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Study aim: To identify symptoms of depression, anxiety, and stress in Brazilian university students of both sexes and the association of physical activity parameters during the COVID-19 pandemic.

INTRODUCTION: This article serves as a 'call to action' for physical therapists in the 21st century with special attention to the needs of Brazilians. Compared with evidence-based practice supporting the use of specific interventions, practice that is informed by contemporary societal and Health priorities has seriously lagged behind over recent decades. 'The First Physical Therapy Summit on Global Health' held at the 2007 World Congress of the World Confederation of Physical Therapy (WCPT) in Canada highlighted the discrepancy between current practice trends globally and contemporary definitions of Physical Therapy (that subsume words such as health, well-being, quality of life, health promotion and prevention); the leading Health priorities within the WCPT regions; the proportions of physical therapists practicing in these priority areas; and the proportions of entry-level Physical Therapy professional education devoted to them. In the 20th century, the profession strived to align itself with societal needs, for example the world wars and poliomyelitis epidemics. Over the past 50 years, lifestyle conditions including ischemic heart disease, smoking-related conditions, hypertension, stroke, obesity, diabetes and cancer have predominated. Despite a remarkable shift from communicable diseases to non-communicable conditions over the past century, the profile of lifestyle conditions within professional practice and education remains low and disproportional to need. This is particularly striking given the unequivocal data in the literature that supports the cost-benefit relationship of noninvasive interventions (primarily Health education and exercise) over the short and long-term, with regard to their prevention, 'cure' and management. Often the outcomes from these simple inexpensive interventions for lifestyle conditions are superior to drugs and surgery, which are largely used to mitigate signs and symptoms rather than to address underlying causes. To enable physical therapists to address lifestyle conditions in all individuals and relieve the substantial societal and economic burdens of these conditions, we make several evidence-based recommendations for reducing their morbidity and mortality that can readily be integrated into daily practice. By systematically incorporating these into practice, physical therapists can make it possible for physicians and surgeons to use their time and expertise more effectively. CONCLUSION: We propose that the Brazilian Physical Therapy community should be strategically positioned to become a model and leader in addressing global Health priorities. [ABSTRACT FROM AUTHOR]

Background: Endothelial dysfunction and peak oxygen uptake (VO 2peak ) are also predictors of increased risk of cardiovascular events in heart transplantation (HTx) recipients. The preservation of endothelial function may contribute to exercise tolerance., Objective: To investigate the correlation between peripheral endothelial function and exercise tolerance through VO 2peak and ventilation to carbon dioxide production slope (VE / VCO 2 slope ) in HTx recipients., Methods: A pilot cross-sectional study was conducted with adult individuals aged 18-65 years, HTx ≥ six months after surgery, who had a stable medical condition and no changes over the last three months of immunosuppressive treatment. The patients underwent an assessment of endothelial function through PAT (EndoPAT-2000®) and performed a cardiopulmonary exercise test (CPET)., Results: A total of 41% of the studied population presented endothelial dysfunction. The individuals were divided into two groups: the endothelial dysfunction (GED; n=9) group and the normal endothelial function (GNEF; n=13) group according to the logarithm of the reactive hyperemia index (LnRHI). There was a positive and moderate correlation between the LnRHI and VO 2 peak (r=0.659, p=0.013) and a negative and moderate correlation between the LnRHI and VE/VCO 2 slope (r= -0.686, p= 0.009) in the GNEF. However, no significant correlations were found in the GED., Conclusion: The results showed that the preservation of peripheral endothelial function is significantly correlated with an increase in exercise tolerance in individuals after HTx. These findings bring important considerations for cardiovascular risk prevention and emphasize that therapeutic strategies with physical training programs must be implemented early., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: To carry out a systematic review to determine the main methods used to study the heart rate variability (HRV) in individuals after the acute phase of COVID-19., Methods: The study followed the Preferred Items for Reporting for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, Web of Science, Scopus and CINAHAL electronic databases were searched from the inception to November 2022. The studies were included if they used HRV assessment based on linear and non-linear methods in long-term COVID-19 patients. Review studies, theses and dissertations, conference abstracts, longitudinal studies, studies conducted on animals and studies that included individuals in the acute phase of the COVID-19 were excluded. The methodological quality of the studies was analyzed using the Joanna Briggs Institute's critical evaluation checklist for cross-sectional analytical studies., Results: HRV was mainly assessed using 24-h Holter monitoring in 41.6% (5/12) of the studies, and 12‑lead ECG was used in 33.3% (4/12). Regarding the type of assessment, 66.6% (8/12) of the studies only used linear analysis, where 25% (3/12) used analysis in the time domain, and 41.6% (5/12) used both types. Non-linear methods were combined with the previously cited linear method in 25% (3/12) of the studies. Moreover, 50% (6/12) of the studies demonstrated post-COVID-19 autonomic dysfunction, with an increase in the predominance of cardiac sympathetic modulation. The average score of the evaluation checklist was 6.6, characterized as having reasonable methodological quality., Conclusion: 24-h Holter and 12‑lead ECG are considered effective tools to assess HRV in post-COVID-19 patients. Furthermore, the findings reveal diverse effects of COVID-19 on the autonomic nervous system's sympathovagal balance, which might be influenced by secondary factors such as disease severity, patients' overall health, evaluation timing, post-infection complications, ventilatory functions, and age., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023. Published by Elsevier Inc.)

Background: Clinical practice of aerosol delivery in conjunction with respiratory support devices for critically ill adult patients remains a topic of controversy due to the complexity of the clinical scenarios and limited clinical evidence., Objectives: To reach a consensus for guiding the clinical practice of aerosol delivery in patients receiving respiratory support (invasive and noninvasive) and identifying areas for future research., Methods: A modified Delphi method was adopted to achieve a consensus on technical aspects of aerosol delivery for adult critically ill patients receiving various forms of respiratory support, including mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula. A thorough search and review of the literature were conducted, and 17 international participants with considerable research involvement and publications on aerosol therapy, comprised a multi-professional panel that evaluated the evidence, reviewed, revised, and voted on recommendations to establish this consensus., Results: We present a comprehensive document with 20 statements, reviewing the evidence, efficacy, and safety of delivering inhaled agents to adults needing respiratory support, and providing guidance for healthcare workers. Most recommendations were based on in-vitro or experimental studies (low-level evidence), emphasizing the need for randomized clinical trials. The panel reached a consensus after 3 rounds anonymous questionnaires and 2 online meetings., Conclusions: We offer a multinational expert consensus that provides guidance on the optimal aerosol delivery techniques for patients receiving respiratory support in various real-world clinical scenarios., (© 2023. The Author(s).)

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19., (© 2023. The Author(s).)

Objective: To investigate the repercussions of traumatic brachial plexus injury (TBPI) on diaphragmatic mobility and exercise capacity, compartmental volume changes, as well as volume contribution of each hemithorax and ventilation asymmetry during different respiratory maneuvers, and compare with healthy individuals. The velocity of shortening of the diaphragm, inspiratory, and expiratory muscles were also assessed., Participants: The cross-sectional study was conducted with 40 male individuals (20 with TBPI who have not undergone nerve transfer surgery [mean age 30.1 ± 5.3] and 20 healthy paired by age and body mass index). Only patients with C8-T1 root avulsion were studied., Main Outcome: Compartmental and hemithoracic volumes, as well as asymmetry between the affected and unaffected sides were assessed using optoelectronic plethysmography. The 6 minute walking test was performed to evaluate exercise capacity, while diaphragm mobility was assessed during quiet breathing (QB) using an ultrasound device., Results: TBPI patients with mean lesion time of 174 ± 45.24 days showed a decreased pulmonary function, respiratory muscle strength, exercise capacity, and diaphragm mobility (all p < .001) compared with healthy. The pulmonary ribcage compartment of the affected side was the main contributor to the reduction in volume during inspiratory capacity, vital capacity, and inspiratory load imposition (all p < .05). This compartment also exhibited a higher ventilation asymmetry with reduced shortening velocity of the inspiratory ribcage muscles., Conclusion: Compared with healthy, TBPI patients who have not undergone nerve transfer surgery present low exercise capacity and diaphragmatic mobility, as well as reduced volume of the upper ribcage compartment on the affected side that leads to reduced shortening velocity and ventilation asymmetry., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To evaluate the effect of a 12-week whole-body vibration (WBV) training program on quadriceps muscle strength, quadriceps thickness, the 6-min walk test (6MWT), respiratory muscle strength and quality of life in adults with a kidney transplant., Method: Five renal transplant recipients (age: 43-52 years; body mass: 67.1 kg; height: 1.60 m) were examined individually before and after a 12-week WBV program (two weekly sessions, 35 Hz frequency, 2-4 mm amplitude) using quadriceps strength, quadriceps thickness, 6-min walking test, inspiratory muscle strength and quality of life., Results: There were no complications during WBV protocol, and the program was considered safe. Two of the participants changed quadriceps muscle strength, and one increased muscle thickness. Inspiratory muscle strength improved in one participant. The distance covered on 6MWT increased for two participants. Most of the subjects (P3, P4 and P5) reported improved quality of life, mainly regarding pain and social aspects., Conclusion: The protocol improved the physical function and quality of life in some of the patients. However, WBV training prescription should be adjusted according to individual needs. Thus, studying the use of WBV in this patient group is necessary to understand and apply the benefits for this population., (© 2020 John Wiley & Sons, Ltd.)

Objective: To determine reference values of sniff nasal inspiratory pressure (SNIP) in healthy children., Methods: This cross-sectional observational study included healthy children aged 6 to 11 years of both sexes. The volunteers underwent a pulmonary function test to rule out respiratory disorders. Respiratory muscle strength was measured using maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), respectively, with MIP close to functional residual capacity (FRC) and residual volume, while MEP to total lung capacity. SNIP was performed through the nostril contralateral to the occlusion, close to FRC. Two 6-minute walk tests were performed to assess functional exercise capacity., Results: The sample comprised 121 healthy children (62 girls); 54% presented body mass index (BMI) percentile less than 85th and 46% more than equal to 85th percentile, higher than expected. SNIP values were similar between sexes (91.1 ± 21.0 cmH 2 O in girls and 87.7 ± 19.4 cmH 2 O in boys; P = .36) as well as the means of lower limits of normal (56.88 cmH 2 O for girls and 56.66 cmH 2 O for boys). Girls presented SNIP measurements larger than those of the MIP of FRC (P < .0001), while boys presented similar mean values for both. We found a positive correlation between SNIP and BMI percentile (r = .25, P = .04) in girls, unlike boys, in whom no correlation was observed., Conclusions: SNIP reference values and mean lower limits of normal were defined for healthy children aged 6 to 11. BMI percentile seems to positively influence the inspiratory muscle strength measured by SNIP in girls only., (© 2019 Wiley Periodicals, Inc.)

Although the physical therapist profession is the leading established, largely nonpharmacological health profession in the world and is committed to health promotion and noncommunicable disease (NCD) prevention, these have yet to be designated as core physical therapist competencies. Based on findings of 3 Physical Therapy Summits on Global Health, addressing NCDs (heart disease, cancer, hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an urgent professional priority. The Third Summit established the status of health competencies in physical therapist practice across the 5 World Confederation for Physical Therapy (WCPT) regions with a view to establish health competency standards, this article's focus. Three general principles related to health-focused practice emerged, along with 3 recommendations for its inclusion. Participants acknowledged that specific competencies are needed to ensure that health promotion and NCD prevention are practiced consistently by physical therapists within and across WCPT regions (ie, effective counseling for smoking cessation, basic nutrition, weight control, and reduced sitting and increased activity/exercise in patients and clients, irrespective of their presenting complaints/diagnoses). Minimum accreditable health competency standards within the profession, including use of the WCPT-supported Health Improvement Card, were recommended for inclusion into practice, entry-to-practice education, and research. Such standards are highly consistent with the mission of the WCPT and the World Health Organization. The physical therapist profession needs to assume a leadership role vis-à-vis eliminating the gap between what we know unequivocally about the causes of and contributors to NCDs and the long-term benefits of effective, sustained, nonpharmacological lifestyle behavior change, which no drug nor many surgical procedures have been reported to match., (© 2019 American Physical Therapy Association.)

Background: Trans-nasal pulmonary aerosol delivery using high flow nasal cannula (HFNC) devices is described with the administration of high gas flows exceeding patient inspiratory flow (HF) and with lower flows (LF). The aim of this pilot clinical trial was to compare deposition and distribution of radiolabeled aerosol via nasal cannula in healthy adults across three rates of gas flow delivered with active heated humidification, and to further identify the impact of aerosol administration without heated humidity., Methods: Twenty-three (23) healthy adults (16F) were randomized to receive aerosol with active heated humidification or unheated oxygen at gas flows of 10 L/min ( n = 8), 30 L/min ( n = 7), or 50 L/min ( n = 8). Diethylenetriaminepentaacetic acid labeled with 1 millicurie (37 MBq) of Technetium-99m (DTPA-Tc99m) was mixed with NaCl to a fill volume of 1 mL, and administered via mesh nebulizer placed at the inlet of the humidifier. Radioactivity counts were performed using a gamma camera and the regions of interest (ROIs) were delimited with counts from the lungs, upper airways, stomach, nebulizer, circuit, and expiratory filter. A mass balance was calculated and each compartment was expressed as a percentage of the total., Results: Lung deposition (mean ± SD) with heated humidified gas was greater at 10 L/min than 30 L/min or 50 L/min (17.2 ± 6.8%, 5.71 ± 2.04%, and 3.46 ± 1.24%, respectively; p = 0.0001). Using unheated carrier gas, a lung dose of aerosol was similar to the active heated humidification condition at 10 L/min, but greater at 30 and 50 L/min ( p = 0.011). Administered gas flow and lung deposition were negatively correlated ( r = -0.880, p < 0.001)., Conclusions: Both flow and active heated humidity inversely impact aerosol delivery through HFNC. Nevertheless, aerosol administration across the range of commonly used flows can provide measurable levels of lung deposition in healthy adult subjects (NCT02519465).

Aim: To assess thoracoabdominal asynchrony (TAA) and the presence of paradoxical motion in middle stage amyotrophic lateral sclerosis (ALS) and its relationships with chest wall tidal volume (V T,CW ), breathing pattern and cough peak flow (CPF)., Methods: Phase angle (θ) between upper (RCp) and lower ribcage (RCa) and abdomen (AB), as well as percentage of inspiratory time for the lower ribcage (IP RCa ) and abdomen (IP AB ) moving in opposite directions were quantified using optoelectronic plethysmography in 12 ALS patients during quiet breathing and coughing. Paradoxical motion of the compartments was based on threshold values of θ and IP, obtained in twelve age and sex matched healthy persons., Results: During quiet breathing, significantly higher RCa and AB θ (p < .05), IP RCa (p = 0.001) and IP AB (p < 0.05) were observed in ALS patients as compared to controls. In ALS patients, correlations between RCa and AB θ with forced vital capacity (FVC) (r=-0.773, p < 0.01), vital capacity (r=-0.663, p < 0.05) and inspiratory capacity (IC) (r=-0.754, p < 0.01), as well as between RCp and RCa θ with FVC (r=-0.608, p < 0.05) and CPF (r=-0.601, p < 0.05) were found. During coughing, correlations between RCp and AB θ with CPF (r=-0.590, p < 0.05), IC (r=-0.748, p < 0.01) and V T,CW (r=-0.608, p < 0.05), as well as between RCa and AB θ with CPF (r=-0.670, p < 0.05), IC (r=-0.713, p < 0.05) and peak expiratory flow (r=-0.727, p < 0.05) were also observed in ALS patients. ALS patients with paradoxical motion presented lower vital capacity and FVC %pred (p < 0.05) compared to those without paradoxical motion., Conclusions: Middle stage ALS patients exhibit TAA and paradoxical motion during quiet spontaneous breathing and coughing. In addition, diaphragmatic weakness (i.e. decrease in excursion of the RCa and AB compartments) was observed earlier in the lower ribcage rather than the abdominal compartment in this population., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To assess the variations of end-expiratory volume of chest wall (EEVcw) measured by optoelectronic plethysmography (OEP) as a diagnostic tool in exercise-induced asthma (EIA) among asthmatic preschool children., Methods: Forty children diagnosed with asthma were included in the study. Spirometry was used as a gold standard test for comparison with OEP. A 10% decline in forced expiratory volume in 1 second was considered positive for EIA. OEP was performed with 8 cameras at a frequency of 60 Hz and 89 markers were placed on the thoraco-abdominal surface of participants. Following bronchoprovocation testing on a treadmill, series of OEP and spirometry were conducted between 5 and 30 minutes after exercise. To obtain the ideal cut-off point, a receiver operating characteristic (ROC) curve was constructed for the largest EEVcw. The highest Youden index was used as criteria to obtain the cut-off point with the best sensitivity and specificity., Results: Of the 40 children studied, 16 had EIA. According to the ROC curve, the cut-off point of 0.185% for EEWcw provided mean sensitivity (95% confidence interval) of 93.75% (0.69-0.99), for a specificity of 83.33% (0.63-0.95), when using the largest increase in the period of 5-30 minutes post-exercise. The low area of the ROC was 0.93 (0.85-1.00) for p < 0.001., Conclusion: OEP can be accurately used to replace spirometry in asthmatic children unable to adequately execute the required manoeuvres.

To investigate whether whole body vibration (WBV) training increases the explosive force of the knee extensors in chronic kidney disease (CKD) patients. Fourteen CKD patients undergoing hemodialysis were randomly allocated in WBV training or Sham group. Explosive force parameters (contractile impulse [CImp] and relative rate of force development [RFDr]) obtained in early (30 and 50 msec) and late phases (100 and 200 msec) of the knee extensors force/time curve. CImp and RFDr obtained at the early phase of force/time curve reduced after the intervention period, with a smaller decline for WBV (CImp at 50 msec [~-15% and -51%, P =0.038], RFDr at 30 msec [~-22% and -52%, P =0.044] and RFDr at 50 msec [~-11% and -54%; P =0.008]). In the late phase there was a lower decline for WBV group compared to Sham group, respectively: CImp: 100 msec (~-8% and -55%, P =0.025), 200 msec (~-3% and -46%, P = 0.025); RFDr 100 msec (~0.01% and -56%, P =0.033), 200 msec (~-5% and -36%, P =0.004). Three months of WBV training may attenuate the explosive force reduction in CKD patients., Competing Interests: CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.

Purpose: The design development of a small, hand held, battery operated, breath actuated inhaler as a drug/device platform for inhaled insulin posed a number of technical challenges. Our goal was to optimize lung deposition and distribution with aerosol generators producing 3-6 μm particle size distribution., Methods: In silico modeling with computational fluid dynamics (CFD) and in vitro testing of device components were assessed using an Alberta idealized adult airway (Copley, UK) to optimize mouthpiece and aerosol path design for dose delivered distal to the trachea. Human factors use testing was designed to determine the ability to perform inspiratory manuevers with LED guidance within target flow limits. In vivo testing with healthy normal subjects of radiolabeled aerosol compared 2 breathing patterns for lung deposition efficiency, distribution, and subject preference., Results: CFD demonstrated that flows ≤5 L/min and ≥15 L/min reduced the delivery efficiencg. Prototypes tested with inspiratory flow of 10 L/min provided up to 70% of dose delivered distal to the model throat with aerosols of 3 to 6 μm. Users guided by LED were able to inhale for 8-24 s with 5 s breath hold. Lung dose >70% with peripheral to central ratios >2.0 were achieved, with subject preference for the longer inspiratory time with breath hold., Conclusion: The device design phase integration led to a novel design and inspiratory pattern with greater levels of peripheral deposition than previously reported with commercial inhalers. The rationale and process of the application of these methods are described with implications for use in future device development.

Objectives: To assess the acute effects of air stacking on cough peak flow (CPF) and chest wall compartmental volumes of persons with amyotrophic lateral sclerosis (ALS) versus healthy subjects positioned at 45° body inclination., Design: Cross-sectional study with a matched-pair design., Setting: University hospital., Participants: Persons (N=24) with ALS (n=12) and age-matched healthy subjects (n=12)., Main Outcomes Measures: CPF, chest wall compartmental inspiratory capacity, chest wall vital capacity, chest wall tidal volume and operational volumes, breathing pattern, and percentage of contribution of the compartments to the inspired volume were measured by optoelectronic plethysmography., Results: Compared with healthy subjects, significantly lower CPF (P=.007), chest wall compartmental inspiratory capacity (P<.001), chest wall vital capacity (P<.001), and chest wall tidal volume (P<.001) were found in subjects with ALS. Immediately after air stacking, CPF (P<.001) and chest wall compartmental inspiratory capacity (P<.001) significantly increased in both groups, with values returning to basal only in healthy subjects. After air stacking, the abdominal compartment (P=.004) was determined to be responsible for the inspired volume in subjects with ALS. Significantly higher chest wall vital capacity (P=.05) was observed in subjects with ALS 5 minutes after air stacking, with the rib cage compartment (P=.049) being responsible for volume change. No differences were found in chest wall vital capacity and compartmental volumes of healthy subjects. Chest wall tidal volume (P<.001) significantly increased during the protocol in the healthy subjects, mainly because of end-inspiratory (P<.001) and abdominal volumes (P=.008). No significant differences were observed in percentage of contribution of the compartments to the inspired volume and end-expiratory volume of both groups. No significant differences were found in chest wall tidal volume, operational volume, and breathing pattern in persons with ALS., Conclusions: Air stacking is effective in increasing CPF, chest wall compartmental inspiratory capacity, and chest wall vital capacity of persons with ALS with no hyperinflation. Differences in compartmental volume contributions are probably because of lung and chest wall physiological changes., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The intracellular redox state of alveolar cells is a determining factor for tolerance to oxidative and pro-inflammatory stresses. This study investigated the effects of intratracheal co-administration of antioxidants encapsulated in liposomes on the lungs of rats subjected to sepsis. For this, male rats subjected to sepsis induced by lipopolysaccharide from Escherichia coli or placebo operation were treated (intratracheally) with antibiotic, 0.9% saline and antioxidants encapsulated or non-encapsulated in liposomes. Experimental model of sepsis by cecal ligation and puncture (CLP) was performed in order to expose the cecum. The cecum was then gently squeezed to extrude a small amount of feces from the perforation site. As an index of oxidative damage, superoxide anions, lipid peroxidation, protein carbonyls, catalase activity, nitrates/nitrites, cell viability and mortality rate were measured. Infected animals treated with antibiotic plus antioxidants encapsulated in liposomes showed reduced levels of superoxide anion (54% or 7.650±1.263 nmol/min/mg protein), lipid peroxidation (33% or 0.117±0.041 nmol/mg protein), protein carbonyl (57% or 0.039 ± 0.022 nmol/mg protein) and mortality rate (3.3%), p value <0.001. This treatment also reduced the level of nitrite/nitrate and increased cell viability (90.7%) of alveolar macrophages. Taken togheter, theses results support that cationic liposomes containing antioxidants should be explored as coadjuvants in the treatment of pulmonary oxidative damage., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Tidal breathing measurements by Opto-Electronic Plethysmography (OEP) has been reported for infants limited to protocols with two chest wall compartments. Standard protocol for the analysis of adults, with three compartments of chest wall, has been unavailable for analysis of infants. We aimed to study the agreement of simultaneous measurements of tidal volume by OEP (VT,OEP ) and a heated pneumotachograph (PNT) (VT,PNT ) performed during sleeping in 20 infants (gestational age 35.1 ± 4.6 weeks) at 3-4 months postconceptual age with a three compartment protocol. From PNT and OEP measurements, tidal volume corrected (VT,PNT ) for ambient conditions were calculated with a total number of 200 breaths. The two methods were in good agreement with tidal volume mean difference of 0.02 ml and limit of agreement -4.11 to 4.08 ml (95%CI), no relationship was found between differences and means of OEP and PNT measurements. Pulmonary rib cage, abdominal rib cage and abdomen contributed by 12.4 ± 9.7%, 5.2 ± 5.1%, and 82.4 ± 11.4% to VT,OEP , respectively. The OEP experimental protocol based on 52 markers and a three-compartment model of the chest wall could be used in spontaneously sleeping infants. Pediatr Pulmonol. 2016;51:850-857. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

It is not completely described how aging affect ventilatory kinematics and what are the mechanisms adopted by the elderly population to overcome these structural modifications. Given this, the aim was to evaluate the acute effects of different inspiratory efforts on ventilatory pattern and chest wall compartmental distribution in elderly women. Variables assessed included: tidal volume (Vt), total chest wall volume (Vcw), pulmonary rib cage (Vrcp%), abdominal rib cage (Vrca%) and abdominal compartment (Vab%) relative contributions to tidal volume. These variables were assessed during quiet breathing, maximal inspiratory pressure maneuver (MIP), and moderate inspiratory resistance (MIR; i.e., 40% of MIP). 22 young women (age: 23.9 ± 2.5 years) and 22 elderly women (age: 68.2 ± 5.0 years) participated to this study. It was possible to show that during quiet breathing, Vab% was predominant in elderly (p<0.001), in young, however, Vab% was similar to Vrcp% (p=0.095). During MIR, Vrcp% was predominant in young (p<0.001) and comparable to Vab% in elderly (p=0.249). When MIP was imposed, both groups presented a predominance of Vrcp%. In conclusion, there are differences in abdominal kinematics between young and elderly women during different inspiratory efforts. In elderly, during moderate inspiratory resistance, the pattern is beneficial, deep, and slow. Although, during maximal inspiratory resistance, the ventilatory pattern seems to predict imminent muscle fatigue., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Questions: In people with chronic obstructive pulmonary disease, does the Manual Diaphragm Release Technique improve diaphragmatic mobility after a single treatment, or cumulatively? Does the technique also improve exercise capacity, maximal respiratory pressures, and kinematics of the chest wall and abdomen?, Design: Randomised, controlled trial with concealed allocation, intention-to-treat analysis, and blinding of participants and assessors., Participants: Twenty adults aged over 60 years with clinically stable chronic obstructive pulmonary disease., Intervention: The experimental group received six treatments with the Manual Diaphragm Release Technique on non-consecutive days within a 2-week period. The control group received sham treatments following the same regimen., Outcome Measures: The primary outcome was diaphragmatic mobility, which was analysed using ultrasonography. The secondary outcomes were: the 6-minute walk test; maximal respiratory pressures; and abdominal and chest wall kinematics measured by optoelectronic plethysmography. Outcomes were measured before and after the first and sixth treatments., Results: The Manual Diaphragm Release Technique significantly improved diaphragmatic mobility over the course of treatments, with a between-group difference in cumulative improvement of 18mm (95% CI 8 to 28). The technique also significantly improved the 6-minute walk distance over the treatment course, with a between-group difference in improvement of 22 m (95% CI 11 to 32). Maximal expiratory pressure and sniff nasal inspiratory pressure both showed significant acute benefits from the technique during the first and sixth treatments, but no cumulative benefit. Inspiratory capacity estimated by optoelectronic plethysmography showed significant cumulative benefit of 330ml (95% CI 100 to 560). The effects on other outcomes were non-significant or small., Conclusion: The Manual Diaphragm Release Technique improves diaphragmatic mobility, exercise capacity and inspiratory capacity in people with chronic obstructive pulmonary disease. This technique could be considered in the management of people with chronic obstructive pulmonary disease., Trial Registration: NCT02212184., (Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: In vivo deposition studies of aerosol administration during noninvasive ventilation (NIV) are scarce in the literature. The aim of this study was to compare radioaerosol pulmonary index and radioaerosol mass balance in the different compartments (pulmonary and extrapulmonary) of radio-tagged aerosol administered using vibrating mesh nebulizers and conventional jet nebulizers during NIV., Methods: This was a crossover clinical trial involving 10 healthy subjects (mean age of 33.7 ± 10.0 y) randomly assigned to both treatment arms of this study: group 1 (NIV + vibrating mesh nebulizer, n = 10) and group 2 (NIV + jet nebulizer, n = 10). All subjects inhaled 3 mL of technetium-99m diethylenetriaminepentaacetic acid (25 mCi) and 0.9% saline solution via vibrating mesh and jet nebulizers during NIV through a face mask secured with straps while receiving positive inspiratory and expiratory pressures of 12 and 5 cm H2O, respectively. Scintigraphy was performed to count radioaerosol particles deposited in the regions of interest to determine radioaerosol mass balance from the lungs, upper airways, stomach, nebulizer, ventilator circuit, inspiratory and expiratory filters, and mask as a percentage., Results: Vibrating mesh nebulizers deposited 972,013 ± 214,459 counts versus jet nebulizer with 386,025 ± 130,363 counts (P = .005). In a determination of mass balance, vibrating mesh nebulizers showed a higher deposition of inhaled radioaerosol compared with jet nebulizers (23.1 ± 5.8% vs 6.1 ± 2.5%, P = .005) and a higher proportion of radioaerosol deposited into the lungs (5.5 ± 0.9% versus 1.5 ± 0.6%, respectively, P = .005). The residual drug volume was lower with vibrating mesh nebulizers (5.1 ± 1.5%) compared with jet nebulizers (41.3 ± 4.2%, P = .005)., Conclusions: During NIV in healthy subjects, vibrating mesh nebulizers delivered > 2-fold more radiolabeled drug into the respiratory tract compared with conventional jet nebulizers. Additional studies are recommended in subjects with asthma, COPD, bronchiectasis, and cystic fibrosis to better understand differences in both aerosol delivery and response. (ClinicalTrials.gov registration NCT01889524.)., (Copyright © 2015 by Daedalus Enterprises.)

Background: Different types of nebulizers and interfaces are used for the treatment of adults and children with pulmonary diseases. The purpose of this study was to determine the efficiency of a mesh nebulizer (MN) with a proprietary adapter and a jet nebulizer (JN) under different configurations in adult and pediatric models of spontaneous breathing. We hypothesize that delivery efficiency of JN and MN will differ depending on the interface used during aerosol therapy in simulated spontaneously breathing adult and pediatric models. While we expect that aerosol delivery with JN will be less efficient than MN, we also hypothesize that lung deposition obtained with the adult lung model will be more than that with the pediatric lung model in all conditions tested in this study., Methods: A lung model using a teaching manikin connected to a sinusoidal pump via a collecting filter at the level of the bronchi simulating a spontaneously breathing adult (Vt 500 mL, RR 15 bpm, I:E ratio 1:2) or pediatric patient (Vt 150 mL, RR 25 bpm, I:E ratio 1:2). Albuterol sulfate (2.5 mg/3 mL) was aerosolized with JN (Mistymax 10, Airlife) or MN (Aerogen Solo(®), Aerogen) with the Adapter (Aerogen Solo(®) Adapter, Aerogen Ltd, Galway, Ireland) using mouthpiece, aerosol mask, and valved-mask in adults and the dragon mask, aerosol mask, and valved-mask in pediatrics (n=3). The Adapter, specifically designed for MN, was attached to all the interfaces used in this study with supplemental oxygen of 2 lpm, and in addition, the MP was tested with no additional flow in the adult model. The JN was driven with 10 lpm based on the manufacturer's label. Drug was eluted from the filter and analyzed via spectrophotometry. Descriptive statistics, dependent t-test and one-way analysis of variance were used for data analysis. Significant level was set at 0.05., Results: In adults, delivery efficiency of JN with the valved mask was significantly greater than that with the aerosol mask (p=0.01). Aerosol delivery of JN with the mouthpiece was not statistically significant from the valved mask (p=0.123) and the aerosol mask (p=0.193). Drug delivery with MN with mouthpiece (15.42±1.4%) and valved-mask (15.15±1.1%) was greater than the open aerosol mask (7.54±0.39%; p=0.0001) in the adult lung model. With no flow mouthpiece delivery increased>2 fold (34.9±3.1%; p=.0001) compared to use of 2 lpm of flow. Using the JN with the pediatric model deposition with valved-mask (5.3±0.8%), dragon mask (4.7±0.9%), and aerosol mask (4.1±0.3%) were similar (p>0.05); while drug delivery with MN via valved-mask (11.1±0.7%) was greater than the dragon mask (6.44±0.3%; p=0.002) and aerosol mask (4.6±0.4%; p=0.002), and the dragon mask was more efficient than the open aerosol mask (p=0.009) CONCLUSION: The type of nebulizer and interface used for aerosol therapy affects delivery efficiency in these simulated spontaneously breathing adult and pediatric models. Drug delivery was greatest with the valved-mouthpiece and mask with JN and MN, while the standard aerosol mask was least efficient in these simulated spontaneously breathing adult and pediatric lung models. Delivery efficiency of JN was less than MN in all conditions tested in this study except in the aerosol mask. Lung deposition obtained with the adult lung model was more than that with the pediatric lung model.

Background: Neuromuscular diseases (NMDs) lead to different weakness patterns, and most patients with NMDs develop respiratory failure. Inspiratory and expiratory muscle strength can be measured by maximum static inspiratory pressure (PImax) and maximum static expiratory pressure (PEmax), and the relationship between them has not been well described in healthy subjects and subjects with NMDs. Our aim was to assess expiratory/inspiratory muscle strength in NMDs and healthy subjects and calculate PEmax/PImax ratio for these groups., Methods: Seventy (35 males) subjects with NMDs (amyotrophic lateral sclerosis, myasthenia gravis, and myotonic dystrophy), and 93 (47 males) healthy individuals 20-80 y of age were evaluated for anthropometry, pulmonary function, PImax, and PEmax, respectively., Results: Healthy individuals showed greater values for PImax and PEmax when compared with subjects with NMDs. PEmax/PImax ratio for healthy subjects was 1.31 ± 0.26, and PEmax%/PImax% was 1.04 ± 0.05; for subjects with NMDs, PEmax/PImax ratio was 1.45 ± 0.65, and PEmax%/PImax% ratio was 1.42 ± 0.67. We found that PEmax%/PImax% for myotonic dystrophy was 0.93 ± 0.24, for myasthenia gravis 1.94 ± 0.6, and for amyotrophic lateral sclerosis 1.33 ± 0.62 when we analyzed them separately. All healthy individuals showed higher PEmax compared with PImax. For subjects with NMDs, the impairment of PEmax and PImax is different among the 3 pathologies studied (P < .001)., Conclusions: Healthy individuals and subjects with NMDs showed higher PEmax in comparison to PImax regarding the PEmax/PImax ratio. Based on the ratio, it is possible to state that NMDs show different patterns of respiratory muscle strength loss. PEmax/PImax ratio is a useful parameter to assess the impairment of respiratory muscles in a patient and to customize rehabilitation and treatment., (Copyright © 2015 by Daedalus Enterprises.)

Objective: To analyze in obese women the acute effects of the breath stacking technique on thoraco-abdominal expansion., Design and Methods: Nineteen obese women (BMI ≥ 30 kg/m(2)) were evaluated by anthropometry, spirometry and maximal respiratory muscle pressures and successively analyzed by Opto-Electronic Plethysmography and a Wright respirometer during quiet breathing and breath stacking maneuvers and compared with a group of 15 normal-weighted healthy women. The acute effects of the maneuvers were assessed in terms of total and compartmental chest wall volumes at baseline, end of the breath stacking maneuver and after the maneuver. Obese subjects were successively classified into two groups, accordingly to the response during the maneuver, group 1 = prevalent rib cage or group 2 = abdominal expansion., Results: Age was significantly lower in group 1 than group 2. When considering the two obese groups, FEV1 was lower and minute ventilation was higher only in group 2 compared to controls group. During breath stacking, inspiratory capacity was significant differences in obese subjects with a smaller expansion of the pulmonary rib cage and a greater expansion of the abdomen compared to controls and also between groups 1 and 2. A significant inverse linear relationship was found between age and inspiratory capacity of the pulmonary rib cage but not of the abdomen., Conclusions: In obese women the maximal expansion of the rib cage and abdomen is influenced by age and breath stacking maneuver could be a possible therapy for preventing respiratory complications.

The purpose of this study was to evaluate the performance in the 6-minute walk test (6 MWT) of elderly patients with chronic obstructive pulmonary disease (COPD) by comparing to a group of healthy elderly patients, performed with and without verbal encouragement. This cross-sectional study compared 40 patients with COPD (forced expiratory volume in the first second (FEV1%) = 53.7 ± 23.8%; forced vital capacity (FVC%) = 65.5 ± 20.8%; and the FEV1/FVC ratio = 55.4 ± 12.4) and 40 healthy elderly patients (control). The 6 MWT's were performed with and without verbal encouragement according to the American Thoracic Society (ATS), monitoring the distance walked (6 MWD), the duration of walking (TW) and the perceived effort index (PEI) through the Borg scale between the groups. No differences were observed in patients with COPD when the tests were performed with and without verbal encouragement for the 6 MWD, TW and PEI, the same occurring in the control group for the 6 MWD, TW and PEI, respectively. The use of verbal encouragement was not sufficient to promote improvement in the performance of the 6 MWT (6 MWD, TW and PEI) of patients with COPD and healthy elderly patients.

Objective: Evaluate the influence of posture on ventilatory pattern, compartmental distribution of volume of chest wall and thoraco-abdominal kinematics of patients with severe chronic obstructive pulmonary disease (COPD)., Design: Cross-sectional study., Methods: Twelve, male patients with severe COPD (Forced Expiratory Volume in the first second (FEV1) = 24.35 ± 4.52%, Forced Vital Capacity% (FVC%) = 60 ± 13.39% and relationship FEV1/FVC = 53.42 ± 14.47). The distribution of the volume of the ribcage [pulmonary rib cage (Rcp), abdominal ribcage (Rca) and abdomen (Ab)] during quiet breathing in a sitting position without back support (SWB), sitting with backrest (SB) and supine position (SUP) was determined using an opto-electronic plethysmograph., Results: The following differences were observed: a greater tidal volume in the SWB position when compared to the SB position (p = 0.01); greater expiratory time in the SUP position in relation to the SWB (p = 0.03) and SB (p = 0.01); and increased abdominal contribution to the tidal volume in the SUP position in relation to the SWB (p < 0.01) and SB (p < 0.001). No difference was found in the thoraco-abdominal synchrony among the positions., Conclusion: Sitting position without back support enhances the activation of respiratory muscles by increasing the tidal volume and supine position seems to favor lung deflation by increasing the expiratory time. It seems appropriate to adopt these positions to optimize the ventilation/perfusion relationship and physiotherapeutic intervention in different clinical conditions.

Background and Purpose: Immersion in water, with the head above the water line, causes acute physiological changes in the pulmonary and cardiovascular systems. The aim of this study was to evaluate the acute physiological responses to immersion on lung volumes and respiratory muscle strength at different depths., Methods: A cross-sectional study was conducted in 28 healthy individuals (21.75 ± 1.99 years; 13 men and 15 women). Anthropometric and spirometric data as well as respiratory muscle strength were evaluated. Evaluations were carried out on dry land (DL) and in a pool at three different levels of immersion: iliac crests (IC), xiphoid appendix of the sternum (XA) and clavicles (CL). The order of evaluation for spirometry and maximal inspiratory and expiratory pressures between DL and the different levels of immersion was randomized. The ANOVA test for repeated measures with post hoc Tukey was applied to compare the variables., Results: Vital capacity exhibited lower values at the CL level compared with DL, XA and IC (p < 0.01). The most significant change in forced expiratory volume in the first second (FEV(1)) occurred under immersion at CL and XA levels. No differences in maximal expiratory pressure were found in the comparisons between the different levels of immersion and DL (p = 0.19). There was nevertheless a decrease in maximum inspiratory pressure with immersion at the CL level (91 ± 23 cmH(2)O) compared with DL (105 ± 29 cmH(2)O), XA (99 ± 24 cmH(2)O) and IC (101 ± 25 cmH(2)O) values (p < 0.01)., Conclusion: The results suggest that immersion at the level of the clavicles and xiphoid appendix alters lung function and respiratory muscle strength when compared with the values measured out of the water and immersed at the IC level in healthy individuals, demonstrating the influence of hydrostatic pressure on the respiratory system., (Copyright © 2013 John Wiley & Sons, Ltd.)

Aim: This research aims to analyze the acute effect of incremental inspiratory loads on respiratory pattern and on the predominant activity frequency of inspiratory muscle, taking into account differences in gender responses. Optoelectronic Plethysmography was performed during loads in 39 healthy subjects (20 women), placing 89 markers on the thoracic-abdominal wall to obtain total and regional volumes. Surface electromyography (SEMG) was taken simultaneously on the Sternocleidomastoid and Diaphragm muscles, to calculate the predominant muscle activity frequency through wavelet analysis. Inspiratory loads were performed using Threshold(®)with 2 min of breathing at different levels, ranging from a load of 10 cmH(2)O plus 5 cmH(2)O to 40 cmH(2)O or fatigue., Results: Inspiratory Time increased during loads. Total and compartmental volumes increased with different regions, changing at different loads. These changes in volume occur earlier in women (20 cmH(2)O) than in men (30 cmH(2)O). The predominant activity frequency of Sternocleidmastoid muscle decreased at 30 cmH(2)O, while Diaphragm activity decreased at 40 cmH(2)O., Conclusion: The acute effects of incremental inspiratory loads are increases of total and regional volumes and inspiratory time. As for muscle activity, the predominant activity frequency declined in Sternocleidomastoid and Diaphragm muscles, but at different loads. Such respiratory and SEMG patterns and gender differences should be considered when clinical interventions are performed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Excess body fat, particularly in the abdominal region, is responsible for respiratory system alterations. To study if and how both lung function and thoraco-abdominal volume variations during quiet breathing are altered in obese women and to determine if different obesity patterns in women have an influence on lung and chest wall function, 30 obese women (BMI ≥ 40 kg/m(2)) with both central and peripheral obesity were studied by spirometry and opto-electronic plethysmography during quiet breathing and compared with normoweight women. Compared to controls, obese were characterized by lung restriction and higher minute ventilation at rest. Pulmonary rib cage tidal volume variations were significantly lower and abdominal volume variations higher in obese women. No differences were found between central and peripheral obese women. In conclusion, in obese women, independently if obesity is central or peripheral, both lung function and thoraco-abdominal pattern during spontaneous breathing are strongly altered. The amount of fat in the abdominal compartment, and not the peripheral, alters the respiratory system., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Unlabelled: Our aim was to assess the relationships between cortisol, interleukin-2 (Il-2) and tumor necrosis factor-α (TNF-α) levels in elderly with and without COPD presenting with or without depressive symptoms. Forty COPD patients and 53 elderly individuals with no COPD took part in the study. Depressive symptoms (Geriatric Depression Scale=GDS-15), IL-2 and TNF-α, serum cortisol, number of comorbidities, smoking habits and body composition were evaluated. The prevalence of depressive symptoms was higher in COPD group. The number of comorbidities was higher in patients with depressive symptoms. No differences were found between IL-2, TNF-α and cortisol levels, years of smoking and smoked pack-years in the groups. The COPD group obtained lower body mass index (BMI) and fat content and higher fat free mass index as well as greater nutritional depletion., Conclusions: Depressive symptoms as well as fat and lean body composition, due to preserved BMI in those with nutritional depletion, must be investigated., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Were evaluated individuals divided into two groups: we studied chronic heart failure (CHF) (19 patients with CHF plus cardiomegaly) and control (12 healthy volunteers) during performance of inspiratory loaded breathing (ILB). We evaluated: spirometry, functional capacity through the six-minute walk test (6MWT), and distribution of thoracoabdominal volumes via optoelectronic plethysmography (OEP), namely volume variations of pulmonary rib cage (Vrc,p), abdominal rib cage (Vrc,a), and abdomen (Vab). In each compartment, the percentage contributions of right and left sides were also calculated. During ILB, patients with heart failure were characterized by a significant reduction of the Vrc,a volume variations compared to the control group. Correlations were found between left %Vrc,a on the left side measured during ILB and left ventricular ejection fraction (r=0.468; p=0.049), and dyspnea after the 6MWT (r=-0.878; p<0.01).Then, patients with CHF and cardiomegaly are characterized by a reduced mobility in left part of the lower part of the rib cage, that contributes leading to increased perception of dyspnea during submaximal exercise., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Background and Purpose: Breath stacking (BS) is used as an alternative method for lung expansion therapy and the assessment of inspiratory capacity in uncooperative patients. The aims of the present study were to identify the reproducibility of the BS technique in healthy volunteers and to compare BS with conventional spirometry with regard to inspiratory capacity., Methods: A cross-sectional study was carried out. Eighty-five healthy volunteers (21.78 ± 2.79 years; 41 men, 44 women) underwent spirometry and BS. Lung function, anthropometric and cardiopulmonary parameters were evaluated prior to the intervention. BS was performed with a unidirectional inspiratory valve by two different examiners. The order of each examiner was randomized. Spirometric tests were performed three times, and the BS manoeuvre was evaluated three times by each examiner. Respiratory rate, heart rate and peripheral arterial oxygen saturation were determined before, during and following the manoeuvre., Results: There were no statistically significant differences in the intra-examiner and inter-examiner analyses for the volume mobilized during BS, respiratory rate, duration of BS manoeuvre or perceived effort index (p > 0.05). The intra-class correlation coefficient was greater than 0.7 for all variables analysed. Maximal volumes achieved using the BS technique were significantly higher than those achieved with conventional spirometry (p < 0.0001)., Conclusion: Data from both the intra-examiner and inter-examiner analyses suggest that the BS technique is reproducible. This technique mobilizes greater lung volumes than conventional spirometry., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: During the second stage of labor, the progression of the fetal expulsion depends on many factors related to maternal and fetal parameters, including the voluntary abdominal pushing., Objectives: This study aimed to correlate the maternal and fetal parameters that may influence the voluntary maternal pushes during the second stage of labor by using surface electromyography., Methods: The electromyographic activity of the rectus abdominis and external oblique muscles were measured during the second stage of labor in 24 Brazilian pregnant women. The diastasis of the rectus abdominis, the body mass index and the uterine fundal height were analyzed as maternal parameters and the fetal weight, cephalic circumference, APGAR scores and arterial pH and CO2 were analyzed as fetal parameters. The oxytocin usage and the expulsive phase duration were considered., Results: A negative correlation between the rectus abdominis diastasis and the rectus abdomini muscle electromyographic parameters was found (r=-0.407 p=0.04). No statistically significant correlations were found among the rectus abdominis and external oblique muscles electromyography and the other maternal or fetal parameters, as well as among expulsive phase duration and the oxytocin usage., Conclusions: This study suggests that the rectus abdominis diastasis may be an influential parameter in generating voluntary pushes during the second stage of labor, however it cannot be considered the only necessary parameter for a successful labor.

Background: Heliox and forward-leaning posture (torso inclined forward at 50-60° with the elbows resting on the thighs) are adjuncts in the administration of nebulized bronchodilator to patients with acute asthma., Methods: We randomized 59 patients who presented to the emergency department in severe asthma crisis, into 4 treatment groups: nebulized bronchodilator + oxygen; nebulized bronchodilator + oxygen + forward-leaning posture; nebulized bronchodilator + heliox; and nebulized bronchodilator + heliox + forward-leaning posture. Before and after the bronchodilator treatments the subjects were seated with torso erect, breathing room air. Each subject received 2 doses, 20 min apart, of nebulized fenoterol (2.5 mg) plus ipratropium bromide (0.25 mg) in 3 mL of 0.9% saline, delivered with a semi-closed valved aerosol reservoir. The nebulizer was run with oxygen or 80:20 heliox. The post-treatment pulmonary function tests were performed 15 min after the second nebulization. The group's mean age was 35.1 ± 13.6 y, and there were 20 men and 39 women., Results: The oxygen + forward-leaning-posture group had a greater FEV(1) improvement than the oxygen group (59% vs 38%, P = .02). The heliox + forward-leaning-posture group had a greater FEV(1) improvement than the oxygen group (103% vs 38%, P = .001) and the heliox group (103% vs 42%, P = .03). The heliox group had greater reduction in respiratory rate than the oxygen group (P = .03). The heliox + forward-leaning-posture group had significantly greater peak expiratory flow improvement than any of the other groups., Conclusions: Heliox plus forward-leaning posture during bronchodilator nebulization improves bronchodilator efficacy in patients with severe acute asthma. (ClinicalTrials.gov registration NCT00922350).

Objectives: This cross-sectional study was designed to examine the effects of the Valsalva Maneuver (VM) and its duration on the acid- base equilibrium of the neonate and its maternal repercussions during the expulsive stage of labor, after standard breathing and pushing instructions were given., Methods: A convenience sample of women with low risk pregnancy (n=33; mean age 22.5±3.7 y and gestational age 38.1±1.12 wks) and their newborns were studied during the expulsive stage of vaginal labor. Coaching consisted of standard recommendations for breathing including prolonged VMs coordinated with pushing. Maternal outcomes included the need for uterus fundal pressure maneuver and episiotomy, perineal trauma and posture. Neonatal outcomes included blood gases sampled from the umbilical cord, and Apgar scores. Data were analyzed with the Fisher's exact test, chi-square test, and Pearson correlation coefficient., Results: None of the maternal outcomes were associated with VM duration. With respect to neonatal outcomes, increased VM duration was associated with reduced venous umbilical pH (r=-0.40; p=0.020), venous base excess (r=-0.42; p=0.014) and with arterial base excess (r=-0.36; p=0.043). Expulsive stage time was negatively associated with umbilical venous and arterial pH., Conclusions: VM duration during fetal expulsion in labor negatively affects fetal acid-base equilibrium and potentially the wellbeing of the neonate. Our results support the need to consider respiratory strategies during labor, to minimize potential risk to the mother and neonate.

Background: Muscle respiratory strength studies during pregnancy are very scarce. The aim of this paper is to describe maximum inspiratory (PImax) and expiratory (PEmax) mean pressure values in women during their first pregnancy and to determine the relationship between the anthropometric, morphologic and physiologic variables of these pressures., Methods: One hundred and twenty women (120) primigravidas were studied from the 5th to 40th gestational week, ages ranging from 20 to 29 years old, euthrophic and with low risk pregnancies., Results: PImax and PEmax mean values were 88.5 ± 16.52 cmH(2)O and 99.76 ± 18.19 cmH(2)O respectively. There was no association between gestational age and PImax (r = -0.06; p = 0.49) or PEmax (r = -0.11; p = 0.22). There was also no difference between PImax and PEmax during pregnancy trimesters and no correlation between pregnancy age and the pressures in each trimester. Height was the only anthropometric variable indicating a significant PImax (r = 0.20; p = 0.02) association. Fundal uterus height and inter-recti abdominis distance were not associated to respiratory pressure values. PEmax is not associated with the group of predictor variables (p = 0.127) and PImax demonstrated an independent association with height and dyspnea during physical exertion reflected by the following equation: PImax = 0.6 + 57.9 height - 1.68 dyspnea under effort. The present study suggests that inspiratory and expiratory maximum pressure values are not altered during different stages of pregnancy, however longitudinal studies are needed to assess changes over time., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Jet nebulization (JN) and non-invasive mechanical ventilation (NIMV) through bi-level pressure is commonly used in emergency and intensive care of patients experiencing an acute exacerbation of asthma. However, a scientific basis for effect of JN coupled with NIMV is unclear. Objective. To evaluate the effect of jet nebulization administered during spontaneous breathing with that of nebulization with NIV at two levels of inspiratory and expiratory pressures resistance in patients experiencing an acute asthmatic episode. Methods. A prospective, randomized controlled study of 36 patients with severe asthma (forced expiratory volume in 1 second [FEV(1)] less than 60% of predicted) selected with a sample of patients who presented to the emergency department. Subjects were randomized into three groups: control group (nebulization with the use of an unpressured mask), experimental group 1 (nebulization and non-invasive positive pressure with inspiratory positive airway pressure [IPAP] = 15 cm H(2)O, and expiratory positive airway pressure [EPAP] = 5 cm H(2)O), and experimental group 2 (nebulization and non-invasive positive pressure with IPAP = 15 cm H(2)O and EPAP = 10 cm H(2)O). Bronchodilators were administered with JN for all groups. Dependent measures were recorded before and after 30 minutes of each intervention and included respiratory rate (RR), heart rate (HR), oxygen saturation (SpO(2)), peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), and forced expiratory flow between 25 and 75% (FEF(25-75)). Results. The group E2 showed an increase of the peak expiratory flow (PEF), forced vital capacity (FVC), FEV(1) (p < 0.03) and F(25-75%) (p < 0.000) when compared before and 30 minutes after JN+NIMV. In group E1 the PFE (p < 0.000) reached a significant increase after JN+ NIMV. RR decreased before and after treatment in group E1 only (p = 0.04). Conclusion. Nebulization coupled with NIV in patients with acute asthma has the potential to reduce bronchial obstruction and symptoms secondary to augmented PEF compared with nebulization during spontaneous breathing. In reversing bronchial obstruction, this combination appears to be more efficacious when a low pressure delta is used in combination with a high positive pressure at the end of expiration.

This study had as objective to correlate the resistance of the carotid artery and the functional autonomy of old women. The resistance of the carotid artery was evaluated through the method called Doppler and the functional autonomy through tests related to daily activities (Protocol GDLAM). In the description of the data it was used measures of localization and dispersion. The internal right carotid resistance got mean and pattern deviation respectively (0.71 +/- 0.07) and functional autonomy mean and pattern deviation respectively (30.40 +/- 6.31). The coefficient of the correlation of Spearman showed a strong association between the variation of the study (r = 0.998; p = 0.000). The results suggest that the bigger the table of contents of the resistance of the carotid artery is the bigger will be the difficulty of execution of the daily life tasks.

Unlabelled: Inspiratory muscles training in COPD is controversial not only in relation to the load level required to produce muscular conditioning effects but also in relation to the group of patients benefiting from the training. Consequently, inspiratory muscular response assessment during Threshold therapy may help optimizing training strategy. The objective of this study was to evaluate the participation of the diaphragm and the sternocleidomastoid (SMM) muscle to overcome with a 30% Threshold load using surface electromyography (sEMG) and to analyze the correlation between SMM activation, maximum strength level of inspiratory muscles (MIP) and obstruction degree in COPD patients (FEV1). We studied seven healthy elderly subjects, mean age of 68+/-4 years and seven COPD patients, FEV1 45+/-17% of the predicted value, with mean age 66+/-8 years. sEMG analysis of SMM muscles and diaphragm were obtained through RMS (root-mean-square) during three stages: pre-loading, loading and post-loading., Results: In the COPD group, the RMS of the SMM increased 28% during load (p<0.05) while the RMS of the diaphragm remained constant. In the elderly there was a trend of a 11% increase in diaphragm activity and of 7% in SMM activity but, without reaching significance levels. SMM activity demonstrated good correlation with the obstruction level (r=-0.537)., Conclusion: To overcome the load required by Threshold therapy, COPD patients demonstrated an increase of accessory muscles activity, represented by SMM. For the same relative load this increase seems to be proportional to the degree of pulmonary obstruction.

Background and Purpose: Patients with chronic obstructive pulmonary disease (COPD) present pulmonary hyperinflation as the main cause of mechanical disadvantages in respiratory muscles. Measurement of the force generated by those muscles is converted into pressure changes. The aim of the present study was to evaluate the maximal inspiratory pressure (MIP) from the residual volume (RV) and from the functional residual capacity (FRC), in patients with COPD, and to determine which pulmonary volume should be used in physiotherapy so as to obtain higher MIP results., Method: An investigation of 18 male patients with stable COPD. Patients were examined using a manual vacuometer to measure the MIP of 20 daily manoeuvres. Ten measurements were taken from the RV and 10 from the FRC, taken alternately with an interval of 1 minute between each measurement, for five consecutive days., Results: Increases in MIP were obtained from the RV measurements (mean +/- SE) from 59.7 (+/- 5.2) to 66.6 (+/- 5.3) cm H2O (F(4,64) = 3.34; p < 0.015) and from the FRC measurements, from 55.4 (+/- 4.9) to 64.4 (+/- 4,8) cm H2O (F(4,64) = 6.72; p < 0.001). Post hoc analysis showed an increase, over consecutive days, in both RV and FRC. For FRC, an increase was revealed on the second and third days, a fall was found on the fourth day and a new increase was found on the last day. MIP reached different levels, between RV and FRC, on the first (t = 2.888; p = 0.010) and fourth (t = 2.165; p = 0.045) days., Conclusion: In the present study, MIP reached higher levels at FRC during the five days of evaluation, and a learning effect occurred in the patients. Motor units from the respiratory muscles may have been recruited in order to perform the manoeuvres during the days of evaluation. The study suggests that there is good evidence for the use of the FRC as a parameter to find the major MIP value.

In areas with low house dust mite (HDM) allergen exposure, both mite sensitization and asthma prevalence are low. In most other areas, HDM allergen exposure is higher than the threshold for sensitization. In this setting, is HDM allergen exposure a factor which is causally related to the development of asthma in HDM-sensitive individuals? To answer this question, the cumulative prevalence of asthma was evaluated in a group of 157 schoolchildren, aged 10 and 11 yrs, who were allergic to HDM allergen, and compared it with HDM allergen exposure and atopic status, using univariate and multivariate analysis. HDM allergen levels were measured in mattress dust using an enzyme-linked immunosorbent assay (ELISA) method. Of mattress dust samples, 94% had an HDM allergen level >2 microg x g dust(-1). Atopy was evaluated by means of skin prick tests using five common allergens. Among the predictive variables studied by means of univariate analysis, only the number of positive skin tests and male sex correlated with asthma prevalence, but not HDM allergen exposure. Logistic regression analysis also demonstrated that the number of positive skin tests correlated with asthma prevalence (odds ratio (OR)=1.38, p=0.05), whereas the OR for HDM allergen exposure was 1.0. This survey suggests that, in a geographical area with high HDM allergen exposure, asthma prevalence is not linked with HDM allergen levels.

Background: Previous experiments have shown that in vivo Fel d 1 production is under hormonal control. It strongly decreased 1 month after castration of male cats and increased after testosterone injection., Objective: These results led us to put forward the hypothesis that Fel d 1 production could be more important in male that in female cats. Five adult male and five adult female cats were studied., Methods: On day 0 three separate sites of each cat's trunk were shaved, and a 5.72 cm2 area in each site was washed twice (D0a and D0b) with 5 ml of distilled water. Then a collar was attached to the neck to prevent contamination from saliva. Twenty-four hours later on day 1, all areas were washed again once (D1a). Skin washes and fur extracts from the shaved areas were evaluated for Fel d 1 content. The same procedures (apart from collection of fur) were repeated 5 months later., Results: The Fel d 1 level was higher in the first skin wash of male cats compared with that of female cats on each separate site of the trunk in both experiments, initially and 5 months later. Results were significant in the first experiment (median Fel d 1 per milliliter: 69.4 and 28.9 mU, respectively, for the combined three sites; p < 0.05). Fel d 1 production over a 24-hour period was higher in male cats, but the difference did not reach statistical significance. Furthermore, correlation between Fel d 1 levels in washes D0a and in fur was highly significant (p < 0.01)., Conclusion: These results confirm that Fel d 1 originates from skin. Furthermore, they suggest that Fel d 1 production is higher in male than in female cats.

Background: Major cat allergen Fel d I is produced consistently by skin and by sebaceous glands before being spread on the fur., Objective: Since cats have tubular anal glands secreting sebum, proteins and lipids, we looked at the possible presence of Fel d I in these secretions and compared the levels found to those already reported in other cat tissues or secretions., Methods: Thirty-seven cats were studied. Fel d I dosage in the anal sacs' secretions was performed using an enzyme linked immunosorbent assay (ELISA) method and total protein evaluation by the Bradford's method., Results: The geometric mean Fel d I concentration was 41 U/g secretion which represents 3.4% of the total protein levels. This amount is the highest ever reported in cat tissues or secretions., Conclusion: The close association of Fel d I protein with skin sebaceous glands and anal sacs both with holocrine function and lipids' secretions in one hand, and the homology of chain I of Fel d I with some steroid-binding proteins in other hand, suggest a possible physiological role for Fel d I in the regulation of lipids on skin and cat fur.

Background: Because allergic sensitization seems to occur especially during infancy, we decided to evaluate such an exposure in day nurseries., Methods: Thirty day nurseries in Marseilles, which were selected at random, were visited during 2 weeks in April 1993. Routine cleaning includes daily cleaning of smooth floors, weekly laundering of sheets, and monthly cleaning of soft toys. Mattresses are encased in synthetic covers. Dust samples were collected from four settings: infants' mattresses and pillows, smooth floors, and soft toys. Levels of mite, cockroach, cat, and dog allergens were analyzed with a monoclonal antibody-based ELISA., Results: Mite allergen levels were lower than the proposed threshold level for sensitization (2 micrograms/gm of dust) on 94% of mattresses and soft toys and on 100% of floors and pillows. Cat allergen levels in mattresses ranged from less than 0.1 to 4.5 micrograms/gm dust. On floors, cat allergen levels ranged from less than 0.1 to 2.4 micrograms/gm dust. Only 10% of pillows and soft toys had levels greater than 2 micrograms/gm of dust. Fel d I levels were significantly higher (p < 0.03) in mattresses from nurseries with curtains and were correlated with the percentage of children with a cat at home. In almost all day nurseries, cockroach allergen (Bla g I and Bla g II) levels were very low. Only three samples from mattresses had dog allergen levels greater than 2 micrograms of Can f I allergen per gram of dust. On floors the level was always lower than 2 micrograms/gm., Conclusions: These data clearly show that indoor allergen levels are much lower in day nurseries than in most houses. Most samples contain allergen levels below threshold levels for sensitization. Thus children of atopic parents are less likely to become sensitized to indoor allergens in day nurseries than in their own homes. In addition, this study emphasizes the efficacy of avoidance measures such as use of synthetic protective mattress covers, frequent washing of sheets and soft toys, and avoidance of carpets and curtains.

Background: Striking differences in mite counts and mite-allergen levels have been documented between dwellings located at sea level and high altitude. Apart from relative humidity (RH), several other factors, ie, temperature, UV exposure, and altitude per se could account for this difference., Objective: To evaluate whether RH by itself could influence mite infestation by comparing mite-allergens levels in two towns differing only with respect to RH., Methods: We compared group I allergen content in two Moroccan towns: Casablanca, located on the seashore and Marrakech located at 1404 feet. Mean (+/- SD) RH in years 1990 and 1991 was 81.2 +/- 2.9% in Casablanca and 56.0 +/- 7.6% in Marrakech. Mean annual temperatures were 17.7 +/- 4.0 degrees C and 20.2 +/- 6.4 degrees C in Casablanca and Marrakech, respectively. In each town, 20 asymptomatic subjects agreed to participate in the study. Their mattresses were vacuum-cleaned for a standardized duration (2 min/m2). Mite allergen-content was evaluated using monoclonal antibodies and ELISA and results expressed as micrograms of group I (Der pI+Der f I) allergens per gram of dust (micrograms/g dust)., Results: Mean (+/- SD) group I allergen level was 8.3 +/- 8.8 micrograms/g in Casablanca and 0.6 +/- 0.6 micrograms/g dust in Marrakech, a difference that is highly significant (P = .001). In both areas, mean Der f I allergen level was low (0.7 +/- 0.5 and < 0.1 micrograms/g dust, in Casablanca and Marrakech, respectively)., Conclusion: This study shows that house dust mite allergen content in households depends on RH rather than on temperature.