Inspiratory muscle resistive training in respiratory failure

In this study, 4 patients who had failed weaning attempts using traditional methods underwent inspiratory muscle resistive training (IRT). Three patients showed improvements in inspiratory muscle strength (mean peak negative inspiratory pressure improved from 38 to 54 cm H2O) and in respiratory muscle endurance (mean PCO2 at the end of the same or a longer period of spontaneous breathing improved from 70 to 52 mmHg). These 3 patients were successfully weaned from mechanical ventilation after 10 to 24 days of IRT. A fourth patient showed no improvement and could not be weaned. This pilot study demonstrated that IRT can be useful in preparing patients with chronic respiratory failure for weaning from mechanical ventilation.     

Psychological approach to chronic respiratory failure]

Patients with chronic respiratory diseases, particularly chronic respiratory failure, are seriously handicapped mentally and physically as compared with those with diseases of other medical fields. This is because their disorders relate to breathing, which is the basic physical function directly associated with sustaining life. The authors have attempted a psychosomatic approach for patients with chronic respiratory disorders. Clinical science in this field of medicine in Japan is far behind that of other advanced nations. In the Comprehensive Emphysema Inventory, it was clearly reported that in many cases, psychological stress is involved in the onset of dyspnea. In SRQ-D or MAS, moreover, decreased motivation for treatment, anxiety regarding prognosis, and conflict were notable in psychosomatic tests. Patients on home oxygen therapy (HOT) appear to have problems in family relations and in the daily-living environment, even though HOT provides both mental and physical benefits. It was also noted that holistic or comprehensive care designed for improvement of not only physical condition, but also psychosocial aspects and quality of life, is essential to achieve good results in the respiratory rehabilitation of patients affected by chronic respiratory failure.     

Respiratory muscle dysfunction and training in chronic heart failure

A characteristic feature of chronic heart failure (CHF) is reduced exercise tolerance. Several factors contributing to this have been identified, including alterations in central haemodynamics, skeletal muscle oxygen utilisation and respiratory muscle dysfunction. This review focuses on abnormalities identified in respiratory muscle structure and function in CHF and recent evidence for the benefit of selective inspiratory muscle training in CHF. Included in this review are findings from original investigations, with a specific focus on recent published data.     

噻托溴胺联合呼吸操训练治疗稳定期慢性阻塞性肺病患者的临床研究

目的探讨噻托溴胺联合呼吸操训练对慢性阻塞性肺疾病(chronic obstructive pulmonary disease,慢阻肺)稳定期患者的肺通气功能、生活质量以及运动耐力的影响。方法选择2014年10月至12月稳定期慢阻肺患者共73例,随机分为常规药物治疗组(A组,n=37)和呼吸操训练组(B组,n=36)。对A组患者常规吸入噻托溴胺,有氧疗指征者给予长期家庭氧疗。B组患者除应用噻托溴胺和(或)氧疗外,指导呼吸操训练,方法包括腹式呼吸、缩唇呼气及全身性呼吸体操。记录每例患者入组时及12周后的FEV1占预计值的百分比(FEV1%Pred)、圣乔治呼吸疾病问卷(SGRQ)评分及6 min步行距离(6MWD)。结果入组时两组患者的性别、平均年龄、肺功能分级、FEV1%Pred、SGRQ评分及6MWD均无显著差异(P0.05)。干预12周后两组患者FEV1%Pred、SGRQ评分及6MWD均较治疗前有显著变化。其中B组患者的SGRQ评分显著低于A组,B组患者的6MWD显著长于A组(P0.05)。结论在常规吸入长效抗胆碱能药物治疗外,配合呼吸操训练可更好的改善稳定期慢阻肺患者的生活质量及运动耐力。     

Home respiratory muscle training in patients with chronic obstructive pulmonary disease

OBJECTIVE AND BACKGROUND: The benefits of inspiratory muscle strength training in decreasing symptoms, disability or handicap of patients affected by COPD are not well established. The objective of this study was to assess the efficacy of the constant use of a new flow-volumetric inspiratory exerciser, named Respivol, in improving respiratory functional parameters in COPD patients. METHODS: Twenty consecutive ambulatory patients affected by COPD were enrolled. Each patient was assessed, before and after 3 and 6 months inspiratory exercise with Respivol, for the following clinical parameters: maximal inspiratory pressure, maximal expiratory pressure, dyspnoea grade, quality of life by a self-administered St George questionnaire and a 6-min walking test. After a brief progressive ambulatory training programme, inspiratory exercise with Respivol was performed at home for 6 months. All patients used Respivol together with medical treatment. RESULTS: Maximal inspiratory pressure and maximal expiratory pressure values were significantly increased after 3 and 6 months of exercise. Dyspnoea grade was significantly reduced and the 6-min walking test showed an increase in effort tolerance, after 6 months of home training. Quality of life assessment showed an improvement, associated with a decrease of respiratory disease symptoms. CONCLUSIONS: Inspiratory muscle strength training with Respivol seems to be efficient in reducing symptoms and improving quality of life in adults with COPD.     

影响慢性肝衰竭患者生存时间的独立危险因素及其预测模型

目的 探讨影响慢性肝衰竭患者生存时间的独立危险因素,并建立预测模型公式.方法 采用回顾性病例分析方法,选择天津市第三中心医院2002年5月-2007年5月行人工肝治疗的慢性肝功能衰竭、病历资料完整的患者362例,收集其临床资料,并使用SPSS13.0进行统计学分析,其中定量资料使用t检验和秩和检验,定性资料使用卡方检验,并进一步使用Cox回归分析筛选出对生存时间有影响的独立危险因素.根据Cox回归模型筛选出的独立危险因素建立适合我国慢性肝衰竭的预测模型公式.结果 经Cox回归筛选影响生存时间的独立危险因素中有统计学差异的有:Child-Pugh评分、血钠值、是否有胆酶分离、是否有腹水、年龄、酪氨酸、精氨酸.本研究建立的Cox模型(包括Child-Pugh评分、血钠值、是否有胆酶分离、是否有腹水、精氨酸、酪氨酸、年龄)公式为:Cox公式评分=0.31×年龄-6.62×合并腹水分数(是为1分,否为2分)+10.16×胆酶分离分数(是为2分,否为1分)+4.65×Child-Pugh分值0.39×血钠值+0.05×酪氨酸值+0.04×精氨酸值.该公式的AUC值为0.782,最佳临界值为27.69.结论 Child-Pugh评分、血钠值、是否有胆酶分离、是否有腹水、年龄、酪氨酸、精氨酸是影响生存时间的独立危险因素.本研究建立的Cox模型公式对慢性肝衰竭患者的生存时间有较好的预测性.     

老年慢性呼吸衰竭的氧疗与呼吸锻炼

对老年慢性呼吸衰竭的氧疗和呼吸锻炼就四方面的问题阐述如下。1　呼吸衰竭的概念　　呼吸衰竭 (简称呼衰 )可分两个类型 :Ⅰ型是休息状态下呼吸空气时 ,患者存在低氧血症 (ＰａＯ2 <8ｋＰａ)和正常或低ＰａＣＯ2 (<6ｋＰａ) ,此可称为弥散功能障碍型呼衰 ;Ⅱ型呼衰为低ＰａＯ2 和高ＰａＣＯ2 (>6 6 7ｋＰａ) ,也可称之为通气功能障碍型呼衰 ;Ⅰ型到后期多转变为Ⅱ型。至于急性呼衰和慢性呼衰的区别在于前者是指由于某种原因在短期内引起的呼吸功能失代偿 ,例如脑炎、脑外伤、电击、溺水、药物中毒、吸入毒性气体等 ,最典型的代表就是成人…     

The effect of physical training on skeletal muscle in patients with chronic heart failure

BACKGROUND: The improvement of exercise capacity in patients with chronic heart failure (CHF) by physical training has been connected with reversal of the abnormalities in muscle fiber distribution and with the reduced activity of the enzymes of oxidative metabolism in skeletal muscle. However, the change in fiber type distribution induced by training is controversial and in previous studies the activities of the rate-limiting enzymes of the metabolic pathways have not been measured. AIMS: To examine the effect of dynamic training on percentage distribution of muscle fibers, on activities of the rate-limiting enzymes of the metabolic pathways and on electrophysiology in skeletal muscle. METHODS: A total of 27 patients with stable CHF (NYHA class II-III) were randomized to a training (N=12) or a control (N=15) group. The training group exercised on a bicycle ergometer for 30 min three times a week for 3 months using a load corresponding to 50-60% of their peak oxygen consumption. This was followed by a 3-month training period at home according to personal instructions. The control group did not change its physical activities. We studied muscle histology and measured the activities of the rate-limiting enzymes of anaerobic glycolysis (phosphofructokinase, PFK), glycogenolysis (phosphorylase), citric acid cycle (alpha-ketoglurate dehydrogenase, KGDH) and fatty acid oxidation (carnitinepalmitoyl transferase I and II, CPT I and II) from biopsies of the vastus lateralis muscle at baseline and after 3 and 6 months. Muscle strength and strength endurance with surface EMG and macro EMG of the right knee extensors were also determined. RESULTS: Exercise capacity, particularly submaximal, improved in the training group. The activity of PFK rose significantly but that of the other enzymes did not when compared with the change in the controls. Training had no effect on the percentage distribution of slow-twitch and fast-twitch muscle fibers or on capillary density around these fibers in skeletal muscle. Maximum voluntary force, strength endurance and the function of motor units remained unaffected. CONCLUSIONS: Dynamic training results in improved exercise endurance in CHF. In skeletal muscle, the capacity of anaerobic glycolysis is increased but that of the citric acid cycle and fatty acid oxidation is not. Furthermore, the improvement in exercise endurance seems to be independent of changes in the percentage distribution of muscle fibers, capillarity or electrophysiological factors.     

Markedly improved skeletal muscle function with local muscle training in patients with chronic heart failure

Background: Reduced heart pump function and skeletal muscle abnormalities are considered important determinants for the low physical exercise capacity in chronic heart failure. Because of reduced ventricular function, traditional physical rehabilitation may cause underperfusion and low local work intensity, thereby producing suboptimal conditions for skeletal muscle training. Hypothesis: The study was undertaken to determine the effects of local exercise training, designed as one- or two-legged knee extensor training, on exercise capacity in patients with moderate chronic heart failure. Because such exercise models use only about one quarter to half the muscle mass used in cycle ergometer training, the influence of a restricted circulatory capacity should therefore be limited. Further, we aimed to determine whether or not chronic heart failure skeletal musculature abnormalities are counteracted with such training. Methods: Fourteen patients with chronic heart failure [age 58 ± 3 years, ejection fraction (EF) 28 ±4%] were randomized to two different training protocols three times a week for 8 weeks and compared with a nontraining control group (n = 7, age 62 ± 3, EF 27 ± 3%). Group 2L (n = 7) underwent simultaneous two-legged knee extensor training (about 4 kg working muscle) for 15 min at 65–75% of VO₂ max of the two-legged kick. Group 1L (n = 7) trained each leg at a time for 15 min of continuous one-legged dynamic knee extensor work with the same training load per muscle mass, that is, at 35% of VO₂ max of the two-legged kick (about 2 kg working muscle). Peak VO₂ of two-legged knee extensor exercise (1/min), two-legged endurance (W), and strength (Nm) were determined before and after the training period. The activity of citrate syn-thase (CS) was estimated in tissue samples from the quadriceps femoris muscle. Results: Peak VO₂ did not change with training. Two-legged knee extensor endurance exercise capacity increased by an average of 40–50% (p<0.01) in all training patients in both the 2L and 1L groups, while no change was observed in the control group. Depressed skeletal muscle CS activity increased by 25–35% in both training groups (p<0.01). Strength increased by 16% in the 2L group after training (p<0.05), while no change was seen in the 1L and control groups. Conclusions: Skeletal muscle changes in stable moderate chronic heart failure are not entirely irreversible. A major factor contributing to these changes and to exercise limitation is deconditioning. Local muscle training is efficient and can at least partially improve skeletal muscle function in these patients. Different degrees of local activation, that is, one- or two-legged knee extensor exercise, do not seem to differ in terms of their effect on exercise capacity. Depressed skeletal muscle oxidative capacity adapts to such physical training with increased activity to an extent not different from that for healthy volunteers.     

A comparative study of cefepime for chronic respiratory tract infections]

The clinical efficacy, safety and usefulness of Cefepime (CFPM), a new cephem antibiotics, in chronic respiratory infections were evaluated in a comparative study against Ceftazidime (CAZ). Each drug was administered by intravenous drip infusion at a dose of 1.0 g (nominal potency), twice daily for 14 days, and the following results were obtained: 1. A total of 170 cases were enrolled in this study. Efficacy rates ("good" or better responses) as evaluated by the subcommittee were 86.2% (56/65) in the CFPM group and 84.5% (60/71) in the CAZ group, with no significant difference between the two groups. 2. Efficacy rates ("good" or better responses) as evaluated by attending physicians were 83.3% (55/66) in the CFPM group and 84.5% (60/71) in the CAZ group with no significant difference between the two groups. 3. Bacteriologically, eradication rates were 83.3% (40/48) in the CFPM group and 88.2% (45/51) in the CAZ group, with no significant difference between the two groups. 4. Side effects occurred in none of the patients in the CAZ group and in 4 of the 66 patients in the CFPM group. There was a significant difference between the two groups (Fisher's test p = 0.0489). The incidence of abnormal laboratory findings were 17.6% (12/68) in the CFPM group and 21.1% (16/76) in the CAZ group. There was no significant difference between the two groups. 5. The utility rates evaluated by the subcommittee were 81.8% (54/66) in the CFPM group and 84.5% (60/71) in the CAZ group with no significant difference between the two groups. Only in the incidence of side effects, there was a significant difference between the two groups (Fisher's test p = 0.0489), but there was no significant difference in other items of efficacy, safety and usefulness between the two groups. These results indicate that CFPM is useful for the treatment of chronic respiratory tract infections.     

Exercise training increases respiratory muscle strength and exercise capacity in patients with chronic obstructive pulmonary disease and respiratory muscle weakness

BackgroundHow respiratory muscle strength influences the effectiveness of pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD) is unclear.ObjectiveTo investigate the benefits of PR in subjects with COPD according to respiratory muscle strength.MethodsNinety-seven subjects with COPD were evaluated using maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), pulmonary function tests, the cardiopulmonary exercise test (CPET), and the St. George's Respiratory Questionnaire (SGRQ). Subjects were divided into four groups: 1 (normal MIP and MEP); 2 (low MIP); 3 (low MEP); and 4 (low MIP and MEP). Subjects underwent PR for 3 months; MIP, MEP, SGRQ, and CPET were evaluated post-PR.ResultsSubjects with both poor MIP and MEP had the highest dyspnea score, lowest exercise capacity, and poorest health-related quality of life (HRQoL). PR improved exercise capacity and HRQoL in all groups, with more improvement in MIP, MEP, tidal volume (on exercise), and dyspnea (at rest) in subjects with both low MIP and MEP.ConclusionsPatients with respiratory muscle weakness had worse dyspnea, lower exercise capacity, and poorer HRQoL at baseline. Exercise training improved respiratory muscle strength with concurrent improvement of exercise capacity, HRQoL, and dyspnea score. Subjects with both poor baseline MIP and MEP showed greater benefits of PR.     

Effectiveness of noninvasive positive-pressure ventilation for patients with chronic stable hypercapnic respiratory failure]

The effectiveness of noninvasive positive pressure ventilation (NPPV) was evaluated in 20 patients with chronic stable hypercapnic respiratory failure. Patients were assigned to receive domiciliary long-term oxygen therapy (LTOT group, n = 11) or LTOT plus NPPV (NPPV group, n = 9). The primary endpoints were the health-related quality of life (HRQL), as assessed by the Medical Outcome Study Short Form 36 (SF 36) questionnaire, and the activities and instrumental activities of daily living (ADL and IADL), as assessed by the Groningen Activity Restriction Scale (GARS). Secondary endpoints were mortality, the number of acute exacerbation episodes that required endotracheal intubation, and the length of hospital stay. Significant improvement was observed in the SF 36 physical functioning subscale (30.6 +/- 19.9 to 41.1 +/- 21.6, p = 0.02) and GARS score (36.1 +/- 9.0 to 32.3 +/- 8.5, p = 0.02) of the NPPV group. One patient in the NPPV group and 7 patients in the LTOT group underwent endotracheal intubation (relative risk = 0.18, p = 0.03). Differences in length of hospital stay (8.2 +/- 4.1 days vs. 31.6 +/- 35.8 days, p = 0.07) and mortality rate (1/9 vs. 3/11, p = 0.59) for the NPPV and LTOT groups were not statistically significant. We conclude that the utilization of NPPV for patients with chronic respiratory failure is effective in preventing the deterioration of underlying disease and in improving the quality of life.     

Continuous oximetry monitoring in patients undergoing home oxygen therapy for chronic respiratory failure]

We investigated the clinical usefulness of continuous nocturnal oxygen saturation monitoring in patients undergoing home oxygen therapy (HOT). The subjects were 11 patients with chronic respiratory disease in the process of healing from acute exacerbation. None were mechanically ventilated. Each subject underwent full overnight oximetry. One patient was excluded from further investigation because of periodic desaturation suggestive of sleep apnea. The remaining 10 subjects included 5 patients with sequelae of pulmonary tuberculosis, 2 with diffuse panbronchiolitis, 1 with chronic pulmonary emphysema, 1 with chronic bronchitis, and 1 with kyphoscoliosis. All underwent full overnight and 30 min daytime oximetry monitoring for 23.7 +/- 7.4 (mean +/- SD) consecutive days. Daytime oximetry was performed when subjects were awake and resting in supine position. Mean nocturnal oxygen saturation (NmSpO2) and mean daytime oxygen saturation (DmSpO2) were calculated from data obtained from 0:00 through 5:00 hrs and from data obtained during a stable 10 min daytime period, respectively. The difference between NmSpO2 and DmSpO2 (delta SpO2), the percentage of total sleep time with SpO2 < or = 90% (DST 90) and nocturnal lowest oxygen saturation (NLSpO2) were calculated once daily for each subject. There were significant (p < 0.05) correlations between NmSpO2 and NLSpO2, between NmSpO2 and DST 90, and between NLSpO2 and DST 90 in all subjects. However, significant (p < 0.05) correlations between NmSpO2 and DmSpO2 were observed in only 6. During acute exacerbation, NmSpO2 was lower than DmSpO2, and delta SpO2 increased. Conversely, with the amelioration of acute symptoms, delta SpO2 decreased and NmSpO2 was higher than DmSpO2. There was a significant (p < 0.05) reverse correlation between NmSpO2 and delta SpO2 in 9 subjects. We concluded that monitoring nocturnal oxygen saturation is clinically useful to assessments of oxygenation status in patients undergoing HOT, and that it may assist the early diagnosis of acute exacerbation of respiratory failure.     

无创正压通气治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭临床观察

目的 探讨经面罩双水平气道正压通气(bi-level positive airway pressure,BiPAP)呼吸机治疗慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)合并Ⅱ型呼吸衰竭的疗效.方法 88例COPD并发Ⅱ型呼吸衰竭患者随机分为治疗组和对照组,两组均给予抗感染、解痉平喘、止咳祛痰、能量支持等常规治疗,对照组加低浓度氧疗,治疗组加面罩BiPAP呼吸机治疗.观察面罩舒适度、临床症状、血气分析、生命体征、肺功能、漏气情况及不良反应.结果 治疗组与对照组相比,治疗72 h后心率、呼吸频率、动脉血二氧化碳分压、pH值均明显下降,住院天数缩短.动脉血氧分压、动脉血氧饱和度、肺活量、用力肺活量及第1秒用力呼气容积明显上升,差异均具有统计学意义(P<0.01).治疗组总有效率86.4%(38/44)与对照组68.2%(30/44)相比差异有统计学意义(P<0.05).结论 COPD合并呼吸衰竭患者早期使用BiPAP呼吸机治疗,对肺功能、低氧血症和CO2潴留改善明显,疗效显著.