Bruno, Selma SousaAraújo, Clênia Oliveira2020-05-212020-05-212019-12-16ARAÚJO, Clênia Oliveira. Efeitos da ventilação não invasiva versus treinamento muscular respiratório associado à reabilitação cardiovascular na insuficiência cardíaca crônica. 2019. 174f. Tese (Doutorado em Fisioterapia) - Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, 2019.https://repositorio.ufrn.br/jspui/handle/123456789/29041Introduction: Dyspnea is one of the most common symptoms of efforts in chronic heart failure with reduced left ventricular ejection fraction (HFrEF) and progresses relentlessly with disease progression, leading to reduced functional capacity. Therefore, investigations on the use of non-invasive ventilation (NIV) or respiratory muscle training (RMT) become essential since they can better guide clinical decision-making to optimize exercise tolerance during Cardiovascular Rehabilitation (CR). The use of NIV has been shown to be effective in reducing cardiorespiratory work in HF, while protocols involving the combination of inspiratory muscle training (IMT) and expiratory muscle training (EMT) can be innovative and have an additive effect on exercise performance after TMR. However, the evidence for the effectiveness of this protocol is not well established to date. Although ventilatory inefficiency in HF may be aggravated as a result of expiratory muscle weakness, EMT is not clear in the literature, with only a series of case reports showing improvement in ventilatory parameters and these beneficial effects have not yet been confirmed by randomized studies. Thus, we hypothesize that the modality combining EMT plus IMT associated with CR may have effects that are superior or similar to the use of NIV plus CR. Objectives: The first study aimed to analyze the effects of EMT plus IMT associated with CR versus CR plus NIV on exercise tolerance, respiratory muscle performance and quality of life in HFrEF. The 2nd study; the objective was to assess the additional benefit of EMT plus IMT when compared to IMT alone in HFrEF. The third study was a systematic review that aimed to assess the effects of IMT on the kinetics of oxygen consumption (VO2) in individuals with HF compared to healthy individuals. Methods: The research was divided into three stages. Initially, a randomized clinical trial was carried out, involving 17 patients with CHF who were allocated to Group 1 CR - control (n = 6), Group 2 - CR plus NIV (n = 5), Group 3 - CR plus EMT + IMT (n = 6). All patients were evaluated before and after 12 weeks of the structured supervised CR program three times a week. Group 2 - RC + VNI with Continuous positive airway pressure mode (CPAP adjusted to 8 cmH2O for 20 minutes), using the VPAP TM Auto 25 ResMed System (ResMed® USA). CR plus TMR, for 30 minutes, being 15 minutes with inspiratory load up to 40% of maximum inspiratory pressure (MIP) and 15 minutes with expiratory load between 5 and 15% of MEP, with the EMT performed according to the protocol performed in study by Cahalin et al. The second study: was a controlled and randomized trial; Fourteen patients with HFrEF who were randomized into three groups: Group 1: Usual care (control); Group 2: TMI (load 40% of MIP), Group 3; IMT plus EMT (load 5-15% of MEP), with exercises for 12 weeks. And the third study; a systematic review; the search included the MEDLINE, PEDRo, Embase, Cinahl and Cochrane Central databases to assess the effects of IMT on VO2 kinetics. Results: Therefore, in the 1st study: when compared to NIV versus EMT + IMT, these complementary therapies associated with CR were similar in terms of the six-minute walking distance (6MWD) and VO2peak, however there was a significant difference in the Minnesota Living with Heart Failure Questionnaire (MLHFQ) compared to control (24.6 vs. 19.2 in RC plus NIV, p = 0.0001; and 26.6 vs. 19.2 in CR + EMT plus IMT, p <0.0001). CR plus NIV led to an additional increase in forced vital capacity (FVC). The CR plus EMT + IMT showed an additional benefit in the maximum inspiratory and expiratory pressures (p <0.0001) when compared to both the use of NIV plus CR and the control group. Both CR plus NIV or CR associated with EMT plus IMT can provide additional quality of life benefits. In the second stage; The training combining IMT plus EMT demonstrated additional improvement in the 6MWD, (339 ± 39 vs. 434 ± 31; p = 0.037); maximum voluntary ventilation (MVV; 69.6 ± 2.7 vs. 77.4 ± 4.0; p = 0.021), compared to the control group (usual care). And in MEP; (75 ± 13 vs. 115 ± 16; p = 0.002); when compared to both the isolated IMT. The study suggests that IMT + EMT can contribute to the additional MEP gain; compared to isolated IMT. In addition, it can optimize exercise tolerance in patients with HFrEF compared to control. And in the third stage, the systematic review that included three randomized trials evaluating the effects of IMT on VO2 kinetics; demonstrated that IMT in HF can significantly improve VO2 recovery kinetics, meaning differences in VO2 kinetics of -0.66mL/kg/min (95% CI, -0.84 to -0.47; n = 56) and at VO2 peak at 5.03mL/kg/min (95% CI, - 6.73 to -3.32, n = 56). The behavior of the VO2 dynamics seems different between a patient with HFrEF and healthy individuals. In healthy individuals, some authors did not observe significant changes in VO2max during the incremental test after the IMT or Sham intervention, but the amplitude of the kinetics of slow oxygen consumption was reduced and the initial maximum inspiratory pressure increased significantly. Therefore, due to a small number of studies, the results of this review are inconclusive. The analysis of VO2 kinetics according to the GRADE approach, the quality of the evidence presented by this result was low, due to the limitations in the methodology, imprecision and inconsistency of the results. The effects of complementary therapies associated with CR may depend on the exercise protocol, the patients' baseline clinical conditions and the form of assessment. Therefore, the combination of EMT plus IMT during CR may be superior to the use of NIV in improving the performance of ventilatory muscles in patients with HFrEF.Acesso AbertoInsuficiência cardíacaReabilitação cardiovascularTreinamento muscular expiratórioTreinamento muscular inspiratórioVentilação não invasivadoctoralThesisCNPQ::CIENCIAS DA SAUDE::FISIOTERAPIA E TERAPIA OCUPACIONAL