Trial Information

Effects of the Breathing Muscular Training to Volume and the Pressure in MIP and MEP of Institutionalized Elderly

The physiologic alterations of the aging are systemic and they seem to be more evident in
the institutionalized elderly. The advanced age is associated to the decrease of the force
of the skeletal muscles, as well as the one of the muscles respiratory. In the breathing
system happen important muscle-skeletal alterations, interfering in the mechanics
ventilatory. The changes in the compliance of the thoracic wall and of the lung stcruture
resulting in imprisonment of air, air-trapping ", increasing the breathing work
simultaneously the and functional residual capacity (FRC) with consequent decrease of the
pressure maximum expiratory. Also the decreases of the pick of flow expiratory and changes
in the curve flow-volume contributing to the closing of the outlying aerial roads. This way
the breathing muscular function will be strongly harmed and correlated with the state
nutritional and it forces muscular outlying. Besides, modifications in the curvature of the
diaphragm, with a negative effect for the capacity to generate muscular force, collaborating
for the decrease inspiratory.

The participant was completely evaluated, including personal information, medical history
and a physical examination.

Measurement of Translation provided gratis.

MIP and MEP: Before and after the respiratory muscle training, inspiratory and expiratory
strength were evaluated and analysed through the maximum inspiratory pressure (MIP) and
maximum expiratory pressure (MEP), respectively. This was measured using a device called a
vacuum manometer (analogical with operational intervals of -120 to + 120 cmH2O, Critical
Med/USA-2002 and display with scale intervals of 4 cmH2O). During MIP measurements, a nasal
clip was used, which prevented air from escaping during the evaluation. In MIP measurements,
the mouth and oropharynx can create negative pressure that can alter the results depending
on whether the glottis opens (correct form) or closes (improper form). To prevent this
interference of the orofacial musculature in the MIP measurements, an escape orifice was
placed in the measurement instrument. This orifice relieved the pressure without
significantly affecting the pressure produced by the respiratory muscles. Five tests were
carried out to get three acceptable measures (i.e., duration of at least 2 seconds and an
absence of emptying).

Acceptable tests were required to have at least two reproducible measurements (a maximum
difference of 5% between the two maxima). A rest of at least one minute between tests was
used for better equalization of the volumes and (consequently) the attainment of maximum
pressures. To measure MEP, the patient was instructed to inhale until reaching total
pulmonary capacity (TPC) and to carry through a supported expiratory effort down to the
residual volume (RV). A seated position was used when measuring both MIP and MEP.

Threshold Group Training: after the measurement of the initial MIP and MEP (pre-training),
the elderly individuals of the TG were submitted to a respiratory exercise program. The
research of Ide et al. (2007) showed that this program contributes to an increase in chest
expansion in healthy elderly people. The program was composed of the following exercises:
active/resistance exercise of horizontal adduction-abduction and flexion-extension of the
shoulder joint; active/resistance exercise of anterior flexion associated with rotation of
the trunk and lateral flexion of the trunk; active/resistance exercise of lateral rotation
of the trunk; active/resistance exercise to put the superior members above the head. The
relaxation protocol consisted of inspiration and deep expiration without the accompaniment
of other movements. After training, the Threshold® IMT (Respironics USA - 2004) was used.
This device is commercially offered in the form of a transparent plastic cylinder; at one
end is a valve that is kept closed for the positive pressure by a spring, while at the other
end is a nipple. The valve blocks the aerial flow until the patient generates inspiratory
pressure sufficient to overcome the spring.

The utilization of Threshold in this research began with a gradual load, starting with 50%
of the MIP of each individual and increasing 10% per week until the fourth week. From the
fifth week on, this was increased by 5% until 100% was reached in the eighth week or the
maximum pressure value of the Threshold IMT (41 cmH2O) was reached. Thereafter, this value
was kept constant in the final two weeks. The sessions lasted 20 minutes and consisted of
seven series of strengthening (2 minutes each) with an interval of 1 minute between the
series; sessions were conducted three times per week for ten weeks.

In the use of this training program, all the elderly individuals had been evaluated
separately and trained in a group with individualized attention.

Voldyne Group Training: The same respiratory exercises used in the TG were used in the VG.

The maximum inspiratory sustentation technique (MIS) using the Voldyne mobilizes great
pulmonary volumes and thereby increases the intra-alveolar pressure until the end of the
supported inspiration. The increase in the intra-alveolar pressure is directly proportional
to the contractile strength of the respiratory muscles (diaphragm and accessories), thus
justifying the fact that intense muscular activity is required to reach the total pulmonary
capacity (TPC) and to support inspiration at this level.

The use of EI (Voldyne®) incentive spirometry as muscular training in elderly people and as
a basis for physiotherapy followed some guidelines. The patient's trunk was positioned at
30º relative to the horizontal plane, providing more diaphragmatic conscription. The device
was positioned vertically. The volume indicator was visible to the patient to provide visual
biofeedback. The patient was instructed to carry out a slow and deep inspiration until
reaching TPC from the functional residual capacity (FRC). Slow inspiration favours a laminar
flow. A sustentation of the maximum inspiration of around three seconds was recommended.
Expiration occurred normally until the FRC was reached. During the use of Voldyne, patient
hyperventilation was avoided. Intervals of 60 seconds between the inspiration support maxima
were recommended 11. The elderly subjects received a verbal command to initiate a new
inspiration. In this study, the Voldyne was used for 20 minutes, that is, 40 repetitions
with 2 repetitions per minute. The procedure lasted 10 weeks at a frequency of three times
per week. The group was supervised intermittently during the twenty minutes to ensure that
hyperventilation was not occurring.

Control Group Training: This group received only respiratory exercises. The exercises was
composed of the following exercises: active/resistance exercise of horizontal
adduction-abduction and flexion-extension of the shoulder joint; active/resistance exercise
of anterior flexion associated with rotation of the trunk and lateral flexion of the trunk;
active/resistance exercise of lateral rotation of the trunk; active/resistance exercise to
put the superior members above the head. The relaxation protocol consisted of inspiration
and deep expiration without the accompaniment of other movements.

Statistical Treatment:The average and standard deviation (av ± sd) were calculated for age,
body mass index, maximum respiratory pressure and functional autonomy. The normality of the
sample was evaluated by the Shapiro-Wilk test and the homogeneity of the variance by the
test of Levene. For the within-groups analysis variables, the parametric Student's t test or
Wilcoxon was used when appropriate (for homogeneous or heterogeneous distribution of the
data, respectively). For the between-groups evaluation, the nonparametric Kruskal-Wallis
test was used followed by the Mann-Whitney multiple comparisons test. The statistical
significance level adopted was p < 0.05. Excel and the SPSS v14.0 statistical package
program were used to evaluate the data.