La réhabilitation respiratoire tient une place importante dans la prise en charge des patients atteints de Broncho-pneumopathie chronique obstructive (BPCO) stables en induisant des bénéfices au niveau de la tolérance à l’effort, la fonction et la masse musculaire périphérique. La présence d’un stress oxydant élevé à l’état basal, considéré comme un des principaux facteurs impliqués dans l’atteinte musculaire périphérique, est bien admise malgré les discordances rapportées dans la littérature notamment au niveau du système antioxydant. L’absence d’amélioration des marqueurs du stress oxydant au cours d’un programme de réhabilitation respiratoire constitue une limite probable aux adaptations musculaires escomptées. Cependant, même si une supplémentation en antioxydants semble être une intervention adaptée permettant de réduire le stress oxydant et d’améliorer l’atteinte musculaire périphérique, son efficacité reste toujours à prouver chez les patients BPCO.Ainsi, nos objectifs étaient de déterminer et caractériser l’hétérogénéité des marqueurs du stress oxydant en vue d’étudier les effets d’une supplémentation en antioxydants adaptée sur des marqueurs spécifiques de l’atteinte musculaire périphérique des patients BPCO stables. A travers une analyse globale intégrant toute la complexité du stress oxydant, ce travail de thèse a montré que les principaux déficits en antioxydants chez les patients BPCO stables se situent au niveau de l’équilibre vitamine C/E, du zinc et du sélénium. De plus, nos résultats ont permis de déterminer des profils de patients caractérisés notamment par des sous-groupes de femmes ayant une majoration des taux de peroxydes lipidiques. Basé sur les principaux déficits identifiés et malgré l’importante hétérogénité des réponses, nous avons montré qu’une supplémentation en antioxydants permettait d’optimiser les bénéfices d’un programme de réhabilitation respiratoire en améliorant la FMIV, la Vo2sl et la surface de section transversale (SSt) des fibres musculaires de patients BPCO stables. Ainsi, dans l’optique d’une approche par phénotypes, l’utilisation de valeurs de références de la SSt, comme établies dans notre seconde étude, semble constituer un biomarqueur adapté mais celles-ci doivent être optimisées afin d’être applicable chez les patients BPCO. Pour conclure, outre l’intérêt pour l’utilisation d’une supplémentation en antioxydants au cours d’un programme de réhabilitation respiratoire, nos résultats contribuent à améliorer les connaissances sur le rôle du stress oxydant dans la physiopathologie de l’atteinte musculaire périphérique des patients BPCO. De plus, une meilleure compréhension et caractérisation de l’hétérogénéité, à la fois du stress oxydant et de l’atteinte musculaire périphérique, ouvrent des perspectives de recherche prometteuses dans l’optique d’une adaptation de la prise en charge des patients BPCO. / Pulmonary rehabilitation is considered as a major component in the management of chronic obstructive pulmonary disease (COPD) patients by inducing benefits on exercise capacity, peripheral function and muscle mass. Elevated oxidative stress at baseline, considered as one of the main factors involved in peripheral muscle impairment, is well accepted despite the discrepancies reported in the literature especially on antioxidant system. The absence of oxidative stress marker improvement following a pulmonary rehabilitation program is a likely limit to the expected muscle adaptations. However, although antioxidant supplementation seems to be an appropriate intervention for reducing oxidative stress and improving peripheral muscle impairment, its effectiveness remains to be proven in COPD patients.Thus, our objectives were to determine and characterize the oxidative stress marker heterogeneity in order to study the effets of a suitable antioxidant supplementation on specific peripheral muscle markers in stable COPD patients.Through a comprehensive analysis integrating the oxidative stress complexity, this work showed that the main antioxidant deficits in stable COPD patients are on the vitamin C/E balance, zinc and selenium. Moreover, our results allowed to determine patient profiles characterized in particular by a women subgroup with an increased rate of lipid peroxides. Based on the main identified deficits and despite the large response heterogeneity, we have shown that antioxidant supplementation may optimize the benefits of a pulmonary rehabilitation program by improving especially muscle fiber strength, cross-sectional area (CSA) and maximal oxygen consumption of stable COPD patients. Thus, from the perspective of a phenotype approach, the use of CSA reference values, as established in our second study, appears to be a suitable biomarker but these should be optimized in order to be relevant in COPD patients.Finally, besides the benefits of using an antioxidant supplementation during pulmonary rehabilitation program, our results contribute to improve our knowledge about the role of oxidative stress in the pathophysiology of peripheral muscle impairment in COPD patients. Furthermore, a better understanding and characterization of heterogeneity of both oxidative stress and peripheral muscle impairment opens up promising research prospects with a view of adjusting the management of COPD patients.

Made available in DSpace on 2016-12-06T17:07:30Z (GMT). No. of bitstreams: 1 Flavia.pdf: 707311 bytes, checksum: b01aae9df04e18a9b52de6e7999f0aa3 (MD5) Previous issue date: 2011-03-02 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality worldwide with a substantial and increasing societal burden especially on underdeveloped countries. The present current study aimed at assessing the clinical and economic benefits of a pulmonary rehabilitation (PR) program with emphasis on physical exercise in COPD patients. Thirty patients with stable moderate to severe COPD were randomly assigned to two groups. The experimental group (EG) (mean age 69,53 ± 9,12, FEV1 % 36,1 ± 11,4) took part in a 8-week exercise program (3 times a week) and the control group (CG) (mean age 68,53 ± 9,43, FEV1 % 40,13 ± 14,33) was instructed to practice home physical activity without supervision. Changes in physiological measurements of six-minute walk test (6MWT) and pulmonary function, as well as changes in clinical variables as the BODE prognosis index, the St. George s Respiratory Questionnaire (SGRQ) and dyspnea using de BORG scale were examined. Admission rate due to disease exacerbations was measured over 4 months following PR initiation to calculate the direct health costs of COPD and the admission rate between EG and CG groups. Data analysis showed an improvement in physiological and clinical variables after PR in the EG. There was an increase in 6MWT walking distance (310±115 vs 403±63 m, p<0.01), in decrease SGRQ total score (54±14 vs 41±18, p=0,005) and in the BODE index (6,7±2,2 vs 3,7±2, p<0,01 ). Conversely, in the CG, there was a decrease in 6MWT walking distance (364±118 vs 332±141, p=0,02) after the following time. The EG showed a lower BODE prognosis index after the PR program than the CG (3,7±2 vs 5,5±2,5, p=0,03). The admission rate was higher for the CG than for the EG (6 vs 2). The mean for direct health costs in the CG was higher than the mean for the EG (R$ 2.439,5 ± 3.092,7 vs R$ 1.389,20 ± 2.146 p = 0,2891 ).Total costs for the CG were also significantly higher than the total costs for the EG (R$ 20.837,70 vs 36.593,10; p<0,01). PR reduced hospital admission with a 67,5% relative risk reduction (RRR) and a 27% absolute risk reduction (ARR), and a 3,7 number needed to treat (NNT) in 4 months following time. No adverse effects due to intervention were reported. In sum, the findings suggest clinical benefits with lower costs and a decrease on the number of hospital admissions after a PR program with emphasis on physical exercise in COPD patients. / A doença pulmonar obstrutiva crônica (DPOC) é uma das principais causas de morbidade e mortalidade no mundo com um crescente e substancial encargo social principalmente sobre os países em desenvolvimento. O presente estudo objetivou avaliar os benefícios clínicos e econômicos de um programa de reabilitação pulmonar (RP) com ênfase no exercício físico em pacientes com DPOC. Trinta pacientes com DPOC estável moderada a grave foram randomizados em dois grupos. O grupo experimental (GE) (media idade 69,53 ± 9,12, VEF1 % 36,1 ± 11,4) participou de um programa de exercícios com duração de 8 semanas (3 vezes por semana) e o grupo controle (GC) (média idade 68,53 ± 9,43, VEF1 % 40,13 ± 14,33) foi orientado a realizar atividade física em domicílio sem supervisão. Foram avaliados as alterações nas variáveis fisiológicas como a distância percdorrida no teste de caminhada de 6 minutos (TC6m) e função pulmonar, assim como as alterações nas variáveis clínicas como o índice prognóstico de BODE e o questionário de qualidade de vida St. George s Respiratory Questionnaire (SGRQ). As internações hospitalares em decorrência das exacerbações da doença foram aferidas no período de 4 meses após o início do programa de RP a fim de calcular o custo sanitário direto da doença e a taxa de internação entre os grupos. A análise de dados mostrou uma melhora significativa em variáveis clínicas e fisiológicas após a RP no GE. Houve um aumento na distancia percorrida no TC6m (310±115 vs 403±63 m, p<0.01), diminuição no índice de BODE (6,7±2,2 vs 3,7±2, p<0,01 ) e nos escores do questionário de qualidade de vida St. George s Respiratory Questionnaire ((54±14 vs 41±18, p=0,005). No GC, houve uma redução na distância caminhada no TC6m (364±118 vs 332±141, p=0,02) após o período de seguimento. O GE mostrou um menor índice prognóstico de BODE após o programa de RP quando comparado com o GC (3,7±2 vs 5,5±2,5, p=0,03). Houve uma maior taxa de internação no GC em comparação ao GE (6 vs 2). A média de custo do GC foi maior em relação ao GE (R$ 2.439,5 ± 3.092,7 vs R$ 1.389,20 ± 2.146 ; p = 0,2891) O custo total no GC também foi significativamente maior em relação ao GE (R$ 20.837,70 vs 36.593,10 ; p<0,01). A RP reduziu a admissão hospitalar com uma redução relativa de risco (RRR) de 67,5% e uma redução absoluta de risco (RRA) de 27% e um número necessário para tratar 3,7 (number need to treat - NNT) nos 4 meses de seguimento. Não houve relato de efeito adverso da intervenção. Em resumo, os resultados sugerem benefícios clínicos com menores custos e diminuição do número de admissões hospitalares após um programa de RP com ênfase no exercício físico em pacientes com DPOC.

La maladie pulmonaire obstructive chronique (MPOC) est une maladie respiratoire irréversible, évolutive et très fréquente qui fait peser un lourd fardeau sur le système de santé, les patients et leurs proches. La réadaptation pulmonaire (RP) est efficace pour réduire la dyspnée et l’utilisation des ressources en soins de santé et pour améliorer la capacité physique et la qualité de vie des patients. L’entraînement physique est la pierre angulaire de la RP, mais elle n’est bénéfique que si les patients 1) assistent aux séances d’exercice, 2) se conforment à l'intensité des exercices prescrits et 3) maintiennent l'exercice physique régulier après la RP. La dépression comorbide est disproportionnée dans la MPOC et s’est révélée être un facteur prédictif de « mauvaise » fréquentation de la RP, et d'abandon de la pratique physique régulière après le programme. À notre connaissance, aucune étude ne s'est intéressée aux prédicteurs de conformité à l'intensité d'exercice prescrit pendant la RP et seules quelques études ont explorées les facteurs associés au maintien de l'exercice après la RP. L’objectif principal de cette étude consistait à examiner dans quelle mesure les symptômes dépressifs à l'entrée de la RP permettent de prédire 1) la présence aux séances de RP, 2) le respect de l'intensité (conformité) des exercices d’endurance prescrits pendant la RP, et 3) le niveau d’exercice physique maintenu 9 mois après la RP. Un deuxième objectif consistait à explorer d'autres variables susceptibles d'être associées à ces paramètres. Trente-six patients (64 % de femmes) atteints de la MPOC stable, modérée à sévère, ont été inscrits à un programme de RP de 12 semaines comportant 36 séances d’exercice physique supervisé. À l’entrée du RP les patients ont rempli l’Inventaire de Dépression de Beck (BDI-II, le prédicteur principal) et le formulaire C de l’Échelle du locus de contrôle sur la santé (LCS), et ont subi des tests de fonction pulmonaire et une épreuve d’effort progressif à vélo (pour déterminer l'intensité de l'exercice pour la RP). Ensuite, ils ont été répartis de façon aléatoire dans trois groupes à intensité d’exercice différente. La fréquentation de la RP était définie comme le pourcentage de séances suivies; la conformité, comme la durée d’entraînement pratiquée à la fréquence cardiaque cible; et le maintien de l'exercice physique régulier comme le niveau d’exercice fait au cours d’une semaine 9 mois après la RP (enregistré dans un journal d’activité physique et calculé en équivalents métaboliques de l’effort [MET] minutes ). La médiane (écart interquartile ou IQR) du score au BDI-II était de 8,5 points (6-13), la médiane (IQR) du taux de la fréquentation aux séances était de 83% (67-94), la médiane du taux de compliance à l’intensité d'exercice était de 94% (71-99), et la médiane du nombre de minutes MET après la RP était de 706 (445-1146). Les analyses de régression linéaire ne montrent pas de relation entre les symptômes dépressifs pré-RP et la fréquentation des séances de la RP (ß = 0,12; p = 0,478). Par-contre, ils étaient associés à la conformité à l'intensité de l’exercice physique pendant la RP (ß = -0,40; p = 0,047), et à la poursuite de la pratique d’un exercice physique régulier après la RP (ß = -0,50; p = 0,004). Les analyses étaient ajustées pour des covariables prédéfinies. Les analyses exploratoires ont révélé que certaines variables supplémentaires (y compris LCS) étaient associées aux issues mesurées. Les résultats de cette étude montrent que même les niveaux de dépression sous-cliniques pourraient jouer un rôle important dans la compliance aux programme de réentraînement, et au maintien d’un style de vie actif après la période de réadaptation. Cela a des implications pour améliorer le dépistage des « mauvais » résultats dans la RP et pour l'élaboration d'interventions ciblées pour améliorer les bénéfices pour la santé découlant de la réadaptation pour la MPOC. / Abstract : Chronic obstructive pulmonary disease (COPD) is an irreversible, progressive, and highly prevalent respiratory illness that poses a great burden on the healthcare system, patients, and their families. Pulmonary rehabilitation (PR) is effective in reducing dyspnea and health care resource utilization, and increasing exercise capacity and quality of life. Exercise training is the cornerstone of PR but is only beneficial if patients 1) attend sessions, 2) comply with the prescribed exercise regimen, and 3) maintain regular exercise after supervised PR ends. Comorbid depression is disproportionately high in COPD and has been found to predict poor attendance at PR and low levels of exercise maintained afterwards. To our knowledge, no study has investigated predictors of exercise compliance during PR, and only a few studies have examined predictors of exercise maintenance post PR. The primary objective of this study was to examine how much baseline depressive symptomatology can predict 1) PR attendance, 2) PR exercise compliance, and 3) levels of exercise maintained at 9-months post PR. A secondary, exploratory objective was to identify additional variables that might also have significant associations with these outcomes. Thirty-six patients (64% female) with stable COPD were enrolled in a 12-week 36-session supervised exercise intervention in the context of a PR program. Patients underwent evaluations at entry to PR which included the Beck Depression Inventory (BDI-II, the main predictor), the Multidimensional Health Locus of Control (HLC) Scale Form-C, pulmonary function tests, and an incremental cycling test (to determine the exercise intensity prescription). Patients were randomized to one of three groups of varying exercise intensity. Attendance was defined as the percent of total sessions attended, compliance as the percent of endurance training time exercising at a prescribed target heart rate, and post-PR exercise as the total exercise performed over a 7-day period recorded in a physical activity diary and calculated as metabolic equivalent of task (MET) minutes. Median (IQR) baseline BDI-II was 8.5 (6-13), median (IQR) percent attendance was 83 (67-94), median (IQR) percent exercise compliance was 94 (71-99), and median (IQR) exercise MET-minutes post PR was 706 (445-1146). In multiple regression analyses, baseline depressive symptomatology did not emerge as a significant independent predictor of PR attendance (ß = .12, p = .478), but was a significant predictor of PR exercise compliance (ß = -.40, p = .047), and of exercise maintained post PR (ß = -.50, p = .004), with adjustment for a-priori defined covariates. Secondary exploratory analyses revealed that certain additional variables (including HLC) had associations with particular outcomes. The findings suggest that even subclinical levels of depression can predict PR exercise compliance and post-PR exercise levels. This has implications for improving screening for, and understanding of, poor outcomes in PR and for developing targeted interventions to optimize the health benefits that can be derived during and after PR for COPD.

Rehabilitation takes an important part in the care for lung transplant candidates with chronic lung disease. The theoretical part of this thesis summarizes current knowledge about motivation and adherence to rehabilitation, about telerehabilitation options (telemonitoring physical activity using pedometer), and their use in lung transplant candidates. In the practical part it was investigated whether extrinsic motivation (education, pedometer, communication with physiotherapist via e-mail) leads to an improvement in the six-minute walking test outcome (6MWD) or in adherence to rehabilitation in lung transplant candidates. It was found no statistically significant improvement in 6MWD nor in adherence to rehabilitation in extrinsically motivated patients waiting for a lung transplant. However, data suggested increasing trend of 6MWD after intervention.

Title The effect of airway clearance techniques on patients with Chronic Obstructive Pulmonary Disease. Objective The main purpose of this study is to expose and evaluate the efficacy of airway clearance techniques on patients with Chronic Obstructive Pulmonary Disease by using pulmonary functions and Quality of Life measurements from recent studies. Methodology This thesis is literature review. The selected studies were according to inclusion and exclusion criteria. The selections of recent studies were published from the year of 2000 until 2017 in English language. The following research databases were selected to identify the relevant topic: PubMed, MEDLINE, Embase, Cochrane, PEDro, and CINAHL. The parameters' results from the articles have been also selected by evaluation the statistical differences according to the P-values. Results Twenty-three articles out of 117 have been found according to inclusion criteria, exclusion criteria, and outcome measures. The techniques were active cycle of breathing technique (ACBT), positive expiratory pressure (PEP), temporary of positive expiratory pressure (T-PEP), Oscillating positive expiratory pressure (O-PEP), high-frequency chest wall oscillation (HFCWO), slow expiration with glottis opened in lateral posture (ELTGOL), postural drainage, and autogenic...