Los músculos respiratorios están sometidos a sobrecarga crónica. En cambio, los músculos de las extremidades están sometidos a un desuso relativo. Esto determinaría cambios a nivel estructural y metabólico, con impacto en la capacidad oxidativa. En los músculos respiratorios ésta se hallaría conservada o incrementada, con cambios proporcionales a la gravedad de la enfermedad. En los músculos de las extremidades inferiores la capacidad oxidativa estaría disminuída; mientras que en las extremidades superiores, se mantendría. Esto último sería el resultado combinado de los efectos deletéreos y de sobrecarga sobre unos músculos que parecen actuar como accesorios de la respiración en la EPOC. Los estudios precedentes que han valorado la capacidad oxidativa muscular, lo han hecho analizando aspectos aislados y en distintos grupos de pacientes.OBJETIVO: Evaluar globalmente la capacidad oxidativa de los músculos esqueléticos de pacientes con EPOC, a través del estudio simultáneo de los diferentes componentes y en diferentes músculos.MÉTODOS: Se estudiaron 34 pacientes (20 con EPOC y 14 controles) sometidos a toracotomía o laparotomía por lesión pulmonar o abdominal localizada. A todos se les realizó evaluación general, estudio funcional completo y finalmente, toma de biopsias musculares (diafragma, intercostal externo y deltoides). Analizamos los siguientes parámetros: localización de las isoformas de cadena pesada de miosina (MyHC) mediante inmunohistoquímica, actividad enzimática fibrilar mediante histoquímica enzimática (ATPasa), actividad enzimática global (citrato sintasa, CS) mediante espectrofotometría, y estudio de la densidad capilar mediante inmunohistoquímica (anticuerpo CD-34).RESULTADOS: El diafragma de los pacientes con EPOC tiende a presentar un incremento en el porcentaje de fibras MyHC-I y ATPasa I. En cambio, la actividad de la CS tiene tendencia a disminuir, mientras que la densidad capilar se halla aumentada (p=0.001). El intercostal tiende a presentar un menor porcentaje de fibras MyHC-I y ATPasa I, con una actividad más baja de la CS, en los pacientes con EPOC (p<0.05). Sin embargo, la densidad capilar está incrementada (p<0.01). En los músculos periféricos (deltoides) de estos enfermos, el porcentaje de MyHC-I tiende a ser menor y el porcentaje de ATPasa I muestra una ligera tendencia a aumentar. La actividad de la CS muestra un incremento significativo (p<0.05), aunque la densidad capilar no evidencia cambios. Además, analizamos enzimas claves de la vía glicolítica. En concreto, fosfofructoquinasa (PFK) y lactatodeshidrogenasa (LDH). La primera disminuye significativamente en el diafragma de los pacientes con EPOC (p<0.05), aumenta en el intercostal (p<0.05) y no se modifica en el deltoides. La LDH se incrementa significativamente en los tres grupos musculares.Al comparar los dos métodos de tipificación fibrilar (inmunohistoquímico y enzimático), no se observaron diferencias significativas para el diafragma. En el intercostal, el método enzimático tendía a infravalorar el porcentaje de fibras oxidativas, fundamentalmente en pacientes con EPOC; mientras que en el deltoides, al contrario, el método enzimático tendía a sobrevalorar dicho porcentaje en estos pacientes.CONCLUSIONES: Los diferentes factores que influyen en la capacidad oxidativa se modifican de forma heterogénea y específica para cada músculo. El diafragma tiende a preservar su capacidad oxidativa, lo que probablemente guarde relación con el "efecto entrenamiento de resistencia" que generaría la EPOC. El intercostal mostraría cambios divergentes relacionados con su actividad intermitente bajo cargas en dicha entidad ("efecto entrenamiento de fuerza"). El deltoides muestra cambios diferentes a los descritos por otros autores en los músculos de las extremidades inferiores (cuádriceps), lo que probablemente guarde relación con su eventual reclutamiento como músculo accesorio de la respiración en pacientes con EPOC. / Respiratory muscles are exposed to chronic overloading, which is in contrast to muscles of the extremities that are exposed to a relative inactivity. These factors would determine changes at the structural and metabolic levels, which would modify the oxidative capacity. This would be maintained (or even increased) in respiratory muscles, being proportional to the severity of the disease. In contrast, the oxidative capacity would be reduced in lower limb muscles, being preserved in the upper limb muscles as a result of the combined effects of deleterious factors and training (upper limb muscles appear to be function as accessory muscles during the ventilatory effort in chronic obstructive pulmonary disease [COPD]). Although previous studies have evaluated the oxidative capacity of skeletal muscles in COPD, different components and muscles have been analyzed separately and in different groups of patients.OBJECTIVE: To assess the whole oxidative capacity of skeletal muscles in patients with COPD by means of the concomitant study of different structural and metabolic components.METHODS: Thirty-four patients (20 COPD and 14 controls) undergoing thoracotomy or laparotomty due to localized lesions in the lung or the abdomen were studied. All patients underwent a complete physical examination, lung functional testing and muscle biopsies of the diaphragm, external intercostal and deltoid muscles at the time of surgery. Samples were processed to determine the site of different myosin heavy chain isoforms (MyHC) using immunohistochemistry, fibrillar oxidative activity (ATPase) through enzymatic histochemical techniques, overall enzyme activity (citrate synthase, CS) using spectrophotometry and capillary density through immunohistochemistry (antibody against-CD34).RESULTS: The diaphragm of COPD patients showed a trend to increase the percentage of both MyHC-I and ATPase I fibres. The activity of CS in contrast, showed a tendency to diminish, and the capillary density was increased (p=0.001). The external intercostal muscle, in turn, showed a trend to a lower percentage of MyHC-I and ATPase I fibres, with a decreased CS activity in COPD (p<0.05). However, capillary density was increased (p<0.01). In the peripheral muscule of these patients (deltoid), the percentage of MyHC-I showed a trend to be lower whereas that of ATPase I exhibited a tendency to be higher. The CS capacity showed an increase (p<0.05) in this muscle, with no changes in the number of vessels. In addition, we analyzed key enzymes involved in the glycolytic pathways, such as phosphofructokinase (PFK) and lactatedehydrogenase (LDH). The former decreased significantly in the diaphragm of COPD patients (p<0.05), increased in the external intercostal muscle (p<0.05) and remained unchanged in the deltoid muscle. LDH activity increased in all three muscles. No differences were observed between the two methods used for fibre typing (imnmunohistochemistry and metabolic activity) in the diaphragm. However, measurement of metabolic activity tended to underestimate the percentage of oxidative fibres in the external intercostal (mostly in COPD patients) and overestimate this percentage in the deltoid muscle.CONCLUSIONS: Different factors involved in the oxidative capacity of the muscle are heterogeneously modified in COPD patients, being specific for each muscle. Overall, the diaphragm preserves its oxidative capacity. This could be related to the "endurance-training effect" elicited by COPD. The external intercostal muscle showed divergent changes, a finding which could be related to its exposure to overloading efforts ("strength training effect"). On the other hand, the deltoid muscle showed different changes to those reported by other authors in muscles of the lower extremities (quadriceps), which probably is related to eventual recruitment as an accessory ventilatory muscle in COPD.

El asma es una enfermedad cuya prevalencia es del 24% en el departamento de Lambayeque. Objetivo: determinar riesgo de asma en niños con sibilancias recurrentes, en dos hospitales del departamento de Lambayeque, durante el período agosto-diciembre del 2011. Material y método: estudio descriptivo transversal, muestreo por conveniencia. Tamaño muestral: 263 niños, calculada con prevalencia del 24%, 95% de confianza, y precisión absoluta de 5%; incluyendo los casos que cumplan los criterios de inclusión y carezcan los de exclusión, identificados mediante revisión de historias clínicas, y aplicación de un cuestionario, fundamentado en el índice predictor de asma. Resultados: el 36% de los sibilantes recurrentes presentaron riesgo alto para asma. El 37,8% de la población del Hospital Regional Docente Las Mercedes, y 32,5% de la población del Hospital Provincial Belén de Lambayeque presentaron riesgo alto para asma. El 34,4% de la población de sexo femenino, y 37,9% de sexo masculino, presentaron riesgo alto de asma. El 41,7% de los niños mayores de dos años presentaron riesgo alto para asma. Conclusión: el 36% de los niños con sibilancias recurrentes de dos hospitales del departamento de Lambayeque, presentaron riesgo alto para asma; sin haber diferencia significativa en cuanto al sexo y a hospital.

Orientador: Ricardo Machado Leite de Barros / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Educação Fisica / Made available in DSpace on 2018-08-09T17:18:56Z (GMT). No. of bitstreams: 1 Sarro_KarineJacon_D.pdf: 1134388 bytes, checksum: b567c37751844e9b74d352b031f141d7 (MD5) Previous issue date: 2007 / Resumo: O presente trabalho teve como objetivo propor e validar um novo método para análise cinemática tridimensional da movimentação da caixa torácica durante a respiração e mostrar uma aplicação do mesmo. A análise cinemática foi utilizada para descrever a movimentação tridimensional das costelas durante a respiração. As coordenadas 3D de marcadores posicionados sobre as costelas e vértebras foram utilizadas para calcular as distâncias transversais e ântero-posteriores da caixa torácica e a orientação das costelas em função do tempo. O método identificou um sinal coerente com o ciclo respiratório para todas as distâncias calculadas e também para os ângulos das costelas ao redor de um eixo quasi-transversal representando os movimentos de elevação e abaixamento das costelas. Também foi capaz de medir a maior variação das distâncias ântero-posteriores e transversais da caixa torácica durante respirações em capacidade vital quando comparadas a respirações em volume corrente. Foram realizados testes para avaliar variáveis relacionadas aos erros de medição do sistema de análise cinemática utilizado. Imagens de ressonância magnética do tronco foram utilizadas para calcular a movimentação relativa entre os marcadores de superfície e as costelas (deslizamento de pele). Os resultados revelaram um erro sistemático abaixo de 1 mm e um desvio padrão experimental de 2,5 mm, o que gerou erros máximos de 2º na medição da variação angular das costelas. A movimentação relativa média entre os marcadores, assumida como a distância entre o marcador e a costela em capacidade pulmonar total menos a distância entre o marcador e a costela em capacidade residual funcional, foi igual a 3,9 mm, valor menor que os relatados na literatura para os membros inferiores ou coluna vertebral. Esses resultados validam o método, mostrando a viabilidade em se usar a análise cinemática para avaliar movimentações das costelas acima de 2º. Uma vez validado, o método foi aplicado a um grupo de sujeitos saudáveis e distinguiu alguns sujeitos com movimentação paradoxal das costelas. Aplicado a um grupo de nadadores, foi capaz de evidenciar alterações nos movimentos respiratórios desse grupo, identificando maior variação angular das costelas e maior correlação entre as curvas dos ângulos das costelas (p<0,05) quando comparado ao grupo controle. Os nadadores também apresentaram maior correlação entre a variação angular das costelas e os volumes parciais do tronco, reforçando o potencial da metodologia em identificar alterações nos padrões respiratórios. Concluindo, este estudo validou o uso da análise cinemática 3-D para avaliar a movimentação das costelas e a coordenação entre elas durante a respiração bem como evidenciou seu potencial na identificação de diferentes comportamentos da movimentação das costelas, mostrando que a prática de natação induziu um padrão otimizado de movimentação da caixa torácica / Abstract: The present work aimed to propose and validate a novel method to the 3D kinematical analysis of the rib cage motion during breathing and to show an example of application. The kinematical analysis was used to describe the 3D motion of the ribs during breathing. The 3D coordinates of surface markers positioned on the ribs, sternum and vertebrae were used to calculate the transversal and anterior-posterior distances of the rib cage and the orientation of the ribs in function of time. The method identified a signal coherent with the breathing cycle for all the distances measured and for the angles of the ribs around the quasi-transversal axis representing the upward and downward movements of the ribs. The method was also able to identify the higher variation of the transversal and anterior-posterior distances of the rib cage during breathing at vital capacity when compared with breathing at tidal volume. Some tests were performed to evaluate variables related to the measurement errors of the system. Magnetic resonance images of the trunk were used to calculate the relative motion between the surface markers and the ribs (soft tissue artifact). The results revealed less than 1 mm of systematic error and a experimental standard deviation of 2.5 mm, which generate maximal errors of 2º on the angular variation of the ribs. The soft tissue artifact was assumed as the distance between the marker and the rib at total lung capacity minus the distance between the marker and the rib at functional residual capacity, and the absolute mean value found was 3.9 mm. This value is smaller than that one found in the kinematics of other segments. The method was applied in a group of swimmers and a control group of non-athletes and was able to distinguish subjects with a paradoxal movement and showed that swimmers presented greater angular variation for all ribs, and greater correlation between the curves of the rib angles (p<0.05). The swimmers also presented higher correlation between the angular variation of the ribs and the variation of the separate volumes of the trunk. In conclusion, this study has validated the use of 3-D kinematic analysis to evaluate the movement of the ribs and their coordination during breathing as well as has shown its potential to identify differences in the behavior of the ribs motion, showing that swimming training induced an optimized pattern of motion of the rib cage / Doutorado / Biodinamica do Movimento Humano / Doutor em Educação Física

La estimación del esfuerzo respiratorio durante el sueño es de una importancia crítica para la identificación correcta de eventos respiratorios en los trastornos respiratorios del sueño (TRS), el diagnóstico correcto de las patologías relacionadas con los TRS y las decisiones sobre la terapia correspondiente. Hoy en día el esfuerzo respiratorio suele ser estimado mediante la polisomnografía (PSG) nocturna con técnicas imprecisas y mediante la evaluación manual por expertos humanos, lo cual es un proceso laborioso que conlleva limitaciones significativas y errores en la clasificación. El objetivo principal de esta tesis es la presentación de nuevos métodos para la estimación automático, invasiva y no-invasiva del esfuerzo respiratorio y cambios en la obstrucción de las vías aéreas superiores (VAS). En especial, la aplicación de estos métodos debería permitir, entre otras cosas, la diferenciación automática invasiva y no-invasiva de eventos centrales y obstructivos durante el sueño. Con este propósito se diseñó y se obtuvo una base de datos de PSG nocturna completamente nueva de 28 pacientes con medición sistemática de presión esofágica (Pes). La Pes está actualmente considerada como el gold-standard para la estimación del esfuerzo respiratorio y la identificación de eventos respiratorios en los TRS. Es sin embargo una técnica invasiva y altamente compleja, lo cual limita su uso en la rutina clínica. Esto refuerza el valor de nuestra base de datos y la dificultad que ha implicado su adquisición. Todos los métodos de procesado propuestos y desarrollados en esta tesis están consecuentemente validados con la señal gold-standard de Pes para asegurar su validez.En un primer paso, se presenta un sistema automático invasivo para la clasificación de limitaciones de flujo inspiratorio (LFI) en los ciclos inspiratorios. La LFI se ha definido como una falta de aumento en flujo respiratorio a pesar de un incremento en el esfuerzo respiratorio, lo cual suele resultar en un patrón de flujo respiratorio característico (flattening). Un total de 38,782 ciclos respiratorios fueron automáticamente extraídos y analizados. Se propone un modelo exponencial que reproduzca la relación entre Pes y flujo respiratorio de una inspiración y permita la estimación objetiva de cambios en la obstrucción de las VAS. La capacidad de caracterización del modelo se estima mediante tres parámetros de evaluación: el error medio cuadrado en la estimación de la resistencia en la presión pico, el coeficiente de determinación y la estimación de episodios de LFI. Los resultados del modelo son comparados a los de los dos mejores modelos en la literatura. Los resultados finales indican que el modelo exponencial caracteriza la LFI y estima los niveles de obstrucción de las VAS con la mayor exactitud y objetividad. Las anotaciones gold-standard de LFI obtenidas, fueron utilizadas para entrenar, testear y validar un nuevo clasificador automático y no-invasivo de LFI basa en la señal de flujo respiratorio nasal. Se utilizaron las técnicas de Discriminant Analysis, Support Vector Machines y Adaboost para la clasificación no-invasiva de inspiraciones con las características extraídas de los dominios temporales y espectrales de los patrones de flujo inspiratorios. Este nuevo clasificador automático no-invasivo también identificó exitosamente los episodios de LFI, alcanzando una sensibilidad de 0.87 y una especificidad de 0.85. La diferenciación entre eventos respiratorios centrales y obstructivos es una de las acciones más recurrentes en el diagnostico de los TRS. Sin embargo únicamente la medición de Pes permite la diferenciación gold-standard de este tipo de eventos. Recientemente se han propuesto nuevas técnicas para la diferenciación no-invasiva de apneas e hipopneas. Sin embargo su adopción ha sido lenta debido a su limitada validación clínica, ya que la creación manual por expertos humanos de sets gold-standard de validación representa un trabajo laborioso. En esta tesis se propone un nuevo sistema para la diferenciación gold-standard automática y objetiva entre hipopneas obstructivas y centrales. Expertos humanos clasificaron manualmente un total de 769 hypopneas en 28 pacientes para crear un set de validación gold-standard. Como siguiente paso se extrajeron características específicas de cada hipopnea para entrenar y testear clasificadores (Discriminant Analysis, Support Vector Machines y adaboost) para diferenciar entre hipopneas centrales y obstructivas mediante la señal gold-standard Pes. El sistema de diferenciación automática alcanzó resultados prometedores, obteniendo una sensibilidad, una especificad y una exactitud de 0.90. Por lo tanto este sistema parece prometedor para la diferenciación automática, gold-standard de hipopneas centrales y obstructivas. Finalmente se propone un sistema no-invasivo para la diferenciación automática de hipopneas centrales y obstructivas. Se propone utilizar la señal de flujo respiratorio para la diferenciación utilizando características de los ciclos inspiratorios de cada hipopnea, entre ellos los patrones flattening. Este sistema automático no-invasivo es una combinación de los sistemas anteriormente presentados y se valida mediante las anotaciones gold-standard obtenidas mediante la señal de Pes por expertos humanos. Los resultados de este sistema son comparados a los resultados obtenidos por expertos humanos que utilizaron un nuevo algoritmo no-invasivo para la diferenciación manual de hipopneas. Los resultados del sistema automático no-invasivo son prometedores y muestran la viabilidad de la metodología empleada. Una vez haya sido validado extensivamente, se ha propuesto este algoritmo para su utilización en dispositivos de terapia de TRS desarrollados por uno de los socios cooperantes en este proyecto. / The assessment of respiratory effort during sleep is of major importance for the correct identification of respiratory events in sleep-disordered breathing (SDB), the correct diagnosis of SDB-related pathologies and the consequent choice of treatment. Currently, respiratory effort is usually assessed in night polysomnography (NPSG) with imprecise techniques and manually evaluated by human experts, resulting in a laborious task with significant limitations and missclassifications.The main objective of this thesis is to present new methods for the automatic, invasive and non-invasive assessment of respiratory effort and changes in upper airway (UA) obstruction. Specifically, the application of these methods should, in between others, allow the automatic invasive and non-invasive differentiation of obstructive and central respiratory events during sleep.For this purpose, a completely new NPSG database consisting of 28 patients with systematic esophageal pressure (Pes) measurement was acquired. Pes is currently considered the gold-standard to assess respiratory effort and identify respiratory events in SDB. However, the invasiveness and complexity of Pes measurement prevents its use in clinical routine, underlining the importance of this new database. . . All the processing methods developed in this thesis will consequently be validated with the gold-standard Pes-signal in order to ensure their clinical validity.In a first step, an (invasive) automatic system for the classification of inspiratory flow limitation (IFL) in the inspiratory cycles is presented.IFL has been defined as a lack of increase in airflow despite increasing respiratory effort, which normally results in a characteristic inspiratory airflow pattern (flattening). A total of 38,782 breaths were extracted and automatically analyzed. An exponential model is proposed to reproduce the relationship between Pes and airflow of an inspiration and achieve an objective assessment of changes in upper airway obstruction. The characterization performance of the model is appraised with three evaluation parameters: mean-squared-error when estimating resistance at peakpressure,coefficient of determination and assessment of IFL episodes. The model's results are compared to the two best-performing models in the literature. The results indicated that the exponential model characterizes IFL and assesses levels of upper airway obstruction with the highest accuracy and objectivity.The obtained gold-standard IFL annotations were then employed to train, test and validate a new automatic, non-invasive IFL classification system by means of the nasal airflow signal. Discriminant Analysis, Support Vector Machines and Adaboost algorithms were employed to objectively classify breaths non-invasively with features extracted from the time and frequency domains of the breaths' flow patterns. The new non-invasive automatic classification system also succeeded identifying IFL episodes, achieving a sensitivity of 0.87 and a specificity of 0.85.The differentiation between obstructive and central respiratory events is one of the most recurrent tasks in the diagnosis of sleep disordered breathing, but only Pes measurement allows the gold-standard differentiation of these events. Recently new techniques have been proposed to allow the non-invasive differentiation of hypopneas. However, their adoption has been slow due to their limited clinical validation, as the creation of manual, gold-standard validation sets by human experts is a cumbersome procedure. In this study, a new system is proposed for an objective automatic, gold-standard differentiation between obstructive and central hypopneas with the esophageal pressure signal. An overall of 769 hypopneas of 28 patients were manually scored by human experts to create a gold-standard validation set. Then, features were extracted from each hypopnea to train and test classifiers (Discriminant Analysis, Support Vector Machines and adaboost classifiers) to differentiate between central and obstructive hypopneas with the gold-standard esophageal pressure signal. The automatic differentiation system achieved promising results, with a sensitivity of 0.82, a specificity of 0.87 and an accuracy of 0.85. Hence, this system seems promising for an automatic, goldstandard differentiation between obstructive and central hypopneas.Finally, a non-invasive system is proposed for the automatic differentiation of central and obstructive hypopneas. Only the airflow signal is used for the differentiation, as features of the inspiratory cycles of the hypopnea, such as the flattening patterns, is used. The automatic, non-invasive system represents a combination of the systems that have been presented before and it was validated with the gold-standard scorings obtained with the Pes-signal by human experts. The outcome is compared to the results obtained by human scorers that applied a new non-invasive algorithm for the manual differentiation of hypopneas. The non-invasive system's results are promising and show the viability of this technique. Once validated, this algorithm has been proposed to be used in therapy devices developed by one of the partner institutions cooperating in this project.

En las Unidades de Cuidados Intensivos no se valora de forma sistemática la ansiedad de los pacientes, a pesar de que éstos informan moderados niveles de ansiedad. De ellos, los pacientes conectados a ventilación mecánica invasiva son los que tienen, por un lado, mayores niveles de ansiedad y, por otro lado, mayor dificultad para contestar largos cuestionarios por su debilidad tanto física como cognitiva. Esta tesis aporta, mediante la compilación de publicaciones científicas, la adaptación de una versión corta de la subescala estado del State- Trait Anxiety Inventory (STAI) en pacientes con ventilación mecánica invasiva, que nunca ha sido usada en nuestro país. Dicha versión consta de 6 ítems y puede ser considerada como una medida válida y fiable de la medida de la ansiedad tanto en pacientes españoles conectados a ventilación mecánica invasiva como en pacientes españoles respiratorios hospitalizados.

L’objectiu d’aquesta tesi es descriure l’epidemiologia de les infeccions respiratòries víriques, tant de les infeccions lleus del tracte respiratori superior com de les infeccions greus del tracta respiratori inferior que requereixen hospitalització en pacients pediàtrics de Manhiça, una zona rural del sud de Moçambic. Els resultats d’aquesta tesi indiquen que la carrega de malaltia associada als virus respiratoris a l’Hospital Distrital de Manhiça és elevada: aproximadament la meitat dels pacients pediàtrics atesos a l’Hospital Distrital de Manhiça amb símptomes d’infecció respiratòria detectem al menys un virus respiratori. La incidència de les infeccions respiratòries augmenta durant l’estació de pluges, i és durant aquesta estació que es produeixen els brots anulars del virus influenza i del virus respiratori sincitial. Les co-infeccions víriques, les infeccions invasives bacterianes i la infecció per l’HIV (virus de la immunodeficiència humana) s’associen a una major severitat i pitjor prognosi de les infeccions respiratòries víriques. / The main objective of this thesis is to describe the epidemiology of viral respiratory infection, both mild upper respiratory infections and severe lower respiratory tract infections requiring hospitalization, in paediatric patients in Manhiça, a rural area of southern Mozambique. Results of this work show that the burden of disease associated with respiratory viruses in Mahiça District Hospital in high: Approximately half of paediatric patients visited at Manhiça District Hospital with respiratory symptoms had, at least, one respiratory virus detected. Incidence of respiratory infections increases during the rainy season and outbreaks of influenza and respiratory syncytial virus also occur during this season. Viral co-infections, invasive bacterial infections and HIV (human immunodeficiency virus) infection are associated with more severe viral respiratory infections and a worse prognosis of such infections.

Los pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) grave están sometidos a cargas respiratorias crónicas, que inducen cambios en la configuración normal del tórax. La hiperinsuflación pulmonar es la consecuencia más importante del incremento de la resistencias en dichos enfermos. Además, la hiperinsuflación pulmonar puede conducir a daño muscular y consiguiente remodelación. Estas alteraciones estructurales son características de la adaptación que sufren los músculos respiratorios para contrarestar los efectos deletéreos del exceso de cargas respiratorias. De hecho, el principal objetivo de este mecanismo de adaptación es mantener los gases arteriales dentro de la normalidad. En este estudio se ha utilizado un modelo animal. Se aplicaron cargas resistivas inspiratorias intermitentes de moderada intensidad (IRLs) a perros Beagle durante un período de tiempo relativamente prolongado para reproducir pacientes con EPOC. OBJETIVOS: 1) Evaluar la presencia de daño en los músculos respiratorios inducido por IRLs en el músculo intercostal externo, diafragma y un músculo control (vasto interno); 2) Investigar los cambios estructurales (distribución de fibras, proporciones de las diferentes isoformas de miosina de cadena pesada (MyHC) y tamaño de las fibras) inducido por la administración de IRLs; 3) Analizar la expresión de citocinas inflamatorias (TNF_) y no inflamatorias (IL10) en dichos músculos. MATERIALES Y MÉTODOS: A todos los animales se les realizó traqueostomía. A los animales del grupo estudio se les aplicó cargas respiratorias equivalentes al 15% de su presión inspiratoria máxima (PIM): 2h/día durante 15 días consecutivos. Los animales del grupo control respiraron sólo a través de la traqueostomía. Se obtuvieron biopsias musculares del diafragma, intercostal externo y vasto interno antes y después de la aplicación de IRLs. El daño muscular se evaluó mediante la técnica de inmunohistoquímica que detectó la presencia de fibronectina intracelular. La distribución de las fibras y su morfometría se analizaron por inmunohistoquímica mediante anticuerpos específicos para MyHC I y II. La técnica de ELISA permitió la semicuantificación de las isoformas de MyHC mediante la utilización de los mismos anticuerpos. La expresión de las citocinas se estudió por RT-PCR. RESULTADOS: La aplicación de IRLs en los amimales del grupo estudio indujo: 1) Un incremento de daño fibrilar en todos los músculos; 2) Respecto a los cambios estructurales, no se observó ninguna modificación en el diafragma. Por el contrario, se observó un incremento de la fibras tipo II en el intercostal externo y una disminución de la cantidad de MyHC I, sin ningún cambio en los diámetros de las fibras. En el músculo vasto interno se observó una pérdida de ambas isoformas de MyHC, y una reducción en los diámetros de ambos tipos de fibras; 3) Se observó un incremento en la expresión de IL10 en el diafragma y en el intercostal externo, sin detectarse un incremento significativo en el músculo periférico (P=0,06). No se observó ningún cambio en la expresión de TNF_ en ninguno de los músculos estudiados. Los resultados obtenidos en el grupo control fueron: 1) Ausencia de daño de membrana en todos los músculos; 2) Ausencia de cambios estructurales; 3) Se detectó un incremento de la expresión de TNF_ en todos los músculos estudiados, sin observarse cambios en la expresión de IL10. CONCLUSIONES: Nuestros resultados sugieren que la actividad muscular es un factor importante en la preservación y remodelación del músculo esquelético mediante mecanismos que implican la expresión de mediadores no inflamatorios tales como la IL10. / BACKGROUND: Patients with severe Chronic Obstructive Pulmonary Disease (COPD) are subjected to chronic respiratory loads, which induce changes in the normal anatomy of the thorax. Pulmonary hyperinflation is the major consequence of the increase in the respiratory resistances observed in patients with COPD. Furthermore, pulmonary hyperinflation may ultimately lead to respiratory muscle damage and consequent remodelling. These structural alterations are characteristic of the adaptation which suffer the respiratoy muscles to counteract the deleterious effects of the chronic respiratory loads superimposed. Indeed, the main goal of this adaptation mechanism is to keep arterial blood gases within adequate limits. In the present study an animal model has been used. Intermittent resistive inspiratory loads (IRLs) of moderate intensity were applied to Beagle dogs during a relatively prolonged period of time in order to mimic patients with COPD. OBJECTIVES: 1) To evaluate the presence of respiratory muscle damage induced by the IRLs in both inspiratory (external intercostal and diaphragm) and control (vastus medialis) muscles; 2) To investigate the structural changes (fiber type distribution, proportion of the differents MyHC isoforms, and fiber size) induced by the IRLs in these muscles; and 3) To analyse the expression of inflammatory (TNF_) and non-inflammatory (IL-10) cytokines in these muscles. MATERIALS AND METHODS: All animals were subjected to tracheostomy. In the study group, the animals were exposed to respiratory loads whose values were 15% of the maximum inspiratory pressure (MIP), and they were applied 2h/day for 15 days. In the control group animals were not exposed to any respiratory load, but tracheostomy. Muscle biopsies from the diaphragm, external intercostal and vastus medialis were obtained before and after the application of IRLs. Muscle damage was evaluated by using specific immunohistochemistry (IHQ) analyses which detect the presence of intracellular fibronectin (membrane damage). Fiber type distribution and fiber morphometry were also examined by IHQ analyses using specific antibodies for MyHC-I and -II isoforms. Enzyme-linked Immunoassay analysis (ELISA) techniques were conducted to semi-quantify the MyHC isoforms using the same antibodies. Cytokine expressions were analysed by RT-PCR. RESULTS: The application of IRLs to the study group of dogs induced: 1) A significant increase of damaged fibers in all muscles studied; 2) Regarding structural changes, no significant changes were observed in the diaphragm. External intercostal muscles showed an increase of type II fibers and a decrease in the amount of MyHC-I isoform without any changes in the fiber diameters. The vastus medialis showed a loss of both MyHC isoforms, and a reduction of both fiber type diameters; 3) There was a significant increase of IL-10 expression in both the diaphragm and the external intercostal muscles, with no significant increase in the peripheral muscle (p=0,06). No changes of TNF_ expression were detected in any of the muscles studied. The findings in the control group were: 1) Absence of membrane damage in all muscles studied; 2) Absence of fiber structural changes; and 3) A significant increase of TNF__expression in all muscles studied with no change in IL-10 expression. CONCLUSIONS: Our results suggest that muscular activity plays an important role in skeletal muscle preservation and remodelling through a mechanism that involves, among others, the expression of anti-inflammatory mediators such as IL-10.

Made available in DSpace on 2014-06-11T19:23:32Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-02-29Bitstream added on 2014-06-13T20:30:20Z : No. of bitstreams: 1 danaga_ar_me_botfm.pdf: 251409 bytes, checksum: a7b3e3680e2f319a5c5122c4c8575ff0 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A ventilação mecânica invasiva é recurso fundamental em unidades de terapia intensiva. Sua aplicação ocorre em quase metade dos pacientes dessas unidades. Entretanto, a VMI associa-se a várias complicações, especialmente quando utilizada por período prolongado. Desse modo, preconiza-se que a interrupção do suporte ventilatório seja realizada assim que possível. A intempestividade em realizar tanto o desmame como a extubação pode gerar graves conseqüências ao paciente, incluindo a necessidade de reintubação. Esta, por sua vez, está relacionada à elevada incidência de pneumonia hospitalar, o que leva ao maior tempo de ventilação mecânica, de permanência na terapia intensiva, aumento no custo hospitalar e da mortalidade. Visto que tanto a ventilação mecânica prolongada como sua retirada prematura podem ser prejudiciais, faz-se necessário o reconhecimento do momento ideal do desmame e extubação. Vários índices fisiológicos foram propostos com o intuito de identificar os pacientes capazes de reassumir a ventilação espontânea. Poucos ofereceram poder preditivo satisfatório e o índice de respiração rápida e superficial parece ser o mais útil devido sua simplicidade e confiabilidade. No entanto, o melhor ponto de corte dos índices fisiológicos raramente foi estabelecido por curva ROC, evidenciando a necessidade de novos estudos. Neste trabalho, foram revisados os estudos que demonstraram a importância da utilização de protocolos de desmame e extubação e avaliaram o papel preditivo dos índices propostos. / Invasive mechanical ventilation is crucial in intensive care units and its application becomes necessary in almost half of the patients. However it has been associated to several complications especially under prolonged use. Therefore it is reccomended that the discontinuation of ventilator support must be attemped as soon as possible. The premature weaning or extubation also can gerate negative consequences to the patient, including the need of reintubation. This is most related to higher incidence of nosocomial pneumonia, increased IMV use and ICU length of stay, hospital costs and elevated mortality rates. Because of both, prolonged IMV and it’s premature discontinuation can be harmful, it is necessary to recognize the optimal moment for weaning and extubation. Many physiological indexes were proposed to distinguish patients ready to breath spontaneously, but fewness demonstrated satisfatory predictive power. Rapid shallow breathing index seems to be the most useful parameter because of its simplicity and reliability. However, in rare studies the best threshold for these indexes was established by ROC curve, making evident the need of further investigations. The present study reviewed articles that demonstrated importance of weaning and extubation protocols utilization and that assessed the predictive role of physiological indexes.

Objective: To study the presence of 8 respiratory viruses (Influenza-A, Influenza-B, RSV-A, RSV-B, Adenovirus, Parainfluenza-1, Parainfluenza-2 and Parainfluenza-3) and atypical bacteria (Mycoplasma pneumonia and Chlamydia pneumonia) in samples from Peruvian children under 5 years-old previously analyzed for Bordetella. Pertussis. Methods: A secondary data analysis was performed from a previous cross-sectional study conducted in children with a probable diagnosis of Pertussis from January 2010 to July 2012. All samples were analyzed via Polymerase Chain Reaction (PCR) for the following etiologies: Influenza-A, Influenza-B, RSV-A, RSV-B, Adenovirus, Parainfluenza 1 virus, Parainfluenza 2 virus, Parainfluenza 3 virus, Mycoplasma pneumoniae and Chlamydia pneumoniae. Results: A total of 288 patients were included. The most common pathogen isolated was Adenovirus (49%), followed by Bordetella pertussis (41%) from our previous investigation; the most prevalent microorganisms were Mycoplasma pneumonia (26%) and Influenza-B (19.8%). Coinfections were reported in 58% of samples and the most common association was found between B. pertussis and Adenovirus (12.2%). Conclusions: There was a high prevalence of Adenovirus, Mycoplasma pneumoniae and other etiologies in patients with a probable diagnosis of pertussis. Despite the presence of persistent cough lasting at least two weeks and other clinical characteristics highly suspicious of pertussis, secondary etiologies should be considered in children under 5 years-old in order to give a proper treatment. / Objetivo: Estudiar la presencia de 8 virus respiratorios (Influenza-A, Influenza-B, RSV-A, RSV-B, Adenovirus, Parainfluenza-1, Parainfluenza-2 y Parainfluenza-3) y bacterias atípicas (Mycoplasma pneumoniae y Chlamydia pneumonia) en muestras de niños peruanos menores de 5 años analizados previamente para Bordetella pertussis Métodos: se realizó un análisis de datos secundarios de un estudio transversal previo realizado en niños con un diagnóstico probable de Pertussis desde enero del 2010 hasta julio del 2012. Todas las muestras se analizaron mediante reacción en cadena de la polimerasa (PCR) para las siguientes etiologías: Influenza-A, Influenza-B, RSV-A, RSV-B, Adenovirus, virus Parainfluenza 1, virus Parainfluenza 2, virus Parainfluenza 3, Mycoplasma pneumoniae y Chlamydia pneumoniae. Resultados: un total de 288 pacientes fueron incluidos en el estudio. El patógeno aislado más común fue el Adenovirus (49%), seguido de Bordetella pertussis (41%) de nuestra investigación previa; los microorganismos más prevelantes fueron Mycoplasma pnemoniae (26%) e Influenza-B (19.8%). Las coinfecciones fueron reportadas en el 58% de las muestras y la asociación más común se encontró entre B. pertussis y Adenovirus (12.2%). Conclusiones: hubo una alta prevalencia de Adenovirus, Mycoplasma pneumoniae y otras etiologías en pacientes con un diagnóstico probable de pertussis. A pesar de la presencia de tos persistente que dura por lo menos dos semanas y otras características clínicas altamente sospechosas de pertussis, se deben considerar las etiologías secundarias en niños menores de 5 años para poder administrar un tratamiento adecuado. / Tesis

Made available in DSpace on 2014-06-11T19:28:34Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-11-22Bitstream added on 2014-06-13T18:07:42Z : No. of bitstreams: 1 000732529.pdf: 1749909 bytes, checksum: a5ef6c0fb72830578e614d5dcc16a3a5 (MD5) / O objetivo deste trabalho foi analisar a fadiga muscular do músculobraquiorradial através do sinal eletromiográfico e da frequência mediana,assim como mensurar a frequência de oscilação da manobradevibração torácica manual realizadapor 09 fisioterapeutas em um boneco de treinamentoadulto para medidas de reanimaçãocardiopulmonar por 16 minutos. A manobra de vibração torácica é uma técnica usada na fisioterapia respiratória com a finalidade de higienização brônquica, a qual propicia a mobilização,eliminação de secreçõese permite otimizar a função pulmonar. Por este serum recurso muito utilizado em pacientes com patologias de origem respiratória, é importante analisar e mensurar tais parâmetros para que possa ser avaliada aefetividadeda técnica e do período de execução. A vibração torácica manualé proporcionadapela contração isométrica dos músculos do antebraço. Omúsculo braquiorradial foi selecionado para análise, pois apresenta maior atividade em um ângulo de aproximadamente 120º de flexão do cotovelo, posição adotada pelo profissional durante oprocedimento. Aatividade muscular deste músculodo membro superior através da EMG de superfície foiregistrada em 3 etapas(1ª, 2ª e 3ª medidas). Simultaneamente, a frequênciade oscilaçãofoi registradacom ousode um acelerômetro. Pode-se observar que não houve diferença estatisticamente significativa do padrão eletromiográfico tanto no domínio temporal quanto no espectral ao comparar os valoresde RMS, frequência mediana e frequência de oscilação de vibração entre as 3 medidas de cada sujeito. Assim, como não houve correlação entre as variáveis com as etapas determinadas, de acordo com os resultados obtidos, concluiu-se que o músculo braquiorradial nãoé um agonistado movimento, pois não houve alteração do sinal EMG e não ocorreu fadiga / The aim ofthis study was toanalyze themusclefatigue of brachioradialis muscleby electromyographic signal and median frequency andmeasurethe oscillation frequency of maneuver of manual chest vibration performed bynine physiotherapists in a adult training dummy for measures of cardiopulmonary resuscitation for 16minutes. The maneuver of chest vibration is atechnique used in respiratory physiotherapy for the purposeof bronchialhygiene which allows mobilization, elimination of secretions andallowsoptimizing the pulmonary function. Themanual chest vibration is provided by the isometric contraction of forearm muscles. The brachioradialis muscle wasselected foranalysis because itis more active at anangle of 120º of elbow flexion position adopted by the professional during theprocedure. Given that this is aresourceoften used in patient withpathologies ofrespiratory origin, it is important to analyze and measuresuch parameters to assess the effectiveness of thetechniqueand the implementation period.The muscle activity of this muscle of the upper limb throughsurfaceEMG was recorded in 3 steps (1st, 2nd and 3rd measures). At the same time, the oscillation frequency was registered using an accelerometer. It can be observed no statistically significant difference of electromyographic patterns in temporal and spectral domain comparing the values of RMS, median frequency and oscillation frequency of vibration among thethree measuresof eachindividual as nocorrelation was found amongvariables with the determined steps.As there was no correlationbetween thevariables with certain phases,according to theresults obtained, it is concludedthat the brachioradialis muscle is not an agonist of movement, because there was no change of the EMG signal and fatigue did not occur