The phase angle cut-off point capable of discriminating hemodialysis patients with reduced exercise tolerance: a cross-sectional study

BACKGROUND

Phase angle (PhA) is a prognostic marker of all-cause mortality in chronic kidney disease. However, no study has investigated this marker as a predictor of exercise intolerance in hemodialysis (HD) patients. The aim of this study was to determine a cut-off point for the PhA capable of discriminating HD patients with reduced exercise tolerance.

METHODS

Thirty-one patients (80.6% men, median age 69 years) were included. The evaluations were performed on three different days, before the HD session. The outcomes evaluated were: biochemical markers, inflammatory and nutritional status, body composition, peripheral muscle strength and exercise tolerance. Performance ≤50% of the predicted value in the six-minute step test (6MST) was defined as reduced exercise tolerance.

RESULTS

Patients presented an average of 67.6 steps (50.5% of predicted) in the 6MST. Fifteen patients (48.4%) were classified with reduced exercise tolerance. The receiver operating characteristic curve indicated a cut-off point of 3.73° for the PhA (sensitivity = 87%, specificity = 81%, and area under the curve = 0.88 [95% CI: 0.76-1.00]; p < 0.001). Patients with reduced exercise tolerance had worse inflammatory and nutritional status, lower PhA and greater impairment of peripheral muscle strength.

CONCLUSION

The cut-off point of 3.73° for the PhA is sensitive and specific to discriminate HD patients with reduced exercise tolerance.

TRIAL REGISTRATION

This study was registered in the Clinical Trials database (no. NCT03779126, date of first registration 19/12/2018).

Functional recovery of chronically critically ill patients in the first days after discharge from the intensive care unit: Feasibility of the 6-minute step test

BACKGROUND

Survivors of chronic critical illness often experience weakness and functional dependence to various degrees after their intensive care unit (ICU) stay. Evaluating their functional status with the traditional six-minute walk test is challenging due to space constraints or patient intolerance.

OBJECTIVE

Our aim was to evaluate the feasibility of using the six-minute step test (6MST) as a measure of functional capacity in chronically critically ill patients early after ICU discharge.

METHODS

This prospective study was undertaken in a private Brazilian hospital. From July 2019 to July 2020, all chronically critically ill patients were asked to participate 48 hours after ICU discharge. On the day of study inclusion and a week later, those who consented underwent functional assessment comprised of the 6MST, peripheral muscle strength using handgrip strength (HGS), and mobility using the ICU mobility scale (IMS).

RESULTS

A total of 40 patients were included. The 6MST was feasible in 40% on the first evaluation and 57% on the second. The median 6MST was 0 [0-5] on the first evaluation and 3.5 [0-7.75] on the second (P = 0.005). The median HGS increased from 11.50 [9.25-18] on the first evaluation to 14.5 [10-20] on the second (P = 0.006). The median IMS was 4.5 [3.25-7] on the first evaluation and 6 [3.25-7] on the second (P<0.001). Despite the significant improvement, all parameters measured remained well below normal.

CONCLUSION

The 6MST was a feasible measure of functional capacity in chronically critically ill patients early after ICU discharge. Patients had functional capacity well below predicted values.

Impact on the ability of healthcare professionals to correctly identify patient-ventilator asynchronies of the simultaneous visualization of estimated muscle pressure curves on the ventilator display: a randomized study (Pmus study)

BACKGROUND

Patient-ventilator asynchronies are usually detected by visual inspection of ventilator waveforms but with low sensitivity, even when performed by experts in the field. Recently, estimation of the inspiratory muscle pressure (P_mus) waveforms through artificial intelligence algorithm has been proposed (Magnamed®, São Paulo, Brazil). We hypothesized that the display of these waveforms could help healthcare providers identify patient-ventilator asynchronies.

METHODS

A prospective single-center randomized study with parallel assignment was conducted to assess whether the display of the estimated P_mus waveform would improve the correct identification of asynchronies in simulated clinical scenarios. The primary outcome was the mean asynchrony detection rate (sensitivity). Physicians and respiratory therapists who work in intensive care units were randomized to control or intervention group. In both groups, participants analyzed pressure and flow waveforms of 49 different scenarios elaborated using the ASL-5000 lung simulator. In the intervention group the estimated P_mus waveform was displayed in addition to pressure and flow waveforms.

RESULTS

A total of 98 participants were included, 49 per group. The sensitivity per participant in identifying asynchronies was significantly higher in the P_mus group (65.8 ± 16.2 vs. 52.94 ± 8.42, p < 0.001). This effect remained when stratifying asynchronies by type.

CONCLUSIONS

We showed that the display of the P_mus waveform improved the ability of healthcare professionals to recognize patient-ventilator asynchronies by visual inspection of ventilator tracings. These findings require clinical validation.

TRIAL REGISTRATION

ClinicalTrials.gov: NTC05144607. Retrospectively registered 3 December 2021.

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study

BACKGROUND

Pulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions.

METHODS

Thirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed.

RESULTS

Mild pulmonary congestion caused a 26.1% decline in DM (R²=.261; P=.004) and 20% reduction in walking time (R²=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines.

CONCLUSION

The mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.

Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study

BACKGROUND

Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events.

METHODS

This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered.

RESULTS

53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%).

CONCLUSIONS

The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.

Functional Recovery Groups in Critically Ill COVID-19 Patients and Their Associated Factors: From ICU to Hospital Discharge

OBJECTIVES

To analyze functional recovery groups of critically ill COVID-19 survivors during their hospital stay and to identify the associated factors.

DESIGN

Prospective observational multicenter study.

SETTING

Demographic, clinical, and therapeutic variables were collected, and physical and functional status were evaluated. The Barthel index was evaluated at three time points: 15 days before hospitalization, at ICU discharge, and at hospital discharge from the ward.

PATIENTS

Patients with functional independence before COVID-19 diagnosis were recruited from four hospitals and followed up until hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Three groups of functional recovery were described for 328 patients: functional independence ( n = 144; 44%), which included patients who preserved their functional status during hospitalization; recovered functionality ( n = 109; 33.2%), which included patients who showed dependence at ICU discharge but recovered their independence by hospital discharge; and functional dependency ( n = 75; 22.8%), which included patients who were dependent at ICU discharge and had not recovered their functional status at hospital discharge. The factors associated with becoming functionally dependent at ICU discharge were time to out-of-bed patient mobilization (odds ratio [OR], 1.20; 95% CI, 1.11-1.29), age (OR, 1.02; 95% CI, 1.01-1.04), hyperglycemia (OR, 2.52; 95% CI, 1.56-4.07), and Simplified Acute Physiology Score (OR, 1.022; 95% CI, 1.01-1.04). Recovery to baseline independence during ward stays was associated with ICU length of stay (OR, 0.97; 95% CI, 0.94-0.99) and muscle strength (Medical Research Council test) at ICU discharge (OR, 1.13; 95% CI, 1.08-1.18).

CONCLUSIONS

Age, hyperglycemia, and time for patient mobilization out of bed were independent factors associated with becoming physically dependent after their ICU stay. Recovery of physical function at hospital discharge was associated with muscle strength at ICU discharge and length of ICU stay.

Efficacy of neuromuscular electrical stimulation with combined low and high frequencies on body composition, peripheral muscle function and exercise tolerance in patients with chronic kidney disease undergoing haemodialysis: a protocol for a randomised, double-blind clinical trial

INTRODUCTION

Neuromuscular electrical stimulation (NMES) as an adjunctive strategy to increase isolated muscular strength or endurance has been widely investigated in patients with chronic kidney disease (CKD) undergoing haemodialysis (HD). However, the efficacy of combined low and high frequencies, to improve both muscular strength and endurance, is unknown. This trial aims to evaluate the efficacy of this combined NMES strategy in this population.

METHODS AND ANALYSIS

This is a randomised controlled trial with blinded assessments and analysis. A total of 56 patients with CKD undergoing HD will be recruited and randomised to an NMES protocol. The evaluations will be performed on three different days at baseline and after 24 sessions of follow-up. Assessments will include the background, insulin-like growth factor, lactate measurement, malnutrition and inflammation score evaluation, an electrical bioimpedance examination, global muscular evaluation by means of the Medical Research Council scale, handgrip strength evaluation, muscular isokinetic evaluation of lower limbs, 6 min step test performance and quality of life (QoL) questionnaire with emphasis on physical function. The patients will be allocated in one of the following four groups: 1) combined low and high frequencies; 2) low frequency; 3) high frequency; and 4) sham stimulation with minimal intensity to generate only sensory perception (with no visible contraction). In all groups, the intensity throughout the session will be the highest tolerated by patient (except for control group). The primary endpoint is the change of peripheral muscle function (muscular strength and endurance). The secondary endpoints will be the changes of body composition; muscle trophism; exercise tolerance; QoL; and nutritional, inflammatory, and metabolic markers. The findings of this study are expected to provide valuable knowledge on how to optimise the NMES intervention, with improvements in both muscle strength and endurance.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee on Research with Humans of Hospital Sírio-Libanês (approval no. 24337707). Written informed consent will be obtained from each participant. The results of the study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03779126.

Effectiveness of a quality improvement strategy with implementation of a specific visual tool to promote ICU early mobilization

Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the "mobility clock", in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in "non-compliance" with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the "after" period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the "non-compliance" rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.

The Six-Minute Stepper Test Is Valid to Evaluate Functional Capacity in Hospitalized Patients With Exacerbated COPD

Background: The six-minute stepper test (6MST) is a self-paced test considered a valid tool to assess functional capacity in stable COPD patients. However, a high floor effect, where a large proportion of participants reach the minimum score when using the measurement instrument, might compromise the test validity in the hospital setting. Therefore, this study aimed at verifying the concurrent validity of 6MST in hospitalized patients with acute exacerbation of COPD (AECOPD).

Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD were considered for inclusion. On the first day, when patients reached minimum clinical criteria considered as the use of non-invasive ventilation less than 2 h for 6 h/period, dyspnea at rest less than 7 (very severe) on the modified Borg scale, a respiratory rate less than 25 breaths per minute, oxygen pulse saturation greater than 88% (considering use of supplemental oxygen) and absence of paradoxical breathing pattern, they underwent a lung function evaluation and answered three questionnaires: Chronic Respiratory Questionnaire (CRQ), Modified Medical Research Council Dyspnea Scale (MMRC), and COPD Assessment Test (CAT). Then, on two consecutive days, patients performed 6MST or six-minute walk test (6MWT), in random order. Each test was performed twice, and the best performance was recorded. Also, the patient’s severity was classified according to the BODE index. Inspiratory capacity measurements were performed before and after each test execution.

Results: Sixteen patients (69.4 ± 11.4 years) with a mean FEV₁ of 49.4 ± 9.9% predicted were included (9 females). There was a strong correlation of the performance in 6MST (number of cycles) with 6MWT (distance walked in meters) in absolute values (r = 0.87, p < 0.001) as well as with the percentage of predicted normal 6MWT (r = 0.86, p < 0.001). There was a strong correlation between the performance in 6MST with the dynamic hyperinflation (r = 0.72, p = 0.002) and a moderate correlation between 6MST with the percentage of reduction of inspiratory capacity (r = 0.68, p = 0.004). We also identified that 6MST showed moderate negative correlations with CAT (r = −0.62, p = 0.01) and BODE index (r = −0.59, p = 0.01).

Conclusion: It could be concluded that 6MST is valid for evaluating functional capacity in hospitalized patients with exacerbated COPD.

Neuromuscular Electrical Stimulation in Patients With Severe COVID-19 Associated With Sepsis and Septic Shock

BACKGROUND

Neuromuscular electrical stimulation (NMES) can be applied to critically ill patients. However, its results on muscle strength and functionality in patients with COVID-19 are unknown.

OBJECTIVE

Evaluate the effects of intervention with NMES on muscle mass and functionality of patients with severe COVID-19 associated with sepsis and septic shock.

METHODS

Seven patients with COVID-19 associated with sepsis or septic shock were selected, but only 5 patients completed all days of the intervention with NMES. The intervention was performed by a single physiotherapist on 7 consecutive days in a daily session of 40 min. The outcome measures were the femoris cross-sectional area; thickness of the anterior compartment of the quadriceps muscle; rectus femoris echogenicity; International Classification of Functioning, Disability, and Health (ICF)-muscle strength; PFIT-s, DEMMI, and the SOMS; feasibility, and safety. The patients were evaluated on days 1, 5, and 8.

RESULTS

The rectus femoris cross-sectional area decreased significantly from days 1 to 8, but showed maintenance of the thickness of the anterior compartment of the quadriceps muscle from days 1 to 8. The MRC score increased significantly from days 1 to 5 and kept this improvement until day 8. All patients showed an increase in the MRC score and reduction of the ICF-muscle strength, meaning improved muscle strength from days 1 to 8. The PFIT-s increased significantly from days 1 to 5 and improved until day 8 compared to day 5. DEMMI and SOMS score increased significantly on day 8 compared to days 1 and 5.

CONCLUSION

Rehabilitation with NMES showed improvement in muscle strength and functionality of patients in this study with a potential protective effect on muscle mass loss in patients with critical COVID-19 associated with sepsis and septic shock. This study is the first report of the potential effects of neuromuscular electrical stimulation in patients with severe COVID-19 associated with sepsis and septic shock.

Noninvasive ventilation and high-flow nasal cannula in patients with acute hypoxemic respiratory failure by covid-19: a retrospective study of the feasebility, safety and outcomes

BACKGROUND

Noninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19.

METHODS

In this retrospective study, we monitored the effect of NIV and HFNC on the SpO₂ and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non-COVID-19.

RESULTS

62.2% of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO₂ increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7% for NIV vs 21.4% for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1% for NIV vs 69.6% for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS-CoV-2 directly involved in assisting COVID-19 patients and non-COVID-19 ones (P = 0.81).

CONCLUSION

The application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.

Bleeding frequency during physiotherapy in thrombocytopenic patients undergoing hematopoietic stem cell transplantation

BACKGROUND

During hematopoietic stem cell transplantation (HSCT) the patients perform activities of low and moderate intensity because have reduced hematological lineages, leaving them susceptible to hemorrhagic events. The objective of this study was to describe the frequency of bleeding events, severity, and possible association with physical exercise in thrombocytopenic patients.

METHODS

A retrospective study with seventy-seven HSCT patients hospitalised, that had a platelet count ≤ 50,000 /μL and received physical exercise during physiotherapy intervention.

RESULTS

Regarding bleeding events, only six were related to physical exercise, and bleeding events occurred more frequently at platelet levels ≤ 10,000 /μL. The most frequent bleeding event was epistaxis, considered of low severity, and with the moderate possibility of being related to physical exercise; followed by extremity hematoma, considered of medium severity and highly related to physical exercise. In this study, there was no occurrence of bleeding events considered of high severity.

CONCLUSION

Bleeding frequency in supervised physical exercise during physiotherapy in adults with thrombocytopenia undergoing HSCT is minor and relatively rare but occurs more frequently in patients with platelet count ≤10,000 /μL. These results encourage the maintenance of physical activity in this population who is at high risk of developing immobility-related complications.

Skeletal Muscle Wasting and Function Impairment in Intensive Care Patients With Severe COVID-19

Background: Intensive care patients commonly develop muscle wasting and functional impairment. However, the role of severe COVID-19 in the magnitude of muscle wasting and functionality in the acute critical disease is unknown.

Objective: To perform a prospective characterization to evaluate the skeletal muscle mass and functional performance in intensive care patients with severe COVID-19.

Methods: Thirty-two critically ill patients (93.8% male; age: 64.1 ± 12.6 years) with the diagnosis of the severe COVID-19 were prospectively recruited within 24 to 72 h following intensive care unit (ICU) admission, from April 2020 to October 2020, at Hospital Sírio-Libanês in Brazil. Patients were recruited if older than 18 years old, diagnosis of severe COVID-19 confirmed by RT-PCR, ICU stay and absence of limb amputation. Muscle wasting was determined through an ultrasound measurement of the rectus femoris cross-sectional area, the thickness of the anterior compartment of the quadriceps muscle (rectus femoris and vastus intermedius), and echogenicity. The peripheral muscle strength was assessed with a handgrip test. The functionality parameter was determined through the ICU mobility scale (IMS) and the International Classification of Functioning, Disability and Health (ICF). All evaluations were performed on days 1 and 10.

Results: There were significant reductions in the rectus femoris cross-section area (−30.1% [95% IC, −26.0% to −34.1%]; P < 0.05), thickness of the anterior compartment of the quadriceps muscle (−18.6% [95% IC, −14.6% to 22.5%]; P < 0.05) and handgrip strength (−22.3% [95% IC, 4.7% to 39.9%]; P < 0.05) from days 1 to 10. Patients showed increased mobility (0 [0–5] vs 4.5 [0–8]; P < 0.05), improvement in respiratory function (3 [3–3] vs 2 [1–3]; P < 0.05) and structure respiratory system (3 [3–3] vs 2 [1–3]; P < 0.05), but none of the patients returned to normal levels.

Conclusion: In intensive care patients with severe COVID-19, muscle wasting and decreased muscle strength occurred early and rapidly during 10 days of ICU stay with improved mobility and respiratory functions, although they remained below normal levels. These findings may provide insights into skeletal muscle wasting and function in patients with severe COVID-19.

Relationship of phase angle and peak torque of knee extensors with the performance in six-minute step test in haemodialysis patients

BACKGROUND

Chronic kidney disease is a systemic disease affecting not only renal function, but also endocrine, cardiovascular, and skeletal muscle systems, with broad impact on functionality. Therefore, the assessment of body composition, peripheral muscle function, and exercise tolerance is also of great importance in this population. In addition, the development of reliable strategies that use feasible tools in clinical practice is of great importance in the functional diagnosis, clinical management and prescription of physical activity.

OBJECTIVE

To assess the relationship between phase angle and peak torque of knee extensors with the performance in six-minute step test of patients with chronic kidney disease undergoing haemodialysis.

METHODS

Observational and cross-sectional study at Haemodialysis Centre of Sírio-Libanês Hospital. The evaluations took place 3 days before the haemodialysis sessions. On the first day, patients underwent anthropometric evaluation and biochemical tests (lactate, urea, creatinine, albumin, ferritin and growth factor similar to insulin type 1 [IGF1]). On the second day, performed electrical bioimpedance and exercise tolerance assessed using the six-minute step test. On the last day, the evaluation of knee extensor muscles strength using isokinetic dynamometry was performed.

RESULTS

Eighteen subjects were included, with a mean age of 62.3 ± 17.6 years. A positive linear correlation was observed between the phase angle, derived from the electrical bioimpedance, and the performance in six-minute step test in these patients. It was also possible to observe a linear correlation between phase angle and IGF1, handgrip strength, peak torque of knee extensors and quality of life questionnaire. The peak torque of knee extensors also presented a linear correlation with IGF1, the performance in six-minute step test and mal-nutrition and inflammation score.

CONCLUSION

Phase angle and peak torque of knee extensors were correlated with the performance in six-minute step test. Therefore, the phase angle seems to be an important marker of reduced peripheral muscle function and exercise tolerance in haemodialysis patients.

Six-minute stepper test in hospitalized elderly patients: Convergent validity, test-retest reliability and safety

OBJECTIVE

To evaluate the convergent validity of the six-minute stepper test (6MST) with the variables used in the diagnosis of sarcopenia (appendicular muscle mass, handgrip strength and six-meter gait speed test), as well as to evaluate test-retest reliability and safety when applied to hospitalized elderly patients. Finally, we aimed to compare the performance in the 6MST between hospitalized elderly patients and healthy elderly from the community.

MATERIALS AND METHODS

Observational and cross-sectional study. Elderly patients admitted to a private hospital and healthy elderly from the community were recruited. On the first day, the patients included underwent the following assessments: anthropometric, handgrip strength (HGS), six-meter gait speed test (6GST) and 6MST. On the second day, before breakfast, patients underwent body composition assessment. The healthy elderly were evaluated on a single day and performed only anthropometric assessment and 6MST.

RESULTS

30 hospitalized patients (age 71.0±7.9 years) and 15 healthy elderly (age 68.1±5.8 years) were included. There was a high correlation of 6MST with 6GST (r = 0.78; p<0.001), moderate correlation with HGS (r = 0.59; p<0.001) and low correlation with appendicular muscle mass (r = 0.45; p = 0.01). There was no statistical difference between the first and second 6MST performed by hospitalized elderly (196.2±91.0 cycles vs. 191.3±103.7 cycles; p = 0.66), in addition to an excellent agreement between these measures (ICC = 0.90; 95% IC 0.78-0.95). Only one adverse event (3.3%) occurred in the sample.

CONCLUSION

6MST showed convergent validity with the functional variables used in the diagnosis of sarcopenia. In addition, excellent test-retest reliability was observed, which indicates the need for a single assessment in hospitalized elderly patients. The prevalence of adverse events during the application of the test is low, without resulting in clinical symptoms; therefore, the test is considered safe for this population. In addition, hospitalized elderly patients perform worse in the 6MST compared to healthy elderly from the community.

Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Relationship between handgrip strength and pulmonary capacity in patients on hemodialysis

Abstract Introduction: Chronic kidney disease (CKD) is defined as loss of kidney function, but its progression leads to systemic changes that compromise the quality of life of patients on dialysis. As such, the decline in lung capacity in this population may be one of the factors related to reduced peripheral muscle strength. Objective: Assess the relationship between handgrip strength (HGS), pulmonary function and respiratory muscle strength in patients with CKD on hemodialysis. Method: Thirty patients with CKD were assessed in terms of anthropometric data, pulmonary function, respiratory muscle strength and HGS. Results: A moderate association was observed between HGS and the variables forced vital capacity (r=0.54; p=0.002), maximum voluntary ventilation (r=0.51; p=0.004) and maximum expiratory pressure (r=0.59; p=0.001), and a weak association with forced expiratory volume in 1 second (FEV1) (r=0.46; p=0.009) and maximum inspiratory pressure (r=0.38; p=0.03). Additionally, about 67% of the sample (n=20) exhibited some degree of restrictive ventilatory defect in the pulmonary function test. With respect to muscle strength, 40% of the sample (n=12) displayed below-normal handgrip strength, as well as low mean MIP and MEP. Conclusion: Decreased lung capacity may be related to a decline in HGS in patients with chronic kidney disease on hemodialysis. Thus, therapeutic strategies aimed at lung expansion and respiratory muscle training may contribute to facilitating and favoring rehabilitation in this population.

Age and Disease have a Distinct Influence on Postural Balance of Patients with COPD

The postural imbalance is an extra-pulmonary condition, associated with chronic obstructive pulmonary disease (COPD). COPD affects older individuals and it is unclear whether balance abnormalities can be described as pathophysiological mechanism or aging. The present study aimed to evaluate the influence of age or disease on postural balance of patients with COPD. Patients with COPD over 50 years old were compared with age- and sex-matched healthy adults, and with sex-matched younger healthy adults (n = 30 in each group). The Modified Sensory Organization Test (mSOT) was performed in four different conditions fixed or sway-referenced surface both either with full or no vision. It was analyzed the center of pressure (CoP) variables: amplitude, velocity, root-mean-square and load asymmetry. Three-way ANOVA and post hoc analysis were performed been represented of age (older or COPD compared with younger healthy adults) or disease influences (COPD compared with older healthy groups). Main results were as follows: The CoP excursion was faster, with higher amplitude and variability progressively from COPD vs. older healthy vs. younger healthy adults (p < 0.05) showing age and disease influences (p < 0.05). Age and disease influences were also observed in the sway-referenced surface in both vision conditions. Impairment in postural balance was found related to aging and disease in patients with COPD older than 50 years.

Quanto tempo de oclusão é necessário para avaliar a pressão inspiratória máxima pelo método da válvula expiratória unidirecional em sujeitos sem via aérea artificial?

RESUMO O objetivo desse estudo foi determinar o tempo de oclusão necessário para avaliar a pressão inspiratória máxima (PIMáx) obtida pelo método da válvula expiratória unidirecional em sujeitos sem via aérea artificial. Foram avaliados 31 sujeitos, com idade entre 18 e 60 anos. A PIMáx foi avaliada pelo método convencional (PIMáxconv) e pelo método da válvula expiratória unidirecional (PIMáxuni), sendo a ordem de avaliação definida por meio de sorteio. Para a medida da PIMáxuni, um manovacuômetro digital foi acoplado a uma válvula expiratória unidirecional e máscara orofacial por 20 segundos de oclusão. Nesse período, todos os sujeitos foram encorajados a realizar esforços inspiratórios máximos. Para definir a ótima duração da manobra, o tempo de esforço foi dividido a cada intervalo de 5 segundos (0-5s, 0-10s, 0-15s, 0-20s). Os intervalos de tempo para obtenção da PIMáxuni foram comparados por meio do teste de ANOVA One-way. Para comparação das médias dos valores de PIMáxconv e PIMáxuni, foi utilizado o teste t de Student. O nível de significância foi de 5%. A média dos valores da PIMáxconv foi de -102,5±23,9 cmH2O, enquanto que a PIMáxuni foi de -117,3±24,8 cmH2O (p<0,001). O valor absoluto máximo da PIMáxuni foi alcançado dentro do intervalo de 0-20 segundos, que foi significativamente superior ao valor absoluto máximo obtido nos primeiros 5 segundos (p=0,036). O tempo de oclusão necessário para avaliar a PIMáx pelo método da válvula expiratória unidirecional em sujeitos colaborativos sem via aérea artificial deve ser de pelo menos 20 segundos.

Comparison of diaphragmatic mobility between COPD patients with and without thoracic hyperkyphosis: a cross-sectional study

Objective:

To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD.

Methods:

Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility.

Results:

A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = −0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210).

Conclusions:

Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.

Validity and reliability of assessing diaphragmatic mobility by area on X-rays of healthy subjects

OBJECTIVE

To investigate the concurrent validity, as well as the intra- and inter-rater reliability, of assessing diaphragmatic mobility by area (DMarea) on chest X-rays of healthy adults.

METHODS

We evaluated anthropometric parameters, pulmonary function, and diaphragmatic mobility in 43 participants. Two observers (rater A and rater B) determined diaphragmatic mobility at two time points. We used Pearson's correlation coefficient to evaluate the correlation between DMarea and the assessment of diaphragmatic mobility by distance (DMdist). To evaluate intra- and inter-rater reliability, we used the intraclass correlation coefficient (ICC [2,1]), 95% CI, and Bland-Altman analysis.

RESULTS

A significant correlation was found between the DMarea and DMdist methods (r = 0.743; p < 0.0001). For DMarea, the intra-rater reliability was found to be quite high for the right hemidiaphragm (RHD)-ICC (2,1) = 0.92 (95% CI: 0.86-0.95) for rater A and ICC (2,1) = 0.90 (95% CI: 0.84-0.94) for rater B-and the left hemidiaphragm (LHD)-ICC (2,1) = 0.96 (95% CI: 0.93-0.97) for rater A and ICC (2,1) = 0.91 (95% CI: 0.81-0.95) for rater B-(p < 0.0001 for all). Also for DMarea, the inter-rater reliability was found to be quite high for the first and second evaluations of the RHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.95 (95% CI: 0.86-0.97), respectively-and the LHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.94 (95% CI: 0.87-0.97)-(p < 0.0001 for both). The Bland-Altman analysis showed good agreement between the mobility of the RHD and that of the LHD.

CONCLUSIONS

The DMarea method proved to be a valid, reliable measure of diaphragmatic mobility.

Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD?

Background

The 6-minute pegboard and ring test (6-PBRT) is a useful test for assessing the functional capacity of upper limbs in patients with stable COPD. Although 6-PBRT has been validated in stable patients, the possibility of a high floor effect could compromise the validity of the test in the hospital setting. The aim of this study was to verify the convergent validity of 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD).

Methods

A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD and healthy elderly participants, voluntarily recruited from the community, were considered for inclusion. All participants underwent a 6-PBRT. Isokinetic evaluation to measure the strength and endurance of elbow flexors and extensors, handgrip strength (HGS), spirometry testing, the modified Pulmonary Functional Status Dyspnea Questionnaire (PFSDQ-M), the COPD assessment test (CAT), and symptoms of dyspnea and fatigue were all measured as comparisons for convergent validity. Good convergent validity was considered if >75% of these hypotheses could be confirmed (correlation coefficient>0.50).

Results

A total of 17 patients with AECOPD (70.9±5.1 years and forced expiratory volume in 1 second [FEV₁] of 41.8%±17.9% of predicted) and 11 healthy elderly subjects were included. The HGS showed a significant strong correlation with 6-PBRT performance (r=0.70; p=0.002). The performance in 6-PBRT presented a significant moderate correlation with elbow flexor torque peak (r=0.52; p=0.03) and elbow extensor torque peak (r=0.61; p=0.01). The total muscular work of the 15 isokinetic contractions of the elbow flexor and extensor muscles showed a significant moderate correlation with the performance in 6-PBRT (r=0.59; p=0.01 and r=0.57; p=0.02, respectively). Concerning the endurance of elbow flexors and extensors, there was a significant moderate correlation with 6-PBRT performance (r=−0.50; p=0.04 and r=−0.51; p=0.03, respectively). In relation to the upper-extremity physical activities of daily living (ADLs) assessed by means of PFSDQ-M, there was a significant moderate correlation of 6-PBRT with three domains: influence of dyspnea on ADLs (r=−0.66; p<0.001), influence of fatigue on ADLs (r=−0.60; p=0.01), and change in ADLs in relation to the period before the disease onset (r=−0.51; p=0.03). The CAT was also correlated with 6-PBRT (r=−0.51; p=0.03). Finally, the performance in 6-PBRT showed a significant moderate correlation with the increase in dyspnea (r=−0.63; p=0.01) and a strong correlation with the increase in fatigue of upper limbs (r=−0.76; p<0.001) in patients with AECOPD. Convergent validity was considered adequate, since 81% from 16 predefined hypotheses were confirmed. There was no correlation between 6-PBRT and patients’ height. The performance in 6-PBRT was worse in patients with AECOPD compared to healthy elderly individuals (248.7±63.0 vs 361.6±49.9 number of moved rings; p<0.001).

Conclusion

The 6-PBRT is valid for the evaluation of functional capacity of upper limbs in hospitalized patients with AECOPD.

Validity and reliability of fluoroscopy for digital radiography: a new way to evaluate diaphragmatic mobility

Background

Fluoroscopy is considered the most accurate method to evaluate the diaphragm, yet most existing methods for measuring diaphragmatic mobility using fluoroscopy are complex. To assess the validity and reliability of a new evaluation method of diaphragmatic motion using fluoroscopy by digital radiography of healthy adults.

Methods

Twenty-six adults were evaluated, according to the parameters: anthropometry and pulmonary function test. The evaluation of diaphragm mobility by means of fluoroscopy by digital radiography method was randomly conducted by two raters (A and B). The Pearson correlation coefficient and the intraclass correlation coefficient (ICC) were used to assess the concurrent validity. The inter-rater and intra-rater reliability of the measurement of diaphragmatic motion was determined using ICC and a confidence interval of 95%.

Results

There was a relationship in the assessment of the concurrent validity. There was good inter-rater reliability for right hemidiaphragm mobility and moderate reliability for left hemidiaphragm in the first assessment. In the second assessment, there was good reliability for the mobility of both hemidiaphragms. There was good intra-rater reliability in the mobility of both hemidiaphragms for raters A and B.

Conclusion

The evaluation of diaphragmatic motion using fluoroscopy by digital radiography proved to be a valid and reliable method of healthy adults.

Reference equations for handgrip strength: Normative values in young adult and middle-aged subjects

BACKGROUND & AIMS

Handgrip strength (HS) has been widely used as a functionality parameter of the upper limbs (UL) and general health. The measurement of HS by dynamometry is a low cost, non-invasive method of simple applicability, widely used in pulmonary rehabilitation and in critical care units. However, there are no reports in the literature of reference equations for the Brazilian population involving young and middle-aged adults. The aim of this study was to establish reference equations to predict normal HS for young and middle-aged adults through demographic and anthropometric data.

METHODS

This is a cross-sectional study with a sample of 80 healthy subjects (40 men and 40 women), aged 20-60 years. Inclusion criteria were: 1) BMI between 18.5 and 30 kg/m²; 2) presence of dominant hand; 3) no cardiac, pulmonary, metabolic, or neurologic diseases; 4) lack of musculoskeletal disorders; 5) no history of fractures or trauma of the UL. Anthropometric measurements of the UL were obtained by a tape (hand length and width, forearm circumference and length). The dominance of hands was defined by the Dutch Handedness Questionnaire. HS measures were obtained by a manual hydraulic dynamometer, according to the recommendations of the American Association of Hand Therapists. Data were analyzed with SPSS for Windows, version 17.0, and treated with descriptive and inferential analysis. Normality was evaluated by Kolmogorov-Smirnov. Pearson or Spearman coefficients and multiple regression analysis were also used.

RESULTS

HS was significantly higher for men compared to women, and also higher for the dominant hand (HSD) compared to the non-dominant hand (HSND) (p < 0.05). No significant differences were found for HS between the age groups 20-30, 30-40, 40-50 and 50-60 years (p > 0.05). No correlation was found between HS and age. A weak correlation was found between HS and BMI. A moderate correlation of HS was observed with weight and height. Finally, moderate and high correlations were found between HS and anthropometric variables of UL. The best reference equations with R², adjusted to 0.71 and 0.70, were respectively: HSD_kg = -15.490 + (10.787 × Gender _{male=1; female=0}) + (0.558 × Forearm circumference) + (1.763 × Hand Length); HSND_kg = -9.887 + (12.832 × Gender _{male=1; female=0}) + (2.028 × Hand Length).

CONCLUSION

The variability of HS is largely explained by gender, forearm circumference, and hand length.

Adjunctive Use of Noninvasive Ventilation During Exercise in Patients With Decompensated Heart Failure

Noninvasive ventilation (NIV) as an adjunct strategy for increasing exercise tolerance has been widely investigated in patients with pulmonary diseases. To our knowledge, there are no studies that have used NIV during exercise in patients with decompensated heart failure (HF). The aim of this study was to evaluate the effects of NIV on exercise tolerance in hospitalized patients with decompensated HF. Thirteen patients (77 ± 15 years) with a mean left ventricular ejection fraction of 35 ± 15% were included. Patients underwent 2 submaximal exercise tests with constant load for lower limbs using a portable cycle ergometer. Tests were performed on the same day with a 60-minute interval between each one, using a randomized crossover design: sham ventilation (continuous positive airway pressure mode, 4 cm H₂O) and intervention situation (NIV in bilevel mode). Primary outcome was the endurance time performed during exercise tests with constant load. Submaximal exercise with NIV in bilevel mode improved endurance time (7.2 ± 2.7 minutes) compared to the tests performed with continuous positive airway pressure (5.1 ± 1.5 minutes; p = 0.008). Increase in endurance time (Δ time) with bilevel test showed a significant correlation with reduction in the slope of dyspnea (Δ Borg) over time (r = -0.73; p = 0.004). There was a significant correlation between endurance time in bilevel tests and maximum inspiratory pressure % predicted (r = 0.68; p = 0.02). In conclusion, NIV was effective in increasing exercise tolerance in hospitalized patients with decompensated HF. (ClinicalTrials.gov registration NCT02122848).

Effects of Neuromuscular Electrical Stimulation During Hemodialysis on Peripheral Muscle Strength and Exercise Capacity: A Randomized Clinical Trial

OBJECTIVE

To evaluate the effects of neuromuscular electrical stimulation of high and low frequency and intensity, performed during hemodialysis, on physical function and inflammation markers in patients with chronic kidney disease (CKD).

DESIGN

Randomized clinical trial.

SETTING

Hemodialysis clinic.

PARTICIPANTS

Patients with CKD (N=51) were randomized into blocks of 4 using opaque sealed envelopes. They were divided into a group of high frequency and intensity neuromuscular electrical stimulation and a group of low frequency and intensity neuromuscular electrical stimulation.

INTERVENTIONS

The high frequency and intensity neuromuscular electrical stimulation group was submitted to neuromuscular electrical stimulation at a frequency of 50Hz and a medium intensity of 72.90mA, and the low frequency and intensity neuromuscular electrical stimulation group used a frequency of 5Hz and a medium intensity of 13.85mA, 3 times per week for 1 hour, during 12 sessions.

MAIN OUTCOME MEASURES

Peripheral muscle strength, exercise capacity, levels of muscle trophism marker (insulin growth factor 1) and levels of proinflammatory (tumor necrosis factor α) and anti-inflammatory (interleukin 10) cytokines.

RESULTS

The high frequency and intensity neuromuscular electrical stimulation group showed a significant increase in right peripheral muscle strength (155.35±65.32Nm initial vs 161.60±68.73Nm final; P=.01) and left peripheral muscle strength (156.60±66.51Nm initial vs 164.10±69.76Nm final; P=.02) after the training, which did not occur in the low frequency and intensity neuromuscular electrical stimulation group for both right muscle strength (109.40±32.08Nm initial vs 112.65±38.44Nm final; P=.50) and left muscle strength (113.65±37.79Nm initial vs 116.15±43.01Nm final; P=.61). The 6-minute walk test distance (6MWTD) increased in both groups: high frequency and intensity neuromuscular electrical stimulation group (435.55±95.81m initial vs 457.25±90.64m final; P=.02) and low frequency and intensity neuromuscular electrical stimulation group (403.80±90.56m initial vs 428.90±87.42m final; P=.007). The groups did not differ in peripheral muscle strength and 6MWTD after the training protocol. In the high frequency and intensity neuromuscular electrical stimulation group, a correlation was observed between the initial and final values of 6MWTD and muscle strength. In the low frequency and intensity neuromuscular electrical stimulation group, correlations occurred only between the 6MWTD and the initial muscle strength. Only the low frequency and intensity neuromuscular electrical stimulation group increased levels of insulin growth factor 1 (252.38±156.35pg/mL initial vs 336.97±207.34pg/mL final; P=.03), and only the high frequency and intensity neuromuscular electrical stimulation group reduced levels of interleukin 10 (7.26±1.81pg/mL vs 6.32±1.54pg/mL; P=.03). The groups showed no differences in tumor necrosis factor α levels.

CONCLUSIONS

Patients with CKD on hemodialysis improve exercise capacity after peripheral neuromuscular electrical stimulation of high and low frequency and intensity. However, the benefits on muscle and inflammatory outcomes seem to be specific for the adopted electrical stimulation strategy.

Functional evolution of critically ill patients undergoing an early rehabilitation protocol

OBJECTIVE

Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit.

METHODS

A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan's parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial).

RESULTS

In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays.

CONCLUSION

The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol.

Unidirectional Expiratory Valve Method to Assess Maximal Inspiratory Pressure in Individuals without Artificial Airway

Introduction

Maximal Inspiratory Pressure (MIP) is considered an effective method to estimate strength of inspiratory muscles, but still leads to false positive diagnosis. Although MIP assessment with unidirectional expiratory valve method has been used in patients undergoing mechanical ventilation, no previous studies investigated the application of this method in subjects without artificial airway.

Objectives

This study aimed to compare the MIP values assessed by standard method (MIP_sta) and by unidirectional expiratory valve method (MIP_uni) in subjects with spontaneous breathing without artificial airway. MIP_uni reproducibility was also evaluated.

Methods

This was a crossover design study, and 31 subjects performed MIP_sta and MIP_uni in a random order. MIP_sta measured MIP maintaining negative pressure for at least one second after forceful expiration. MIP_uni evaluated MIP using a unidirectional expiratory valve attached to a face mask and was conducted by two evaluators (A and B) at two moments (Tests 1 and 2) to determine interobserver and intraobserver reproducibility of MIP values. Intraclass correlation coefficient (ICC_[2,1]) was used to determine intraobserver and interobserver reproducibility.

Results

The mean values for MIP_uni were 14.3% higher (-117.3 ± 24.8 cmH₂O) than the mean values for MIP_sta (-102.5 ± 23.9 cmH₂O) (p<0.001). Interobserver reproducibility assessment showed very high correlation for Test 1 (ICC_[2,1] = 0.91), and high correlation for Test 2 (ICC_[2,1] = 0.88). The assessment of the intraobserver reproducibility showed high correlation for evaluator A (ICC_[2,1] = 0.86) and evaluator B (ICC_[2,1] = 0.77).

Conclusions

MIP_uni presented higher values when compared with MIP_sta and proved to be reproducible in subjects with spontaneous breathing without artificial airway.