Perception of patients with interstitial lung diseases submitted to inspiratory muscle training

BACKGROUND

Although inspiratory muscle training reduces dyspnea in patients with chronic respiratory diseases, it was not yet evaluated in a sample composed exclusively of patients with interstitial lung diseases.

OBJECTIVE

To discuss the perception of patients with interstitial lung diseases about inspiratory muscle training intervention.

METHODS

This is a qualitative study. Data were collected using semi-structured interviews, transcribed, and analyzed by thematic analysis.

RESULTS

Fourteen patients (64 ± 7 years) with interstitial lung disease were interviewed. Average participation in the inspiratory muscle training program was 90% (range, 66-100%). Three themes were elaborated: 1) dyspnea and other symptoms in daily life (e.g. "I could not carry out a bag; I was very uncomfortable"); 2) less symptom and greater performance (e.g. "I wash and change my clothes, house cleaning, do everything without feeling anything"); and 3) IMT: a time dedicated to my health (e.g. "For me it was great because I saw my evolution every day").

CONCLUSION

Patients noticed improvements in symptoms and performance related to daily activities. Despite initial difficulties, patients continued training as planned.

The Effect of Respiratory Muscle Training on Swallowing Function in Patients With Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

The improvement of swallowing function after stroke is a significant challenge faced by patients and health care professionals. However, the current evidence synthesis of the effects of respiratory muscle training (RMT) on swallowing function is limited.

OBJECTIVE

To assess the effectiveness of RMT on swallowing recovery in patients undergoing stroke.

METHODS

The CKNI, WanFang Data, PubMed, CINAHL, Web of Science, Embase, MEDLINE, and Cochrane Library databases were searched for studies evaluating RMT interventions' effect on swallowing outcomes. Risks of bias were evaluated using the approach recommended by the Cochrane Collaboration tool and a summary of findings table was generated using the GRADE approach. Outcomes were synthesized using a random-effects meta-analysis model.

RESULTS

RMT interventions reduced the risk of aspiration (SMD = 1.19; 95% CI, 0.53-1.84), the recovery process of water swallowing function (RR = 1.22; 95% CI, 1.05-1.42), and the activity of the swallowing muscles (SMD = 2.91; 95% CI, 2.22-3.61). However, there was no significant effect of RMT on the functional level of oral intake (SMD = 0.70; 95% CI, -0.03 to 1.42).

CONCLUSIONS

RMT can be regarded as an innovative, auxiliary means in the near future to better manage and improve swallowing function, given its improving effect on work outcomes in this review.

A preliminary study on the respiratory benefits of adaptive video gaming in individuals with cervical spinal cord injuries

PURPOSE

The purpose of this study was to collect preliminary data to assess whether participation in adaptive video gaming using a pneumatic sip-and-puff video game controller may provide respiratory or health benefits for individuals with cervical-level spinal cord injuries.

METHODS

A survey was anonymously distributed to potential participants and consisted of four sections: (1) General Information, (2) Gaming Habits, (3) Respiratory Quality of Life, and (4) Impact of Adaptive Video Gaming on Respiratory Health.

RESULTS

The study included 124 individuals with cervical-level spinal cord injuries. Participants had primarily positive self-rated health and good respiratory quality of life. Nearly half of the participants (47.6%) Agreed or Strongly Agreed that their breathing control has improved after using their sip-and-puff gaming controller and 45.2% Agreed or Strongly Agreed that their respiratory health has improved. Individuals who Agreed or Strongly Agreed that adaptive video gaming has improved their breathing control also reported a significantly higher level of exertion while gaming compared to those who did not Agree or Strongly Agree (p = 0.00029).

CONCLUSIONS

It is possible that there are respiratory benefits of using sip-and-puff video game controllers for individuals with cervical spinal cord injuries. The benefits reported by users were found to be dependent on their level of exertion while playing video games. Further exploration in this area is needed due to the positive benefits reported by participants.

Respiratory muscle training for obstructive sleep apnea: Systematic review and meta-analysis

Obstructive sleep apnea is the most common sleep disorder. This review aims to evaluate the effectiveness and safety of respiratory muscle training in the treatment of patients with obstructive sleep apnea. The study protocol was registered in Prospero Platform (CRD42018096980). We performed searches in the main databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed; Excerpta Medica dataBASE (Embase) via Elsevier; Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Library; Latin American and Caribbean Literature on Health Sciences (LILACS) through the Portal of the Virtual Health Library and Physiotherapy Evidence Database (PEDro) for all randomised-controlled trials published before July 2022. The randomised-controlled trials were assessed for risk of bias and certainty of evidence. Thirteen randomised-controlled trials were included. All studies had an overall high risk of bias. Inspiratory muscle training probably improves systolic blood pressure and sleepiness when compared with sham. However, inspiratory muscle training probably does not improve diastolic blood pressure and maximum expiratory pressure, and may not be superior to sham for apnea-hypopnea index, forced expiratory volume in 1 s, forced vital capacity, sleep quality and quality of life. In addition, it is uncertain whether there is any effect of inspiratory muscle training on maximum inspiratory pressure and physical capacity. Inspiratory muscle training may also improve maximum inspiratory pressure and maximum expiratory pressure compared with oropharyngeal exercises. However, it may not be superior for apnea-hypopnea index, sleep quality, sleepiness, quality of life and functional capacity. When associated with physical exercise, inspiratory muscle training may not be superior to physical exercise alone for maximum inspiratory pressure, maximum expiratory pressure, systolic and diastolic blood pressure, and functional capacity. At the same time, when associated with cardiac rehabilitation exercises, inspiratory muscle training may reduce apnea-hypopnea index, improve inspiratory muscle strength, sleepiness and sleep quality compared with cardiac rehabilitation alone. However, it may not be superior for improving quality of life. Regarding expiratory muscle training, it may improve expiratory muscle strength and sleep quality, but not sleepiness when compared with sham. The evidence on the effects of expiratory muscle training in apnea-hypopnea index is very uncertain.

Effects of high-intensity inspiratory muscle training on systemic inflammatory response in cardiac surgery - A randomized clinical trial

PURPOSE

Preoperative inspiratory muscle training reduces the incidence of postoperative pulmonary complications after cardiac surgery, but training protocols vary widely in terms of intensity. Currently, the mechanisms underlying the effectiveness of this practice are not known. The purpose of the present study is to determine whether preoperative high-intensity inspiratory muscle training (HI-IMT) modulates the perioperative systemic inflammatory response in cardiac surgery patients.

METHODS

Participants awaiting surgical aortic valve replacement were randomized to 3 to 6 weeks preoperative home-based HI-IMT or same duration low-intensity inspiratory muscle training (LI-IMT). The primary outcome was the preoperative value of the soluble tumor necrosis factor receptor 1 (sTNFR1). Secondary outcomes assessed perioperative evolution of the cytokines: sTNFR1, Tumor necrosis factor-α, Interleukin (IL)-6, IL-8, IL10, IL1β, and their combined z-score; reflecting post-training and postoperative inflammatory response. Perioperative pulmonary function and postoperative clinical outcomes were collected.

RESULTS

Between February 2018 and March 30, 2019 patients were randomized, to HI-IMT or LI-IMT. There were no differences between the groups in terms of baseline characteristics. The median (IQR) training duration was 34 (28-44) days. After training, the median (IQR) predicted maximal inspiratory pressure was higher in the HI-IMT vs LI-IMT group (119 (96-142%) vs 97 (81-107%); p = .04) Levels of the sTNFR1 cytokine increased during training in the HI-IMT group, pre vs post training (Median (IQR) 1073 (920; 1219) vs 1172 (965; 1368) ng/L; p = .03). The 24-h postoperative global inflammatory score was lower in the HI-IMT than in the LI-IMT group (Median (IQR), -0.37 (-0.62, 0.03) vs -0.10 (-0.17, 0.49), p = .04). Global inflammatory scores were not different at other time points. There were no significant differences between the groups in post-operative pulmonary function and postoperative clinical outcome.

CONCLUSION

High intensity inspiratory muscle training shows immunomodulatory properties. These properties could explain why preoperative inspiratory muscle training can lead to lung protection after cardiac surgery.

Transformative Physiotherapy Approach in an 80-Year-Old Female: A Case Report of Managing Obstructive Sleep Apnea for Improved Quality of Life

Obstructive sleep apnea (OSA) presents a significant challenge to patients' overall health and well-being, characterized by upper airway collapse during sleep leading to fragmented and non-restorative sleep patterns. This case report describes an 80-year-old female patient presenting with breathlessness, obesity (BMI: 43 kg/m2), sleep disturbances, fatigue, attention deficits, reduced chest compliance, and a history of type 2 diabetes mellitus. Clinical findings revealed ongoing sleep disruptions, worsening breathlessness, progressive weakness, and decreased oxygen saturation levels. The therapeutic intervention involved a comprehensive physiotherapy program targeting respiratory muscle training, lung function improvement, peripheral muscle strengthening, and relaxation exercises. The discussion highlights studies supporting physiotherapeutic interventions such as thoracic extension exercises, neuromuscular stimulation, and oropharyngeal exercises for managing OSA symptoms. Overall, this case underscores the importance of tailored physiotherapy interventions in addressing the multifaceted challenges of OSA, aiming to improve patient outcomes and quality of life.

Respiratory Muscle Training and Its Impact on Balance and Gait in Patients with Severe COPD

Background and Objectives: Improving extrapulmonary symptoms in COPD through respiratory muscle training can help alleviate the burden of respiratory symptoms, reduce fatigue, and improve exercise capacity in patients with COPD. This, in turn, can enhance physical activity, balance, and gait, ultimately improving the overall quality of life for individuals with COPD. This study aimed to investigate the effects of respiratory muscle training on balance and gait in patients with moderate to severe COPD. Materials and Methods: We included 65 patients with moderate to severe COPD randomly assigned to either the pulmonary rehabilitation protocol group (PR) or the pulmonary rehabilitation and inspiratory muscle training group (PR + IMT) for three weeks. Patients performed a spirometry, maximal inspiratory and expiratory pressure (MIP/MEP), 6 min walking test (6MWT), activities-specific balance confidence (ABC) scale questionnaire, Berg Balance Scale (BBS), timed up and go test (TUG), and single-leg stance test (SLS). Results: Rehabilitation had a notable impact on MIP in Group 2 (PR + IMT), with a highly significant difference between pre- and post-rehabilitation distributions (p < 0.0001). At the same time, Group 1 (PR-only) showed no significant changes (p = 0.27). In Group 1 (Control), pre- and post-rehabilitation comparisons reveal slight non-significant changes for SLS EO (p = 0.16), ABC (p = 0.07), TUG (p = 0.06), and BBS (p = 0.13). In contrast, in Group 2 (Cases), there are significant improvements in all variables after rehabilitation compared to the pre-rehabilitation values: SLS EO (p < 0.0001), ABC (p < 0.0001), TUG (p < 0.0001), and BBS (p < 0.0001). Conclusions: Our research demonstrated that respiratory muscle training significantly positively impacts balance and gait performance among patients with moderate to severe COPD compared to a control group.

Pulmonary Function Tests Post-Stroke. Correlation between Lung Function, Severity of Stroke, and Improvement after Respiratory Muscle Training

Stroke is a significant cause of mortality and chronic morbidity caused by cardiovascular disease. Respiratory muscles can be affected in stroke survivors, leading to stroke complications, such as respiratory infections. Respiratory function can be assessed using pulmonary function tests (PFTs). Data regarding PFTs in stroke survivors are limited. We reviewed the correlation between PFTs and stroke severity or degree of disability. Furthermore, we reviewed the PFT change in stroke patients undergoing a respiratory muscle training program. We searched PubMed until September 2023 using inclusion and exclusion criteria in order to identify studies reporting PFTs post-stroke and their change after a respiratory muscle training program. Outcomes included lung function parameters (FEV1, FVC, PEF, MIP and MEP) were measured in acute or chronic stroke survivors. We identified 22 studies of stroke patients, who had undergone PFTs and 24 randomised controlled trials in stroke patients having PFTs after respiratory muscle training. The number of patients included was limited and studies were characterised by great heterogeneity regarding the studied population and the applied intervention. In general, PFTs were significantly reduced compared to healthy controls and predicted normal values and associated with stroke severity. Furthermore, we found that respiratory muscle training was associated with significant improvement in various PFT parameters and functional stroke parameters. PFTs are associated with stroke severity and are improved after respiratory muscle training.

Effects of low workload respiratory training with steam inhalation on lung function in stable asthma: A controlled clinical study

To investigate effects of low workload respiratory muscle training (RMT) on respiratory muscle power and lung function in asthmatics, we recruited asthmatic persons who performed a 4-week training programme. The training included 20 daily ex- and inhalations with counter pressure 30% from the individual maximal expiratory pressure (MEP). Lung function was measured before and after the training programme and a follow-up period. The study also included several subjective endpoints for respiratory symptoms. A significant increase in a training group (n = 27) compared with a control group (n = 20) was seen in MEP (+12.4%, vs. +3.5%, p = 0.086), maximal inspiratory pressure (MIP) (+21.1% vs. +0.82%, p = 0.023), slow vital capacity (VC) (+3.7% vs. +1.5%, p = 0.023) and in forced expiratory time (FET, +15.5%, vs. -5.0%, p = 0.022). After being a control for group A, also group B performed similar RMT as group A. In the combined group (A and B, n = 47) MEP (11.3%, p = 0.003), MIP (19.73%, p < 0.001), VC (4.1%, p < 0.001) and FET (14.7%, p < 0.001) increased significantly from the baseline. Changes in other lung function variables were not indicative. On a scale of 1-5, the subjects perceived improvement in reduction of mucus secretion in the airways (median 3, p < 0.001), alleviation of coughing (median 3, p < 0.001) and reduction in dyspnoea (median 3, p < 0.001). As a conclusion, low workload respiratory training of 4 weeks improved respiratory muscle power and increased VC in patients with stable asthma.

Development of and adherence to an ERAS® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study

BACKGROUND AND OBJECTIVE

There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery.

METHODS

Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire.

RESULTS

The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups.

CONCLUSION

The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.

The results of inspiratory muscle training on cardiac, respiratory, musculoskeletal, and psychological status in patients with stable angina: a randomized controlled trial

PURPOSE

To determine the effect of inspiratory muscle training (IMT) on respiratory and peripheral muscle strength, functional exercise capacity, health-related quality of life (HRQoL), fatigue, depression, and cardiac functions in patients with stable angina.

METHODS

A randomized, controlled, single-blinded study. Twenty patients (59.95 ± 7.35 y, LVEF = 58.77 ± 7.49) with stable angina received IMT at the lowest load (10 cmH2O), and 20 patients (55.85 ± 7.60 y, LVEF = 62.26 ± 7.75) received training at 30% of maximal inspiratory pressure (MIP) seven days/8 weeks. Respiratory muscle strength (MIP; maximal expiratory pressure, MEP), peripheral muscle strength, pulmonary functions, functional exercise capacity (6-min walking test; exercise test), fatigue, HRQoL, depression, and cardiac functions were evaluated before and after.

RESULTS

A statistical difference was found between groups in terms of respiratory and peripheral muscle strength, pulmonary functions, functional exercise capacity (p < 0.05). The results of fatigue, depression, HRQoL, and cardiac functions were similar between the groups (p > 0.05).

CONCLUSIONS

This study is the first to demonstrate the positive effects of IMT in patients with stable angina. IMT is a safe and effective method and is recommended to be added to cardiopulmonary rehabilitation programs and guidelines, as it results in increased peripheral muscle strength and functional exercise capacity in stable angina patients.Implications for rehabilitationInspiratory muscle training (IMT) is a safe and effective method for coronary artery disease (CAD) patients with stable angina.IMT improved respiratory and peripheral muscle strength, functional exercise capacity, pulmonary functions, and health-related quality of life in CAD patients with stable angina.Perception of depression and fatigue were decreased with IMT in CAD patients with stable angina.

Effects of an inpatient rehabilitation programme on functional capacity, quality of life and psychological distress in patients with post covid-19 condition: an observational study

OBJECTIVES

To examine changes in functional capacity, health-related quality of life and psychological distress in patients with post-COVID-19 condition following a multidisciplinary rehabilitation programme. In addition, to explore whether additional respiratory muscle training for more impaired patients might support their recovery process.

DESIGN

Retrospective observational cohort study.

PATIENTS

A total of 779 patients with post-COVID-19 condition (47.9% female, mean age 56.6 years).

METHODS

Measures assessed were: 6-minute walk test (6MWT), 5-level EQ-5D (EQ-5D-5L) including EQ Visual Analogue Scale (EQ-VAS) and Patient Health Questionnaire-4 (PHQ-4). Data were provided pre- and post-rehabilitation from 2 cohorts: (i) patients participating in a regular multidisciplinary rehabilitation programme; and (ii) patients receiving additional respiratory muscle training due to an initially greater level of impairment. Dependent t-tests and general linear mixed models were used for data analysis.

RESULTS

A series of dependent t-tests revealed mean overall improvement for both groups in 6-minute walk test distance (6MWD), EQ-5D-5L index, EQ-VAS and PHQ-4 following the rehabilitation programme. General linear mixed models showed significant interaction effects between groups and time for the EQ-5D-5L index and 6MWD.

CONCLUSION

A multidisciplinary rehabilitation programme appears to have a beneficial impact on the recovery process of patients with post-COVID-19 condition.

An unusual way to improve lung function in congenital myopathies: the power of singing

Congenital myopathies (CMs) are a clinically and genetically heterogeneous group of disorders characterized by early onset weakness, hypotonia and characteristic structural abnormalities in muscle fibres. Hypotonia and weakness can be present at birth or appear in infancy, and a static or slowly progressive clinical course may present with muscle weakness, loss of spontaneous movement, involuntary muscle activity, and muscle atrophy. Often patients develop a restrictive syndrome and respiratory failure and require respiratory support In our case, we described lung improvement and respiratory muscle training due to singing in a young patient, affected by CMs with a poor adherence to non-invasive mechanical ventilation.

Respiratory muscle training induces additional stress and training load in well-trained triathletes-randomized controlled trial

Background: Respiratory muscle training (RMT) has been investigated in the context of improved athletic performance and pulmonary function. However, psychophysiological costs of RMT remain understudied. Voluntary isocapnic hyperpnoea (VIH) and inspiratory pressure threshold loading (IPTL) are widely applied RMT methods. The main purposes of this study were to assess whether RMT induces additional load on well-trained triathletes and determine differences in RMT-induced load between sexes and applied methods. Materials and Methods: 16 well-trained triathletes (n = 16, 56% males) underwent 6 weeks of VIH or IPTL program with progressive overload. Blood markers, subjective measures, cardiac indices, near-infrared spectroscopy indices, inspiratory muscle fatigue, and RMT-induced training load were monitored pre-, in and post-sessions. We used multiple ANOVA to investigate effects of sex, training method, and time on measured parameters. Results: There were significant interactions for acid-base balance (p = 0.04 for sex, p < 0.001 for method), partial carbon dioxide pressure (p = 0.03 for sex, p < 0.001 for method), bicarbonate (p = 0.01 for method), lactate (p < 0.001 for method), RMT-induced training load (p = 0.001 for method for single session, p = 0.03 for method per week), average heart rate (p = 0.03 for sex), maximum heart rate (p = 0.02 for sex), intercostales muscle oxygenation (p = 0.007 for testing week), and intercostales muscle oxygenation recovery (p = 0.003 for testing week and p = 0.007 for method). Conclusion: We found that RMT induced additional load in well-trained triathletes. Elicited changes in monitored variables depend on sex and training method. VIH significantly increased subjective training load measures. IPTL was associated with disbalance in blood gasometry, increase in lactate, and reports of headaches and dizziness. Both methods should be applied with consideration in high-performance settings.

Systemic and Pulmonary Inflammation/Oxidative Damage: Implications of General and Respiratory Muscle Training in Chronic Spinal-Cord-Injured Patients

Chronic spinal cord injury affects several respiratory-function-related parameters, such as a decrease in respiratory volumes associated with weakness and a tendency to fibrosis of the perithoracic muscles, a predominance of vagal over sympathetic action inducing airway obstructions, and a difficulty in mobilizing secretions. Altogether, these changes result in both restrictive and obstructive patterns. Moreover, low pulmonary ventilation and reduced cardiovascular system functionality (low venous return and right stroke volume) will hinder adequate alveolar recruitment and low O₂ diffusion, leading to a drop in peak physical performance. In addition to the functional effects described above, systemic and localized effects on this organ chronically increase oxidative damage and tissue inflammation. This narrative review describes both the deleterious effects of chronic spinal cord injury on the functional effects of the respiratory system as well as the role of oxidative damage/inflammation in this clinical context. In addition, the evidence for the effect of general and respiratory muscular training on the skeletal muscle as a possible preventive and treatment strategy for both functional effects and underlying tissue mechanisms is summarized.

Physical therapy for sleep apnea: a smartphone application for home-based physical therapy for patients with obstructive sleep apnea

Purpose

In this study, we described "PT for Sleep Apnea", a smartphone application for home-based physical therapy of patients with Obstructive Sleep Apnea (OSA).

Methods

The application was created in a joint program between the University of Medicine and Pharmacy at Ho Chi Minh City (UMP), Vietnam, and National Cheng Kung University (NCKU), Taiwan. Exercises maneuvers were derived from the exercise program previously published by the partner group at National Cheng Kung University. They included exercises for upper airway and respiratory muscle training and general endurance training.

Results

The application provides video and in-text tutorials for users to follow at home and a schedule function to assist the user in organizing the training program, which may improve the efficacy of home-based physical therapy in patients with Obstructive Sleep Apnea.

Conclusion

In the future, our group plans to conduct a user study and randomized-controlled trials to investigate whether our application can benefit patients with OSA.

Inspiratory Muscle Training Improves Maximal Inspiratory Pressure Without Increasing Performance in Elite Swimmers

PURPOSE

To analyze the effect of inspiratory muscle training (IMT) on the maximal inspiratory mouth pressure (MIP) and performance of elite swimmers.

METHODS

Eight participants performed a 3000-m swimming test (T-3000), followed by blood lactate measurements at 1 and 5 minutes postexercise.. The testing protocol was carried out before and after 6 weeks of IMT, in which a high-volume IMT group (HV-IMT) (n = 4) performed IMT twice a day-in the morning in a seated position and in the afternoon in a concurrent session of IMT and core muscle training. Also, a low-volume IMT group (LV-IMT) (n = 4) performed IMT in the morning session only.

RESULTS

After the intervention, both groups improved their MIP, HV-IMT (132.75 [27.42] to 156.75 [21.88] cmH2O; P = .010; d = 0.967) and LV-IMT (149.25 [22.82] to 171.50 [23.74] cmH2O; P = .013; d = 0.955), without a significant difference between groups (P = .855). Regarding swimming performance, there were no changes between groups in the T-3000 (P = .472) or lactate removal rate (P = .104).

CONCLUSION

IMT increased inspiratory muscle strength in elite swimmers, but there was no association or meaningful impact on swimming performance.

Inspiratory-Expiratory Muscle Training Improved Respiratory Muscle Strength in Dialysis Patients: A Pilot Randomised Trial

End-stage kidney disease (ESKD) exposes patients to progressive physical deconditioning involving the respiratory muscles. The aim of this pilot randomized controlled trial was to determine the feasibility and effectiveness of low-intensity respiratory muscle training (RMT) learned at the hospital and performed at home. A group of ESKD patients (n = 22) were randomized into RMT or usual care (control group, CON) in a 1:1 ratio. The respiratory training was performed at home with an inspiratory-expiratory system for a total of 5 min of breathing exercises in a precise rhythm (8 breaths per minute) interspersed with 1 min of rest, two times per day on nondialysis days for a total of 4 weeks, with the air resistance progressively increasing. Outcome measures were carried out every 4 weeks for 3 consecutive months, with the training executed from the 5th to the 8th week. Primary outcomes were maximal inspiratory and expiratory pressure (MIP, MEP), while secondary outcomes were lung capacity (FEV1, FVC, MVV). Nineteen patients without baseline between-group differences completed the trial (T: n = 10; Age: 63 ± 10; Males: n = 12). Both MIP and MEP significantly improved at the end of training in the T group only, with a significant difference of MEP of 23 cmH₂O in favor of the RMT group (p = 0.008). No significant variations were obtained for FVC, FEV1 or MVV in either group, but there was a greater decreasing trend over time for the CON group, particularly for FVC (t = -2.00; p = 0.046). Low-fatiguing home-based RMT, with a simple device involving both inspiratory and expiratory muscles, may significantly increase respiratory muscle strength.

Effects of Inspiratory Muscle Training on Muscle Oxygenation during Vascular Occlusion Testing in Trained Healthy Adult Males

Inspiratory muscle training (IMT) may have an additional effect on cardiovascular autonomic modulation, which could improve the metabolism and vascular function of the muscles.

AIM

To determine the effects of IMT on vascular and metabolic muscle changes and their relationship to changes in physical performance.

METHODS

Physically active men were randomly placed into an experimental (IMTG; n = 8) or IMT placebo group (IMTPG; n = 6). For IMT, resistance load was set at 50% and 15% of the maximum dynamic inspiratory strength (S-Index), respectively. Only the IMTG's weekly load was increased by 5%. In addition, both groups carried out the same concurrent training. Besides the S-Index, a 1.5-mile running test, spirometry, and deoxyhemoglobin (HHb_AUC during occlusion) and reperfusion tissue saturation index (TSI_MB and TSI_MP: time from minimum to baseline and to peak, respectively) in a vascular occlusion test were measured before and after the 4-week training program. In addition, resting heart rate and blood pressure were registered.

RESULTS

IMTG improved compared to IMTPG in the S-Index (Δ = 28.23 ± 26.6 cmH₂O), maximal inspiratory flow (MIF: Δ = 0.91 ± 0.6 L/s), maximum oxygen uptake (Δ = 4.48 ± 1.1 mL/kg/min), 1.5-mile run time (Δ = -0.81 ± 0.2 s), TSI_MB (Δ = -3.38 ± 3.1 s) and TSI_MP (Δ = -5.88 ± 3.7 s) with p < 0.05. ΔVO_2max correlated with S-Index (r = 0.619) and MIF (r = 0.583) with p < 0.05. Both ΔTSI_MB and TSI_MP correlated with ΔHHb_AUC (r = 0.516 and 0.596, respectively) and with Δ1.5-mile run time (r = 0.669 and 0.686, respectively) with p < 0.05.

CONCLUSION

IMT improves vascular function, which is related to additional improvements in physical performance.

Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study

Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.

Inspiratory muscle training as adjuvant therapy in obstructive sleep apnea: a randomized controlled trial

The aim of this randomized controlled trial was to analyze the effects of an inspiratory muscle training (IMT) program on apnea and hypopnea index (AHI), inspiratory muscle strength, sleep quality, and daytime sleepiness in individuals with obstructive sleep apnea (OSA), whether or not they used continuous positive airway pressure (CPAP (+/−) therapy. The intervention group underwent IMT with a progressive resistive load of 40-70% of the maximum inspiratory pressure (PImax) for 30 breaths once a day for 12 weeks. The control group was submitted to a similar protocol, but with at a minimum load of 10 cmH₂O. Changes in the AHI were the primary outcome. PImax was measured with a digital vacuometer, daytime somnolence was measured by the Epworth sleepiness scale (ESS), and the quality of sleep by the Pittsburgh Sleep Quality Index (PSQI). CPAP use was treated as a confounder and controlled by stratification resulting in 4 subgroups: IMT−/CPAP−, IMT−/CPAP+, IMT+/CPAP−, and IMT+/CPAP+. Sixty-five individuals were included in the final analysis. Significant variations were found in the 4 parameters measured throughout the study after the intervention in both CPAP− and CPAP+ participants: PImax was increased and AHI was reduced, whereas improvements were seen in both ESS and PSQI. The twelve-week IMT program increased inspiratory muscle strength, substantially reduced AHI, and had a positive impact on sleep quality and daytime sleepiness, whether or not participants were using CPAP. Our findings reinforce the role of an IMT program as an adjunct resource in OSA treatment.

Respiratory function and breathing response to water- and land-based cycling at the matched oxygen uptake

The impact of underwater exercise on respiratory function remains unclear when its metabolic rate is matched with exercise performed on land. Therefore, we compared the breathing responses and respiratory function during and after water (WC)- and land (LC)-based cycling performed at the matched oxygen uptake (VO2 ). Twelve healthy men performed 15 min of incremental WC and LC on separate days. During WC, participants cycled continuously at 30, 45, and 60 rpm (stages 1, 2, and 3) for 5 min each. During LC, participants cycled at 60 rpm for 15 min while wattage was increased every 5 min and adjusted to match VO2 to the WC condition. Breathing patterns during cycling and spirometry data before and after cycling were collected. VO2 during WC and LC was similar. Respiratory rate (WC: 27 ± 3 vs. LC: 23 ± 4 bpm, p = 0.012) and inspiratory flow (WC: 1233 ± 173 vs. LC: 1133 ± 200 ml/s, p = 0.035) were higher and inspiratory time (WC: 1.0 ± 0.1 vs. LC: 1.2 ± 0.2 s, p = 0.025) was shorter at stage 3 during WC than LC. After WC, forced vital capacity (p = 0.010) significantly decreased while no change was observed after LC. These results suggest that at similar metabolic rates during WC and LC, breathing is slightly shallower during WC which may have chronic effects on respiratory muscle function after multiple bouts of aquatic cycling. Underwater exercise may be beneficial for respiratory muscle rehabilitation when performed on a chronic basis.

The rationale of applying inspiratory/expiratory muscle training within the same respiratory cycle in children with bronchial asthma: A placebo-controlled randomized clinical investigation

Objective: Even though positive implications of inspiratory muscle training (In-MT) have been established in children and adolescents with bronchial asthma (C/AwBA), the role of combined inspiratory and expiratory muscle training (Ex-MT) within the same respiratory cycle (In/Ex-SC) is still unknown. This study was, therefore, set out to explore the effect of In/Ex-SC on respiratory muscle strength, pulmonary functions, and control of asthma symptoms in C/AwBA.Methods: This was a placebo-controlled randomized clinical investigation that included 51 C/AwBA (12-18 years). Participants were assigned randomly into three groups: Placebo, In-MT only, or combined In/Ex-SC training (n = 17, each group). The training was conducted for ∼35 min, thrice/week over 12 weeks. The maximal inspiratory (IP_max) and expiratory (EP_max) pressure (indicating the strength of the inspiratory and expiratory muscles, respectively), pulmonary functions [forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), and FEV₁/FVC index], and asthma control test (ACT) were assessed before and after the intervention.Results: The In/Ex-SC yielded larger increases in IP_max and EP_max than either the Placebo training (P=.031 and P=.009 respectively) or the In-MT (P=.029 and P=.032 respectively). Further, In/Ex-SC produced favorable improvement in FEV₁, FVC, and FEV₁/FVC compared to the Placebo training (P=.001, P=.004, and P=.0005 respectively) or In-MT (P=.038, P=.037, and P=.025 respectively) training. Furthermore, In/Ex-SC led to better control of asthma symptoms than the Placebo (P<.001) or In-MT (P=.002) training.Conclusion: This study provides evidence that combined In/Ex-SC can considerably improve respiratory muscle strength, enhance pulmonary function, and promote control over asthma symptoms in C/AwBA.

Stress Resilience Program for Health Care Professionals During a Pandemic: A Pilot Program

BACKGROUND

The COVID-19 pandemic has led to increased burnout and staff turnover for health care providers (HCPs). The purpose of this pilot study was to evaluate the safety and acceptability of a Stress Resilience Program (SRP) for reducing perceived stress and improving resilience among HCPs during a pandemic.

METHOD

Of the 12 HCPs expressing interest in the study, 10 were enrolled in this study. Participants attended three in-person visits (consent/screen, baseline, and end-of-study). The SRP consisted of education related to resilience enhancement and a breathing device (BreatherFit®) for combined respiratory muscle training (cRMT). Participants completed 4 weeks of cRMT and applied situational breathing strategies as needed. Outcomes measured were changes in stress (PSS-10), resilience (BRS), depression (PRIME-MD), and sleep (PSQI and Ōura Ring®).

FINDINGS

The majority of participants were male (60%) and White (60%) with an average age of 39.7 years. Changes from baseline to end-of-treatment indicated a positive trend with significant stress reduction (-3.2 ± 3.9, p = .028) and nonsignificant depression reduction (-0.5 ± 0.7, p = .05). Resilience was high at baseline and continued to stay high during the study with a nonsignificant increase at end-of-study (+0.07 ± 0.7, p = .77). No changes in overall sleep scores were noted. All participants agreed the study was worthwhile, 80% indicated they would repeat the experience, while 90% indicated they would recommend the study to others.

CONCLUSION/APPLICATION TO PRACTICE

Because of its size and portability, SRP is an easily applicable and promising option for reducing stress among HCPs during a high-stress period, such as a pandemic. Larger studies are needed.

The effects of a respiratory training mask on steady-state oxygen consumption at rest and during exercise

No studies have directly measured ventilatory and metabolic responses while wearing a respiratory training mask (RTM) at rest and during exercise. Eleven aerobically fit adults (age: 21 ± 1 years) completed a randomized cross-over study while wearing an RTM or control mask during cycling at 50% Wmax. An RTM was retrofitted with a gas collection tube and set to the manufacturer's "altitude resistance" setting of 6,000 ft (1,800 m). Metabolic gas analysis, ratings of perceived exertion, and oxygen saturation (SpO2) were measured during rest and cycling exercise. The RTM did not affect metabolic, ventilation, and SpO2 at rest compared to the control mask (all, effect of condition: P > 0.05). During exercise, the RTM blunted respiratory rate and minute ventilation (effect of condition: P < 0.05) compared to control. Similar increases in VO2 and VCO2 were observed in both conditions (both, effect of condition: P > 0.05). However, the RTM led to decreased fractional expired O2 and increased fractional expired CO2 (effect of condition: P < 0.05) compared to the control mask. In addition, the RTM decreased SpO2 and increased RPE (both, effect of condition: P < 0.05) during exercise. Despite limited influence on ventilation and metabolism at rest, the RTM reduces ventilation and disrupts gas concentrations during exercise leading to modest hypoxemia.

Respiratory Muscle Training in Patients with Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis

Background: Effective treatments for obstructive sleep apnoea (OSA) include positive pressure, weight loss, oral appliances, surgery, and exercise. Although the involvement of the respiratory muscles in OSA is evident, the effect of training them to improve clinical outcomes is not clear. We aimed to determine the effects of respiratory muscle training in patients with OSA. Methods: A systematic review was conducted in seven databases. Studies that applied respiratory muscle training in OSA patients were reviewed. Two independent reviewers analysed the studies, extracted the data and assessed the quality of evidence. Results: Of the 405 reports returned by the initial search, eight articles reporting on 210 patients were included in the data synthesis. Seven included inspiratory muscle training (IMT), and one included expiratory muscle training (EMT). Regarding IMT, we found significant improvement in Epworth sleepiness scale in −4.45 points (95%CI −7.64 to −1.27 points, p = 0.006), in Pittsburgh sleep quality index of −2.79 points (95%CI −4.19 to −1.39 points, p < 0.0001), and maximum inspiratory pressure of −29.56 cmH2O (95%CI −53.14 to −5.98 cmH2O, p = 0.01). However, the apnoea/hypopnea index and physical capacity did not show changes. We did not perform a meta-analysis of EMT due to insufficient studies. Conclusion: IMT improves sleepiness, sleep quality and inspiratory strength in patients with OSA.

Walking training augments the effects of expiratory muscle training in Parkinson's disease

OBJECTIVES

To investigate the effects of walking training combined with respiratory muscle training (RMT) on pulmonary function, respiratory muscle strength, and functional exercise capacity in patients with Parkinson's disease.

MATERIALS & METHODS

Thirty patients with Parkinson's disease were included in the study. Patients were randomly divided into two groups: the walking and RMT group (W + RMT, n = 15) and the RMT (n = 15) group. Spirometry, respiratory muscle strength, and a 6-min walking test were measured before and after the eighth week of the study. RMT was performed using inspiratory and expiratory threshold loading methods. Walking training intensity was adjusted according to the 6-min walking test. Patients performed 15 min of inspiratory muscle training and 15 min of expiratory muscle training in both groups, and 15 min of walking training in the W + RMT group in addition to RMT, twice per day, 5 days/week, for a total of 8 weeks at home. Training intensity was adjusted once per week for the groups at the hospital.

RESULTS

Respiratory muscle strength and 6-min walking distance were significantly increased (p = .001), and UPDRS-III scores were significantly improved (W + RMT: p = .008 and RMT: p = .01) in the two groups. The increase in maximal expiratory pressure was significantly higher in the W + RMT group than in the RMT group (p = .007).

CONCLUSION

Walking training increases the effect of expiratory muscle training in patients with Parkinson's disease.

Electromyographic study assessing swallowing function in subacute stroke patients with respiratory muscle weakness

BACKGROUND

Dysphagia has been reported to be associated with the descent of the hyolaryngeal complex. Further, suprahyoid muscles play a greater role than infrahyoid muscles in elevation of the hyolarngeal complex. Respiratory muscle training (RMT) can improve lung function, and expiratory muscle strength training can facilitate elevation of the hyoid bone and increase the motor unit recruitment of submental muscles during normal swallowing. This study aimed to investigate the surface electromyography (sEMG) of the swallowing muscles, bilaterally, and the effect of RMT on swallowing muscles in stroke patients with respiratory muscle weakness.

METHODS

Forty patients with first episode of unilateral stroke were included in this retrospective controlled trial. After exclusion of 11 patients with respiratory muscle strength stronger than 70% of the predicted value, 15 were allocated to the RMT group and 14 to the control group. However, eventually, 11 patients in RMT group and 11 patients in control group completed the study. The sEMG of the orbicularis oris, masseter, submental, and infrahyoid muscles were recorded during dry swallowing, water swallowing (2 mL), and forced exhalation against a threshold breathing trainer set at different intensities, at baseline and after 6-week RMT.

RESULTS

Regarding the sEMG of submental muscles, there were significant between-group differences on the latency of the unaffected side (P = .048), significant change from baseline force on the unaffected side (P = .035), and significant between-side difference (P = .011) in the RMT group during dry swallowing. Significant change in the duration from baseline was observed on the affected side of the RMT group when blowing was set at 50% maximal expiratory pressure (MEP; P = .015), and on the unaffected side of the control group when blowing set at 15% MEP (P = .005). Significant difference was observed in the duration between 50% MEP and 15% MEP after 6-week program in the control group (P = .049).

CONCLUSIONS

A 6-week RMT can improve the electric signal of the affected swallowing muscles with more effect on the unaffected side than on the affected side during dry swallowing. Furthermore, RMT with 50% MEP rather than 15% MEP can facilitate greater submental muscle activity on the affected side in stroke patients with respiratory muscle weakness.

Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate if respiratory muscle training is capable of reducing the occurrence of respiratory complications and improving dysphagia (swallowing or cough function) after stroke?

DESIGN

Systematic review of randomized control trials based on the Cochrane guidelines.

PARTICIPANTS

Patients (> 18 years old) were diagnosed with stroke.

INTERVENTION

Respiratory muscle training aimed at increasing respiratory muscles' strength by using the threshold resistance trainer or flow-oriented resistance trainer.

OUTCOME MEASURES

Respiratory complications, swallowing and cough function.

RESULTS

Eleven trials (n=523 participants) were included . Respiratory muscle training reduced the risk of respiratory complications (RR0.51, 95%CI 0.28 to 0.93, I² = 0%,P=0.03, ARD =0.068, NNT=14.71) compared with no/sham respiratory intervention. It also decreased the liquid type PAS scores by 0.81 (95% CI -1.19 to -0.43, I² = 39%, P<0.0001). There was no significant association between respiratory muscle training and FOIS scores, cough function:increased FOIS scores by 0.47 (95%CI -0.45 to 1.39, I² = 55%, P=0.32), decreased PECF-VC by 18.70 L/min (95%CI -59.74 to 22.33, I² = 19%, P=0.37) and increased PECF-RC by 0.05 L/min (95% CI -40.78 to 40.87 I2 = 0%, P=1.00) .

CONCLUSION

This meta-analysis provided evidence that respiratory muscle training is effective in reducing the risk of respiratory complications, and improving dysphagia by reducing penetration or aspiration during swallowing liquid bolus after stroke. However, there was no sufficient evidence to determine that respiratory muscle training improves cough function. Additional multi-center studies using larger patient cohorts are required to validate and support these findings. Furthermore, long-term follow-up studies should be performed to measure outcomes, at the same time avoiding bias due to confounding factors such as heterogeneity of the etiologies of dysphagia.

Detraining Effect on Pulmonary and Cardiovascular Autonomic Function and Functional Outcomes in Patients With Parkinson's Disease After Respiratory Muscle Training: An 18-Month Follow-Up Study

Background: The effect of 3-month respiratory muscle training (RMT) on pulmonary and autonomic function and functional outcomes has been demonstrated in patients with Parkinson's disease (PD); however, there is a paucity of information on the durability of the training effect. In this study, we monitored the pulmonary and cardiovascular autonomic function and clinical severity scales until 18 months after the cessation of RMT to elucidate the detraining effect after RMT.

Methods: All patients with PD receiving RMT were assessed with clinical severity scales as well as pulmonary and autonomic function tests at four different stages (baseline on enrollment, immediately after 3 months of RMT, and 6 and 18 months after cessation of RMT). A control group of PD patients who did not receive RMT was also recruited for comparison. Pulmonary function parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP), were assessed. Cardiovascular autonomic function was assessed using measures including heart rate response to deep breathing (HRDB), Valsalva ratio, and baroreflex sensitivity. Clinical severity scores were also measured using the Hoehn and Yahr staging and the Unified Parkinson's Disease Rating Scale (UPDRS).

Results: The results showed significant improvements in MIP, MEP, HRDB, and UPDRS immediately after RMT. Despite some decay, the improvements in pulmonary function (MIP and MEP) and functional outcomes (UPDRS) remained significant until 6 months of detraining (9 months after enrollment). However, the improvement in cardiovascular autonomic function (HRDB) was reversed after 6 months of detraining.

Conclusions: Based on these findings, we recommend that RMT may be repeated after at least 6 months after previous session (9 months after enrollment) for patients with PD to maintain optimal therapeutic effects.

Association Between Inspiratory Muscle Function and Balance Ability in Older People: A Pooled Data Analysis Before and After Inspiratory Muscle Training

Inspiratory muscle training (IMT) improved balance ability and respiratory muscle function in healthy older adults. The current study is a retrospective analysis to explore the relationship between inspiratory muscle function, balance ability, and adaptation to IMT. All participants (total = 129; IMT = 60; age range = 65-85 years) performed inspiratory and balance assessments, including the mini-balance evaluation system test, maximal inspiratory pressure, and peak inspiratory flow tests. Baseline inspiratory muscle function was positively related to balance ability (p < .05), and IMT-induced improvements in inspiratory function (23.3% in maximal inspiratory pressure, 8.0% in peak inspiratory flow rate, 14.9% in maximal peak inspiratory power) were related to improvements in balance (10.6% in mini-balance evaluation system test), with the greatest improvements (17.0%) observed in the oldest participants (76-85 years old, p < .05). In conclusion, with or without IMT, positive associations between inspiratory function and balance ability exist, with greater improvements in inspiratory muscle function related to greater improvements in balance ability.

Sex-Specific Effects of Respiratory Muscle Endurance Training on Cycling Time Trial Performance in Normoxia and Hypoxia

Objectives: We tested the hypotheses that respiratory muscle endurance training (RMET) improves endurance cycling performance differently in women and men and more so in hypoxia than in normoxia. Design: A prospective pre-post cross-over study with two testing conditions. Methods: Healthy and active women (seven, 24 ± 4 years, mean ± standard deviation [SD]) and men (seven, 27 ± 5 years) performed incremental cycling to determine maximum oxygen consumption (VO_2peak) and power output (W_peak) and on different days two 10-km cycling time trials (TTs) in normoxia and normobaric hypoxia (FiO₂, 0.135, ~3,500 m equivalent), in a balanced randomized order. Next they performed supervised RMET in normoxia (4 weeks, 5 days/week, 30 min/day eucapnic hyperpnea at ~60% predicted maximum voluntary ventilation) followed by identical post-tests. During TTs, heart rate, ear oximetry reading, and W_peak were recorded. Results: The VO_2peak and W_peak values were unchanged after RMET. The TT was improved by 7 ± 6% (p < 0.001) in normoxia and 16 ± 6% (p < 0.001) in hypoxia. The difference between normoxic and hypoxic TT was smaller after RMET as compared with that before RMET (14% vs. 21%, respectively, p < 0.001). All effects were greater in women (p < 0.001). The RMET did not change the heart rate or ear oximetry reading during TTs. Conclusion: We found a greater effect of RMET on cycling TT performance in women than in men, an effect more pronounced in hypoxia. These findings are congruent with the contention of a more pronounced performance-limiting role of the respiratory system during endurance exercise in hypoxia compared with normoxia and more so in women whose respiratory system is undersized compared with that of men.

Effects of respiratory muscle training on cough function in neurological disorders: A systematic review with meta-analysis

BACKGROUND

Patients with neurological disorders can present the weakness of respiratory muscle and impaired cough function. Previous studies have shown that respiratory muscle strength training (RMT) is an effective method of improving the strength of respiratory muscle. The effects of RMT on cough function remain controversial.

OBJECTIVE

We aimed to analyze randomized controlled trials (RCTs) that investigated the effects of RMT on cough function of patients with neurological disorders.

METHODS

Pubmed, Medline, Embase, and the Cochrane Library were searched electronically for RCTs. Two reviewers independently performed data extraction and quality assessment. Data were analyzed by using RevMan 5.3 software of The Cochrane Collaboration.

RESULTS

Five studies with 185 participants were included. The mean PEDro score was 6.2 (range 5 to 7), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training improved peak expiratory cough flow of voluntary cough by 2.16 (95% CI 1.16 to 3.17) and involuntary cough by 2.84 (95% CI 1.29 to 4.39), with statistical significance (P < 0.0001, P = 0.0003). The experimental group had an improvement of 0.19 cmH2O (95% CI -0.12 to 0.5) on the maximal inspiratory pressure, 0.09 cmH2O (95% CI -0.23 to 0.42) on the maximal expiratory pressure, but with no statistical significance (P = 0.23, P = 0.58) between groups.

CONCLUSION

Respiratory muscle training was considered as an effective method for improving cough function. However, this review was insufficient to conclude whether respiratory muscle training was effective in improving inspiratory and expiratory muscle strength, this was opposite with previous meta-analysis. These effects might due to the small samples and different diseases.

Pulmonary rehabilitation for COVID-19: A living systematic review protocol

Objective

This living systematic review aims to provide a timely, rigorous and continuously updated summary of the evidence available on the role of pulmonary rehabilitation in the treatment of patients with COVID-19.

Design

This is the protocol of a living systematic review.

Data sources

We will conduct searches in the L·OVE (Living OVerview of Evidence) platform for COVID-19, a system that maps PICO questions to a repository maintained through regular searches in electronic databases, preprint servers, trial registries and other resources relevant to COVID-19. No date or language restrictions will be applied.

Eligibility criteria for selecting studies and methods

We adapted an already published common protocol for multiple parallel systematic reviews to the specificities of this question. We will include randomized trials evaluating the effect of pulmonary rehabilitation as monotherapy or in combination with other interventions-versus sham or no treatment in patients with COVID-19. Two reviewers will independently screen each study for eligibility, extract data, and assess the risk of bias. We will pool the results using meta-analysis and will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to assess the certainty of the evidence for each outcome.

Ethics and dissemination

No ethics approval is considered necessary. The results of this review will be widely disseminated via peer-reviewed publications, social networks and traditional media.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cardiorespiratory Fitness in Volleyball Athletes Following a COVID-19 Infection: A Cross-Sectional Study

Athletes' lifestyles have been dramatically affected by the coronavirus disease 2019 (COVID-19) pandemic. Since COVID-19 primarily affects the respiratory system and to a lesser degree the cardiovascular system, the goal of this study was to examine the effects of COVID-19-caused detraining on cardiorespiratory fitness (CRF) of recently recovered volleyball athletes. Sixteen experienced volleyball athletes (age 24 ± 4.5 years) who were recently diagnosed and recovered from a COVID-19 infection volunteered to participate in this study and were tested for CRF and spirometry. Given that participants had only mild symptoms of infection, the primary focus of this study was on the effects of detraining on CRF. On average, the time to exhaustion was 9.4 ± 1.4 min. VE, VCO2, RER and oxygen pulse increased, heart rate exceeded 90% of predicted values, and peak VO2 values were typical for this level of athlete (44.1 ± 3.4 mL/kg). Pulmonary function reflected in FVC, FEV1/FVC and MVV values were well above 80% of predicted values for each of the participants while electrocardiography revealed no ischemia, arrythmias or conduction and repolarization abnormalities were found in the tested subjects. Therefore, it can be concluded that participants experienced typical consequences of detraining. Due to a lack of CRF data prior to COVID-19 infection, we were unable to estimate the magnitude detraining had on CRF. Complete CRF assessment after COVID-19 infection in athletes can be useful for screening of residual myocardial and/or respiratory system damage for safe return-to-play decisions.

Effects of Exercise in Patients with Obstructive Sleep Apnoea

Obstructive sleep apnoea (OSA) constitutes a public health problem, with various systemic consequences that can increase cardiovascular morbidity and mortality as well as increase healthcare expenditure. This review discusses the rationale and effects of using general physical exercise, oropharyngeal exercises, and respiratory muscle training as an adjunctive treatment for patients with sleep apnoea. The recommended treatment for OSA is the use of continuous positive airway pressure, which is a therapy that prevents apnoea events by keeping the airways open. In the last decade, coadjuvant treatments that aim to support weight loss (including diet and physical exercise) and oropharyngeal exercises have been proposed to lower the apnoea/hypopnoea index among patients with OSA. Based on the available evidence, health professionals could decide to incorporate these therapeutic strategies to manage patients with sleep apnoea.

Chronic Effects of a Training Program Using a Nasal Inspiratory Restriction Device on Elite Cyclists

This study compared the response of a 9-week cycling training on ventilatory efficiency under two conditions: (i) Combined with respiratory muscle training (RMT) using a new nasal restriction device (FeelBreathe) (FB group) and (ii) without RMT (Control group). Eighteen healthy elite cyclists were randomly separated into the FB group (n = 10) or Control group (n = 8). Gas exchange was measured breath by breath to measure ventilatory efficiency during an incremental test on a cycloergometer before (Pre) and after (Post) the nine weeks of training. The FB group showed higher peak power (Δ (95%HDI) (0.82 W/kg (0.49, 1.17)), VO₂max (5.27 mL/kg/min (0.69, 10.83)) and VT₁ (29.3 W (1.8, 56.7)) compared to Control at Post_FINAL. The FB group showed lower values from Pre to Post_PRE in minute ventilation (VE) (−21.0 L/min (−29.7, −11.5)), Breathing frequency (BF) (−5.1 breaths/min (−9.4, −0.9)), carbon dioxide output (VCO₂) (−0.5 L/min (−0.7, −0.2)), respiratory equivalents for oxygen (EqO₂) (−0.8 L/min (−2.4, 0.8)), heart rate (HR) (−5.9 beats/min (−9.2, −2.5)), respiratory exchange ratio (RER) (−0.1 (−0.1, −0.0) and a higher value in inspiratory time (Tin) (0.05 s (0.00, 0.10)), expiratory time (Tex) (0.11 s (0.05, 0.17)) and end-tidal partial pressure of CO₂ (PETCO₂) (0.3 mmHg (0.1, 0.6)). In conclusion, RMT using FB seems to be a new and easy alternative ergogenic tool which can be used at the same time as day-to-day training for performance enhancement.

Training Specificity of Inspiratory Muscle Training Methods: A Randomized Trial

Introduction

Inspiratory muscle training (IMT) protocols are typically performed using pressure threshold loading with inspirations initiated from residual volume (RV). We aimed to compare effects of three different IMT protocols on maximal inspiratory pressures (PImax) and maximal inspiratory flow (V̇Imax) at three different lung volumes. We hypothesized that threshold loading performed from functional residual capacity (FRC) or tapered flow resistive loading (initiated from RV) would improve inspiratory muscle function over a larger range of lung volumes in comparison with the standard protocol.

Methods

48 healthy volunteers (42% male, age: 48 ± 9 years, PImax: 110 ± 28%pred, [mean ± SD]) were randomly assigned to perform three daily IMT sessions of pressure threshold loading (either initiated from RV or from FRC) or tapered flow resistive loading (initiated from RV) for 4 weeks. Sessions consisted of 30 breaths against the highest tolerable load. Before and after the training period, PImax was measured at RV, FRC, and midway between FRC and total lung capacity (1/2 IC). V̇Imax was measured at the same lung volumes against a range of external threshold loads.

Results

While PImax increased significantly at RV and at FRC in the group performing the standard training protocol (pressure threshold loading from RV), it increased significantly at all lung volumes in the two other training groups (all p < 0.05). No significant changes in V̇Imax were observed in the group performing the standard protocol. Increases of V̇Imax were significantly larger at all lung volumes after tapered flow resistive loading, and at higher lung volumes (i.e., FRC and 1/2 IC) after pressure threshold loading from FRC in comparison with the standard protocol (all p < 0.05).

Conclusion

Only training with tapered flow resistive loading and pressure threshold loading from functional residual capacity resulted in consistent improvements in respiratory muscle function at higher lung volumes, whereas improvements after the standard protocol (pressure threshold loading from residual volume) were restricted to gains in PImax at lower lung volumes. Further research is warranted to investigate whether these results can be confirmed in larger samples of both healthy subjects and patients.

No Evidence That Hyperpnea-Based Respiratory Muscle Training Affects Indexes of Cardiovascular Health in Young Healthy Adults

Introduction

The chronic effects of respiratory muscle training (RMT) on the cardiovascular system remain unclear. This investigation tested to which degree a single sessions of RMT with or without added vibration, which could enhance peripheral blood flow and vascular response, or a 4-week RMT program could result in changes in pulse wave velocity (PWV), blood pressure (systolic, SBP; diastolic, DBP) and other markers of cardiovascular health.

Methods

Sixteen young and healthy participants (8 m/8f) performed 15 min of either continuous normocapnic hyperpnea (RMET), sprint-interval-type hyperpnea (RMSIT) or a control session (quiet sitting). Sessions were performed once with and once without passive vibration of the lower limbs. To assess training-induced adaptations, thirty-four young and healthy participants (17 m/17f) were measured before and after 4 weeks (three weekly sessions) of RMET (n = 13, 30-min sessions of normocapnic hyperpnea), RMSIT [n = 11, 6 × 1 min (1 min break) normocapnic hyperpnea with added resistance] or placebo (n = 10).

Results

SBP was elevated from baseline at 5 min after each RMT session, but returned to baseline levels after 15 min, whereas DBP was unchanged from baseline following RMT. Carotid-femoral PWV (PWV_CF) was elevated at 5 and 15 min after RMT compared to baseline (main effect of time, P = 0.001), whereas no changes were seen for carotid-radial PWV (PWV_CR) or the PWV_CF/PWV_CR ratio. Vibration had no effects in any of the interventions. Following the 4-week training period, no differences from the placebo group were seen for SBP (P = 0.686), DBP (P = 0.233), PWV_CF (P = 0.844), PWV_CR (P = 0.815) or the PWV_CF/PWV_CR ratio (P = 0.389).

Discussion/Conclusion

Although 15 min of RMT sessions elicited transient increases in PWV_CF and SBP, no changes were detected following 4 weeks of either RMET or RMSIT. Adding passive vibration of the lower limbs during RMT sessions did not provide additional value to the session with regards to vascular responses.

Effect of respiratory muscle training on dysphagia in stroke patients-A retrospective pilot study

BACKGROUND

Dysphagia is prevalent with cerebrovascular accidents and contributes to the burden of disease and mortality. Strengthening dysfunctional swallow muscles through respiratory muscle training (RMT) has proven effective in improving swallow effectiveness and safety. However, approaches to strengthen only the expiratory muscle groups (EMST) dominate the clinical study literature, with variable outcomes. This study investigated the effect of simultaneous inspiratory-expiratory muscle strengthening to improve swallowing function in stroke patients.

METHODS

Recorded data of 20 patients receiving pro bono medical care for dysphagia following stroke were allocated to intervention (IG) or control group (CG) based upon whether they chose combined RMT (cRMT) or not while awaiting swallow therapy services. The intervention group was treated with three 5-minute sessions of resistive respiratory muscle training for 28 days, while the control group received no RMT or other exercise intervention. Respiratory and swallow outcomes were assessed pre- and post-intervention and included Mann Assessment of Swallowing Ability (MASA), fiberoptic endoscopic evaluation of swallowing (FEES) with penetration-aspiration scale (PAS), functional oral intake scale (FOIS), patient visual analogue scale (VAS), and peak expiratory flow (PEF).

RESULTS

After 28 days, the intervention group demonstrated greater improvements (P value < 0.05) in PEF (IG: 168.03% vs CG: 17.47%), VAS (IG: 103.85% vs CG: 27.54%), MASA (IG: 37.28% vs CG: 6.92%), PAS (IG: 69.84% vs CG: 12.12%), and FOIS (IG: 93.75% vs CG: 21.21%).

CONCLUSION

cRMT is a feasible and effective method to improve signs and symptoms of dysphagia while improving airway protection.

LEVEL OF EVIDENCE

3.

No Decrease in Blood Pressure After an Acute Bout of Intermittent Hyperpnea and Hypoxia in Prehypertensive Elderly

Prevalence of hypertension, subjective sleep complaints and snoring increases with age. Worse sleep and snoring, in turn, are independent risk factors to develop hypertension. Both respiratory muscle training (RMT) and intermittent hypoxia (IH) are suggested to have positive effects on these physiological and behavioral variables. This study therefore aimed to test the acute effects of a single bout of RMT, with and without IH, on resting blood pressure (BP) and sleep. Fourteen prehypertensive elderly performed a 60-min session of (a) intermittent voluntary normocapnic hyperpnea (HYP) alone, (b) HYP in combination with IH (HYP&IH) and (c) a sham intervention in randomized order. BP, hemodynamics, heart rate variability (HRV), cardiac baroreflex sensitivity (BRS) and pulse wave velocity (PWV) were assessed before and 15, 30 and 45 min after each intervention. Variables of sleep were assessed with actigraphy, pulse oximetry and with questionnaires during and after the night following each intervention. Neither HYP nor HYP&IH resulted in a decrease in BP. Repeated measures ANOVA revealed no significant interaction effect for systolic BP (p = 0.090), diastolic BP (p = 0.151), HRV parameters, BRS and PWV (all p > 0.095). Fragmentation index was lower after both HYP (−6.5 units) and HYP&IH (−8.4 units) compared to sham, p(ANOVA) = 0.046, although pairwise comparisons reveal no significant differences. There were no other significant effects for the remaining sleep variables. We conclude that one bout of intermittent hyperpnea, alone or in combination with IH, is not effective in lowering blood pressure or improving sleep in prehypertensive elderly.

Effectiveness of inspiratory muscle training on respiratory fitness and breathlessness in chronic renal failure: A randomized control trial

BACKGROUND

People with chronic renal failure (CRF) show decreased respiratory fitness and poor quality of life (QOL). Exercise during hemodialysis has been suggested to improve the cardio-respiratory fitness. However, results of effects of respiratory muscle (RM) training on respiratory fitness and QOL are inconsistent. In addition, very few studies explored the association between inspiratory muscle (IM) training and sensation of breathlessness.

OBJECTIVES

To examine the effects of IM training in hemodialysis patients on respiratory fitness QOL and breathlessness.

METHOD

A randomized control trial with 50 CRF, who underwent hemodialysis (25 individuals in each group; IM training and sham group) was designed. Pulmonary function, RM strength, QOL (measured by Kidney Disease Quality of Life-36), and sensation of breathlessness were measured before and after an 8-week intervention.

RESULTS

Compared to the sham group, the IM strength increased in the intervention group after an 8-week program (Δ25.92 ± 8.73 cmH₂ O, p = 0.005). Significantly increased IM and forced vital capacity values in training groups was observed after an 8-week intervention (Δ12.44 ± 3.07 cmH₂ O and Δ0.097 ± 0.046 L, respectively), but not the sham group. Neither, the training group, nor the sham group were significantly different in the QOL. However, feeling of shortness of breath improved after the training program among inspiratory muscle training group, but not the sham group.

CONCLUSION

IM training during hemodialysis could lead to an improvement of respiratory fitness and reduce breathlessness in people with CRF who are receiving hemodialysis. However, QOL was not different after the training program. The study suggests that after 8-week intervention program, IM training (loading exercise) could improve IM strength, pulmonary function without any complications during the intervention program within 1-2 h.

Physical activity and nutrition guidelines to help with the fight against COVID-19

As the world is witnessing the epidemic of coronavirus disease 2019, emerging genetics and clinical pieces of evidence suggest a similar immunopathology to those of severe acute respiratory syndrome and Middle East respiratory syndrome. Staying at home to prevent the spread of the virus and consequently being largely inactive is associated with unintended consequences. These can actually enhance the infection risk and exacerbate poor health conditions including impaired immune function. Physical activity is a feasible way of improving health, particularly physical and mental health in a time of social isolation. However, people with certain health conditions in these circumstances may need a special physical activity programme in addition to any exercise they may already be performing via online programmes. This review aims to provide practical guidelines during the COVID-19 quarantine period. We suggest performing aerobic, resistance training, respiratory muscle training and yoga in the healthy, and in those with upper respiratory tract illness, patients with lower respiratory tract illness should be restricted to respiratory muscle training and yoga. In addition, vitamins D and C, omega-3 fatty acids, and regular consumption of fruit and vegetables might be considered as nutritional aids to support the immune system in those affected by COVID-19.

Inspiratory Muscle Training in COPD

BACKGROUND

The benefits of inspiratory muscle training (IMT) for patients with COPD are documented in the literature, but its isolated effect or association with other interventions, the best training methods, and what type of patient benefits the most are not clear. We sought to assess the effects of IMT on respiratory muscle strength, pulmonary function, dyspnea, functional capacity, and quality of life for subjects with COPD, considering IMT isolated or association with other interventions, presence of inspiratory muscle weakness, training load, and intervention time.

METHODS

We searched the MEDLINE, EMBASE, PEDro, Cochrane CENTRAL, and LILACS databases in June 2018. We also performed a manual search of references in the studies found in the database search and included in this analysis. We included randomized controlled trials that investigated the above-mentioned outcomes and assessed IMT, either isolated or associated with other interventions, in comparison with a control group, placebo, or other interventions, in subjects with COPD. We used the GRADE approach to evaluate the quality of the evidence.

RESULTS

Of 1,230 search results, 48 were included (N = 1,996 subjects). Isolated IMT increased P_Imax (10.64 cm H₂O, 95% CI 7.61-13.66), distance walked in 6-min-walk test (34.28 m; 95% CI 29.43-39.14), and FEV₁ (0.08, 95% CI 0.02-0.13). However, there was no improvement in dyspnea and quality of life. The presence of inspiratory muscle weakness did not change the results; higher loads (60-80% of P_Imax) promoted a greater improvement in these outcomes, and a shorter intervention time (4 weeks) improved P_Imax, but longer intervention times (6-8 weeks) are required to improve functional capacity. IMT associated with other interventions only showed an increase in P_Imax (8.44 cm H₂O; 95% CI 4.98-11.91), and the presence of inspiratory muscle weakness did not change this result.

CONCLUSIONS

Isolated IMT improved inspiratory muscle strength, functional capacity, and pulmonary function, without changing dyspnea and quality of life. Associated IMT only increased inspiratory muscle strength. These results indicate that isolated IMT can be considered as an adjuvant intervention in patients with COPD.

Effectiveness of Respiratory Muscle Training for Pulmonary Function and Walking Ability in Patients with Stroke: A Systematic Review with Meta-Analysis

Background: Neurological dysfunction due to stroke affects not only the extremities and trunk muscles but also the respiratory muscles. Aim: to synthesise the evidence available about the effectiveness of respiratory muscle training (RMT) to improve respiratory function parameters and functional capacity in poststroke patients. Methods: a systematic electronic search was performed in the MEDLINE, EMBASE, SPORTDiscus, PEDro and Web of Science databases, from inception to May 2020. Study selection and data extraction: randomised controlled trials (RCTs) that examined the effects of RMT versus non-RMT or sham RMT in poststroke patients. We extracted data about respiratory function, respiratory muscle strength and functional capacity (walking ability, dyspnea, balance, activities of daily life), characteristics of studies and features of RMT interventions (a type of RMT exercise, frequency, intensity and duration). Two reviewers performed study selection and data extraction independently. Results: nineteen RCTs met the study criteria. RMT improved the first second forced expiratory volume (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP) and walking ability (6 min walking test), but not Barthel index, Berg balance scale, and dyspnea. Conclusions: RMT interventions are effective to improve respiratory function and walking ability in poststroke patients.

A New Nasal Restriction Device Called FeelBreathe® Improves Breathing Patterns in Chronic Obstructive Pulmonary Disease Patients during Exercise

A device called FeelBreathe (FB)^® was designed, developed, and patented for inspiratory muscle training. The main aim was to determine the acute responses on lung ventilation, gas exchange, and heart rate during exercise in patients with chronic obstructive pulmonary disease (COPD) with and without the use of FB. In this study, a randomized cross-over trial was performed with 18 men diagnosed with COPD (FEV₁ between 30% and 70% of its predicted value). Each participant randomly conducted two trials with 30 min of rest between them with the same protocol on a treadmill for 10 min at a constant rate of 50% of VO_2peak. Each test was performed randomly and in a crossover randomized design in two different conditions: (1) oronasal breathing; and (2) nasal breathing with FB (nasal ventilatory flow restriction device). It was observed that FB had positive effects on dynamic hyperinflation, breathing pattern, and breathing efficiency, with higher expiratory and inspiratory time. Despite these differences, blood oxygen saturation percentage, oxygen uptake, and heart rate showed a similar response for both conditions during exercise. The results suggest that exercise performed with FB improved ventilatory responses compared to the oronasal mode in COPD patients. This new tool could be used during most daily tasks and exercise programs.

Can respiratory muscle training therapy effectively manage obstructive sleep apnea syndrome after stroke?: A protocol of systematic review and meta-analysis

BACKGROUND

This study will explore the effectiveness and safety of respiratory muscle training therapy (RMTT) for the treatment of patients with obstructive sleep apnea syndrome (OSAS) after stroke.

METHODS

In this study, we will systematically and comprehensively search Cochrane Library, PubMed, EMBASE, WANGFANG, VIP, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure for relevant literature from their inception to March 1, 2020 without any limitations to language and publication status. We will consider any randomized controlled trials focusing on the effectiveness and safety of RMTT for the treatment of patients with OSAS after stroke. The study quality will be checked using Cochrane risk of bias tool, and statistical analysis will be performed utilizing RevMan 5.3 software.

RESULTS

This study will summarize and synthesize the current evidence of RMTT for the treatment of patients with OSAS following stroke.

CONCLUSION

The findings of this study will assess the present evidence for the benefits and harms of RMTT for treating OSAS after stroke, and will inform clinical practice and future research.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020170355.