Yesim KURTAİŞ AYTÜR, Aysun GENÇ, Akın KAYA, Fatma ÇİFTÇİ, Seçilay GÜNEŞ, Serhat HAYME

Effects of pulmonary rehabilitation on diaphragm thickness and contractility in patients with chronic obstructive pulmonary disease

Background/aim: Studies are showing that pulmonary rehabilitation (PR) increases diaphragmatic excursion by decreasing hyperinflation in patients with chronic obstructive pulmonary disease (COPD). However, there is a lack of knowledge about its effects on the diaphragm thickness (dt) and contractility. This study aims to evaluate the dt and contractility before and after PR in patients with COPD. Materials and methods: All subjects participated in an out-patient PR of 6 weeks and 3 sessions per week prospectively. Dyspnea severity, the disease-specific quality of life (St. Georges Respiratory Questionnaire-SGRQ), pulmonary function tests (PFT), exercise capacity, the dt at the end of the expiration and at maximal inspiration (B-mode ultrasound) were evaluated at baseline and after PR. Results: A total of 34 patients with a mean age and FEV1 61.05 ± 8.22 years and 57.9 ± 20.4% predicted respectively showed improvements in exercise capacity and some items of PFT and SGRQ. Diaphragmatic thickness at the end of the expiration also significantly improved regardless of the disease severity and was positively correlated with functional performance. The 6-weeks of PR didn’t result in a significant difference in diaphragm contractility. Conclusion: The 6-weeks of PR resulted in a significant increase in dt without a significant difference in diaphragm contractility.

PDF

___

1. Hogg JC. Pathophysiology of airflow limitation in chronic obstructive pulmonary disease. Lancet 2004; 364 (9435): 709- 721. doi: 10.1016/S0140-6736(04)16900-6
2. Similowski T, Yan S, Gauthier AP, Macklem PT, Bellemare F. Contractile properties of the human diaphragm during chronic hyperinflation. The New England Journal of Medicine 1991; 325 (13): 917-923. doi: 10.1056/NEJM199109263251304
3. Barreiro E, de la Puente B, Minguella J, Corominas JM, Serrano S et al. Oxidative stress and respiratory muscle dysfunction in severe chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine 2005; 171 (10): 1116–1124. doi: 10.1164/rccm.200407-887OC
4. Ottenheijm CA, Heunks LM, Dekhuijzen PN. Diaphragm muscle fiber dysfunction in chronic obstructive pulmonary disease: toward a pathophysiological concept. American Journal of Respiratory and Critical Care Medicine 2007; 175 (12): 1233-1240. doi: 10.1164/rccm.200701-020PP
5. Okura K, Iwakura M, Shibata K, Kawagoshi A, Sugawara K et al. Diaphragm thickening assessed by ultrasonography is lower than healthy adults in patients with chronic obstructive pulmonary disease. The Clinical Respiratory Journal 2020; 14 (6): 521-526. doi: 10.1111/crj.13161
6. Boon AJ, Harper CJ, Ghahfarokhi LS, Strommen JA, Watson JC, Sorenson EJ. Two-dimensional ultrasound imaging of the diaphragm: quantitative values in normal subjects. Muscle Nerve 2013; 47 (6): 884-889. doi: 10.1002/mus.23702
7. McCool FD, Conomos P, Benditt JO, Cohn D, Sherman CB, Hoppin FG. Maximal inspiratory pressures and dimensions of the diaphragm. American Journal of Respiratory and Critical Care Medicine 1997; 155 (4): 1329-1334. doi: 10.1164/ ajrccm.155.4.9105075
8. Baria MR, Shahgholi L, Sorenson EJ, Harper CJ, Lim KG et al. B Mode ultrasound assessment of diaphragm structure and function in patients with COPD. Chest 2014; 146 (3): 680-685. doi: 10.1378/chest.13-2306
9. Ogan N, Aydemir Y, Evrin T, Ataç GK, Baha A et al. Diaphragmatic thickness in chronic obstructive lung disease and relationship with clinical severity parameters. Turkish Journal of Medical Science 2019; 49 (4): 1073-1078. doi: 10.3906/sag-1901-164
10. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews 2015; 2: CD003793. doi: 10.1002/14651858.CD003793.pub3
11. Ries AL, Kaplan RM, Limberg TM, Prewit LM. Effect of pulmonary rehabilitation on physiologic and psychological outcomes in patients with chronic obstructive pulmonary disease. Annals of Internal Medicine 1995; 122 (11): 823–832. doi: 10.7326/0003-4819-122-11-199506010-00003
12. Corbellini C, Boussuges A, Villafane JH, Zocchi L. Diaphragmatic mobility loss in subjects with moderate to severe COPD may improve after in-patient pulmonary rehabilitation. Respiratory Care 2018; 63 (10): 1271-1280. doi: 10.4187/respcare.06101
13. Chun EM, Han SJ, Modi HN. Analysis of diaphragmatic movement before and after pulmonary rehabilitation using fluoroscopy in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease 2015; 10: 193-199. doi: 10.2147/COPD.S74438
14. Debouche S, Pitance L, Robert A, Liistro G, Reychler G. Reliability and reproducibility of chest wall expansion measurement in young healthy adults. Journal of Manipulative Physiological Therapeutics 2016; 39 (6): 443–449. doi: 10.1016/j.jmpt.2016.05.004
15. Perez T, Burgel PR, Paillasseur JL, Caillaud D, Deslée G et al. Modified Medical Research Council scale vs Baseline Dyspnea Index to evaluate dyspnea in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease 2015; 18; 10: 1663-1672. doi: 10.2147/ COPD.S82408
16. Polatlı M, Yorgancıoğlu A, Aydemir Ö, Yılmaz Demirci N, Kırkıl G et al. St George solunum anketinin Türkçe geçerlilik ve güvenilirliği [Validity and reliability of Turkish version of St. George’s respiratory questionnaire]. Tuberkuloz ve Toraks 2013; 61 (2): 81-87 doi: 10.5578/tt.5404
17. Jones PW, Quirk FH, Baveystock CM. The St George’s respiratory questionnaire. Respiratory Medicine 1991; 85: 25– 31. doi: 10.1016/s0954-6111(06)80166-6
18. Graham BL, Steenbruggen I, Miller MR, Barjaktarevic IZ, Cooper BG et al. Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement. American Journal of Respiratory and Critical Care Medicine 2019; 200 (8): e70-e88. doi: 10.1164/rccm.201908-1590ST
19. Enright PL, McBurnie MA, Bittner V, Tracy RP, Mc Namara R et al. The 6-min walk test: a quick measure of functional status in elderly adults. Chest 2003; 123 (2): 387–398. doi: 10.1378/ chest.123.2.387
20. Tobin MJ, Laghi F, Brochard L. Role of the respiratory muscles in acute respiratory failure of COPD: lessons from weaning failure. Journal of Applied Physiology 2009; 107 (3): 962–970. doi: 10.1152/japplphysiol.00165.2009
21. Harper CJ, Shahgholi L, Cieslak K, Hellyer NJ, Strommen JA, Boon AJ. Variability in diaphragm motion during normal breathing, assessed with B-mode ultrasound. The Journal of Orthopaedic and Sports Physical Therapy 2013; 43 (12): 927– 993. doi: 10.2519/jospt.2013.4931
22. De Bruin PF, Ueki J, Bush A, Khan Y, Watson A, Pride NB. Diaphragm thickness and inspiratory strength in patients with Duchenne muscular dystrophy. Thorax 1997; 52 (5): 472- 475. doi: 10.1136/thx.52.5.472
23. Clanton TL, Levine S. Respiratory muscle fiber remodeling in chronic hyperinflation: dysfunction or adaptation? Journal of Applied Physiology (1985) 2009; 107 (1): 324–335. doi: 10.1152/japplphysiol.00173.2009
24. Donaldson AV, Maddocks M, Martolini D, Polkey MI, Man WD. Muscle function in COPD: a complex interplay. International Journal of Chronic Obstructive Pulmonary Disease 2012; 7: 523–535. doi: 10.2147/COPD.S28247
25. Powers SK, Criswell D, Lieu FK, Dodd S, Silverman H. Diaphragmatic fiber type specific adaptation to endurance exercise. Respiration Physiology 1992; 89 (2): 195-197. doi: 10.1016/0034-5687(92)90050-7
26. Crimi C, Heffler E, Augelletti T, Campisi R, Noto A et al. Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients. International Journal of Chronic Obstructive Pulmonary Disease 2018; 13: 3131-3139. doi: 10.2147/COPD.S171134
27. De Troyer A. Effect of hyperinflation on the diaphragm. The European Respiratory Journal 1997; 10 (3): 708-713. doi: 10.1183/09031936.97.10030708
28. Boon AJ, Sekiguchi H, Harper CJ, Strommen JA, Ghahfarokhi LS et al. Sensitivity and specificity of diagnostic ultrasound in the diagnosis of phrenic neuropathy. Neurology 2014; 83 (14): 1264–1270. doi: 10.1212/WNL.0000000000000841
29. Noda Y, Sekiguchi K, Kohara N, Kanda F, Toda T. Ultrasonographic diaphragm thickness correlates with compound muscle action potential amplitude and forced vital capacity. Muscle Nerve 2016; 53 (4): 522-527. doi: 10.1002/ mus.24902
30. Mador MJ, Patel AN, Nadler J. Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation and Prevention 2011; 31 (1): 52-59. doi: 10.1097/ HCR.0b013e3181ebf2ef