Implicaciones de la calidad de vida en las decisiones quirúrgicas del cáncer de pulmón

Available evidence suggests that the patients with a forced expiratory volume in 1 second [FEV1] over 60% or in which a postoperative FEV1 is predicted over 45%, they do not develop severe disability after lung resection surgery; nevertheless, currently some groups are operating patients with EPOC and FEV1 less than 35%. In emphysema patients can occur that the function improve, as in the volume reduction lung surgery, but in the cases that it does not occur, they can remain with chronic shortness of breath until a 10%. At present, there are not any functional or effort test that be able to predict what patients will present satisfactory residual pulmonary function or chronic shortness of breath or important exercise limitations. It has been noticed that medical team opinion is not satisfactory to predict defi cit in postoperative quality of life. Nevertheless, long-term survivors (more than one year) inform relatively good quality of life, even in which they have pulmonary function reduced. In comparison with other chronic respiratory diseases, the survivors of lung cancer seem to be in better psychological state, the defi cit in quality of life is caused mainly by depression, and not for physical limitation. Therefore, empirical evidence does not justify excluding undergoing surgery on basis of medical team suppositions about a postoperative poor Quality of life. In addition, studies about Quality of Life suggests patients who is undergo lung cancer surgery are willing to assume risks for their survival, although, they want to receive information about how surgery may affect them

Implicaciones de la calidad de vida en las decisiones quirúrgicas del cáncer de pulmón

Available evidence suggests that the patients with a forced expiratory volume in 1 second [FEV1] over 60% or in which a postoperative FEV1 is predicted over 45%, they do not develop severe disability after lung resection surgery; nevertheless, currently some groups are operating patients with EPOC and FEV1 less than 35%. In emphysema patients can occur that the function improve, as in the volume reduction lung surgery, but in the cases that it does not occur, they can remain with chronic shortness of breath until a 10%. At present, there are not any functional or effort test that be able to predict what patients will present satisfactory residual pulmonary function or chronic shortness of breath or important exercise limitations. It has been noticed that medical team opinion is not satisfactory to predict defi cit in postoperative quality of life. Nevertheless, long-term survivors (more than one year) inform relatively good quality of life, even in which they have pulmonary function reduced. In comparison with other chronic respiratory diseases, the survivors of lung cancer seem to be in better psychological state, the defi cit in quality of life is caused mainly by depression, and not for physical limitation. Therefore, empirical evidence does not justify excluding undergoing surgery on basis of medical team suppositions about a postoperative poor Quality of life. In addition, studies about Quality of Life suggests patients who is undergo lung cancer surgery are willing to assume risks for their survival, although, they want to receive information about how surgery may affect them

Recomendações sobre o uso dos testes de exercício na prática clínica

Resumo: A elaboração deste documento pelo grupo de trabalho da European Respiratory Society tem como objectivo apresentar as recomendações sobre o uso clínico dos testes de exercício em doentes com patologia cardiorrespiratória, dando particular ênfase à avaliação funcional, à avaliação do prognóstico e à avaliação das intervenções terapêuticas.A intolerância ao esforço físico é um dos sintomas mais frequentes, condicionando a perda de qualidade de vida do doente com patologia cardiorrespiratória crónica. Pode definir-se âintolerância ao exercícioâ numa perspectiva clínica à incapacidade que o doente apresenta para realizar tarefas que os indivíduos saudáveis considerariam toleráveis.A intolerância ao exercício, considerada em termos do pico de consumo de oxigénio atingido no esforço máximo (VâO2pico) não pode ser prevista por parâmetros avaliados em repouso, como o volume expiratório máximo no primeiro segundo (FEV1), a transferência alvéolo-capilar do monóxido de carbono (DLCO), a fracção de ejecção do ventrículo esquerdo ou o índice de massa corporal (IMC). A avaliação em exercício impõe alguns desafios técnicos: a aplicação de protocolos específicos de incremento de carga de forma precisa e reprodutível, com o recurso habitual a ergómetros, tais como a bicicleta ergométrica e o tapete rolante.A prova de exercício cardiorrespiratória (CPET) é considerada o gold standard na avaliação das causas de intolerância ao exercício em doentes com doença cardíaca e pulmonar e é baseado no princípio de que a falência do sistema ocorre tipicamente quando o sistema (seja ele músculo-energético, cardiovascular ou pulmonar) se encontra sob stress. A CPET compreende a imposição de um exercício com cargas crescentes (ou seja, incremental) limitado por sintomas, enquanto se monitorizam as variáveis cardiopulmonares (exemplo: consumo de oxigénio (VâO2), produção de dióxido de carbono (VâCO2), ventilação minuto (VâE), frequência cardíaca (fC)), a percepção de sintomas (exemplo: a dispneia e o desconforto nos membros inferiores) e, quando necessárias, as avaliações da dessaturação arterial do oxigénio relacionada com o esforço, da hiperinsuflação dinâmica e da força muscular dos membros. Os sistemas são forçados até ao seu limite tolerável, de forma controlada, o que permite detectar respostas que identificam padrões de alteração e que podem ser relacionadas com padrões de referência previamente estudados e publicados pelas sociedades respiratórias europeia e americanas1-3.Neste documento, é descrito o papel da CPET como auxiliar no diagnóstico e na avaliação funcional e prognóstica. A CPET pode: â Fornecer uma medição objectiva da capacidade para o exercício; â Identificar os mecanismos que limitam a tolerância ao exercício; â Estabelecer índices de prognóstico; â Monitorizar a progressão da doença e a resposta às intervenções terapêuticas. â Auxiliar no diagnóstico, em situações de broncoconstrição induzida pelo exercício e de dessaturação arterial do oxigénio. Na identificação das causas de intolerância ao exercício, a CPET pode detectar: â Alterações na entrega de oxigénio (desde a sua entrada nas vias aéreas, passando pelo sistema de transporte cardiocirculatório, até à entrega às mitocôndrias das fibras musculares); â Limitação ventilatória no exercício; â Alteração do controlo ventilatório; â Alteração das trocas gasosas pulmonares; â Percepção excessiva de sintomas (exemplos: dispneia, precordialgia, fadiga muscular periférica); â Disfunção metabólica muscular; â Descondicionamento; â Fraco esforço dispendido. Com um bom esforço realizado, se o valor do pico do consumo de oxigénio atingido foi normal e o motivo para parar a prova foi dispneia ou fadiga muscular, então pode considerar-se que o indivíduo estudado tem uma normal tolerância ao exercício. Este cenário irá excluir doença pulmonar (DPOC, doença intersticial pulmonar, doença vascular pulmonar) ou cardíaca (insuficiência cardíaca congestiva) significativas como causa de intolerância.A prova de exercício cardiopulmonar pode auxiliar no diagnóstico diferencial entre limitação no esforço de origem pulmonar ou cardiocirculatória. Pode fornecer um perfil de respostas que caracterizam determinadas doenças; exemplo: na DPOC são frequentes a limitação ventilatória, a hiperinsuflação dinâmica, a dessaturação arterial com o exercício, a dispneia, a disfunção dos músculos periféricos; na doença intersticial pulmonar são frequentes a dispneia, a restrição ventilatória mecânica e as alterações graves das trocas gasosas. Outros padrões de respostas podem ser encontrados na broncoconstrição induzida pelo exercício, na doença vascular pulmonar, na insuficiência cardíaca e em cardiopatias congénitas. A avaliação cardiorrespiratória no exercício fornece ainda indicadores prognósticos em várias doenças. Descrevem-se neste documento vários trabalhos que estudaram os parâmetros indicadores de prognóstico em doenças como a DPOC, a doença intersticial pulmonar, a hipertensão pulmonar primária, a fibrose quística e a insuficiência cardíaca.Este documento demonstra ainda a utilidade dos testes de exercício na definição das respostas às intervenções terapêuticas, em avaliações seriadas.O grupo de trabalho envolvido neste documento considerou importante apresentar as indicações baseadas na evidência para a realização dos testes de exercício na prática clínica. A evidência actual é clara quanto à utilidade da prova de exercício cardiopulmonar, das provas de marcha e das provas de carga constante na avaliação do grau de intolerância ao exercício, do prognóstico e dos efeitos das intervenções terapêuticas em doentes adultos com doença pulmonar crónica (DPOC, doença intersticial pulmonar, hipertensão pulmonar primária), em crianças e adultos com fibrose quística, em crianças e adultos com broncospasmo induzido pelo exercício, em adultos com insuficiência cardíaca congestiva e em crianças e adolescentes com cardiopatias congénitas.Na elaboração deste documento, os autores pretenderam fornecer as respostas às perguntas que se colocam com frequência na prática clínica: â Quando se deve pedir uma avaliação da intolerância ao esforço? â Qual o teste mais adequado? â Quais as variáveis a seleccionar na avaliação do prognóstico de determinada doença ou na avaliação do efeito de uma intervenção terapêutica particular? O documento contém ainda um suplemento que pode ser obtido on-line e que descreve as bases fisiológicas subjacentes aos parâmetros avaliados nas provas de exercício cardiopulmonar

A simple method to derive speed for the endurance shuttle walk test

Background: The original method for determining endurance shuttle walk test (ESWT) speed involves components that are time consuming for clinicians. We sought to determine: (i) whether components described in the original method for determining ESWT speed held true and; (ii) the agreement between speeds derived using the original method and that equivalent to 85% of the peak speed achieved during the incremental shuttle walk test (ISWT). Methods: Patients with chronic obstructive pulmonary disease (COPD) performed two ISWTs and one ESWT on separate days, wearing a calibrated portable gas analysis unit. A retrospective analysis of these data allowed us to determine whether: (i) the peak rate of oxygen uptake (VO2peak) can be accurately estimated from the incremental shuttle walk distance (ISWD) and; (ii) ESWTs performed at a speed derived using the original method elicited 85% of VO2peak. Agreement between walks speeds was determined using Bland–Altman analysis. Results: Twenty-two participants (FEV1 48 ± 13% predicted, age 66 ± 8 yr) completed the study. The VO2peak estimated from the ISWD was less than that measured during the ISWT (mean difference −4.4; 95% confidence interval (CI), −6.0 to −2.9 ml• kg−1•min−1). The ESWT and ISWT elicited similar VO2peak (mean difference −0.2; 95% CI, −1.5 to 1.2 ml•kg−1•min−1). The mean difference (±limits of agreement) between ESWT speeds was 0.15 (±0.34) km•h−1. Conclusions: Components of the original method for determining the ESWT speed did not hold true in our sample. ESWT speed can be derived by calculating 85% of the peak speed achieved during the ISWT

The Impact of Homogeneous Versus Heterogeneous Emphysema on Dynamic Hyperinflation in Patients With Severe COPD Assessed for Lung Volume Reduction

Dynamic hyperinflation (DH) is a pathophysiologic hallmark of Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to investigate the impact of emphysema distribution on DH during a maximal cardiopulmonary exercise test (CPET) in patients with severe COPD. This was a retrospective analysis of prospectively collected data among severe COPD patients who underwent thoracic high-resolution computed tomography, full lung function measurements and maximal CPET with inspiratory manouvers as assessment for a lung volume reduction procedure. ΔIC was calculated by subtracting the end-exercise inspiratory capacity (eIC) from resting IC (rIC) and expressed as a percentage of rIC (ΔIC %). Emphysema quantification was conducted at 3 predefined levels using the syngo PULMO-CT (Siemens AG); a difference >25% between best and worse slice was defined as heterogeneous emphysema. Fifty patients with heterogeneous (62.7% male; 60.9 ± 7.5 years old; FEV(1)% = 32.4 ± 11.4) and 14 with homogeneous emphysema (61.5% male; 62.5 ± 5.9 years old; FEV(1)% = 28.1 ± 10.3) fulfilled the enrolment criteria. The groups were matched for all baseline variables. ΔIC% was significantly higher in homogeneous emphysema (39.8% ± 9.8% vs.31.2% ± 13%, p = 0.031), while no other CPET parameter differed between the groups. Upper lobe predominance of emphysema correlated positively with peak oxygen pulse, peak oxygen uptake and peak respiratory rate, and negatively with ΔIC%. Homogeneous emphysema is associated with more DH during maximum exercise in COPD patients

No effect of glutamine ingestion on indices of oxidative metabolism in stable COPD

COPD patients have reduced muscle glutamate which may contribute to an impaired response of oxidative metabolism to exercise. We hypothesised that prior glutamine supplementation would enhance View the MathML source peak, View the MathML source at lactate threshold and speed pulmonary oxygen uptake kinetics in COPD. 13 patients (9 males, age 66 ± 5 years, mean ± SD) with severe COPD (mean FEV1 0.88 ± 0.23 l, 33 ± 7% predicted) performed on separate days ramp cycle-ergometry (5–10 W min−1) to volitional exhaustion and subsequently square-wave transitions to 80% estimated lactate threshold (LT) following consumption of either placebo (CON) or 0.125 g kg bm−1 of glutamine (GLN) in 5 ml kg bm−1 placebo. Oral glutamine had no effect on peak or View the MathML source at LT, {View the MathML source peak: CON = 0.70 ± 0.1 l min−1 vs. GLN = 0.73 ± 0.2 l min−1; LT: CON = 0.57 ± 0.1 l min−1 vs. GLN = 0.54 ± 0.1 l min−1} or View the MathML source kinetics {tau: CON = 68 ± 22 s vs. GLN = 68 ± 16 s}. Ingestion of glutamine before exercise did not improve indices of oxidative metabolism in this patient group

WITHDRAWN: La enfermedad pulmonar obstructiva crónica como factor de riesgo cardiovascular

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Ecuaciones de referencia de la capacidad aeróbica máxima ciclo-ergoespirometría para la población española adulta

[EN] Background: Frequently used reference values for clinical exercise testing have been derived from non-random samples and some with poorly defined maximal criteria. Our objective was to obtain population based reference values for peak oxygen uptake ( ̇VO2 ) and work rate (WR) for cardiopulmonary exercise testing in a representative sample of Caucasian Spanish men and women. Methods: 182 men and women, 20–85 years old, were included and exercised on cycle-ergometer to exhaustion. ( ̇VO2 ) and WR were measured. The equations obtained from this sample were validated in an independent cohort of 69 individuals, randomly sampled form the same population. Then a final equation merging the two cohorts (=251) was produced. Results: Height, sex and age resulted predictive of both ̇VO2 peak and WR. Weight and physical activity added very little to the accuracy to the equations. The formulas ̇VO2 peak = 0.017 · height (cm) − 0.023 · age (years) + 0.864 · sex (female = 0/male = 1) ± 179 l min−1 , and peak WR = 1.345 · height (cm) − 2.074 · age (years) + 76.54 · sex (female = 0/male = 1) ± 21.2 W were the best compromise between accuracy and parsimony. Conclusions: This study provides new and accurate ̇VO2 peak and WR rate reference values for individuals of European Spanish descent[ES] Antecedentes: Los valores de referencia utilizados con frecuencia para las pruebas de esfuerzo clínicas derivan de muestras no aleatorias y los criterios máximos para algunos de ellos están mal definidos. Nuestro objetivo fue obtener valores de referencia basados en la población general para el consumo máximo de oxígeno (VO 2 ) y la carga de trabajo (CT) para las pruebas de ejercicio cardiopulmonar a partir de una muestra representativa de varones y mujeres caucásicos españoles. Métodos: Se incluyeron 182 varones y mujeres, de entre 20 y 85 a ̃nos, que realizaron ejercicio en el cicloergómetro hasta el agotamiento. Se midieron el VO 2 y la CT. Las ecuaciones obtenidas de esta muestra se validaron en una cohorte independiente de 69 individuos, seleccionados aleatoriamente de la misma población. A continuación, se creó una ecuación final que fusionó las dos cohortes (n = 251). Resultados: La altura, el sexo y la edad resultaron predictivos tanto del ̇VO2 máximo como de la CT. El peso y la actividad física contribuyeron muy poco a la precisión de las ecuaciones. Las fórmulas ̇VO2 máximo = 0,017 × altura (cm) − 0,023 × edad (a ̃nos) + 0,864 × sexo (mujer = 0/varón = 1) ± 179 L × min−1 ; y CT máxima = 1,345 × altura (cm) − 2,074 × edad (a ̃nos) + 76,54 × sexo (mujer = 0/varón = 1) ± 21,2 W fueron el mejor equilibrio entre precisión y parsimonia. Conclusiones: Este estudio proporciona valores de referencia del ̇VO 2 máximo y la CT nuevos y precisos para personas de ascendencia espa ̃nola europea.This study was supported by a SEPAR (Sociedad Española de Neumología y Cirugía Torácica/Spanish society of Pulmonology and Thoracic Surgery) grant and NEUMOMADRD (Sociedad Madrileña de Neumología y Cirugía Torácica/Madrilenian Society of Pulmonology and Thoracic Surgery) research award

Reproducibility of onset and recovery oxygen uptake kinetics in moderately impaired patients with chronic heart failure

Oxygen (O2) kinetics reflect the ability to adapt to or recover from exercise that is indicative of daily life. In patients with chronic heart failure (CHF), parameters of O2 kinetics have shown to be useful for clinical purposes like grading of functional impairment and assessment of prognosis. This study compared the goodness of fit and reproducibility of previously described methods to assess O2 kinetics in these patients. Nineteen CHF patients, New York Heart Association class II–III, performed two constant-load tests on a cycle ergometer at 50% of the maximum workload. Time constants of O2 onset- and recovery kinetics (τ) were calculated by mono-exponential modeling with four different sampling intervals (5 and 10 s, 5 and 8 breaths). The goodness of fit was expressed as the coefficient of determination (R2). Onset kinetics were also evaluated by the mean response time (MRT). Considering O2 onset kinetics, τ showed a significant inverse correlation with peak- \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document} \ifmmode\expandafter\dot\else\expandafter\.\fi{V}{\text{O}}_{2} \end{document} (R = −0.88, using 10 s sampling intervals). The limits of agreement of both τ and MRT, however, were not clinically acceptable. O2 recovery kinetics yielded better reproducibility and goodness of fit. Using the most optimal sampling interval (5 breaths), a change of at least 13 s in τ is needed to exceed normal test-to-test variations. In conclusion, O2 recovery kinetics are more reproducible for clinical purposes than O2 onset kinetics in moderately impaired patients with CHF. It should be recognized that this observation cannot be assumed to be generalizable to more severely impaired CHF patients

Four patients with a history of acute exacerbations of COPD: implementing the CHEST/Canadian Thoracic Society guidelines for preventing exacerbations

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