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Treinamento muscular respiratório e repouso na DPOC

AUTOR: Bartolome R Celli, MD
EDITOR DE SEÇÃO: Umur Hatipoglu, MD, MBA
EDITOR ADJUNTO: Paul Dieffenbach, MD

Todos os tópicos são atualizados à medida que novas evidências são disponibilizadas e nosso processo de revisão por
pares é concluído.

Revisão da literatura atualizada até:  julho de 2023.

Última atualização deste tópico:  15 de junho de 2023.

INTRODUÇÃO

Os músculos respiratórios constituem um componente vital da bomba respiratória. Sua

contração durante parte do ciclo respiratório altera a configuração anatômica do tórax e
desloca seus componentes, de modo que o ar entra e sai da porção de troca gasosa dos
pulmões [1-3 ] . A importância da musculatura respiratória na doença pulmonar obstrutiva
crônica (DPOC) é ressaltada pelas alterações estruturais do diafragma que tornam os
pacientes mais resistentes à fadiga, incluindo um aumento na quantidade de fibras de
contração lenta e isômeros lentos de cadeias leves de miosina, tropomiosina e troponinas [ 4
,5 ].

O efeito do treinamento e repouso da musculatura respiratória em pacientes com DPOC será

apresentado aqui. Uma visão geral do manejo da DPOC estável, testes de força muscular
respiratória e os papéis da reabilitação pulmonar e do suporte ventilatório noturno são
discutidos separadamente. (Consulte "DPOC estável: visão geral do manejo" e "Reabilitação
pulmonar" e "Suporte ventilatório noturno na DPOC" e "Testes de força muscular
respiratória" .)

TREINAMENTO DE FORÇA E RESISTÊNCIA

Vários estudos demonstraram que a força e a resistência dos músculos respiratórios podem
ser aumentadas com treinamento específico, semelhante ao treinamento dos músculos
esqueléticos [ 6-10 ]. É necessário um estímulo suficiente, como mais de 30% da força
máxima, para que o treinamento ocorra.

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Como a redução da força muscular inspiratória é evidente em pacientes com DPOC, esforços
consideráveis ​têm sido feitos para definir o papel do treinamento muscular respiratório
nesse cenário. Teoricamente, um aumento na força muscular inspiratória (e talvez na
resistência) poderia resultar em melhora da função muscular respiratória. No entanto, isto só
pode ser relevante quando os pacientes têm de suportar cargas inspiratórias superiores à
linha de base, como durante uma exacerbação aguda ou exercício.

O treinamento muscular inspiratório (TMI) melhorou a distância percorrida em seis minutos

e reduziu a dispneia em um estudo que comparou o treinamento expiratório, inspiratório e
combinado [ 11 ]. Revisões sistemáticas e metanálises que incluíram dados de 55 ensaios
clínicos randomizados (ECR) avaliaram o impacto do TMI isoladamente, bem como do TMI
além da reabilitação pulmonar (RP). O TMI sozinho, em comparação com nenhum TMI ou o
uso de um dispositivo simulado, melhora a força muscular inspiratória, o tempo de
resistência, a distância percorrida em 6 ou 12 minutos, a qualidade de vida e algumas
medidas de dispneia, mas muitas das evidências são de baixa qualidade e pelo menos risco
de viés [ 7,12]. Quando adicionado à RP (22 ensaios com 1.446 participantes), o TMI não
melhorou significativamente os escores de dispneia, a distância caminhada de seis minutos
ou a pontuação do questionário respiratório de St. George em comparação com a RP
isoladamente [12 ] . Os dados agrupados indicaram uma melhoria estatística, mas não
clinicamente significativa, nas pressões inspiratórias máximas (11 cmH 2 0, IC 95% 7,4-15,5).
Essas análises sugerem que o TMI pode não melhorar a dispneia, a capacidade funcional de
exercício e a qualidade de vida quando usado com RP. No entanto, é provável que o TMI
melhore estes resultados quando fornecido isoladamente.

Uma revisão sistemática separada indicou que o treinamento muscular expiratório melhora
as forças musculares expiratórias, mas não a distância percorrida em seis minutos ou
dispneia em pacientes com DPOC [ 13 ]. Mais dados são necessários para esclarecer o
possível papel do treinamento muscular expiratório nos resultados clínicos.

Treinamento de força  —  O treinamento de força é alcançado por meio de um estímulo de

alta intensidade e curta duração, como a realização de manobras inspiratórias contra uma
glote fechada ou veneziana. Um aumento nas pressões inspiratórias máximas foi
demonstrado quando os músculos respiratórios foram especificamente treinados para obter
força [ 14,15 ]. Também foi demonstrado que a força muscular respiratória aumenta como
subproduto do treinamento de resistência. É, portanto, possível que alguns dos benefícios
observados relatados após o treino de resistência possam estar relacionados com o
aumento associado da força.

Endurance training — Training for endurance is achieved by low intensity, high repetition

training. Three types of programs have been used: flow resistive loading; threshold loading;
and voluntary isocapnic hyperpnea.

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Flow resistive loading — Data from numerous studies indicate that ventilatory muscle
training with flow resistive breathing results in improved ventilatory muscle strength and
endurance, but has marginal effects on overall exercise performance [7]. It is not clear
whether improved strength and endurance will result in decreased morbidity or mortality or
offers other clinical advantages.

In flow resistive load training, the load consists of using a device with an adjustable
inspiratory breath hole size. The load will increase provided that frequency, tidal volume, and
inspiratory time are held constant. Although most studies in patients with COPD have shown
an improvement in the time that a given respiratory load can be maintained (ventilatory
muscle endurance), the results have to be interpreted with caution, since endurance can be
increased with changes in the pattern of breathing.

A number of controlled studies of resistive breathing have shown an increase in the

endurance time that the ventilatory muscles could tolerate a known load [15-23]. Some have
also shown a significant increase in strength [15-17,19-22] and exercise tolerance [22], and a
decrease in dyspnea during inspiratory loading [16,22]. The pressure required to achieve
training must exceed 30 percent of maximal inspiratory pressure [15,22]. In the studies which
evaluated systemic exercise performance, there was a minimal increase in walking distance
[15,19,21-23].

Threshold loading — With threshold loading, the patient breathes through a device that
requires the patient to generate a threshold or target level of work before inspiratory airflow
can begin. The threshold pressure needed to initiate inspiratory flow is high enough to
ensure training, independent of inspiratory flow rate. When threshold devices are used, the
breathing pattern (inspiratory time and respiratory rate) is not as critically important because
the pressure required to activate the threshold is independent of the flow.

The benefit of inspiratory threshold loading was demonstrated in a trial of 33 patients with
severe COPD who were randomly assigned to receive high intensity training (highest
tolerable inspiratory threshold load) or sham training (only 10 percent of the maximal
inspiratory pressure) three times per week for eight weeks [8]. High intensity training
resulted in a greater increase of the maximum inspiratory pressure (18 versus 5 cm H2O),
maximum threshold pressure (21 versus 2 cm H2O), and six-minute walking distance (27
versus 5 meters), as well as improved dyspnea and fatigue, compared to sham training.

The utility of IMT in facilitating liberation from mechanical ventilation has been explored in
several studies that included but were not limited to patients with COPD:

● In a randomized trial, 92 patients on mechanical ventilation were assigned to

inspiratory muscle training (40 percent of maximal pressure 5 sets of 10 breaths twice a
day, seven days a week) or usual care until extubation, tracheostomy, or death [24].

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Muscle training improved inspiratory muscle strength and tidal volume compared with
usual care but had no effect on weaning outcome.

● IMT with a threshold inspiratory device, starting at the highest tolerated pressure and
titrating upwards, has been tested in patients unable to wean from prolonged
mechanical ventilation. A single-center randomized trial enrolled 69 patients unable to
wean from MV; 35 to the IMT and 34 to the sham group [25]. IMT was performed with a
threshold inspiratory device, set at the highest pressure tolerated and progressed daily.
Subjects completed four sets of 6 to 10 training breaths, five days per week. The
weaning criterion was 72 consecutive hours without MV support. The IMT and sham
groups respectively received 42 ± 26 versus 47 ± 33.0 days of mechanical ventilatory
support prior to starting intervention. The sham group's pre- to post-training maximal
inspiratory pressure (MIP) change was not significant, while the IMT group's MIP
increased (-44 ± 18 versus -54 ± 18 cm H2O). Twenty-five of 35 IMT subjects weaned (71
percent, 95% CI 55 to 84 percent), while 16 of 34 (47 percent, 95% CI 31-63 percent)
sham subjects weaned. The number of patients needed to be treated for effect was 4
(95% CI 2 to 80).

An IMT program can lead to increased MIP and improved weaning outcome in failure-
to-wean patients compared with sham treatment. These results are further supported
by a randomized trial of 101 patients of whom 48 were assigned to the IMT group and
53 to the control group [26]. IMT was associated with a substantially higher gain in
muscle strength as assessed by the maximal inspiratory pressure (-71 cm H2O [-51 to
-83 cm H2O] versus -48 cm H2O [-36 to -72 cm H2O]). Outcomes at the 60th day of ICU
were significantly better in the intervention group regarding both survival (71 versus 49
percent) and weaning success (75 versus 45 percent). These studies support a potential
use of IMT in patients with weak respiratory muscles unable to wean after prolonged
MV.

For patients who have already weaned from mechanical ventilation, a course of IMT may
improve exercise capacity. In a small study, 29 patients with COPD who remained
hypercapnic after successful weaning from mechanical ventilation to noninvasive ventilation
were randomized to IMT or sham training for four weeks during a pulmonary rehabilitation
program [9]. Patients in the IMT group significantly improved their walking distance (3 to 186
m) and their maximal inspiratory pressure (-6 to -33 cm H2O), suggesting that IMT
significantly enhances functional exercise capacity and increases respiratory muscle strength
and power. However, no major changes were seen in arterial blood gases and no evidence
was presented for effect on health status.

Voluntary isocapnic hyperpnea — Voluntary isocapnic hyperpnea is a training method in

which patients maintain high levels of ventilation over time (for 15 minutes, two or three

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times daily). Sufficient carbon dioxide is added to inspired gas to maintain a constant arterial
tension of carbon dioxide (PaCO2), which is measured indirectly by the end-tidal partial
pressure of CO2 (EtCO2). (See "Carbon dioxide monitoring (capnography)".)

Studies evaluating the efficacy of respiratory muscle endurance training using voluntary
isocapnic hyperpnea have had different results. Two controlled studies reported increases of
maximal sustained ventilatory capacity (MSVC) in patients with COPD who were trained for
six weeks, but the improvement in exercise endurance was no better than that observed in
the control group [27,28]. In contrast, a subsequent study demonstrated improvement of
endurance exercise capacity, respiratory muscle endurance capacity, perception of dyspnea,
and quality of life compared to control subjects [29].

In a variation of hyperpnea training, 313 patients who underwent open cardiac surgery were
randomly assigned to daily home training with deep breathing exercises for two months or
to usual care. No differences were observed in health status measured with the short form
36 questionnaire or in lung function [30].

Novel training methods — The use of non-conventional methods of training to improve

ventilator muscle synchronization and function has gained some attention. Amongst them,
the implementation of Tai-Chi techniques for patients with COPD was the topic of a Cochrane
Database Systematic review of 12 randomized trials with 984 patients, lasting from six weeks
up to one year. In total, the review documented a small but significant improvement in the
six-minute walk distance (mean difference [MD] 29.6 meters, 95% CI 10.5-48.8 meters) and in
the FEV1 (0.11 L, 95% CI 0.02-0.20 L). However, the effect on dyspnea and health status
remained inconclusive. More studies are needed to establish the value of these training
methods on health resource utilization and outcomes.

Potential deleterious effects — There is also the potential for ventilatory muscle training to
be deleterious. Breathing at a high proportion of the functional reserve or with a prolonged
inspiratory time may induce muscle fatigue [31]. Both factors are an intrinsic part of training;
it is therefore possible that a sufficiently intense training program may precipitate fatigue.
This may explain why compliance with such training programs is low, with up to 50 percent of
patients failing to complete the studies.

RESPIRATORY MUSCLE RESTING

Respiratory muscles may fatigue when working against a sufficiently large load. This has
been shown to occur experimentally in normal volunteers and patients with chronic
obstructive pulmonary disease (COPD) [1-3]. Clinically, respiratory muscle fatigue appears to
play an important role in the acute respiratory failure of patients with COPD. In comparison,
patients with chronic stable COPD are not suffering from chronic respiratory muscle fatigue.

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Acute on chronic respiratory failure — For patients with acute on chronic respiratory

failure due to an exacerbation of COPD, the use of noninvasive ventilation (NIV), which
enables respiratory muscle unloading and resting, has been shown to be beneficial [32-35].
The implementation of NIV for acute on chronic respiratory failure in COPD is discussed
separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and
contraindications".)

Patients best suited for this method were those with elevated arterial PCO2 who were able to
cooperate with the care givers and had no other important co-morbid problems, such as
sepsis or severe pneumonia. Because NIV is potentially dangerous, patients considered for
this therapy should be closely monitored and treated by individuals familiar with this
ventilatory technique [36].

The various trials evaluated different outcomes, including rate of intubation, length of stay in
the intensive care unit or in the hospital, dyspnea, and mortality. Although not all studies
found the same results in the most important outcomes (such as mortality, intubation,
length of hospital stay, and complications such as pneumonia), there was uniform
agreement that respiratory muscle resting using NIV was effective in reversing acute
respiratory failure and preventing complications. Approximately, five patients need to be
treated with acute NIV to prevent one intubation and only eight patients need to be treated
to prevent one death [37].

Chronic stable COPD — The possibility that the respiratory muscles of patients with severe
COPD are functioning close to the threshold for fatigue, as suggested by chronic
hypoventilation and consequent hypercapnia, has led numerous investigators to explore a
potential role of resting the respiratory muscles with noninvasive negative or positive
pressure ventilation. While older trials showed no benefit to NIV for most of the outcomes
studied [31,38-43], subsequent trials that employed higher inspiratory pressures (so-called
high-intensity NIV) with an aim to reduce arterial tension of carbon dioxide (PaCO2) to
normal or near-normal levels have offered more favorable results [44-46].

The European Respiratory Society (ERS) and the American Thoracic Society (ATS)
independently reviewed the role of NIV in stable hypercapnic COPD using evidence-based
systematic review methodology [47,48]. The ERS concluded that high-intensity NIV may
decrease exacerbations, reduce dyspnea (as measured by improvements in the Medical
Research Council Dyspnea score), and improve health-related quality of life, although they
noted a low certainty of evidence [47]. Similarly, the ATS systematic review found that
potential benefits of NIV included reductions in hospital admissions and dyspnea and also
improved functional capacity and six-minute walk distance [48]. It seems possible that high-
intensity NIV achieves these results through more successful rest of the diaphragm than was
achieved in the earlier studies of lower intensity NIV [47].  

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Based on these evidence-supported documents, an expert panel from several societies (ATS,
American College of Chest Physicians, American Association of Respiratory Care, and the
American Academy of Sleep Medicine) published practical recommendations aimed at
improving the application of NIV for patients with hypercapnic stable COPD (PaCO2 ≥52
mmHg on the patient’s usual oxygen supplementation regimen) [49]. For such patients, the
panel advises the following:

● Obstructive sleep apnea (OSA) should be considered and excluded on clinical grounds
(no formal study needed).

● Bi-level positive airway pressure (BPAP) ventilation with a backup rate is preferred for
initial therapy in most patients.

● The patient should be seen between 31 to 90 days after initiation of NIV to monitor
adherence and response to therapy. If the ventilation goals are achieved (patient is
adherent with four hours or more of NIV per night and clinical improvement noted), NIV
should be continued with frequent monitoring. If the patient fails to achieve these
goals, transition to a home mechanical ventilator should be considered.

In spite of the great advances in the appropriate selection of COPD patients who may benefit
from long term NIV, more studies are needed to better identify patients who are likely to
benefit and to clarify the optimal NIV settings.

The use of nocturnal NIV in patients with severe COPD and hypercapnia is discussed in
greater detail separately. (See "Nocturnal ventilatory support in COPD".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Chronic obstructive
pulmonary disease".)

SUMMARY

● In patients with COPD, respiratory muscle training increases the strength and capacity
of the muscles to endure a respiratory load. Inspiratory muscle training (IMT) is likely to
improve dyspnea, functional exercise capacity, and quality of life when provided alone.
However, IMT may not improve these outcomes when used as a component of a
pulmonary rehabilitation program. (See 'Strength and endurance training' above.)

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● It seems logical to predict that increases in strength and endurance would help
respiratory muscle function. However, this may only be relevant when patients must
handle inspiratory loads that are greater than baseline, such as during an acute
exacerbation or exercise. (See 'Strength and endurance training' above.)

● The exact criteria for patient selection remain unclear. Stable patients with dyspnea and
respiratory muscle weakness are likely to benefit from respiratory muscle training. IMT
may be beneficial in patients with respiratory muscle weakness who have been unable
to wean after long-term mechanical ventilation, but further study is needed. (See
'Strength and endurance training' above.)

● Respiratory muscle training can induce deleterious effects, such as an uncomfortable

degree of fatigue, when breathing at a high proportion of the functional reserve or with
a prolonged inspiratory time. (See 'Potential deleterious effects' above.)

● For patients with an exacerbation of COPD complicated by hypercapnic acidosis (arterial

tension of carbon dioxide [PaCO2] >45 mmHg or pH <7.30) who do not require
emergent intubation and lack contraindications to NIV, a trial of bilevel noninvasive
ventilation (NIV) is advised, as described in detail separately. (See 'Respiratory muscle
resting' above and "Noninvasive ventilation in adults with acute respiratory failure:
Benefits and contraindications".)

● Intermittent respiratory muscle rest during nocturnal NIV using sufficient inspiratory
pressures to reduce PaCO2 to normal or near-normal levels (so-called high-intensity
NIV) may be of benefit in stable patients with severe hypercapnic COPD. NIV appears
more effective in patients discharged after hospitalization for an exacerbation who
remain hypercapnic (PaCO2 >55 mmHg) with a stable pH (>7.30), although more study is
needed to clarify the risks and benefits. (See 'Chronic stable COPD' above.)

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Topic 1452 Version 21.0

Contributor Disclosures
Bartolome R Celli, MD Não há relacionamento(s) financeiro(s) relevante(s) com empresas inelegíveis
para divulgar. Umur Hatipoglu, MD, MBA Nenhuma relação financeira relevante com empresas
inelegíveis para divulgar. Paul Dieffenbach, MD Não há relacionamento(s) financeiro(s) relevante(s)
com empresas inelegíveis para serem divulgadas.

As divulgações dos colaboradores são revisadas quanto a conflitos de interesse pelo grupo editorial.
Quando encontrados, estes são abordados através de um processo de revisão multinível e através de
requisitos para referências a serem fornecidas para apoiar o conteúdo. O conteúdo referenciado
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evidência do UpToDate.

Política de conflito de interesses

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