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BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use

Background Wearing a surgical mask in hospitalized patients has become recommended during care, including rehabilitation, to mitigate coronavirus disease 2019 (COVID-19) transmission. However, the mask may increase dyspnoea and raise concerns in promoting rehabilitation activities in post-acute COVID-19 patients. Objective To evaluate the impact of the surgical mask on dyspnoea, exercise performance and cardiorespiratory response during a 1-min sit-to-stand test in hospitalized COVID-19 patients close to discharge. Methods COVID-19 patients whose hospital discharge has been planned the following day performed in randomized order two sit-to-stand tests with or without a surgical mask. Outcome measures were recorded before, at the end, and after two minutes of recovery of each test. Dyspnoea (modified Borg scale), cardiorespiratory parameters and sit-to-stand repetitions were measured. Results Twenty-eight patients aged 52 ± 10 years were recruited. Compared to unmasked condition, dyspnoea was significantly higher with the mask before and at the end of the sit-to-stand test (mean difference[95%CI]: 1.0 [0.6, 1.4] and 1.7 [0.8, 2.6], respectively). The difference was not significant after the recovery period. The mask had no impact on cardiorespiratory parameters nor the number of sit-to-stand repetitions. Conclusion In post-acute COVID-19 patients near hospital discharge, the surgical mask increased dyspnoea at rest and during a submaximal exercise test but had no impact on cardiorespiratory response or exercise performance. Patients recovering from COVID-19 should be reassured that wearing a surgical facemask during physical or rehabilitation activities is safe. These data may also mitigate fears to refer these patients in rehabilitation centres where mask-wearing has become mandatory.

Introduction: The intermittent intrapulmonary deflation (IID) technique is a recent airway clearance technique that intends to delay the onset of expiratory flow limitation (EFL) during exhalation. We showed in a previous study that IID increased the expiratory volume of COPD patients compared to quiet breathing and positive expiratory pressure (PEP) therapy. We hypothesized that it was due to the attenuation of the EFL. Objectives: To verify the physiologic effects of IID and PEP techniques on EFL with a mechanical lung model. Methods: A mechanical lung model was created to assess the effects of IID and PEP techniques. The thorax was simulated by a plexiglas box in which an adult test lung was connected. A calibration syringe simulated the inspiratory phase. Later, with activation of the IID, the expiratory phase was driven by the deflation generated by the device. With PEP, the expiration occurred maintaining an expiratory pressure between 5-10 cmH2O. A pneumotachograph and a pressure transducer were placed in series for flow, volumes and pressure measurements. Results: The model reproduced physiological characteristics of EFL. However, the deflation of the model was slowed by IID and PEP, and flow remained almost constant, so flow limitation was reduced. Conclusion: The IID and PEP attenuate EFL and increase exhaled volume in the in vitro model.

Breathing control exercises are an important component of occupational therapy in patients with chronic obstructive pulmonary disease (COPD). Delivering these exercises in group settings may enhance their benefits. Therefore, this study assessed the effectiveness of breathing control exercises delivered in a group format to patients with severe COPD remitting from an acute pulmonary exacerbation. This randomized controlled trial of 6 weeks’ duration compared the addition of breathing exercise sessions delivered in a group setting to a standard exercise inpatient rehabilitation program (usual care) versus usual care alone. The standard exercise program consisted of endurance and strength training and therapeutic patient education. The intervention group received, in addition to usual care, 20 sessions of 30 min duration of breathing control exercises in a group setting. The primary outcome was quality of life (Saint George’s Respiratory Questionnaire). Secondary outcomes were the COPD assessment test, modified Borg scale, handgrip strength test, and five-time sit-to-stand test. Thirty-seven patients aged 69 ± 7 years were recruited. After the 6-week period, all outcomes significantly improved and exceeded the minimal clinically important difference in the intervention group only. Between-group changes were significant for each outcome. Conclusions: breathing control exercises in a group setting provide clinically relevant benefits in patients with severe COPD who are remitting from an acute pulmonary exacerbation.

BACKGROUND: The delivery of a high and consistent [Formula: see text] is imperative to treat acute hypoxemia. The objective of this study was to analyze the effective inspired oxygen concentration delivered by different low-flow oxygen therapy systems challenged with different oxygen flows and respiratory patterns in an experimental lung model. METHODS: An adult lung model ventilated in volume control mode simulated different respiratory patterns to obtain mean inspiratory flow of 22.5, 30.0, 37.5, or 45.0 L/min. The oxygen concentration sampled inside the lung model by nasal cannula, simple face mask, non-rebreather mask, and double-trunk mask above nasal cannula tested at oxygen flows of 10, 12.5, and 15 L/min was quantified. The 3 masks were sealed tight onto the model’s airway opening. They were also tested with standardized leaks to determine their clinical performance. RESULTS: All oxygen delivery systems delivered higher oxygen concentration with increasing oxygen flows, regardless of the respiratory pattern. Within each device, the increase in inspiratory flow decreased oxygen concentration when using nasal cannula (P = .03), the simple face mask (P = .03), but not the non-rebreather mask (P = .051) nor the double-trunk mask (P = .13). In sealed condition, the double-trunk mask outperformed the non-rebreather mask and simple face mask (P < .001); mean oxygen concentration was 84.2%, 68.5%, and 60.8%, respectively. Leaks amplified oxygen concentration differences between the double-trunk mask and the other masks as the oxygen delivery decreased by 4.6% with simple face mask (95% CI 3.1–6.1%, P < .001), 7.8% with non-rebreather mask (95% CI 6.3–9.3%, P < .001), and 2.5% with double-trunk mask (95% CI 1–4%, P = .002). With leaks, the oxygen concentration provided by the simple face mask and the non-rebreather mask was similar (P = .15). CONCLUSIONS: Lung oxygen concentration values delivered by the double-trunk mask were higher than those obtained with other oxygen delivery systems, especially when leaks were present.

Riassunto La bronchiolite acuta del lattante (BAL) e un’infezione virale del tratto respiratorio inferiore. Andando da una forma lieve, compatibile con una gestione ambulatoriale, a una forma piu grave, che richiede il ricovero in ospedale, la sua gravita puo variare da un bambino all’altro. Tuttavia, la gestione in fisioterapia respiratoria (FR) associata alla BAL si e troppo spesso ridotta alla semplice esecuzione iterativa di una tecnica o di un atto. Questo articolo propone un approccio riflessivo, basato sulla sintomatologia piuttosto che sulla patologia, che deve essere un prerequisito per qualsiasi trattamento di FR nella BAL. Qualsiasi cura dovrebbe, infatti, iniziare con una valutazione rigorosa per raccogliere e assemblare tutte le informazioni pertinenti che modulano il contenuto dell’intervento fisioterapico. Quest’ultimo include, caso per caso, il disingombro nasale e/o bronchiale, l’educazione terapeutica, la nozione di monitoraggio e l’eventuale decisione di non applicare alcuna tecnica reindirizzando il bambino al Pronto Soccorso. Quando la valutazione porta a una gestione, qualsiasi tecnica o manovra utilizzata deve essere scelta, adattata e valutata alla luce delle caratteristiche anatomiche e fisiopatologiche legate all’immaturita del sistema respiratorio del lattante. L’effetto di questo trattamento deve, quindi, essere costantemente rivalutato ed eventualmente riconsiderato durante e dopo la sua realizzazione. Si noti che questo e anche un momento privilegiato di scambio per l’educazione terapeutica dei genitori. La gestione in FR della BAL non puo, quindi, essere improvvisata. Si basa sull’approccio rigoroso e giustificato di un fisioterapista esperto e preparato.

Objective: To investigate the effects of rehabilitation methods on leg muscle function and functional performance in cystic fibrosis. Data sources: A literature search was conducted in PubMed (MEDLINE), Scopus and the Cochrane Library from inception to October 12, 2020. A secondary hand search through reference lists from identified articles was conducted. Review methods: Three authors independently checked the full-text copies for eligibility of relevant articles. Randomized controlled trials were included. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The PRISMA guidelines were followed. Results suggestive of leg muscle function (e.g. strength, power, endurance, and fatigue) and functional performance were reported. Results: The search identified 8 studies (233 patients). The overall quality of these articles was good. Rehabilitation modalities investigated were physical exercises (aerobic, anaerobic and resistance training) ( n = 7) and neuromuscular electrical stimulation ( n = 1). Most studies ( n = 4) reported on the effects of combined aerobic and resistance training and showed improvement on leg strength when exercises were supervised. Aerobic training alone or the use of neuromuscular electrical stimulation also enhanced leg strength, whereas anaerobic training did not. Two studies evaluated leg fatigue and found no improvement compared to standard care. One study assessed the effect of exercises on functional performance and found no improvement when compared to standard care. No studies emphasized the impact of rehabilitation methods on leg muscle endurance or power. Conclusion: Combined aerobic and resistance training enhances leg muscle strength in cystic fibrosis. There is insufficient data on other leg muscle outcomes, nor on alternative rehabilitation strategies.

Introduction: Nasal irrigation is regularly used in infants to relieve upper airway symptoms. However, because there is no consensus on good practice, nasal irrigation in infants is described and applied heterogeneously among clinicians and between clinical trials. Objective: The aim of this study was to establish consensus regarding the use of nasal irrigation in infants. Methods: A panel of Belgian physiotherapists and physicians experienced in performing nasal irrigation in infants were surveyed using the Delphi technique. Three survey rounds were used. Participants rated their level of (dis)agreement to each statement in each round using a 6-point Likert scale. Consensus was defined for statements which collected at least 75% of responses in agreement or disagreement. The questionnaire of Round 1 was built on nasal irrigation practice habits previously collected from parents, childcare workers, and healthcare professionals. Questionnaires from rounds 2 and 3 were amended based on experts written feedback. Results: Thirty experts (12 physicians and 18 physiotherapists) completed all 3 questionnaires. Consensus was achieved for 47 of 75 statements (63%) distributed over the following domains: “contraindications,” “indications and frequency of use,” “irrigation means,” “solution preparation,” “solution volume,” “realization of the technique,” and “assessment of the efficacy of nasal irrigation.” Conclusion: This study provides the first well-constructed consensus on good practice on nasal irrigation in infants. Consensus on several statements across different domains were established but require validation in future trials. This study also proposes direction for future research focusing on statements that did not reach consensus.

BackgroundOnly a few data associated to wearability of facemask during exercise are available in children. The aim of the study was to evaluate the effect of wearing a facemask on perceived exertion (primary aim), dyspnea, physical performance, and cardiorespiratory response during a submaximal exercise test in children aged between 8 and 12 years. MethodThis study was performed in 2021 in healthy volunteer children from 8 to 12 years. They performed prospectively two one-minute sit-to-stand test (STST), with or without a surgical facemask. The perceived exertion (modified Borg scale), dyspnea (Dalhousie scale), heart rate and pulsed oxygen saturation were recorded before and after STST. The STST measured the submaximal performance. ResultsThirty-eight healthy children were recruited (8-9 years: n=19 and 10-11 years: n=19). After the STST, the perceived exertion increased with or without a facemask (8-9 years group: +1 [0.6; 1.4] and +1.6 [1.0; 2.1]) –10-11 years group: +1.3 [0.7; 1.8]) and +1.9 [1.3; 2.6]) and it was higher with the facemask. The difference between the two conditions in perceived exertion was not clinically relevant in any group (mBorgf: 0.56 pts and 0.68 pts, respectively). The different domains of dyspnea assessed with Dalhousie scale were not influenced by the facemask. The submaximal performance measured by the STST was not changed by the mask whatever the age group. The cardio-respiratory demand was not clinically modified.ConclusionThe surgical facemask had no impact on dyspnoea, cardiorespiratory parameters, and exercise performance during a short submaximal exercise in healthy children.

BACKGROUND: Treating hypoxemia while meeting the soaring demands of oxygen can be a challenge during the COVID-19 pandemic. OBJECTIVE: To determine the efficacy of the surgical facemask and the double-trunk mask on top of the low-flow oxygen nasal cannula on arterial partial pressure of oxygen (PaO2) in hypoxemic COVID-19 patients. DESIGN: Randomized controlled trial. PARTICIPANTS: Hospitalized adults with COVID-19 and hypoxemia treated with the low-flow nasal cannula were enrolled between November 13, 2020, and March 05, 2021. INTERVENTIONS: Patients were randomized in a 1:1:1 ratio to receive either the nasal cannula alone (control) or the nasal cannula covered by the surgical facemask or the double-trunk mask. Arterial blood gases were collected at baseline and 30 min after the use of each system. The oxygen output was adapted afterwards to retrieve the baseline pulse oxygen saturation. The final oxygen output value was recorded after another 30-min period. MAIN MEASURES: The primary outcome was the absolute change in PaO2. Secondary outcomes included changes in oxygen output, arterial partial pressure of carbon dioxide (PaCO2), vital parameters, and breathlessness. KEY RESULTS: Arterial blood samples were successfully collected in 24/27 (8 per group) randomized patients. Compared to the nasal cannula alone, PaO2 increased with the surgical facemask (mean change: 20 mmHg, 95% CI: 0.7-38.8; P = .04) and with the double-trunk mask (mean change: 40 mmHg; 95% CI: 21-59; P < .001). Oxygen output was reduced when adding the surgical facemask (median reduction: 1.5 L/min [95% CI: 0.5-4.5], P < .001) or the double-trunk mask (median reduction: 3.3 L/min [95% CI: 2-5], P < .001). The double-trunk mask was associated with a PaCO2 increase of 2.4 mmHg ([95% CI: 0-4.7], P = .049). Neither mask influenced vital parameters or breathlessness. CONCLUSIONS: The addition of the surgical facemask or the double-trunk mask above the nasal cannula improves arterial oxygenation and reduces oxygen consumption.

BACKGROUND: Surgical (SM) or cloth facemasks (CM) has become mandatory in many public spaces during the COVID-19 pandemic. They may interfere with the participation in physical activities. [...]

OBJECTIVES This systematic review aimed to discuss the prevalence and the risk factors of the musculoskeletal pain in chronic obstructive pulmonary disease (COPD). DATA SOURCE AND STUDY SELECTION Four databases were analysed (Scopus, PubMed, Cochrane and EMBASE). We excluded systematic reviews, meta-analyses, conference abstracts and case reports. Two authors independently checked for the eligibility of the relevant articles. The risk of bias was evaluated using the Newcastle Ottawa Quality Assessment Scale and the Joanna Briggs Institute critical appraisal checklist. The selection and evaluation of studies followed the PRISMA guidelines. RESULTS Twenty studies were retrieved, including from 21 to 7952 patients with COPD. The prevalence of pain was highly heterogeneous across studies: 7-89.7%. Pain was mostly reported in the lumbar (7-69%) and cervical spine (11-48.3%) and the chest (44-82.8%). The main risk factors for developing pain were old age, sex (female), level of physical activity (low) and comorbidities. CONCLUSION Pain is a very common symptom in patients with COPD. Despite this, few clinical trials have investigated the pain. It appears to be located primarily in the lumbar, cervical and thoracic regions and facilitated by being a female, a low level of physical activity, comorbidity(ies) and old age.

La fisioterapia basata sull’evidenza e un concetto centrale nella pratica clinica corrente. E una pratica integrativa che comprende sia gli elementi scientifici (conoscenze) che l’esperienza individuale e collettiva dei professionisti e gli elementi e le preferenze propri del paziente.

La kinesiterapia basada en la evidencia es un concepto central de la practica clinica actual. Se trata de una practica integradora que abarca tanto los elementos cientificos (conocimientos) como el conocimiento experto individual y colectivo de los profesionales, asi como elementos y preferencias propios de los pacientes.

Resume Introduction C’est dans les voies aeriennes peripheriques qu’apparaissent les premieres anomalies pulmonaires dans la mucoviscidose. Tres precoce, cette atteinte est d’abord infraclinique et evolue insidieusement puisque ces petites voies aeriennes (PVA) sont relativement ignorees par les epreuves fonctionnelles respiratoires conventionnelles. Etat des connaissances La methode de rincage d’un gaz inerte, qui donne acces a l’indice de clairance pulmonaire (ICP), est non invasive et plus abordable que les autres techniques d’investigation des PVA. L’ICP est reproductible et nettement plus sensible a une atteinte des PVA que les indices derives de la spirometrie. Le test requiert de l’operateur un investissement important. Perspectives La recente commercialisation d’appareils mesurant l’ICP laisse entrevoir son application au domaine clinique. Cependant, les valeurs d’ICP sont tributaires de l’equipement utilise, ce qui souleve de nombreuses questions theoriques. Les algorithmes specifiques devraient etre ameliores et plus transparents. La standardisation du test reste perfectible. D’autres indices derives du test meriteraient d’etre davantage etudies. Conclusions L’ICP a sa place en recherche pour detecter precocement les anomalies pulmonaires fonctionnelles dans la mucoviscidose et evaluer l’efficacite de nouveaux traitements, notamment chez les patients avec une fonction pulmonaire preservee. Son interet en pratique clinique apparait probable mais reste a preciser.

Background Surgical (SM) or cloth facemasks (CM) has become mandatory in many public spaces during the COVID-19 pandemic. They may interfere with the participation in physical activities. Objective To evaluate how these masks influence dyspnoea (primary outcome), exercise performance and cardiorespiratory response during a 1-min sit-to-stand test (1STST), and to assess masks discomfort sensations. Methods A randomized crossover trial was conducted in healthy adults. They performed 3 1STST (with either no mask (NM), a SM, or a CM) separated from each other by 24–72 h. The number of 1STST repetitions and leg rate of perceived exertion (RPE) were measured. Dyspnoea (Borg scale), hearth rate, respiratory rate and SpO2 were recorded before and at the end of 1STST, as well as after a short resting period. Several domains of subjective discomfort perceptions with masks were assessed. Results Twenty adults aged 22 ± 2y (11 males) were recruited. Wearing the CM generated significantly higher dyspnoea than NM at all time points, but it only became clinically relevant after the 1STST (median difference, 1 [95%CI 0 to 1]). The SM generated a small but significant higher leg RPE than NM (median difference, 1 [95%CI 0 to 1]). The masks had no impact on 1STST performance nor cardiorespiratory parameters. Both masks were rated similarly for discomfort perceptions except for breathing resistance where CM was rated higher. Conclusions In healthy adults, the CM and SM had minimal to no impact on dyspnoea, cardiorespiratory parameters, and exercise performance during a short submaximal exercise test.

BACKGROUND: The impact of the COVID-19 pandemic on functional exercise capacity seemed quickly clinically evident. The objective of this study was to assess the functional exercise capacity of patients with severe COVID-19 and to evaluate the effect of a telerehabilitation program in the specific context of the COVID-19 pandemic. METHOD: Patients hospitalized for severe or critical COVID-19 were recruited. The functional exercise capacity (1-min sit-to-stand test (STST)) was prospectively quantified at discharge. A telerehabilitation program was then proposed. A control group was composed with the patients refusing the program. RESULTS: At discharge, none of the 48 recruited patients had a STST higher than the 50th percentile and 77% of them were below the 2.5th percentile. SpO2 was 92.6 ± 3.0% after STST and 15 patients had oxygen desaturation. After 3-months of follow-up, the number of repetitions during STST significantly increased either in telerehabilitation (n = 14) (p < 0.001) or in control groups (n = 13) (p = 0.002) but only one patient had a result higher than the 50th percentile (in Telerehabilitation group) and 37% of them were still under the 2.5th percentile for this result. The improvement was significantly and clinically greater after the telerehabilitation program (p = 0.005). No adverse events were reported by the patients during the program. CONCLUSIONS: Patients hospitalized for COVID-19 have a low functional exercise capacity at discharge and the recovery after three months is poor. The feasibility and the effect of a simple telerehabilitation program were verified, this program being able to substantially improve the functional recovery after three months.

Physiotherapy techniques are regularly prescribed in the hypermobile type Ehlers-Danlos syndrome (hEDS) and they are appreciated by the patients. The objective of this systematic review was to investigate the effect of the different physiotherapy techniques related to the children and adult patients with hEDS. PubMed, SPORTDiscus, Cochrane Library, PEDro, Scopus, and Embase databases were analyzed from inception to April 2020. Characteristics of the studies (authors), patients (sample size, sex, age, Beighton score), and nonpharmacological treatment (length of the program, number of session, duration of the session, and type of intervention), and the results with the dropout rate were extracted. From the 1045 retrieved references, 6 randomized controlled trial with a sample size ranging from 20 to 57 patients were included in the systematic review. There was a huge heterogeneity in the interventions. The durations of the program were from 4 to 8 weeks. Pain or proprioception demonstrated significant improvements in the intervention group regardless of the type of intervention. A benefit of the inspiratory muscle training was observed on functional exercise capacity. The quality of life was systematically improved. Physiotherapy benefits on proprioception and pain in patients with hEDS even if robust randomized control studies are missing.

Dear Editor, Hypoxaemia is a typical feature of the coronavirus disease 2019 (COVID-19). The rapid rise in the number of patients requiring oxygen therapy during the pandemic may cause a sharp increase in oxygen demands and potential threats of supply disruption, particularly in developing countries1 or nursing homes. Moreover, the use of elevated oxygen flows via nasal cannula raises concerns about exhaled air dispersion distance and the potential risk of generating aerosols [...]

BACKGROUND: The delivery of a high and consistent fraction of inspired O2 (FiO2) is imperative to treat severe acute hypoxemia. [...]

Introduction/aims Oropharyngeal dysphagia is common in patients with neuromuscular diseases (NMDs). Its early recognition is vital for proper management. We tested a large cohort of adult NMD patients for oropharyngeal dysphagia using the Sydney Swallow Questionnaire (SSQ). We also looked for possible differences in characteristics of oropharyngeal dysphagia in various NMD groups and diseases. Finally, we compared results of this screening with those from their corresponding medical records for eventual "clinical history" of dysphagia. Methods We asked patients to fill in the SSQ during follow-up outpatient visits at our neuromuscular reference center. A total score above the cutoff score of 118.5 out of 1700 was indicative of oropharyngeal dysphagia. Results Of the 304 adult patients assessed for eligibility, 201 NMD patients (96 women and 105 men, aged 49.0 ± 16.2 years) were included and tested in this study. Oropharyngeal dysphagia was detected in 45% of all the NMD patients when using the SSQ, whereas only 12% had a positive medical record for dysphagia. The median SSQ scores for patients with myotonic syndromes (including myotonic dystrophy type 1), with amyotrophic lateral sclerosis, and with facioscapulohumeral dystrophy were above the cutoff score. The SSQ scores obtained revealed distinct oropharyngeal dysphagia characteristics in the different NMD groups and diseases. Discussion The SSQ tests positively for oropharyngeal dysphagia in a higher proportion of NMD patients compared with their medical records. The distinct oropharyngeal dysphagia characteristics we revealed in different NMD groups and diseases may help to elaborate adapted clinical approaches in the management of oropharyngeal dysphagia.

Study Objective: Telemedicine (TM) for continuous positive airway pressure (CPAP) treated patients may save health-care resources without compromising treatment effectiveness. We assessed the effect of TM (AirView Online System, ResMed) during the CPAP habituation phase on 3-month and 1-year treatment adherence and efficacy in patients with moderate-to-severe obstructive sleep apnea (OSA).Methods: At CPAP initiation, 120 patients diagnosed with OSA were randomized to either usual care (UC) or TM during the habituation phase (clinical registration: ISRCTN12865936). Both groups received a first face-to-face appointment with a sleep care giver at CPAP initiation. Within the following month, 2 other physical visits were scheduled in the UC group whereas two phone consultations were planned in the TM group, in which CPAP parameters were remotely adapted. Additional physical visits were programmed at the patient's request. Face-to-face consultations were scheduled at 3 and 12 months after CPAP initiation. The primary outcome was the mean CPAP daily use over the course of 12 months.Results: Twenty of 60 patients stopped CPAP therapy in the UC group vs. 14 of 60 in the TM group (p = 0.24). In per protocol analysis, mean [95% CI] daily CPAP use among 86 patients still using CPAP at 12 months was 279 [237; 321] min in the 38 patients on UC and 279 [247; 311] min in the 43 patients on TM, mean difference [95% CI]: 0 [−52; 52] min, P = 0.99. Total consultation time per patient was not different between groups, TM: 163 [147; 178] min, UC: 178 [159; 197] min, difference: −15 [−39; 9] min, p = 0.22.Conclusions: Telemedicine during the CPAP habituation phase did not alter daily CPAP use or treatment adherence and did not require more healthcare time. Telemedicine may support clinic attendance for CPAP titration.Clinical Trial Registration: [ISRCTN], identifier [ISRCTN12865936].

Background: Patients with coronavirus disease (COVID-19) can develop severe hypoxemia. Meeting the soaring demands of oxygen may be a challenge. Objective: To test the efficacy of an easily handmade system, the double-trunk mask (DTM), in reducing oxygen consumption while maintaining patient’s oxygenation level. Methods: Hospitalized adults with COVID-19 and hypoxemia treated with low-flow oxygen therapy we recruited. The standard oxygen delivery system was replaced by the DTM with nasal cannula for 30 minutes with an oxygen output adapted to maintain an identical oxygen saturation by pulse oximetry. The standard oxygen delivery system was then reinstated for 30 minutes. Primary outcome was the absolute change in oxygen flow between the standard delivery systems and the DTM. Secondary outcomes were changes in blood gases, vital parameters and patient comfort. Results: Eleven patients were analyzed (mean age 61 years; 27% male). Compared with standard delivery systems, the oxygen output was significantly reduced with the DTM (median, 5 vs 1.5 L/min (95% CI -4 to -1.5, p=0.003)) when oxygen saturation and arterial oxygen tension remained stable. The DTM was also associated with a significant but slight increase in arterial carbon dioxide tension (median, 36 mmHg vs 37 mmHg, p=0.006), and respiratory rate (median, 26 vs 30 breaths/min, p=0.05). Other parameters were unaltered. The DTM was generally judged less comfortable than the baseline oxygen delivery system, especially in patients requiring low oxygen flow at baseline. Conclusions: The DTM is a simple and efficient system to reduce oxygen consumption. This may have clinical implications in places where oxygen supplies are limited.

La méthode retenue pour cette réponse rapide est basée sur une synthèse des données probantes disponibles les plus pertinentes, les recommandations nationales et internationales, ainsi que sur une consultation des parties prenantes. Ce document a été élaboré collégialement entre la HAS, le Conseil national de l’ordre des masseurs-kinésithérapeutes et les référents des CNP et sociétés savantes : CMK, GKR-SPLF, SFP, SKR. Validation par le collège de la HAS en date du 16 avril 2020.

BACKGROUND: Air-flow oscillations generated by exhaling through oscillatory positive expiratory pressure (OPEP) devices favor airway clearance. Variations in mechanical properties between different devices may influence therapeutic efficacy. The objective of this study was to assess mechanical properties in vitro and to compare the performance of 6 OPEP devices at different resistance levels under active expiratory flow patterns. METHODS: 4 gravity-dependent OPEP devices (ie, Flutter, Gelomuc, Pari O-PEP, Shaker Medic Plus) and 2 gravity-independent OPEP devices (ie, Acapella Choice and Aerobika) were each tested at low, medium, and high resistance settings. All devices were independently connected to a pulmonary waveform generator that reproduced active exhalation flows. Expiratory flow-volume curves were retrieved from 4 subjects with different stages of obstruction severity and were scaled according to either peak expiratory flow (4, 6, and 8 L/s) or volumes (2, 3 and 4 L), thus amounting to 24 active exhalations. Resulting waveforms were divided into 4 parts and the 2 middle parts were used to extract the following mechanical data: positive expiratory pressure (PEP), maximum expiratory pressure (Ppeak), oscillation frequency, and flow oscillation amplitude. The percentage of tests achieving oscillation frequencies ≥ 12 Hz and PEP ≥ 10 cm H2O was calculated for each device. RESULTS: Mechanistic effects of the Acapella, Aerobika, and Shaker devices were not comparable. The Flutter, Gelomuc, and Pari devices behaved similarly and achieved more tests with optimum oscillation frequency and PEP values than the other devices. These 3 devices also produced the highest oscillation amplitudes at the low-resistance level, whereas the Aerobika elicited higher and consistent oscillation amplitudes at medium and high resistance settings. CONCLUSIONS: Operational parameters differed between and within devices, yet the Flutter, Gelomuc, and Pari devices were similar in many aspects. Therapeutic efficacy may depend on the selected OPEP device and set resistance.

Background: SIMEOX produces a non-invasive succession of very short air depressions through a mouthpiece during expiration. Therefore, the SIMEOX technology claims to reduce expiratory flow limitation. Objective: To assess the safety and to measure expiratory volume and flow mobilized with SIMEOX. Methods: Non-smoker adults with no history of cardio-respiratory disease were recruited. Each participant performed 3 slow vital capacity (VC) maneuvers followed by 3 slow maximal exhalations from total lung capacity with SIMEOX. Flow and volume were measured using a pneumotachograph. The highest volume of each attempt was reported while flow was averaged from the 3 repetitions. Participants were further categorized according to the lower limit of normality (LLN) of VC calculated from ERS 1993 equations. Results: Thirty-two subjects (21F, 24 ± 8y) were recruited. Mean (±SD) volume during slow expiration with SIMEOX and slow VC was respectively 4.01 ± 0.93L and 4.05 ± 1.08L (p=0.55). Mean expiratory flow with SIMEOX was significantly lower than during slow VC (0.8 ± 0.1L/s vs 2 ± 0.9L/s, p Conclusions: Our preliminary data suggest that SIMEOX modifies the expiratory pattern and may be able to mobilize an extra volume of air in subjects with abnormal lung function. Collection of data in patients with COPD is ongoing.

Introduction The aim of this systematic review was to summarize the effects of yoga, qi gong or tai chi in COPD patients. Methods Studies evaluating effects of the selected complementary therapies on lung function, dyspnea, quality of life or functional exercise capacity in COPD patients were identified and reviewed from three databases. Results Eighteen studies were included. Six studies evaluated the effects of yoga and the others focused on tai chi or qi gong separately or combined. The duration of the programs ranged from 6 weeks to 6 months and the frequency from 2 to 7 times a week. Each session reached 30 to 90 minutes. Benefits were observed on lung function and functional exercise capacity but benefit was clearly stated neither on quality of life nor on dyspnea. Conclusion This systematic review highlights the potential of these therapies as complementary therapeutic approach in COPD patients.

Dear Editor, The increasing importance of exercises as medicine in adults and children implies the evaluation of functional exercise capacity. The 6-min walk test (6MWT) is the reference test [1]. However, other field tests [sit-to-stand test (STST), step test, shuttle test etc.] have been developed to offer complementary information or to overcome the barriers related to resources needed for the 6MWT, such as a long hallway, the need for a second repeat of the test and the time constraints to perform the test. [...]

Background: Many oscillatory positive expiratory pressure (OPEP) devices exist and some of them use unique mechanism to produce air-flow oscillations. However their operational parameters and elicited therapeutic effects may vary. Objectives: To assess the mechanical performance of 6 OPEP devices at different resistance levels. Methods: Four gravity-dependent (Flutter, Gelomuc, Shaker, PARI-OPEP) and 2 gravity-independent OPEP devices (Acapella Choice and Aerobika) were tested at 3 resistance levels (low, medium, high). Each device was independently attached to an artificial lung driven by a ventilator in order to simulate an active exhalation. Ventilator settings were adjusted to produce peak expiratory flow rate between 40-45 L.min-1 at 10 breaths.min-1. The middle-third of the exhalation phase was used to compare positive expiratory pressure (PEP), oscillatory frequency (OF) and pressure amplitude (PA). Optimal operational parameters were defined as OFs of 12 Hz or above and PEP ranging between 10-20 cmH2O. Corresponding PAs at these settings were analysed. Results: Only gravity-dependent devices at medium and high resistance levels produced the desired OFs and PEP settings, ranging from 16 to 22 Hz and 12 to 18 cmH2O, respectively. Corresponding PAs ranged from 0.6 to 1.8 cmH2O. Compared to these devices, Acapella and Aerobika elicited higher PAs (from 1.7 to 4.2 cmH2O) although they did not achieve optimal PEP or OF parameters. Conclusions: The gravity-dependent devices displayed close mechanical performances and produced optimal operational parameters at the simulated exhalation settings. Acapella and Aerobika probably require higher expiratory pressure to reach theoretical therapeutic effectiveness.

BACKGROUND: Positive expiratory pressure (PEP) is regularly used as a self-administered airway clearance technique. OBJECTIVE: The aim of this study was to evaluate the need to teach the correct use of the PEP device and to measure the progress of the success rate of the maneuver after training. METHOD: A PEP system (PariPEP-S Sytem) was used to generate PEP in 30 healthy volunteers. They were instructed by a qualified physical therapist to breathe correctly through the PEP device. Then they were evaluated during a set of ten expirations. Two other evaluations were performed at day 2 and day 8 (before and after feedback). The mean PEP and the success rate were calculated for each set of expirations. The number of maneuvers needed to obtain a correct use was calculated on the first session. RESULTS: An optimal PEP was reached after 7.5 SD 2.7 attempts by all subjects. Success rates and mean pressures were similar between the different sets of expirations (p=0.720 and p=0.326, respectively). Pressure variability was around 10%. After one week, 30% of subjects generated more than two non-optimal pressures in the set of ten expirations. No difference in success rate was observed depending on the evaluations. CONCLUSION: This study demonstrates that good initial training on the use of the PEP device and regular follow-up are required for the subject to reach optimal expiratory pressure.

BACKGROUND: Lung clearance index (LCI), a measure of ventilation inhomogeneity derived from a multiple-breath washout test, is a promising tool for assessing airway function in patients with non-cystic fibrosis bronchiectasis. However, it is unknown whether ventilation inhomogeneity could improve after successful elimination of excessive secretions within bronchiectasis. The objective of this work was to assess the short-term effects of lung secretion clearance using the autogenic drainage technique on standard lung function tests and LCI in subjects with non-cystic fibrosis bronchiectasis. METHODS: Nitrogen-based multiple-breath washout, spirometry, and body plethysmography tests were performed 30 min before autogenic drainage in adults with stable non-cystic fibrosis bronchiectasis. The autogenic drainage session was followed by a 5-min break, after which the tests were repeated in the same order. Sputum expectorated during autogenic drainage was quantified as dry weight and correlated with change between post- and pre-measurements (Δ). Paired t test or Wilcoxon signed-rank tests were used to compare pre- and post-autogenic drainage measurement outcomes. A P value of ≤.05 was considered as statistically significant. RESULTS: Twenty-four subjects were studied (18 females, median age [range]: 65 [21–81] y). Mean ± SD LCI significantly improved after autogenic drainage (10.88 ± 2.62 vs 10.53 ± 2.35, P = .042). However, only 20% of subjects with mucus hyperproduction during autogenic drainage had a ΔLCI that exceeded measurement variability. The percent of predicted slow vital capacity (SVC%) also slightly improved (88.7 ± 19.3% vs 90 ± 19.1%, P = .02). ΔLCI was inversely related to dry sputum weight (r = −.48, P = .02) and ΔSVC% (r = −.64, P = .001). ΔSVC% also correlated with dry sputum weight (r = 0.46, P = .02). CONCLUSIONS: In adults with non-cystic fibrosis bronchiectasis and mucus hypersecretion, autogenic drainage improved ventilation inhomogeneity. LCI change may be the result of the maximum recruited lung volume and the amount of cleared mucus secretion. (ClinicalTrials.gov registration NCT02411981.)

Background: Lung clearance index (LCI), a measure of ventilation inhomogeneity, is increasingly studied in non-cystic fibrosis bronchiectasis (NCFB). However, its interest in assessing interventions in this disease remains unclear. In addition, chest physiotherapy is frequently advocated in patients with NCFB despite a lack of objective benefit using standard lung function tests. Objectives: To assess the short-term effects of autogenic drainage (AD) in NCFB adults using standard lung function tests and LCI. Methods: LCI, spirometry and body plethysmography tests were performed before 30-min AD in stable NCFB patients. After the AD session, the tests were repeated in the same order. Dry and wet expectorated sputum were quantified during the AD session and correlated with % of change between post and pre measurements (Δ, in %). Results: 24 patients were studied (18 F, median (range) age: 65y (21 – 81). LCI significantly improved with AD (mean ± SD: 10.88 ± 2.62 vs 10.53 ± 2.35, p Conclusion: In NCFB adults, AD has a significant short-term impact on ventilation inhomogeneity. LCI change may be the result of the maximal mobilized lung volume recruited and the amount of cleared mucus secretion.

Background Comparability of multiple breath washout (MBW) systems has been little explored. We assessed agreement in lung clearance index (LCI) from two similar, commercial nitrogen MBW setups in patients with Cystic Fibrosis (CF) and controls. Methods The EasyOne Pro (NDD) and Exhalyzer D (EM) were randomly applied in 85 adults (34 with CF) and 97 children (47 with CF and normal forced expiratory volume in one second). We assessed differences between setups in LCI, lung volumes and breathing pattern and diagnostic performance for detecting abnormal lung function. Results Compared to NDD, EM measured higher LCI, functional residual capacity and cumulative expired volume while respiratory rate was lower. Mean difference (limits of agreement) in LCI was 1.30 (−2.34 to 4.94). In CF, prevalence of abnormal LCI was greater in children and similar in adults using EM compared to NDD. Conclusions Agreement of MBW outcomes between setups is poor and explained by nitrogen measurement techniques and breathing pattern.

Introduction : Les nombreux bénéfices de l’exercice physique chez les patients atteints de bronchopneumopathie chronique obstructive ont été démontrés. Le but de cette revue systématique est de résumer les éléments en faveur du bénéfice de l’exercice physique sur la fonction respiratoire, la capacité aérobie maximale et la qualité de vie des patients atteints de mucoviscidose. Méthodes : La recherche a été réalisée avec la base de données Medline entre 2000 et 2015. Une recherche complémentaire a été réalisée en utilisant les bibliographies des articles retrouvés par la recherche initiale. Résultats : Dix-sept études ont été retrouvées. Une grande disparité des résultats est notée dans les différentes études. Aucun bénéfice systématique n’a été retrouvé sur la fonction respiratoire, la capacité aérobie maximale et la qualité de vie. Aucune relation entre le type de programme utilisé et les bénéfices éventuels n’a pu être mise en évidence. Conclusions : L’exercice physique entraîne une amélioration de la fonction respiratoire, de la capacité aérobie maximale et de la qualité de vie au cours de la mucoviscidose, mais de façon non systématique. Il semble encore difficile de déduire des ces résultats un programme-type d’exercices physiques adaptés à l’ensemble des patients atteints de mucoviscidose. [Impact of physical exercise in cystic fibrosis patients: A systematic review] Introduction Beneficial effects of physical exercise have been previously demonstrated in patients with chronic obstructive pulmonary disease. The aim of this systematic review was to summarize the evidence supporting physical exercise to improve on lung function, exercise capacity and quality of life in cystic fibrosis patients. Methods Medline database was used to search clinical studies from 2000 to 2015. We also analyzed the bibliographic section of the included studies, in order to identify additional references. Results A total of 17 studies were identified. A great disparity was found in the results of the different studies. No systematic benefit was found on lung function, exercise capacity or quality of life. No relationship between the type of program and the benefits achieved was observed. Conclusions Evidence that physical exercise benefits lung function, exercise capacity and quality of life in cystic fibrosis patient is inconsistent and evidence does not support a particular standardized program for all patients.

Objective: To develop a standardized, reliable, valid spine model of active trunk movements that accurately discriminates kinematic patterns of patients with chronic non-specific low back pain from those of healthy subjects. Design: Comparative cohort study. Subjects: Healthy subjects (n = 25) and patients with chronic non-specific low back pain (n = 25) aged 30-65 years. Methods: Subjects performed 7 trunk movements from a seated position at non-imposed speed during 2 sessions. Nine markers on bony landmarks measured range of motion and speed of 5 spinal segments, recorded by 8 optoelectronic cameras. Results: Both groups showed good-excellent reliability in all movements for range of motion and speed of all spinal segments (intraclass correlation (ICC), 0.70-0.96; standard error of measurement, expressed as a percentage, 19.4-3.3%). The minimal detectable change in the patient group was 16.7-53.7%. Range of motion and speed in all spinal segments for trunk flexion, rotation, and flexion with rotation differed significantly between groups (p

Complex actions can be regarded as a concatenation of simple motor acts, arranged according to specific rules. Because the caudal part of the Broca's region (left Brodmann's area 44, BA 44) is involved in processing hierarchically organized behaviors, we aimed to test the hypothesis that this area may also play a role in learning structured motor sequences. To address this issue, we investigated the inhibitory effects of a continuous theta-burst TMS (cTBS) applied over left BA 44 in healthy subjects, just before they performed a serial RT task (SRTT). SRTT has been widely used to study motor skill learning and is also of interest because, for complex structured sequences, subjects spontaneously organize them into smaller subsequences, referred to as chunks. As a control, cTBS was applied over the vertex in another group, which underwent the same experiment. Control subjects showed both a general practice learning effect, evidenced by a progressive decrease in RT across blocks and a sequence-specific learning effect, demonstrated by a significant RT increase in a pseudorandom sequence. In contrast, when cTBS was applied over left BA 44, subjects lacked both the general practice and sequence-specific learning effects. However, surprisingly, their chunking pattern was preserved and remained indistinguishable from controls. The present study indicates that left BA 44 plays a role in motor sequence learning, but without being involved in elementary chunking. This dissociation between chunking and sequence learning could be explained if we postulate that left BA 44 intervenes in high hierarchical level processing, possibly to integrate elementary chunks together.

Background In CF children, LCI is a more sensitive index of lung disease than FEV1. However, some studies included significant proportions of children with abnormal FEV1 and data obtained using commercially available devices are still limited. Objective To compare diagnostic performance of LCI measurements using two commercially available devices in a clinic where median FEV1 of children (6— Methods Children were studied under stable condition, in the setting of a routine visit. Before spirometry, MBWN2 was performed in duplicate using both the Exhalyzer D (Ecomedics, Switzerland) and the EasyOne Pro (NDD, Switzerland), in random order on the same session. Agreement between devices was assessed by Bland–Altman plot. Diagnostic performance of LCI was defined as the proportion of patients with LCI z-score >2 (reference values derived from duplicate measurements in 47 healthy children). Results 2 acceptable LCI values were obtained with both devices in 44 children with CF [25 M, mean (SD) age: 12.9 y (3.7), range: 6–18]. All had normal FEV1: mean (SD) 100% (14.1) according to GLI. Mean LCI was 9.81 (2.23) with EM and 8.35 (1.86) with NDD, corresponding to +5 and +2.5 SD respectively; mean difference (95% confidence interval) was 1.46 (–1.75, 4.67). The proportion of patients with normal FEV1 but high LCI was 32/44 (73%) with EM and 18/44 (41%) with NDD, p = 0.001. Diagnostic performances of FEF25–75 and LCI NDD were comparable. Conclusion In this group of CF children with normal FEV1, EM yielded higher LCI values and was significantly more sensitive than NDD in detecting ventilation abnormalities.