Função pulmonar e força muscular respiratória na alta hospitalar em pacientes com COVID-19 pós internação em Unidade de Terapia Intensiva

The aim of this study was to describe pulmonary function and respiratory muscle strength (RMS) at hospital discharge of patients with severe COVID-19 cases and correlate with peripheral muscle strength, time on mechanical ventilation (MV) and hospital stay and use of medications.This is a cross-sectional study including patients who were admitted to the ICU for COVID-19. Theassessment at hospital discharge included the following variables: RMS, pulmonary function, and peripheral muscle strength [Medical Research Council score and handgrip dynamometry]. Twenty-five patients were included, with a mean age of 48.7±12.3 years. It was observed that 72% of patients had restrictive ventilatory disorder, in addition to reduced RMS [maximum inspiratory pressure (MIP) of 74% and maximum expiratory pressure (MEP) of 78% out of the predicted value]. RMS (MIP and MEP, respectively) correlated negatively with time on MV (r=-0.599, p=0.002; r=-0.523, p=0.007) and hospital stay (r=-0.542, p=0.005; r=-0.502, p=0.01), and positively with FVC (r=0.825, p=0.000; r=0.778, p=0.000), FEV1 (r=0.821, p=0.000; r=0.801, p=0.000), PEF (r=0.775, p=0.000; r=0.775, p=0.000) and handgrip strength (r=0.656, p=0.000; r=0.589, p=0.002).We conclude that patients with severe COVID-19 cases presented, at the time of hospital discharge, reduced RMS and changes in lung function, and a negative correlation between RMS and time on IMV and hospital stay, and a positive correlation with lung function and hand grip strength.O objetivo deste estudo foi descrever a função pulmonar e a força muscular respiratória (FMR) na alta hospitalar de pacientes com quadros críticos da COVID-19 e correlacionarcom a força muscular periférica, tempo de ventilação mecânica (VM) e de internação hospitalar e uso de medicações.Trata-se de um estudo transversal, incluindo pacientes que estiveram internados na UTI por COVID-19. A avaliação, na alta hospitalar, incluiu as seguintes variáveis:  FMR, função pulmonar e força muscular periférica [escore Medical Research Council e dinamometria de preensão palmar]. Foram incluídos 25 pacientes, com idade média de 48.7±12.3 anos. Foi observado que 72% dos pacientes apresentaram distúrbio ventilatório restritivo, além de redução da FMR [pressão inspiratória máxima (PImáx) de 74% e pressão expiratória máxima (PEmáx) 78% do predito]. A FMR (PImáx e PEmáx respectivamente) apresentou correlação negativa com o tempo de VM (r=-0,599, p=0,002; r=-0,523, p=0,007) e de internação hospitalar (r=-0,542, p=0,005; r=-0,502, p=0,01) e positiva com a CVF (r=0,825, p=0,000; r=0,778, p=0,000), VEF1 (r=0,821, p=0,000; r=0,801, p=0,000), PFE (r=0,775, p=0,000; r=0,775, p=0,000) e força de preensão palmar (r=0,656, p=0,000; r=0,589, p=0,002). Concluímos que pacientes com quadros críticos da COVID-19 apresentaram, na alta hospitalar, redução da FMR e alterações da função pulmonar, e correlação negativa entre a FMR e o tempo de VMI e de internação hospitalar e positiva com a função pulmonar e a força de preensão palmar.Este estudio tuvo como objetivo describir la funciónpulmonar y la fuerza muscular respiratoria (FMR) al alta hospitalariade pacientes con condiciones críticas del Covid-19 y correlacionarlascon la fuerza muscular periférica, el tiempo de ventilaciónmecánica (VM) y de hospitalización y uso de medicamentos.Se trata de un estudio transversal con pacientes que ingresaronen Unidades de Cuidados Intensivos por Covid-19. La evaluaciónen el alta hospitalaria incluyó las siguientes variables: FMR, funciónpulmonar y fuerza muscular periférica (puntuación Medical ResearchCouncil –MRC– y dinamometría manual). Participaron 25 pacientes,con una edad media de 48,7±12,3 años. Se observó que el 72% delos pacientes presentó trastorno ventilatorio restrictivo, ademásde una reducción de la FMR (presión inspiratoria máxima –PImáx–del 74% y presión espiratoria máxima –PEmáx– del 78% del valorpredicho). La FMR (PImáx y PEmáx, respectivamente) mostró unacorrelación negativa con la duración de la VM (r=−0,599, p=0,002;r=−0,523, p=0,007) y la hospitalización (r=−0,542, p=0,005; r=−0,502,p=0,01), pero una correlación positiva con la capacidad vital forzada(CVF) (r=0,825, p=0,000; r=0,778, p=0,000), el volumen espiratorioforzado en el primer segundo (VEF1) (r=0,821 , p=0,000; r=0,801,p=0,000), el flujo espiratorio máximo (FEM) (r=0,775, p=0,000;r=0,775, p=0,000) y la fuerza de agarre (r=0,656, p=0,000; r =0,589,p=0,002). Se concluye que los pacientes en condiciones críticas delCovid-19 presentaron al alta hospitalaria: reducción de FMR; cambiosen la función pulmonar; correlación negativa entre la FMR y detiempo de ventilación mecánica invasiva (VMI) y de hospitalización;y correlación positiva con la función pulmonar y la fuerza de agarr

Equações internacionais superestimam a força muscular ventilatória em crianças e adolescentes com fibrose cística

The aim of the present study was to compare the results of standardization of ventilatory muscle strength data using three international reference values and one Brazilian reference in children and adolescents with cystic fibrosis (CF). This was a retrospective study, which included patients with CF aged 8 to 12 years and in regular follow-up at an outpatient facility. Demographic and anthropometric data were collected. All patients included in the sample should have had ventilatory muscle strength and lung function measured in the past 12 months. The standardization of the results was made using predicted values from each equation. Data were compared using one-way ANOVA. We included 24 patients, 62.5% males, with mean age of 10.5±1.53 years, height 138.0±0.08 cm, weight 34.6±7.9 kg, FEV1 93.29±29.02% and FVC 103.78±26.12%. The maximum inspiratory (MIP) and expiratory (MEP) pressures (cmH2O) observed were 92.1±22.8 and 98.9±24.5, respectively. After standardization by the different equations, we found that the international reference tend to overestimate the findings. The Brazilian equation showed values significantly lower (p;100%) in 91.6, 79.1, and 75.0% of the subjects and MEP in 66.6, 87.5 and 50% of them, while using the national equation only 50.0 and 37.5% of subjects were above 100%, respectively. The results of standardization of ventilatory muscle strength in children and adolescents with CF aged 8 to 12 years using international equations overestimate the values of maximal respiratory pressures.El objetivo de este estudio fue comparar los resultados de la normalización de los datos de fuerza muscular ventilatoria utilizando tres ecuaciones de referencia internacionales y una nacional en niños y adolescentes con fibrosis quística (FC). Estudio retrospectivo, en el cual fueron incluidos pacientes con FC, edad entre 8 y 12 años y control ambulatorio regular. Fueron colectados datos demográficos y variables antropométricas. Todos los pacientes incluidos deberían haber realizado test de fuerza muscular ventilatoria y espirometría en los últimos 12 meses. La normalización de los resultados fue realizada utilizando las variables predictoras requeridas en cada ecuación estudiada. Los datos fueron comparados utilizando una ANOVA de una vía. Fueron incluidos 24 pacientes, 62,5% masculinos, media de edad 10,5±1,53 años, estatura 138,0±0,08 cm, masa corporal 34,6±9,07 kg, VEF1 93,29±29,02% y CVF 103,78±26,12%. Las presiones (cmH2O) inspiratoria (PIMAX) y expiratoria (PEMAX) máximas encontradas fueron 92,1±22,8 y 98,9±24,5, respectivamente. Después de la normalización por las diferentes ecuaciones, se demostró que las internacionales tienden a sobreestimar los hallazgos para nuestra población. La ecuación nacional presentó valores medios previstos significativamente (p;100%) en 91,6, 79,1, y 75,0% de los sujetos y la PEMAX en 66,6, 87,5 y 50%, mientras la ecuación nacional estimaría apenas 50,0 y 37,5% de los individuos, respectivamente. La normalización de los resultados de fuerza muscular ventilatoria en niños y adolescentes entre 8 y 12 años con FC utilizando ecuaciones internacionales sobreestiman los valores de las presiones respiratorias máximas.O objetivo deste estudo foi comparar os resultados da normalização dos dados de força muscular ventilatória utilizando-se três equações de referência internacionais e uma nacional em crianças e adolescentes com fibrose cística (FC). Estudo retrospectivo, no qual foram incluídos pacientes com FC, idade entre 8 e 12 anos e acompanhamento ambulatorial regular. Foram coletados dados demográficos e variáveis antropométricas. Todos os pacientes incluídos deveriam ter realizado teste de força muscular ventilatória e espirometria nos últimos 12 meses. A normalização dos resultados foi realizada utilizando-se as variáveis preditoras requeridas em cada equação estudada. Os dados foram comparados utilizando-se uma ANOVA de uma via. Foram incluídos 24 pacientes, 62,5% masculinos, média de idade 10,5±1,53 anos, estatura 138,0±0,08 cm, massa corporal 34,6±9,07 kg, VEF1 93,29±29,02% e CVF 103,78±26,12%. As pressões (cmH2O) inspiratória (PIMAX) e expiratória (PEMAX) máximas encontradas foram 92,1±22,8 e 98,9±24,5, respectivamente. Após a normalização pelas diferentes equações, demonstrou-se que as internacionais tendem a superestimar os achados para a nossa população. A equação nacional apresentou valores médios previstos significativamente (p;100%) em 91,6, 79,1, e 75,0% dos sujeitos e a PEMAX em 66,6, 87,5 e 50%, enquanto a equação nacional estimaria apenas 50,0 e 37,5% dos indivíduos, respectivamente. A normalização dos resultados de força muscular ventilatória em crianças e adolescentes entre 8 e 12 anos com FC utilizando-se equações internacionais superestimam os valores das pressões respiratórias máximas

Reference Values for Inspiratory Muscle Endurance in Healthy Children and Adolescents.

To generate reference values for two inspiratory muscle endurance (IME) protocols in healthy children and adolescents.This is an observational, cross-sectional study, in healthy children and adolescents from 4 to 18 years of age. Weight, height, maximal inspiratory pressure (MIP) and IME were measured using two protocols. A fixed load of 30% of MIP with a 10% increment every 2 minutes was used in the incremental threshold loading protocol. As for the maximal loading protocol, a fixed load of 70% of MIP was used and the time limit (Tlim) achieved until fatigue was measured.A total of 462 participants were included, 281 corresponding to the incremental loading protocol and 181 to maximal loading. There were moderate and positive correlations between IME and age, MIP, weight and height in the incremental threshold loading. However, the regression model demonstrated that MIP and age were the best variables to predict the IME. Otherwise, weak and positive correlations with age, weight and height were found in the maximal loading. Only age and height influenced endurance in the regression model. The predictive power (r2) of the incremental threshold loading protocol was 0.65, while the maximal loading was 0.15. The reproducibility measured by the intraclass correlation coefficient (ICC) was higher in the incremental loading (0.96) compared to the maximal loading test (0.69).IME in healthy children and adolescents can be explained by age, height and MIP. The incremental threshold loading protocol showed more reliable results and should be the model of choice to evaluate IME in the pediatric age group

Reliability of ultrasound in the assessment of muscle thickness in critically ill children

Introduction: Ultrasound has been used to quantify and qualify muscle morphology in critically ill children and can detect changes in muscle thickness. The aim of this study was to assess the reliability of ultrasound measurement of muscle thickness in critically ill children and to compare the assessments made by an expert with those made by inexperienced sonographers. Material and methods: Cross-sectional observational study conducted in the paediatric intensive care unit of a tertiary care university hospital in Brazil. The sample included patients aged 1 month to 12 years who received invasive mechanical ventilation for at least 24 h. Ultrasound images of the biceps brachii/brachialis and quadriceps femoris were obtained by one experienced sonographer and several inexperienced sonographers. We assessed intrarater and inter-rater reliability by means of the intraclass correlation coefficient (ICC) and Bland-Altman plot analysis. Results: Muscle thickness was measured in 10 children with a mean age of 15.5 months. The mean thickness of the assessed muscles as 1.14 cm for the biceps brachii/brachialis (standard deviation [SD], 0.27) and 1.85 cm for the quadriceps femoris (SD, 0.61). The intrarater and inter-rater reliability were good for all sonographers (ICC > 0.81). The differences were small, there was no significant bias in the Bland-Altman plots and all measurements were within the limits of agreement, except for 1 measurement of biceps and quadriceps. Conclusion: Sonography can be used in critically ill children to accurately assess changes in muscle thickness, even by different evaluators. More studies are needed to establish a standardised approach to the use of ultrasound for monitoring muscle loss in order to incorporate it in clinical practice. Resumen: Introducción: La ecografía se ha utilizado para cuantificar y calificar la morfología muscular de niños críticamente enfermos, detectando posibles cambios en el grosor muscular. El objetivo del estudio fue evaluar la fiabilidad de la medición por ecografía del grosor muscular en niños críticamente enfermos y comparar la evaluación de un examinador experto con la de examinadores con poca experiencia. Material y métodos: Estudio observacional transversal en la unidad de cuidados intensivos pediátricos de un hospital universitario de tercer nivel en Brasil. Se incluyeron pacientes entre 1 mes y 12 años que recibieron ventilación mecánica invasiva durante un mínimo de 24 horas. Se obtuvieron imágenes ecográficas del bíceps braquial/braquial y cuádriceps femoral en evaluaciones realizadas por un ecografista experimentado y ecografistas inexpertos. La concordancia intra- e interevaluador se estableció mediante el coeficiente de correlación intraclase (CCI) y el análisis gráfico de Bland-Altman. Resultados: Se midió el grosor muscular en 10 niños con una edad media de 15,5 meses. El grosor medio de los músculos evaluados fue de 1,14 cm ± 0,27 para el bíceps braquial/braquial y de 1,85 cm ± 0,61 para el cuádriceps femoral. La fiabilidad intraevaluador e interevaluador fue muy buena (CCI > 0,81) para todos los ecografistas. Las diferencias fueron pequeñas, sin detectarse en el análisis de los gráficos de Bland-Altman, y todas las mediciones estuvieron dentro de los límites de concordancia, excepto una medición de bíceps y cuádriceps. Conclusión: La ecografía se puede utilizar en niños en estado crítico para evaluar con precisión los cambios en el grosor muscular, incluso por diferentes evaluadores. Se necesitan más estudios para establecer un enfoque estandarizado en el uso de esta herramienta para la monitorización de la pérdida muscular con el fin de incorporar su uso en la práctica clínica

Characteristics of the subjects included.

<p>Characteristics of the subjects included.</p

Bland-Altman plots showing the individual differences between both evaluations of the incremental threshold loading (A) and maximal loading (B) protocols, in relation to the mean values of IME.

<p>The solid lines indicate the mean differences between the measurements and the dotted lines indicate the 95% limits of agreement.</p