3rd Journal Reading Asian Pacific Society of Respirology

April 9th, 2020 (2018)

High-intensity inspiratory muscle

training in bronchiectasis:
A randomized controlled trial
Presented by: dr. Aulia Angraini
Supervised by: dr. Sunaryo B. Sastradimaja Sp. KFR

DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION

FACULTY OF MEDICINE UNIVERSITAS PADJADJARAN
HASAN SADIKIN GENERAL HOSPITAL BANDUNG
Introduction
Inspiratory muscle weakness
Expiratory muscle weakness
Cough

Muscle load and capacity discordance

Excessive
Excessive
Effectiveness of coughing ↓
Fatigue
Fatigue secretions
secretions Dyspnoea

Bronchiectasis

Decreased exercise tolerance

Removal airway secretions ↓

Hypoventilation
Exercise
intolerance Dyspnoea

Infection
Respiratory failure
Introduction

Previous studies The possible

indicated respiratory mechanisms are primary
muscle weakness in Unknown underlying weakness and
patients with hyperinflation-related
bronchiectasis functional

Inspiratory muscle Using a threshold

training (IMT) device

Enhance velocity of
Decreased inspiratory Increase exhalation Allow more time for
inspiratory muscle
time time lung emptying
contraction
Introduction
In Bronchiectasis

The IMT improved both inspiratory and

expiratory muscle strengths without any
impact on pulmonary function, quality of
life (QOL) or exercise capacity

Interval-based high-intensity IMT (H-

IMT)  provide more respiratory
muscle function improvement than
low-to-medium-intensity loads
Introduction
Studies investigating Aim: to examine the impact of
the effects of IMT in isolated respiratory muscle training
bronchiectasis are on significant physiological and
limited clinical findings in bronchiectasis

Purpose

• To explore the effects of H-IMT and low-IMT on exercise capacity in

patients with clinically stable non-cystic fibrosis (CF) bronchiectasis

Hypothesis

• H-IMT would cause increased exercise capacity in stable bronchiectasis.

Methods
Subjects
Participant
• Clinically stable patients with non-CF bronchiectasis aged 18–65 years were

Time

• June 2013 to June 2016.

Bronchiectasis
• Confirmed by clinical history, including coughing, shortness of breath, exertional dyspnoea,
pulmonary function tests (PFT) and high-resolution computed tomography (HRCT).

Subjects
• were randomly divided into two groups: H-IMT and low-intensity IMT (control).

Assessors

• blinded to the groups.

Methods
Subjects

Inclusion criteria

• No significant coexisting disease affecting ability to undertake exercise, ability to walk and
willingness to cooperate in the study.

Exclusion criteria

• Patients with neurological complications, advanced orthopaedic disease, advanced heart

failure, acute exacerbations in the last 3 weeks, and patients on antibiotics and previously
participated in a rehabilitation programme

Approval
• Hacettepe University Ethics Committee

Primary outcome measure

• Incremental shuttle walk test (ISWT) distance

Methods
Measurement

All measurements were performed at the beginning and end of the 8-week programmes

Dyspnoea and Respiratory muscle Respiratory muscle

PFT Exercise capacity QOL
fatigue strength endurance

• Standard • Modified Medical • Electronic mouth • Threshold loading • ISWT • Leicester Cough
spirometer Research Council pressure device device, using the Questionnaire
(Spirodoc; MIR, (MMRC) dyspnoea sustainable (LCQ).
Rome, Italy) scale and Fatigue inspiratory
Severity Scale pressure (SIP) test
(FSS)
Methods
Inspiratory muscle training

The patients underwent H-IMT for 3 days/week for 8 weeks.

One session/week was performed under the supervision

Other two sessions/week were performed at home.

A threshold loading device was used to ensure inspiratory muscle loading

Methods
Inspiratory muscle training

First session Second session Third session

• The target workload • The study and rest • Inspiratory muscle load
was selected at 30% of ratio of 2:1 progressed was targeted to be at
MIP to 30% MIP within least 70% of the MIP
• The H-IMT group interval IMT. • There was a total
underwent IMT with a • No training was given period of 14 min of
1-min warm-up on an during the 1-min rest loaded breathing and
inspiratory load of 15% period. 7 min of recovery
of MIP • Three-minute cycles
were repeated seven
times, and each
session lasted 21 min
Methods
Statistical Analysis
Statistical
Statistical analysis
analysis
• SPSS Statistics

The
The Expectation
Expectation Maximization
Maximization (EM)
(EM)
• to overcome missing cases (two from H-IMT and one from control)

Normality
Normality of
of the
the data
data
• Kolmogorov–Smirnov test

Two
Two independent
independent groups
groups of
of numerical
numerical variables
variables
• Student’s t- test or the Mann–Whitney U-test

Categorical
Categorical comparisons
comparisons
• Chi-square test

Baseline
Baseline values
values
• Student's t-test

Level
Level of
of significance
significance
• p < 0.05.
Results
Results
Results
Results
Discussion
An 8-week H-IMT increased
The H-IMT has improved
exercise capacity in non-CF
respiratory muscle strength and
patients with bronchiectasis
endurance, and social aspects
with low to intermediate
of the QOL.
severity

We evaluated exercise capacity using the ISWT. At baseline, 69.57% of patients from
the H-IMT Exercise
group and
capacity 63.64%
diminishes of patients from the control group were at lower than
in bronchiectasis

the percent predicted values of ISWT, stating a reduced ISWTexercise capacity

 At baseline, 69.57% of
patients from the H-IMT group and
63.64% of patients from the control
group were at lower than the percent
predicted values of ISWT, stating a
reduced exercise capacity
Due to ventilatory changes, gas exchange problems, respiratory mechanics,
cardiovascular disorders, musculoskeletal changes and psychological factors
Discussion

Although not statistically significant, forced expiratory volume in

1 s (FEV1) % predicted was 12% worse in the intervention arm

We also found no change in PFT and dyspnea after H-IMT in patients

with bronchiectasis, similar to the previous studies using IMT

H-IMT does not affect expiratory airflow and

breathlessness in mild lung function impairment

Chronic fatigue is frequent in bronchiectasis

and may affect exercise capacity and QOL
Discussion
• Two studies investigated IMT in bronchiectasis.

Inspiration against resistance during

IMT

• In the first study, an 8-week moderate-intensity (MIP 30–60%, 15 min) IMT added to
ExT did not show an increase in MIP.

may increase the activation of the

expiratory muscles by the last force
• In the second study, which had low statistical power, a programme of low-intensity extension
IMT (MIP 30%), MIP and MEP improved by 39% and 44%, respectively, after 8 weeks.

In our study, H-IMT increased MIP and MEP by significant increase in MEP
43.53% and 11.67%, respectively.
Discussion

Respiratory muscle endurance reflects the sustained performance

of a given workload.

No study has investigated respiratory muscle endurance during

IMT.

In our study, respiratory muscle endurance improved by 207 s

(139%) in H-IMT and by 38 s (22%) in the control group, which
were lower than the value of 261 improvement in a meta-
analysis
Discussion

QOL assessment is essential to

understand the effects of disease on
patient’s life and response to
intervention.

We found social dimension scores were reduced in

the H-IMT group at the beginning of the study,
probably due to the effects of increased number of
hospitalizations and the presence of haemoptysis,
reflecting the severity of the disease.
Discussion
H-IMT protocol was used

to
to increase
increase exercise
exercise capacity,
capacity, respiratory
respiratory muscle
muscle endurance
endurance and
and inspiratory
inspiratory muscle
muscle strength
strength as
as well
well as
as dyspnea
dyspnea in
in patients
patients with
with
bronchiectasis.

Both
Both the
the data
data in
in literature
literature and
and those
those in
in our
our study suggest that
study suggest that H-IMT
H-IMT may
may bebe used
used in
in bronchiectasis
bronchiectasis patients
patients as
as efficient
efficient to
to increase
increase
exercise
exercise capacity
capacity

The findings of our study  respiratory muscles are capable of H-IMT, and it could be used as home-based.

Thus,
Thus, it
it may
may increase
increase the
the patient’s
patient’s compliance
compliance and
and facilitate
facilitate implementation
implementation for
for healthcare
healthcare professionals
professionals
Discussion
Limitations

Inability to perform the initial 2-week assessment

period from the H-IMT protocol study which may
act as a familiarization period

Number of patients included as we did

not account for discontinuations
Conclusion

The H-IMT increased exercise capacity in

patients with non-cystic fibrosis
bronchiectasis.

It has also positive effects on respiratory

muscle strength and endurance, and social
aspects of QOL.
Thank You
Leicester Cough Questionnaire (LCQ).