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Mecanismos de Limitação nas AVD na DPOC
J. ALBERTO NEDERJ. ALBERTO NEDERProf. Adjunto Livre-DocenteProf. Adjunto Livre-Docente
Disciplina de Pneumologia da UNIFESP-EPMDisciplina de Pneumologia da UNIFESP-EPM
Mecanismos de Mecanismos de limitação das AVD na limitação das AVD na
DPOCDPOC
J. ALBERTO NEDERJ. ALBERTO NEDERProf. Adjunto Livre DocenteProf. Adjunto Livre Docente
Disciplina de Pneumologia do Departamento de MedicinaDisciplina de Pneumologia do Departamento de Medicina
VVM
VVM
VE
VO2
.
FC
PREV
Res Vent
Res Crono
LIMITAÇÃO VENTILATÓRIA
NormalDPOC
VELLOSO M et al.
VE
AUMENTO DO TRABALHO ELASTICOAUMENTO DO TRABALHO ELASTICOSECUNDÁRIO À HIPERINSUFLAÇÃOSECUNDÁRIO À HIPERINSUFLAÇÃO
VPEFVPEF
VcVc
PP
VcVc
PP
SOLUÇÃO – SOLUÇÃO – FREQÜÊNCIA ? FREQÜÊNCIA ?
TLCTLC
VOLUMEVOLUME
DYNAMIC HYPERINFLATIONDYNAMIC HYPERINFLATION
AIRWAYSAIRWAYS
FLOWFLOW
EILVEILV
EELVEELV
AUTO-PEEPAUTO-PEEP
IRVIRV
Expiratory time“too short” !!
DPOCDPOC
Pdi / Pdi maxPdi / Pdi max
Time, min
Rest 2 4 6 END
EE
LV
, L
4,0
4,5
5,0
5,5
6,0
6,5
TFTPCFCP
Dynamic Hyperinflation and Breathlessness DuringWalking and Cycling in COPD
Submitted: Am J Respir Crit Care MedAlbuquerque A et al.
TREADMILLPRE-BD
POST-BD
CYCLE PRE-BD
POST-BD
ARMS UP ARMS DOWN
Velloso M, Jardim JR
Velloso M, Jardim JR
A COMPETIÇÃO MUSCULAR RESPIRATÓRIA-PERIFÉRICANA DPOC
A COMPETIÇÃO MUSCULAR RESPIRATÓRIA-PERIFÉRICANA DPOC
Abordagem Integrada dasConseqüências Fisiopatológicas da DPOC
X
15%
85%
Musc. Periférica
Musc. Respir.
5%
95%
% do fluxomuscular Progressão
do exercício
Musc.Periférica
Musc. Respir.
Hierarquia no aporte sangüíneo na atividade física
Dynamic Hyperinflation: COPD
RestRest ExerciseExercise
RVRV
EELVEELV
EILVEILV
TLCTLC
VtVt
ICIC
MARKED INCREASE IN RESPIRATORY MUSCLE PERFUSION DEMANDS !!
DEMANDA METABÓLICA VENTILATÓRIA NA DPOC
Walking
40% VO2peak
QUAL SERIA O PAPEL DO “ROUBO DE FLUXO” NA DPOC ?
8%
92%
% do fluxomuscular Progressão
do exercício
Musculatura apendicular
Musculatura ventilatória
35%
65%
Submitted: Am J Respir Crit Care Med
Skeletal muscle oxygenation
CTL
ISQ
Near-infrared spectroscopy
Tissue Oxygenation Index= ([HbO2]/[HbTOT]) x 100
NIRS data interpretationNIRS data interpretation
HbOHbO22 and and HHbHHb
Tissue Oxygenation Index (TOI)Tissue Oxygenation Index (TOI) HbHbTOT TOT (local blood volume)(local blood volume)
DURING CONSTANT WORK RATE EXERCISEDURING CONSTANT WORK RATE EXERCISE
RESPIRATORY MUSCLE UNLOADINGRESPIRATORY MUSCLE UNLOADING
CARDIAC OUTPUT and/or CaOCARDIAC OUTPUT and/or CaO22
Systemic oxygen deliverySystemic oxygen delivery Local blood flow due to flow redistributionLocal blood flow due to flow redistributionfrom respiratory to locomotor musclesfrom respiratory to locomotor muscles
INCREASEDINCREASED UNCHANGED / REDUCEDUNCHANGED / REDUCED
UNLOADING THERESPIRATORY MUSCLES
Proportional AssistedVentilation
BLOOD FLOW
Débito Cardíaco Não-Invasivo
Cardiografia por Impedância TranstorácicaCardiografia por Impedância Transtorácica
NIRS
QT
PAV and exercise tolerancePAV and exercise tolerance
337 337 189 s 189 s vsvs. 273 . 273 142 s 142 s
13/16 patients improved Tlim with PAV compared to sham13/16 patients improved Tlim with PAV compared to sham
HbOHbO22
HHbHHb
HbHbTOTTOT TOITOI
NIRS data interpretationNIRS data interpretation
HbOHbO22 and and HHbHHb
Tissue Oxygenation Index (TOI)Tissue Oxygenation Index (TOI) HbHbTOT TOT (local blood volume)(local blood volume)
DURING CONSTANT WORK RATE EXERCISEDURING CONSTANT WORK RATE EXERCISE
RESPIRATORY MUSCLE UNLOADINGRESPIRATORY MUSCLE UNLOADING
CARDIAC OUTPUT and/or CaOCARDIAC OUTPUT and/or CaO22
Systemic oxygen deliverySystemic oxygen delivery Local blood flow due to flow redistributionLocal blood flow due to flow redistributionfrom respiratory to locomotor musclesfrom respiratory to locomotor muscles
INCREASEDINCREASED UNCHANGED UNCHANGED / / REDUCEDREDUCED
ConclusionConclusion
Respiratory muscle unloading during high-intensity exercise can improve peripheral muscle oxygenation under similar systemic oxygen delivery in advanced COPD
Study ImplicationsStudy Implications
Our data suggest that a fraction of the cardiac output might be diverted from the appendicular muscles to subserve the exercise-related work of breathing in these patients
Limitação Crônica ao Fluxo Expiratório
Efeitos mecânico-ventilatórios
Efeitoscardiovasculares
Efeitoshemodinâmicos
Dispnéia
Intolerânciaàs atividades
Incapacidade
Fadigabilidadeperiférica
HIPOXEMIA DISFUNÇÃOMUSCULAR
POSTURAATIVIDADE
DPOCUMA DOENÇA SISTÊMICA