Prolonged Expiration Research Articles

Prolonged Slow Expiration (PSE) and Prone Position Intervention in Children : A Literature Review

<p>Nursing interventions to reduce the impact of respiratory problems in children aged < 24 months in inpatient rooms are not only a science but also an art. This study aimed to determine the effectiveness of Prolonged Slow Expiration (PSE) and prone position in improving respiratory function in hospitalized children aged < 24 months with respiratory distress in inpatient rooms. This literature review examined thirteen peer-reviewed journals based on inclusion criteria. The results of the review showed that PSE and prone position can reduce the respiratory frequency, maintain the neuromechanical diaphragm, and increase tidal volume. PSE was more effective at lowering the bronchiolitis scale score, preventing the child from experiencing moderate to severe respiratory distress, and decreasing relative sputum production. The prone position is more effective in increasing SaO2 even when using mechanical ventilation (MV), can increase maximal inspiratory pressure (MIP) and tissue oxygenation index (TOI), provides sleeping comfort, improves cardiorespiratory function, reduces moderate to severe respiratory distress, and can perform intubation. It can be concluded that PSE is a safe and easy therapy to administer to mild respiratory distress patients but has not a significant effect on children < 24 months with moderate to severe respiratory distress in inpatient rooms.</p>

Effectiveness of a preoperative breathing exercises intervention on patients undergoing cardiac surgery: a systematic review

Effectiveness of a preoperative breathing exercises intervention on patients undergoing cardiac surgery: a systematic review

Changes in the autonomic and respiratory patterns of mice submitted to short‐term sustained hypoxia

Short-term sustained hypoxia (SH) in rats induces changes in sympathetic-respiratory coupling and sympathetic overactivity, which seems to be linked to hypertension. However, there is no previous experimental data about the effects of SH on the autonomic and respiratory pattern in mice. In the present study we tested the hypothesis that mice submitted to SH present autonomic and respiratory changes similarly to rats. To reach this goal we evaluated the effects of 24-hour SH exposure on cardiovascular, respiratory and autonomic parameters in baseline conditions and upon chemoreflex activation.C57BL/6J mice (7-8 weeks old, ~25g) were deeply anesthetized for femoral artery and jugular vein catheterization. Four days later, they were submitted to SH (24h, FiO2 0.1) or normoxia. At the end of SH protocol, arterial pressure, heart rate and ventilation were recorded in vivo. Peripheral chemoreflex was activated via KCN injection (0.16 mg/Kg, i.v.). In another experimental group, we performed in situ recordings of phrenic (PN), abdominal, (AbN), cervical vagus (cVN) and thoracic sympathetic (tSN) nerves activities of SH mice using the working heart-brainstem preparation. All experimental protocols were approved by the Institutional Ethics Committee (#140/2019 and #163/2019). In the in vivo approach, although SH mice (n=13) presented a significant decrease in baseline HR (510 ± 22 vs 633 ± 16 beats min-1; P = 0.002) compared with the controls (n=17), no differences were observed in mean arterial pressure levels (109 ± 2 vs 106 ± 2 mmHg; P=0.443). SH mice (n=14) also showed significantly increased respiratory frequency [(fR) 277 ± 8 vs 203 ± 6 breaths.min-1; P <0.0001], tidal volume [(VT) 14 ± 1 vs. 12 ± 1mL.Kg1; P = 0.0019)], and ventilation [(VE) 3927 ± 164 vs 2390 ± 104 mL.Kg-1.min-1; P < 0.0001)] compared with controls (n=17). The magnitudes of bradycardic responses to chemoreflex activation were greater in SH mice (n=8) than in controls (n=11; -329 ± 36 vs -210 ± 30 beats min-1, P=0.02). In the in situ approach, baseline PN discharge (PND) frequency was significantly reduced in SH mice (n=11) in relation to controls (n=26) (0.69 ± 0.06 vs 1.13 ± 0.10 Hz, P=0.0154). The incidence of Late-E bursts in AbN activity in SH mice (n=10) was significantly increased in relation to controls (n=20) (83.3 ± 7.7 vs 24.3 ± 8.0%, P<0.0001). The duration of expiration in SH mice (n=11) was longer than in controls (n=22) (1.13 ± 0.16 vs 0.67 ± 0.07s, P= 0.0002) due to an increase in the duration of post-inspiration (0.78 ± 0.12 vs 0.35 ± 0.04s, P= 0.0032). tSNA in the SH group (n=10) was significantly reduced during late-expiration (E2) compared with the control group (n=16) (19.0 ± 4.3 vs 39.7 ± 4.2%, P= 0.0203). The data are showing that 24-h SH protocol in mice produces: a) an increase in parasympathetic tone to the heart, which seems to be related to changes in their breathing pattern; and b) prolonged expiration and active expiration associated with a reduction in sympathetic activity during E2. This autonomic imbalance favoring the parasympathetic componente may explain why mice, different of rats, do not develop hypertension after SH.

Compound Unani formulations used in Zeeq-un-Nafas (Bronchial Asthma) with their therapeutic importance: An overview

Asthma is one of the most common chronic diseases in modern society and there is increasing evidence to suggest that its incidence and severity are increasing. There is a high prevalence of usage of complementary medicine for asthma. Current estimates suggest that 300 million people worldwide suffer from Bronchial asthma. This disease is very well recognized since ancient times in Unani system of medicine. Various ancient Unani Scholars and Physicians have use different Arabic terms like Rabu (short inspiration and prolonged expiration), Buhar, Dama, Intesab-un-Nafas and Zeequn Nafas under the caption of bronchial asthma. They also described the etiopathological factors, clinical features, types, and various complications of bronchial asthma that are presented in detail in their concerning treatises. Unani physicians have been treating this disease for thousands of years and they have mentioned various single as well as compound drugs viz; Kakra Seenghi (Pistacia integerrima) Arusa (Adhatoda vasica), Ajmod (Apium graveolens), Aslussoos (Glycyrrhiza glabra), Bazrul banj (Hyoscyamus niger), Biskhapra (Trianthema portulaca), Doodhi (Euphorbia hirta), Nil(Indigofera: tinctoria), Qinnab (Cannabis sativam) etc. and the compound formulations in the forms of - Kushta, Majoon , Hubb, Sharbat, Arqiyat, Joshanda, Khenshanda, Laooq ,Tiryaq, Sikanjabeen, Rub, Roghaniyat for its treatment. The relevance formulations have been described in this review paper with their ingredients and usage also to provide the benefit to the students and researchers for their further researches

Mandibular advancement device as treatment trial for catathrenia (nocturnal groaning).

Catathrenia is a rare disease, classified as isolated symptoms and normal variants under sleep-related breathing disorders in the International Classification of Sleep Disorders, third edition. Because of its rarity, the research on its pathogenesis and treatment is insufficient. This study aimed to evaluate whether the mandibular advancement device (MAD) could be considered an alternative treatment trial and if so, to explore factors predicting its effectiveness. Thirty patients (12 men and 18 women, aged 16-67 years) with catathrenia participated in the study. They underwent standard clinical evaluation, questionnaires, physical examinations, craniofacial evaluations, video polysomnography, and imaging of the upper airway before and after the insertion of the MAD. The groaning index (groaning episodes per hour of sleep) and apnea-hypopnea index were evaluated, and anatomic factors predicting effectiveness were explored. The sleep efficiency of most patients was higher than 80%, and groaning was present throughout all stages of sleep. With the insertion of the MAD, the groaning index decreased significantly from 5.8 (2.7-14.3) to 2.8 (1.3-12.2) events/h (P = .014). Age had a negative effect on efficacy. Mandibular repositioning of the MAD, especially the amount of vertical opening and changes of the cross-sectional area of the hypopharynx, was positively related with efficacy. The MAD could be considered a possible treatment trial for those seeking treatment for groaning. Registry: Chinese Clinical Trial Register; Name: The etiology of catathrenia based on oral and maxillofacial system; URL: http://www.chictr.org.cn/showproj.aspx?proj=22286; Identifier: ChiCTR-COC-17013239. Yu M, Hao Z, Xu L, Wen Y, Han F, Gao X. Mandibular advancement device as treatment trial for catathrenia (nocturnal groaning). J Clin Sleep Med. 2021;17(9):1767-1776.

Ambulatory chest physiotherapy in mild-to-moderate acute bronchiolitis in children under two years of age- A randomized control trial.

Objective:The aim of this study was to compare the role of a chest physiotherapy (CP) intervention to no intervention on the respiratory status of children under two years of age, with mild-to-moderate bronchiolitis.Methods:Out of 80 eligible children observed in the Emergency Room, 45 children completed the study with 28 randomized to the intervention group and 17 to the control group. The intervention protocol, applied in an ambulatory setting, consisted of combined techniques of passive prolonged slow expiration, rhinopharyngeal clearance and provoked cough. The control group was assessed with no chest physiotherapy intervention. The efficacy of chest physiotherapy was assessed using the Kristjansson Respiratory Score at the admission and discharge of the visit to the Emergency Room and during clinical visits at day 7 and day 15.Results:There was a significant improvement in the Kristjansson Respiratory Score in the intervention group compared to the control group at day 15 [1.2 (1.5) versus 0.3 (0.5); -value, in the control and intervention groups, respectively], with a mean difference (95% CI) of ( to ).Conclusion:Chest physiotherapy had a positive impact on the respiratory status of children with mild-to-moderate bronchiolitis.Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT04260919.

THE EFFECT OF MUSIC THERAPY ON PEAK EXPIRATORY FLOW, ANXIETY, AND DEPRESSION IN COPD PATIENTS

Introduction : Biopsychological factors of anxiety in patients with Chronic Obstructive Pulmonary Disease (COPD) will cause symptoms of increased respiration rate and prolonged expiration duration. Meanwhile, depression in COPD patients will increase the damage to lung functional capacity. This study aims to determine the difference in the impact of music therapy on increasing the value of peak expiratory flow rate, anxiety, and depression in the treatment group and the control group. Methods : Quasi-experimental one group pre-test-post test was conducted on 46 COPD patients in RSUD Prof. Dr. Soekandar Mojosari and RSUD Basoeni Mojokerto with simple random sampling technique. This research was conducted by providing music therapy intervention in the treatment group. The statistical test used was the Independent t-test to determine the difference in peak expiratory flow values in the two groups, while the Mann-Whitney U test was used to determine the difference between anxiety and depression in the two groups. Results : There were differences in the intervention group who received music therapy with the control group with p-value = 0.005 (p &lt;0.05), and the difference between anxiety (Z = -3.813) and depression (Z = -3.868) values with an asymp sign value. = 0,000. Conclusion : There are differences in PEF values, anxiety, and depression between the treatment group and the control group, where this therapy affects the PEF value, anxiety, and depression.

Polysomnographic characteristics and acoustic analysis of catathrenia (nocturnal groaning)

Objective: Catathrenia is a sleep disorder characterized by nocturnal groaning sounds emitted during prolonged expiration. As a rare condition, its polysomnographic findings were inconsistent. We aimed to present polysomnographic characteristics of catathrenia patients and perform acoustic analysis of groaning sounds. Approach: Twenty-three patients (eight males and 15 females) diagnosed with catathrenia by video-polysomnography were included. They underwent clinical evaluation and physical examination, and answered a questionnaire. Acoustic analyses (oscillograms and spectrograms) of catathrenia and snoring signals were performed by Praat 6.1.09. Sounds were classified according to Yanagihara criteria. Main results: The average age of catathrenia patients was 29.6 ± 10.0 years, with a body mass index of 22.3 ± 5.1 kg m−2. A total of 3728 groaning episodes were documented. Catathrenia events of 16 patients (70%) were rapid eye movement (REM)-predominant. The average duration of groaning was 11.4 ± 4.6 s, ranging from 1.3 to 74.9 s. All signals of groaning were rhythmic or semi-rhythmic, classified as type I and type II, respectively, with formants and harmonics. Snoring events were observed in nine patients. Snoring mainly occurred in the non-REM stage, with a duration of less than 1.5 s. Signals of snoring were chaotic, classified as type III, without harmonics. Significance: Catathrenia occurred in all sleep stages but mainly in REM. Durations of groaning varied greatly across patients. Acoustic characteristics of catathrenia were typical. Groaning had rhythmic or semi-rhythmic waveform, formants and harmonics, indicating vocal origin, while snoring had chaotic waveform.

Immediate Effects and Safety of High-Frequency Chest Wall Compression Compared to Airway Clearance Techniques in Non-Hospitalized Infants With Acute Viral Bronchiolitis.

No studies have investigated the use and safety of high-frequency chest wall compression (HFCWC) for non-hospitalized infants with acute viral bronchiolitis (AVB). The aim of the present study was to evaluate the immediate effects and safety of HFCWC as compared to airway clearance techniques in children with AVB. In this randomized clinical trial in non-hospitalized infants (0-12 months old) with mild to moderate AVB, children were randomized into 2 groups: airway clearance techniques (20 min of prolonged slow expiration and provoked cough) or HFCWC (15 min). A single session was performed and children were evaluated at baseline and at 10 min and 20 min after treatments. Outcomes measures were the Wang severity score, [Formula: see text], sputum wet-weight, and the presence of adverse events. A total of 91 infant subjects, mean age 7.9 ± 2.6 months, were included. Significant (P = .004) between-group differences were found in the Wang score, which was 0.28 points lower in the airway clearance techniques group. There was a greater increase of infants classified as normal and a greater decrease of those classified as mild according to the Wang score when airway clearance techniques were used compared to the use of HFCWC (P = .009). The sputum wet-weight was lower in subjects treated with the airway clearance techniques (P < .001). Although [Formula: see text]improved in both groups, no differences were found between them. There was also no difference for adverse events, and the majority of children did not present any adverse events after 20 min. The use of HFCWC induced similar clinical effects as airway clearance techniques and was safe for non-hospitalized infants with AVB. Both techniques reduced respiratory symptoms and acutely improved [Formula: see text]. (ClinicalTrials.gov: NCT03835936.).

Managing COPD with expiratory or inspiratory pressure load training based on a prolonged expiration pattern.

BackgroundExertional prolonged expiration should be identified as a therapeutic target in COPD. The efficacy of expiratory or inspiratory pressure load training (EPT/IPT) based on the degree of prolonged expiration was investigated.MethodsA total of 21 patients with COPD were divided into two groups according to the exertional change in the inspiratory duty cycle (TI/Ttot). For 12 weeks, patients whose exertional TI/Ttot decreased received EPT (EPT group, n=11, mean percentage forced expiratory volume in 1 s (%FEV1), 32.8%) and those whose exertional TI/Ttot increased received IPT (IPT group, n=10, mean %FEV1, 45.1%).ResultsThe therapeutic responses were as follows. In both groups, endurance time (EPT, +5.7 min, p<0.0001; IPT, +6.1 min, p=0.0004) on the constant work rate exercise test (WRET) and peak oxygen uptake increased (EPT, p=0.0028; IPT, p=0.0072). In the EPT group the following occurred: 1) soon after commencement of exercise with the constant WRET, the expiratory tidal volume (VTex) increased, reducing dyspnoea; 2) VTex and mean expiratory flow increased and then prolonged expiration (p=0.0001) improved at peak exercise with the incremental exercise test (ET); and 3) St. George's Respiratory Questionnaire total, activity and impact scores were improved. In the IPT group, on both the constant WRET and incremental ET, breathing frequency increased, which led to greater exercise performance with effort dyspnoea.ConclusionsThis study showed the benefits of EPT/IPT on exercise performance. If the choice of managing COPD with EPT/IPT is appropriate, inexpensive EPT/IPT may become widespread as home-based training.

Expiratory variability index (EVI) is associated with the severity of acute bronchial obstruction in small children: A proof-of-concept study.

BackgroundLung function testing in small children is cumbersome. However, reduced variability of tidal breathing recorded using impedance pneumography (IP) during sleep was recently found to be a potential objective marker of wheeze in children aged 1‐5 years. We aimed to investigate how an acute bronchial obstruction (BO) and its severity, and recovery thereof reflect in expiratory variability index (EVI).MethodsEVI was measured using a wearable IP system (Ventica®) during sleep in 40 healthy controls (aged 1.5‐5.9 years) and 30 patients hospitalized due to acute BO (aged 1.3‐5.3 years). In healthy controls, EVI was measured for 1‐3 nights at their homes. Patients were measured for several nights during hospitalization, as practically feasible, and at home 2 and 4 weeks post‐discharge.ResultsWe received 79 EVI results from 39 controls and 139 from 30 patients. 90% had previous BO episodes, 30% used asthma controller medication before and 100% after hospitalization. Compared to controls, EVI was significantly lower during hospitalization (P < .0001) having significant correlation with number of days to discharge (r = −.38, P = .004). At 2 or 4 weeks post‐discharge, EVI was not significantly different from the controls (P = .14, P = .49, respectively). EVI was significantly associated with chest auscultation findings (P = .0001) being 17.5 (4.9) (median, IQR) with normal auscultation, 15.6 (7.4) in those with prolonged expiration and 11.4 (6.8) in those with wheeze and/or rales and crackles.ConclusionsEVI was found to be a sensitive, objective marker of acute BO, showing strong association with changes in clinical status in wheezy children aged 1‐5 years.

Pranayamas and Their Neurophysiological Effects.

Introduction:The millenarian breathing exercises from Yoga, commonly called Pranayamas, are known to induce meditative states, reduce stress, and increase lung capacity. However, the physiological mechanisms by which these practices modulate the human nervous system still need to be unveiled.Objectives:The aim of this work was to review studies describing the influence of breathing exercises on the brain/mind of humans.Methodology:We reviewed articles written in English and published between 2008 and 2018. Inclusion and exclusion criteria were based on the PRISMA recommendations to filter articles from Science Direct, PubMed, and Virtual Health Library databases. Patient/Population, Intervention, Comparison, and Outcome technique and Prospective Register of Systematic Reviews registration were also considered.Results:From a total of 1588 articles, 14 attended the criteria. They were critically compared to each other and presented in a table divided into study; country; sample size; gender; age; objective; technique; outcome.Discussion:In general, the 14 papers highlight the impact of yogic breathing techniques on emotional and cognitive performance.Conclusion:In-depth studies focusing on specific aspects of the practices such as retentions, prolonged expiration, attention on fluid respiration, and abdominal/thoracic respiration should better elucidate the effects of Yogic Breathing Techniques (YBT).

Participation of GABAB Receptors of Parafacial Respiratory Group in the Regulation of Respiration in Rats.

The respiratory effects of microinjections of baclofen and 2-hydroxysaclofen into the parafacial respiratory group were studied in experiments on rats. It was shown that activation of GABAB receptors of the parafacial respiratory group suppressed external respiration due to a decrease in the tidal volume and inspiratory flow rate. In parallel, we observed a decrease in the amplitude and an increase in the duration of inspiratory bursts of the diaphragm. Injection of GABAB receptor blocker into the parafacial respiratory group increased pulmonary ventilation due to an increase in volumetric parameters of the inspiratory phase. This effect was accompanied by prolongation of expiration and lengthening of the intervals between the inspiratory bursts of the diaphragm. These results suggest that GABAB receptors of the parafacial respiratory group are an important element of the central mechanisms regulating the volumetric respiratory parameters and are involved in the regulation of the phases of the respiratory cycle.

Assessment of inspiration and expiration time using infrared thermal imaging modality

Breathing is one of the important vital signs assessed by healthcare practitioner for patient monitoring and disease management. There are several methods used to evaluate breathing activities such as respiratory inductive plethysmography, impedance pneumography, bioacoustics method, spirometry and manual assessment. Most of these devices require external attachment on patient such as belt, electrodes and sensor which could be inconvenient if used over a long period of time. Infrared Thermal Imaging (ITI) is a contactless device that detects temperature changes which can be used to assess breathing since hot air particles are being released to surrounding through nose which create temperature variance during breathing. Majority of studies conducted on breathing function were focused on respiratory rate. Therefore, this study assessed the timing of inspiration (TI) and expiration (TE) in three different breathing patterns which are normal, prolonged expiration and rapid breathing by using Infrared Thermal Imaging (ITI). A total of thirty-three subjects were required to simulate various breathing patterns by using a video-guided method. The assessment of TI and TE was recorded using ITI and Respiratory Inductive Plethysmograph (RIP) simultaneously. Results obtained from the ITI images show consistent deflections on the plotted graph which reflect the transition point of inspiration and expiration. This transition point allowed us to measure the TI and TE between ITI and RIP. Our analysis shows that there are no significant differences of the reading obtained between ITI and RIP in TI and TE. Correlation analysis also shows that there was positive correlation between measurement obtained by ITI and RIP. These findings suggest that ITI technique could be used as an alternative method to assess breathing dynamics.

Hypoxia‐induced Sighs Correlate with High Amplitude Bursts in Splanchnic (S), but not Renal (R) or Lumbar (L), Sympathetic Nerve Activity (SNA): Role of Bombesin‐Like Peptides in the PreBotzinger Complex

Previous experiments in inactin anesthetized (100 mg/kg, i.v.) spontaneously breathing male SD rats found that hypoxia (HX, O2 saturation ~ 50%) increased frequency(F) and amplitude (amp) of phrenic (Ph) nerve activity (NA) during eupnea, but distribution of SSNA across eupneic Ph cycles was similar for normoxia and HX [inspiration (I1, I2) &gt; expiration (E1, E2)]. HX produced high amp bursts in PhNA (~ 4 to 6/min), followed by brief apnea (sighs). Correlation analysis during sighs revealed that SSNA redistributed such that high amplitude bursts in SSNA occurred in late inspiration (I2 &gt; I1, E1, E2). In current experiments RSNA (n = 6) and LSNA (n = 3) were correlated with PhNA during HX. During eupnea RSNA was greater in late expiration compared to late inspiration (E2 &gt; I2) with a similar trend for LSNA. HX produced PhNA sighs, but neither RSNA nor LSNA preferentially correlated with phases of the Ph cycle. In the PreBotzinger Complex (PreBot) 2 bombesin‐like peptides (Bom), neuromedin B (NMB) and gastrin‐releasing peptide (GRP), generate sighs (Li et. al., 2016). We evaluated the role of NMB and GRP in the Pre‐Bot in redistribution of SSNA during sighs. PhNA and SSNA were correlated before and after bilateral microinjections (100 nl) into the PreBot of a Bom receptor agonist cocktail [Bom‐agonists) in rats breathing 100% O2 (n = 3). Bom‐agonists increased Ph amp and F during eupnea, but the distribution of SSNA across the eupneic Ph cycle was similar before and after PreBot Bom‐agonists (I1, I2 &gt; E1, E2). Bom‐agonists produced high amp bursts in PhNA (131% of eupneic; 4.6 ± 0.5/min) with prolonged expiration (0.90 ± 0.08 vs 0.74 ± 0.07 sec), indicative of sighs. However, unlike sighs due to HX, with PreBot Bom‐agonists while rats breathed 100% O2, the distribution of SSNA across the Ph cycle was similar for sighs and eupnea (I1, I2 &gt; E1, E2). In separate rats (n = 4), a cocktail of Bom‐antagonists was injected bilaterally (100 nl) into the PreBot (PreBot‐bX) during HX. PreBot‐bX decreased the number (2.6 ± 0.3 vs 1.4 ± 0.4/min) and amplitude (P= 0.08) of PhNA sighs. Correlation of SSNA across the Ph cycle was not changed by preBot‐bX during eupnea (I1, I2 &gt; E1, E2), but HX‐induced redistribution of SSNA during sighs (I2 &gt; E1, E2) was eliminated by PreBot‐bX. Thus, Bom‐like peptides in the PreBot contribute to sighs, but correlation of sighs with high amp bursts in SSNA was evident only with HX‐induced sighs. Based on these results and our previous finding that inhibition of the paraventricular nucleus of the hypothalamus (PVN) resulted in uncoupling of SSNA with inspiratory sighs, we speculate that HX activates descending projections from the PVN which modulate cardiorespiratory coupling in the medulla during sighs.Support or Funding InformationNIH R01 HL98602This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

NEUROENDOCRINE TUMOR OF LUNG PRESENTING AS COPD AND TREATMENT OUTCOME ON LONG-TERM FOLLOW-UP

PURPOSE: Neuroendocrine tumors (NET) comprise 25% primary lung cancers. But still there is lack of consensus regarding management. We discuss such a case presenting like COPD, ultimate diagnosis, management and long-term follow-up. METHODS: A 40-year-old man with 15 pack-year smoking history presented on May 2013 with cough and sputum production for 1 month and breathlessness for 10 days. On auscultation, breathe sound vesicular with prolonged expiration and bilateral wheezes. Chest X-ray was unremarkable, spirometry consistent with obstructive airway disease. Symptoms subsided on medication. Seven months later, he presented with worsening dyspnoea. HRCT showed a soft tissue density lesion at subcarinal region. Bronchoscopy revealed a submucosal tumor nearly occluding right principal bronchus, involving carina and lower trachea. Biopsy was taken via rigid scope, but histopathology was inconclusive. Surgical exploration was planned. Right thoracotomy was done with excision of right principal bronchial tumor and bronchoplasty with resection of subcarinal lymph node. Histopathology revealed neuroendocrine tumor. Immunohistochemistry showed synaptophysin and chromogranin positive, Ki67 negative. Features compatible with well differentiated neuroendocrine carcinoma (carcinoid tumor). RESULTS: Oncology team started cisplatin and etoposide. Periodic FOB and CT scan revealed no residual disease. He is under observation for last 5 years and doing well. CONCLUSIONS: Surgery is the treatment of choice according to TNM classification. Currently, there is no consensus on adjuvant chemotherapy after complete resection. Clinical trials are needed in this setting. CLINICAL IMPLICATIONS: Clinical presentation of pulmonary NET varies according to it’s location and rarely by hormonal hypersecretion. Many patients present with symptoms that often mimic other respiratory conditions, thus complicating diagnosis.

Prolonged slow expiration technique improves recovery from acute bronchiolitis in infants: FIBARRIX randomized controlled trial

Objective: To examine the effect of prolonged slow expiration respiratory physiotherapy treatment on the acute bronchiolitis severity scale and O2 saturation at short-time and at medical discharge in infants and the hospital stay. Design: Randomized controlled trial. Setting: Infants’ unit of university hospital. Participants: Infants with acute bronchiolitis (N = 80). Intervention: Infants were randomized into respiratory treatment (RT) with prolonged slow expiration or treatment as usual (control) for one-week period. Main outcome measures: The primary outcomes were Acute Bronchiolitis Severity Scale score and O2 saturation, recorded shortly after each intervention during the stay and at medical discharge, and the hospital stay. Results: The RT had a significantly lower Acute Bronchiolitis Severity Scale 10-minute after the first intervention (mean difference −1.7 points, 95% confidence interval (CI) −3.0 to −0.38), 2 hours after (–2.0 points, 95% CI −3.2 to −0.86) and the last day before medical discharge (−1.3 points, 95% CI −2.1 to 0.51). No changes were detected in O2 saturation. The survival analysis of time at medical discharge showed decrease in the average number of days to achieve an Acute Bronchiolitis Severity Scale of less than 2 points (RT: 2.6 days, 95% CI 2.1–3.1; Control: 4.4 days, 95% CI 3.6–5.1). Conclusion: A prolonged slow expiration physiotherapy reduces Acute Bronchiolitis Severity Scale scores and does not change O2 saturation. Infants in RT group stay less days in hospital than infants in control group and no adverse events were detected.

Role of GABAA Receptors of Parafacial Respiratory Group in Control of Respiration in Rats.

The role of GABAergic inhibition in the regulation of activity of the parafacial respiratory group was studied on narcotized mature rats. Microinjections of GABAA agonist muscimol into the parafacial respiratory group inhibited external respiration and bioelectrical activity of the diaphragmatic muscle resulting in diminished tidal volume and decreased respiration rate accompanied by prolonged inspiration, expiration, and intervals between the inspiratory bursts in the phrenic electromyogram. In contrast, microinjections of GABAA antagonist bicuculline into this group stimulated respiration and markedly increased its volumetric parameters. In addition, blockade of GABAA receptors affected the expiratory phase and interburst intervals in the phrenic electromyogram, but produced no effect on respiration rate. These findings attested to contribution of GABAA-mediated inhibition into the performance of parafacial respiratory group. The study revealed different roles of GABAA receptors in modulation of the mechanisms of respiration rate control in mature rats and formation of inspiratory motor outputs originating from the parafacial respiratory group.

Effects of long-term respiratory muscle endurance training on respiratory and functional outcomes in patients with Myasthenia gravis.

Myasthenia gravis (MG) is characterized by reduced muscle endurance and often leads to respiratory complications. A long-term respiratory muscle endurance training (RMET) based on normocapnic hyperpnea was introduced for the first time in MG patients. We investigated RMET effects on respiratory endurance (RE), MG symptoms, lung function and physical fitness and compared the results with a control group (CG). The training period consisted of four weeks intensive training (IT; five 30-min training sessions per week) followed by twelve months maintenance training (MT; five 30-min training sessions over two weeks). Eighteen patients with mild to moderate MG participated as the training group (TG), six patients served as CG. RE, lung function, MG score and physical fitness were tested before and after IT and after three to twelve months of MT. Only 12 TG patients completed the entire training period. Thirteen months of training significantly increased RE measured as time until exhaustion (Tlim) to 412% of baseline (P < 0.001). The MG score improved from 0.67±0.09 to 0.41 ± 0.1 (p = 0.004), and the number of squats per minute as a measure of physical fitness increased in the TG to 160% of baseline (p = 0.015). While lung function did not change during the training period, we observed a modulation in the breathing pattern at rest with prolonged expiration (122% of baseline, p = 0.028). In addition, TG reported subjective improvements in MG symptoms, respiratory symptoms and physical fitness by 49%, 58% and 64%, respectively (P < 0.001). No significant changes were observed in the CG. This is the first controlled long-term RMET study in MG patients. The results demonstrated that this normocapnic hyperpnea training is feasible and beneficial for patients with mild to moderate MG and is a valuable supplement to conventional drug treatment.

Effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis

ObjectiveTo evaluate the effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis (AVB). MethodsA literature review was done searching the Pubmed, LILACS, PEDro, and Scielo databases. The following key words were used: bronchiolitis, physiotherapy, techniques, physical therapy, and chest physiotherapy. Both controlled and uncontrolled clinical trials, without limits as to date, were selected. ResultsFifteen articles were included and the use of different techniques of respiratory physiotherapy showed positive results in eight studies. Most (11) were controlled clinical trials, and only two had a double-blind design. Of the 14 studies with a control group, in six this group was submitted to nasopharyngeal aspiration. The most widely used techniques were manual vibration and postural drainage (eight studies), and then tapping/percussion (seven studied). The maneuvers considered as current, e.g., prolonged slow expiration, expiratory flow acceleration, and rhinopharyngeal retrograde clearance, were used in four, four, and two studies, respectively. ConclusionsThe use of respiratory physiotherapy in children with AVB remains controversial. The heterogeneity of techniques evaluated in the studies limits the interpretation of efficacy, although its use was considered safe. Recent findings indicating a reduction in the length of the hospital stay remain to be confirmed.