Artículos Seleccionados 1998 - NEUMOCARDIOLOGIA

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Autor/es: d'Amours-RH; Riegler-FX; Little-AG

Lugar: Department of Anesthesia, University of Pennsylvania Medical Center, Philadelphia, USA.

Fuente: Chest-Surg-Clin-N-Am. 1998 Aug; 8(3): 703-22

ISSN: 1052-3359

Idioma: ENGLISH

Resumen: Persistent chest wall pain is common after thoracotomy and is usually caused by recurrence or progression of malignancy. It should prompt efforts to identify and treat the causative disease. A minority of patients experience persistent pain not related to neoplasm. This pain may last for years, but is usually not severe. A small subset of these patients experience persistent severe pain, which may be debilitating. The pain may be owing to various causes. Diagnosis and treatment should be individualized and directed toward the causes believed to be present. First-line pharmacologic therapies include NSAIDs, tricyclic antidepressants, antiepileptics, and low-dose opioids. Some patients require more sophisticated treatment from multidisciplinary pain-management clinics. This treatment may include nerve blocks, physical therapy, sympathectomy, cryoneurolysis, or long-term neuromodulation with epidural analgesia or spinal cord stimulation. Because of the severe pain these patients may experience and the difficulty and expense associated with treatment, prevention may be the best strategy for dealing with this problem. Recent laboratory and clinical studies indicate that minimizing perioperative pain can suppress certain alterations in the nervous system that may prevent the genesis and maintenance of chronically painful conditions. This suggests that strategies for avoiding PTPS may begin with aggressive perioperative anesthetic and analgesic techniques. More effective application of knowledge already available from laboratory studies awaits further clinical trials. New drugs such as NMDA inhibitors hold promise for more effective treatment in the future.

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Título en Inglés: The management of neuromuscular ventilatory failure.

Autor/es: Bach-JR; Zhitnikov-S

Lugar: Department of Physical Medicine, UMDNJ-New Jersey Medical School, Newark, USA.

Fuente: Semin-Pediatr-Neurol. 1998 Jun; 5(2): 92-105

ISSN: 1071-9091

Idioma: ENGLISH

Resumen: All patients with respiratory impairment have either primarily ventilatory or primarily oxygenation impairment. Patients with neuromuscular conditions fall into the former category but are all too often managed as though they had the latter with oxygen therapy, bronchodilators, chest physical therapy, intermittent positive pressure breathing, and so on. This approach can only hasten respiratory failure and management by tracheostomy-However, it has been reported that with the use of noninvasive respiratory muscle aids, respiratory morbidity and mortality can be prevented for most patients with neuromuscular disease without resort to tracheostomy or even hospitalization.

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Título en Inglés: Rehabilitation of patients admitted to a respiratory intensive care unit.

Autor/es: Nava-S

Lugar: Respiratory Intensive Care Unit, Centro Medico di Montescano, S. Maugeri Foundation, Italy.

Fuente: Arch-Phys-Med-Rehabil. 1998 Jul; 79(7): 849-54

ISSN: 0003-9993

Idioma: ENGLISH

Resumen: OBJECTIVE: Pulmonary rehabilitation has been shown to be of benefit to clinically stable patients with chronic obstructive pulmonary disease (COPD). This study examined the effect of pulmonary rehabilitation on some physiologic variables in COPD patients recovering from an episode of acute respiratory failure. DESIGN: A prospective, randomized study. SETTING: A respiratory intensive care unit (RICU). PATIENTS: Eighty COPD patients recovering from an episode of acute respiratory failure were randomized in a 3:1 fashion to receive stepwise pulmonary rehabilitation (group A, n=60 patients) or standard medical therapy (group B, n=20 patients). MAIN OUTCOME MEASURES: Improvements in exercise tolerance, sense of breathlessness, respiratory muscle function, and pulmonary function test values were measured, respectively, by exercise capacity (6-minute walking distance [6MWD]), dyspnea score (Visual Analog Scale [VAS]), maximal inspiratory pressure (MIP), forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC). INTERVENTIONS: Group A received pulmonary rehabilitation that consisted of passive mobilization (step I), early deambulation (step II), respiratory and lower skeletal muscle training (step III), and if the patients were able, complete lower extremity training on a treadmill (step IV). Group B received standard medical therapy plus a basic deambulation program. RESULTS: Sixty-one of 80 patients were mechanically ventilated at admission to the unit and most of them were bedridden. Twelve of the 60 group A patients and 4 of the 20 group B patients died during their RICU stay, and 9 patients required invasive mechanical ventilation at home after their discharge. The total length of RICU stay was 38+/-14 days for patients in group A versus 33.2+/-11 days for those in group B. Most patients from both groups regained the ability to walk, either unaided or aided. At discharge, 6 MWD results were significantly improved (p < .001) in Group A only. MIP improved in Group A only (p < .05), while VAS scores improved in both groups, but the improvement was more marked in group A (p < .001) than in group B (p < .05). CONCLUSIONS: COPD patients who were admitted to a RICU in critical condition after an episode of acute respiratory failure and who, in most cases, required mechanical ventilation benefited from comprehensive early pulmonary rehabilitation, compared with patients who received standard medical therapy and progressive ambulation.

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Título en Inglés: The intrapulmonary percussive ventilator and flutter device compared to standard chest physiotherapy in patients with cystic fibrosis.

Autor/es: Newhouse-PA; White-F; Marks-JH; Homnick-DN

Lugar: Department of Pediatrics, Michigan State University, Kalamazoo Center for Medical Studies 49008, USA.

Fuente: Clin-Pediatr-Phila. 1998 Jul; 37(7): 427-32

ISSN: 0009-9228

Idioma: ENGLISH

Resumen: Stasis of viscid secretions in cystic fibrosis (CF) leads to chronic infection, inflammation, and lung destruction. Chest physiotherapy (CPT) has been used for many years to assist in the removal of these secretions. However, the need for independently administered CPT exists, particularly for adolescents and the older CF patient. Two devices, the intrapulmonary percussive ventilator (IPV) and the Flutter device (Flutter) have been promoted for this purpose. This study compares these devices to standard, manual CPT. There was no difference in sputum quantity produced with any method studied. Transiently lower oxygen saturation was noted with standard CPT compared with the IPV and Flutter. Inconsistent but significant improvements in flow rates were noted with the two devices compared to standard CPT. Important trends to lower lung volumes, probably indicating decreased air trapping, were also noted with all three therapies at 1 and 4 hours after administration. There were no adverse effects with any treatment regimen. Larger and longer studies of these devices compared to standard CPT and with each other are warranted to assess their value for independent administration of CPT in CF patients and to determine long-term effects on maintenance of pulmonary function.

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Título en Inglés: Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and quality of life in both women and men with chronic heart failure.

Autor/es: Tyni-Lenne-R; Gordon-A; Europe-E; Jansson-E; Sylven-C

Lugar: Department of Physical Therapy, Karolinska Institute, Sweden. Raija.Tyni-Lenne@physio.hs.sll.se

Fuente: J-Card-Fail. 1998 Mar; 4(1): 9-17

ISSN: 1071-9164

Idioma: ENGLISH

Resumen: BACKGROUND: Data of training effects in chronic heart failure patients are based on findings in men. The purpose of this study was to compare the effects of skeletal muscle endurance training between men and women with chronic heart failure. METHODS AND RESULTS: Twelve consecutive men (mean [+/- SD] age 58 +/- 9 years, left ventricular ejection fraction 29 +/- 9%) and 12 women (60 +/- 10 years, left ventricular ejection fraction 28 +/- 7%) with moderate, chronic heart failure stratified according to age and inclusion criteria were investigated at baseline and after 8 weeks of knee extensor endurance training. The activity of skeletal muscle citrate synthase and resting heart rate were similar in men and women at baseline and with training improved (P < .0001) similarly in both genders. Peak work rate (P < .0001), peak oxygen uptake (P < .001) and muscle strength (P < .05) at baseline were higher in men than in women. Training improved peak work rate (P < .0001) and muscle strength (P < .0001) similarly in both genders, while improvement in peak oxygen uptake was better in women (P < .001). The distance ambulated during 6 minutes was similar in both genders at baseline and increased after training more in men (P < .004). The overall and physical Sickness Impact Profile indicated similarly reduced health-related quality of life in men and women, while worse psychosocial quality of life was observed in men (P < .05). Both genders improved after exercise training in the overall, physical, and psychosocial Sickness Impact Profile (P < .01). CONCLUSIONS: Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and the health-related quality of life in women as well as in men with moderate, chronic heart failure.

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Título en Inglés: Exercise training in heart failure: inpatient and outpatient considerations.

Autor/es: Cahalin-LP

Lugar: Boston University, Sargent College of Allied Health Professions, Physical Therapy Department, MA 02215, USA.

Fuente: AACN-Clin-Issues. 1998 May; 9(2): 225-43

ISSN: 1079-0713

Idioma: ENGLISH

Resumen: Exercise training has become increasingly important in the treatment of heart failure patients. It has long been known that the exercise tolerance of a patient with heart failure is related to his or her morbidity and mortality. Recently, it has been proved that exercise training improves cardiorespiratory function, functional status, and psychosocial status of heart failure patients. It is unknown whether these improvements will improve morbidity and mortality but quality of life appears to be enhanced. Subtle improvements in these areas may lead to a more satisfying and productive life for many heart failure patients. However, further investigation of the specific effects of such improvements is needed.

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Título en Inglés: Experience from controlled trials of physical training in chronic heart failure. Protocol and patient factors in effectiveness in the improvement in exercise tolerance. European Heart Failure Training Group.

Fuente: Eur-Heart-J. 1998 Mar; 19(3): 466-75

ISSN: 0195-668X

Idioma: ENGLISH

Resumen: BACKGROUND: Beneficial effects of physical training on exercise tolerance, autonomic and skeletal muscle function and limb blood flow have been demonstrated in chronic heart failure. Because this rehabilitation is expensive, may involve risk, and has unknown effects on prognosis, the possibility of predicting benefit on the basis of individual patient data is intriguing. The most suitable exercise training programme has not yet been established. METHODS AND RESULTS: We reviewed the progress of 134 stable heart failure patients studied in randomized controlled trials of physical training. A significant training effect (+13% peak oxygen consumption, +17% exercise duration) was associated with improved autonomic indices (resting catecholamines and hormones, heart rate variability), without significant side-effects. No ventilatory, haemodynamic, autonomic or clinical factor at baseline was a predictor of outcome. Similar beneficial effects were observed in both male and female patients. The improvement in oxygen consumption after 16 weeks training was higher than after 6 weeks (+2.6 +/- 3.0 vs +0.3 +/- 3.1 ml.kg.min-1, P < 0.05). The combination of cycle ergometer with calisthenic exercises was more beneficial than cycle ergometer alone (+2.7 +/- 4.2 vs 1.2 +/- 2.0 ml.kg.min-1, P < 0.01). The presence of nonsustained ventricular tachycardia did not preclude a training effect. Patients older than 70 years were able to train, although less effectively than the younger ones. No difference in exercise gain was observed whether the patients trained in the hospital or at home. CONCLUSION: The positive effects of physical rehabilitation in chronic stable heart failure patients are confirmed. No baseline patient factor was significantly correlated with outcome. A tailored, moderate, home-based, combined cycle ergometer, plus calisthenic exercise training seems safe and beneficial in a large cohort of heart failure patients, with similar benefits in a variety of conditions and different hospital settings.

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Título en Inglés: Short- and long-term neurological outcomes following neonatal chest physiotherapy.

Autor/es: Beeby-PJ; Henderson-Smart-DJ; Lacey-JL; Rieger-I

Lugar: Department of Neonatal Medicine, King George V Hospital, Sydney, Australia.

Fuente: J-Paediatr-Child-Health. 1998 Feb; 34(1): 60-2

ISSN: 1034-4810

Idioma: ENGLISH

Resumen: OBJECTIVE: To test the hypothesis that chest physiotherapy in extremely premature infants is associated with abnormal neurological outcomes. METHODS: All babies born during the years 1992-1994 at gestations of 24-29 weeks who survived to 28 days were included in the study cohort (n=213). Chest physiotherapy was provided by trained physiotherapists for babies with secretions causing obstruction to the airway or for babies with evidence of collapse and/or consolidation. The relationship between chest physiotherapy and cystic brain lesions at discharge, or cerebral palsy (CP) and developmental quotient (DQ) at 1 year corrected age, were then explored. RESULTS: Ninety-seven babies (45% of the cohort) received physiotherapy. No baby had a brain lesion similar to that described as encephaloclastic porencephaly. Babies receiving physiotherapy had significantly lower birthweights and gestational ages. Of the 13 babies found to have either periventricular leucomalacia or porencephalic cysts, seven (7%) were in the physiotherapy group, and six (5%) were in the nonphysiotherapy group. Of the babies surviving to 1 year corrected age, 189 (92%) had multidisciplinary follow-up. Eleven (13%) of the babies who received physiotherapy had suspected CP, and 14 (13%) of those not receiving physiotherapy had CP. The DQ of those who received physiotherapy was 96.0+/-16.6, and 101.6+/-16.6 for those who did not. Following adjustment for gestational age and other unequal risk factors using logistic regression, none of the above outcomes was significantly associated with the number of physiotherapy treatments. CONCLUSION: We could find no evidence that chest physiotherapy, as given in our unit, was associated with abnormal neurological outcomes in extremely preterm infants.

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Título en Inglés: Effect of high-frequency oral airway and chest wall oscillation and conventional chest physical therapy on expectoration in patients with stable cystic fibrosis.

Autor/es: Scherer-TA; Barandun-J; Martinez-E; Wanner-A; Rubin-EM

Lugar: Division of Pulmonary Diseases, University of Miami School of Medicine, USA.

Fuente: Chest. 1998 Apr; 113(4): 1019-27

ISSN: 0012-3692

Idioma: ENGLISH

Resumen: STUDY OBJECTIVE: To compare the effect of high-frequency oral airway oscillation, high-frequency chest wall oscillation, and conventional chest physical therapy (CPT) on weight of expectorated sputum, pulmonary function, and oxygen saturation in outpatients with stable cystic fibrosis (CF). DESIGN: Prospective randomized trial. SETTING: Pediatric pulmonary division of a tertiary care center. PATIENTS: Fourteen outpatients with stable CF recruited from the CF center. INTERVENTIONS: Two modes of oral airway oscillation (1: frequency 8 Hz; inspiratory to expiratory [I:E] ratio 9:1; 2: frequency 14 Hz; I:E ratio 8:1), two modes of chest wall oscillation (1: frequency 3 Hz; I:E ratio 4:1; 2: frequency 16 Hz; I:E ratio 1:1, alternating with frequency 1.5 Hz, I:E ratio 6:1), and CPT (clapping, vibration, postural drainage, and encouraged coughing) were applied during the first 20 min of 4 consecutive hours. MEASUREMENTS AND RESULTS: Sputum was collected on an hourly basis for a total of 6 consecutive hours. During the first and the last hour, patients collected sputum without having any treatment and underwent pulmonary function tests (PFTs). Oxygen saturation was measured at 30-min intervals during hours 1 to 6. For the first 20 min of the second to the fifth hour, patients received one of the treatments. To assess the effect of the intervention, the weight of expectorated sputum during hours 2 to 6 was averaged and expressed as percentage of the weight expectorated during the first hour (baseline). For the five treatment modalities, mean sputum dry and wet weights ranged between 122% and 185% of baseline. There was no statistically significant difference among the treatment modalities. As measured by sputum wet weight, all oscillatory devices tended to be less effective than CPT (p=0.15). As measured by dry weight, oral airway oscillation at 8 Hz with an I:E ratio of 9:1 and CPT tended to be more effective than the other treatment modalities (p=0.57). None of the treatment modalities had an effect on PFTs and oxygen saturation and all were well tolerated. CONCLUSION: In outpatients with stable CF, high-frequency oscillation applied via the airway opening or via the chest wall and CPT have comparable augmenting effects on expectorated sputum weight without changing PFTs or oxygen saturation. In contrast to CPT, high-frequency oral airway and chest wall oscillations are self-administered, thereby containing health-care expenses.

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Título en Inglés: Chest physiotherapy may be associated with brain damage in extremely premature infants.

Autor/es: Harding-JE; Miles-FK; Becroft-DM; Allen-BC; Knight-DB

Lugar: Department of Pediatrics, National Women's Hospital, Epsom, Aukland, New Zealand.

Fuente: J-Pediatr. 1998 Mar; 132(3 Pt 1): 440-4

ISSN: 0022-3476

Idioma: ENGLISH

Resumen: OBJECTIVES: To determine whether a characteristic form of brain damage (encephaloclastic porencephaly) was associated with chest physiotherapy treatment in preterm babies. METHODS: A retrospective case-control study was undertaken among 454 infants of birth weight less than 1500 gm cared for during the 3-year period of 1992 to 1994. Thirteen babies of 24 to 27 weeks of gestation who weighed 680 to 1090 gm at birth had encephaloclastic porencephaly. Twenty-six control subjects were matched for birth weight and gestation. RESULTS: The patients received two to three times as many treatments with chest physiotherapy in the second, third, and fourth weeks of life as did control infants (median 79 vs 19 treatments in the first 4 weeks, p < 0.001). Patients also had more prolonged and severe hypotension in the first week than did control subjects (median duration of hypotension 4 vs 0.5 days, p < 0.01), and were less likely to have a cephalic presentation (31% vs 81%, p < 0.01). Since December 1994 no very low birth weight baby has received chest physiotherapy treatment in the first month of life in our nursery, and no further cases have occurred. CONCLUSIONS: Encephaloclastic porencephaly may be a previously unrecognized complication of chest physiotherapy in vulnerable extremely preterm infants.

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Título en Inglés: Pulmonary function in hospitalized infants and toddlers with cystic fibrosis [see comments]

CM: Comment in: J Pediatr 1998 Mar;132(3 Pt 1):380-1

Autor/es: Clayton-RG Sr; Diaz-CE; Bashir-NS; Panitch-HB; Schidlow-DV; Allen-JL

Lugar: Department of Pediatrics, Temple University School of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134, USA.

Fuente: J-Pediatr. 1998 Mar; 132(3 Pt 1): 405-8

ISSN: 0022-3476

Idioma: ENGLISH

Resumen: In older children with cystic fibrosis (CF), well-documented improvements in lung function occur during hospitalization for treatment of pulmonary exacerbations. OBJECTIVES: (1) To test the hypothesis that improvement in lung function occurs in infants and toddlers hospitalized because of CF pulmonary exacerbations. (2) To compare changes in lung function measured during forced expiratory flow and tidal breathing. STUDY DESIGN: Seventeen infants and toddlers with CF were evaluated at the beginning and end of hospitalization by the rapid thoracic compression technique to yield maximal flow at forced residual capacity. Tidal mechanics were measured by the esophageal balloon technique to yield lung conductance and compliance. RESULTS: Lung function improved during the course of hospitalization. The greatest change was observed in measurements of maximal flow at functional residual capacity (.VmaxFRC), increasing from 38.5% +/- 6% predicted (mean +/- SEM) to 59.8% +/- 6% at the end (p < 0.005). Lung conductance (GL) increased from 60% +/- 6% to 78% +/- 8% (p < 0.02); lung compliance (CL) increased from 66% +/- 5% to 75% +/- 5% (p < 0.03). The degree of improvement of .VmaxFRC, GL, and CL was related to baseline measurements; those with poorer pulmonary function at baseline had the greatest degree of improvement during hospitalization. CONCLUSION: Assessments of airflow obstruction from measurements of .VmaxFRC and GL do not necessarily demonstrate similar findings in a given infant with CF, perhaps because these two techniques measure different physiologic properties. Changes in .VmaxFRC may best reflect the predominant pathophysiology of lung disease in infants and toddlers with CF.

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