Inspiratory muscle training in pulmonary hypertension: TREMMI protocol
Marília Souza Leão, Lucas Mellaci Bergamascki, Vivian Bertoni Xavier, Rodrigo Boemo Jaenisch, Roberto Stirbulov, Vera Lúcia dos Santos Alves
Background: Although the progressive nature of pulmonary hypertension (PH), including the impairment of respiratory muscle function, studies have demonstrated beneficial effects of physical exercise on the functional limitations caused by the disease in this population, being an important ally to the conventional drug therapy. There is no training protocol focused exclusively on respiratory musculature that is performed without supervision, since these patients have low adherence to the rehabilitation programs performed in an outpatient setting. Respiratory muscle training (RMT) improves functional capacity and quality of life (QoL) in patients with chronic diseases such as heart failure and COPD. However, the effects of an unsupervised RMT protocol on PH are not yet known. Objective: To developed an unsupervised, home-based RMT protocol for patients with PH. Methods: A double-blind, controlled, randomized clinical trial to evaluate the effectiveness of this protocol on respiratory muscle strength and endurance, functional capacity, by the six-minute walk test and QoL with the questionnaire The Medical Outcomes Study 36- item Short Form Health Survey (Sf-36) before and after an unsupervised training protocol and performed in a home environment with POWERbreathe. Two groups (IMT and SHAM) will be followed for 12 weeks with training performed 30 minutes daily. Results: We hope the intervention idealized by the protocol may will increase the respiratory muscle strength and endurance, the walk distance in six-minute walk test and QoL. Conclusions: Patients with PH who perform the intervention with inspiratory muscle training protocol may will be increase the respiratory muscle strength, functional capacity and QoL.
1. American Thoracic Society. ATS Statement: guidelines for the six-minute walk test. Am J Respr Crit Care Med. 2002;166:111-7.
2. Babu AS, Padmakumar R, Maiya AG, Mohapatra AK, Kamath RL. Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials. Heart Lung Circ. 2016 Apr;25(4):333- 41.
3. Bosnak-Guclu M, Arikan H, Savci S, Inal-Ince D, Tulumen E, Aytemir K, et al. Effects of inspiratory muscle training in patients with heart failure. Respir Med. 2011;105:1671-81.
4. Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P. CONSORT Statement for Randomized Trials of Nonpharmacologic Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic Trial Abstracts. Annals of Internal Medicine. 2017;167(1):40–7.
5. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Revista Brasileira de Reumatologia. 1999;39(3):143-50.
6. Dall’Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle training in patients with heart failure and inspiratory muscle weakness: a randomized trial. J Am Coll Cardiol. 2006;47(4):757-63.
7. Fowler RM, Gain KR, Gabbay E. Exercise intolerance in pulmonary arterial hypertension. Pulm Med. 2012;359:204:10.
8. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2015; 37:67–119.
9. Galiè N, Simonneau G. The Fifth World Symposium on Pulmonary Hypertension. J Am Coll Cardiol. 2013;62:1–3.
10. Gosselink R, De Vos J, Van den Heuvel SP, Segers J, Decramer M, Kwakkel G. Impact of inspiratory muscle training in patients with COPD: what is the evidence?. Eur Respir J. 2011;37:416-25.
11. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62:42–50.
12. Mainguy V, Maltais F, Saey D, Gagnon P, Martel S, Simon M, et al. Peripheral muscle dysfunction in idiopathic pulmonary arterial hypertension. Thorax. 2010;65:113–17.
13. Mereles D, Ehlken N, Kreuscher S, Ghofrani S, Hoeper M, Halank M, et al. Exercise and Respiratory Training Improve Exercise Capacity and Quality of Life in Patients With Severe Chronic Pulmonary Hypertension. Circulation. 2006;114:1482-89.
14. Meyer FJ, Borst MM, Zugck C, Kirschke A, Schellberg D, Kübler W, et al. Respiratory muscle dysfunction in congestive heart failure: clinical correlation and prognostic significance. Circulation. 2001;103(17):2153–58.
15. Meyer FJ, Lossnitzer D, Kristen AV, Schoene AM, Kübler W, Katus HA, et al. Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension. Eur Respir J. 2005;25(1):125–130.
16. Muza SR, Silverman MT, Gilmore GC, Hellerstein HK, Kelsen SG. Comparison of scales used to quantitate the sense of effort to breathe in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1990; 141: 909–913.
17. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J Med Biol Res. 1999;32(6):719-27.
18. Panagiotou M, Peacock AJ, Johnson MK. Respiratory and limb muscle dysfunction in pulmonary arterial hypertension: a role for exercise training?. Pulm Circ. 2015;5:424–34.
19. Saglam M, Arikan H, Vardar-Yagli N, Calik-Kutukcu E, Inal-Ince D, Savci S, et al. Inspiratory Muscle Training in Pulmonary Arterial Hypertension. Journal of Cardiopulmonary Rehabilitation and Prevention.
20. Simonneau G, Galiè N, Lewis JR, Langleben D, Seeger W, Domenighetti G, et al. Clinical classification of pulmonary hypertension. Journal of the American College of Cardiology. 2004;43(12):S5-S12.
21. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62:34–41.
22. Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, et al. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. J Am Coll Cardiol. 2013;62:22–33.