RMT and no training groups in per cent predicted vital capacity (VC%) (MD 3.50, 95% CI -14.35 to 21.35; 1 trial, N = 30; low-certainty evidence).Becker or limb-girdle muscular dystrophyOne RCT (N = 21) compared 12 weeks of IMT with breathing exercises in people with Becker or limb-girdle muscular dystrophy. The evidence was of very low certainty and conclusions could not be drawn.Myasthenia gravisIn myasthenia gravis, there may be no clear difference between RMT and breathing exercises on measures of lung capacity, in the short term (TLC MD -0.20 L, 95% CI -1.07 to 0.67; 1 trial, N = 27; low-certainty evidence). Effects of RMT on quality of life are uncertain (1 trial; N = 27).Some trials reported effects of RMT on inspiratory and/or expiratory muscle strength; this evidence was also of low or very low certainty.

AUTHORS' CONCLUSIONS

RMT may improve lung capacity and respiratory muscle strength in some NMDs. In ALS there may not be any clinically meaningful effect of RMT on physical functioning or quality of life and it is uncertain whether it causes adverse effects. Due to clinical heterogeneity between the trials and the small number of participants included in the analysis, together with the risk of bias, these results must be interpreted very cautiously.

Peak expiratory flow in obese subjects in different positions

Objective: To analyze the peak expiratory flow (PEF) in obese subjects in standing (ST), seated (SE), supine (SU), prone (PR), and right and left lateral decubitus (RL and LL) positions. Methods: 36 obese volunteers, aged between 18 and 54 years, and nonsmokers, were evaluated by anthropometric data; spirometry; international physical activity questionnaire (IPAQ); and PEF in ST, SE, SU, PR, RL, and LL positions, randomly. Results: The mean age was 27.3 ± 7.4 years and BMI of 38.7 ± 3.2 kg/m²; IPAQ results: active (50%), irregularly active (25%), very active (16.7%), and sedentary (08.3%); spirometry results: FVC = 100.33%, FEV₁ = 92.83%, FEV₁/FVC ratio = 0.95, FEF_25-75% = 85.55%. The PEF (L/min) were within the normal range and there was no difference between the ST and SE (428.6 ± 100.9 and 430.0 ± 100.1). Comparing ST and SE to the other positions, in absolute and percent of predicted values (L/min and %), there was a decrease in the SU (85.4 ± 14.9), PR (401.1 ± 92.4 and 84.1 ± 14.4), RL (398.6 ± 94.7 and 83.3 ± 14.9) (p < 0.05), and there was no difference to SU (409.4 ± 102.8) and LL (410.3 ± 93.9 and 85.8 ± 14.5). Conclusion: The PEF of healthy obese are similar in the standing and seated positions. The PEF decreases in the lying positions, except for the LL, that could be used as an alternative for measurements.

Inspiratory muscle training for children and adolescents with neuromuscular diseases: A systematic review

Patients with neuromuscular diseases are at risk of morbidity and mortality due to respiratory compromise caused by respiratory muscle weakness. A systematic review was performed using pre-specified search strategies to determine the safety of inspiratory muscle training (IMT) and whether it has an impact on inspiratory muscle strength and endurance, exercise capacity, pulmonary function, dyspnoea and health-related quality of life. Randomised, quasi-randomised, cross-over and clinical controlled trials were included if they assessed the use of an external IMT device compared to no, sham/placebo, or alternative IMT treatment in children aged 5-18 years with neuromuscular diseases. Seven full-text articles and two on-going trials (n = 168) were included. Most studies used threshold IMT devices over a medium to long-term period, and none reported any adverse events. Studies differed regarding intensity, repetitions, frequency, rest intervals and duration of IMT. Six studies reported no significant improvement in pulmonary function tests following IMT. Two comparable studies reported significant improvement in inspiratory muscle endurance and four studies reported significantly greater improvement in inspiratory muscle strength in experimental groups. The latter was confirmed in a meta-analysis of two comparable studies (overall effect p < 0.00001). Other outcome measures could not be pooled. There is currently insufficient evidence to guide clinical IMT practice, owing to the limited number of included studies; small sample sizes; data heterogeneity; and risk of bias amongst included studies. Large sample randomised controlled trials are needed to determine safety and efficacy of IMT in paediatric and adolescent patients with neuromuscular diseases.