Mecanismos de Limitação nas AVD na DPOC J. ALBERTO NEDER Prof. Adjunto Livre-Docente Disciplina de Pneumologia da UNIFESP-EPM

Mecanismos de limitação das AVD na DPOC J. ALBERTO NEDER Prof. Adjunto Livre Docente Disciplina de Pneumologia do Departamento de Medicina

LIMITAÇÃO VENTILATÓRIA VVM VE FC Res Vent VVM Normal DPOC VE-HR RESPONSE PREV Res Crono . VO2

VE VELLOSO M et al.

AUMENTO DO TRABALHO ELASTICO SECUNDÁRIO À HIPERINSUFLAÇÃO VPEF Vc Vc P P SOLUÇÃO –  FREQÜÊNCIA ?

DYNAMIC HYPERINFLATION FLOW Expiratory time “too short” !! AIRWAYS AUTO-PEEP TLC IRV EILV EELV VOLUME

DPOC  Pdi / Pdi max

Dynamic Hyperinflation and Breathlessness During Walking and Cycling in COPD TREADMILL PRE-BD POST-BD PRE-BD POST-BD CYCLE Albuquerque A et al. Submitted: Am J Respir Crit Care Med

ARMS UP ARMS DOWN

Velloso M, Jardim JR

Velloso M, Jardim JR

Abordagem Integrada das Conseqüências Fisiopatológicas da DPOC A COMPETIÇÃO MUSCULAR RESPIRATÓRIA-PERIFÉRICA NA DPOC X

% do fluxo muscular Musc. Periférica Musc. Respir. Musc. Periférica Progressão do exercício Musc. Periférica Respir. DISTRIBUIÇÃO DE FLUXO

Hierarquia no aporte sangüíneo na atividade física

Dynamic Hyperinflation: COPD TLC IC EILV Vt EELV During exercise, EILV increases towards TLC. EELV increases because of air trapping (dynamic hyperinflation). Thus, operational lung volumes are shifted onto the flatter portion of the curve, increasing the elastic work of breathing. An example of this dynamic is represented by the effect of taking a deep breath and then trying to talk before exhaling. This is what COPD feels like all the time. RV Rest Exercise MARKED INCREASE IN RESPIRATORY MUSCLE PERFUSION DEMANDS !!

DEMANDA METABÓLICA VENTILATÓRIA NA DPOC 40% VO2peak Walking

QUAL SERIA O PAPEL DO “ROUBO DE FLUXO” NA DPOC ? % do fluxo muscular Progressão do exercício Musculatura apendicular Musculatura ventilatória

Submitted: Am J Respir Crit Care Med

Skeletal muscle oxygenation Near-infrared spectroscopy ISQ CTL

Tissue Oxygenation Index= ([HbO2]/[HbTOT]) x 100

NIRS data interpretation DURING CONSTANT WORK RATE EXERCISE RESPIRATORY MUSCLE UNLOADING  HbO2 and  HHb  Tissue Oxygenation Index (TOI)  HbTOT (local blood volume) CARDIAC OUTPUT and/or CaO2 UNCHANGED / REDUCED INCREASED  Local blood flow due to flow redistribution from respiratory to locomotor muscles  Systemic oxygen delivery

Proportional Assisted UNLOADING THE RESPIRATORY MUSCLES Proportional Assisted Ventilation BLOOD FLOW

Débito Cardíaco Não-Invasivo Cardiografia por Impedância Transtorácica

QT NIRS

PAV and exercise tolerance 337  189 s vs. 273  142 s 13/16 patients improved Tlim with PAV compared to sham

 HbO2  HHb  HbTOT  TOI

NIRS data interpretation DURING CONSTANT WORK RATE EXERCISE RESPIRATORY MUSCLE UNLOADING  HbO2 and  HHb  Tissue Oxygenation Index (TOI)  HbTOT (local blood volume) CARDIAC OUTPUT and/or CaO2 UNCHANGED / REDUCED INCREASED  Local blood flow due to flow redistribution from respiratory to locomotor muscles  Systemic oxygen delivery

Conclusion Respiratory muscle unloading during high-intensity exercise can improve peripheral muscle oxygenation under similar systemic oxygen delivery in advanced COPD

Study 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 Efeitos cardiovasculares Efeitos hemodinâmicos POSTURA ATIVIDADE Fadigabilidade periférica Dispnéia Intolerância às atividades HIPOXEMIA DISFUNÇÃO MUSCULAR Incapacidade

DPOC UMA DOENÇA SISTÊMICA