Objective: In view of the current COVID-19 pandemic, the objective of this study was to determine, through a systematic review and meta-analysis, whether the use of N95/FFP2 masks during aerobic exercise has a significant impact on HR, RR, SpO2, and blood pressure (BP) in healthy individuals. Methods: We searched the MEDLINE database for studies published in English between 2005 and 2021. To reduce bias and increase reliability, only randomized controlled trials and randomized crossover clinical trials were considered for inclusion. The selected outcomes included HR, RR, SpO2, and BP, with perceived exertion being evaluated by means of the Borg scale. Results: Eight controlled trials were included in the meta-analysis. Seven evaluated HR (p > 0.05), five evaluated RR (p > 0.05), five evaluated SpO2 and BP (p > 0.05 for both), and six evaluated perceived exertion, presenting controversial results such as risk ratios that were grouped for each variable. Conclusions: This study suggests that N95 and FFP2 masks do not have significant effects on HR, RR, SpO2, and BP during aerobic exercise in healthy individuals.

Keywords: N95 respirators; Heart rate; Respiratory rate; Oxygen saturation; Blood.

Objective: To evaluate the efficacy of wearing a mask to prevent COVID-19 infection. Methods: This was a systematic review and meta-analysis of cohort and case-control studies, considering the best level of evidence available. Electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov) were searched to identify studies that evaluated the effectiveness of wearing masks compared with that of not wearing them during the COVID-19 pandemic. Risk of bias and quality of evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation. Results: Of the 1,028 studies identified, 9 met the inclusion criteria (2 cohort studies and 7 case-control studies) and were included in the analysis. The meta-analysis using cohort studies alone showed statistically significant differences, wearing a cloth mask decreased by 21% [RD = -0.21 (95% CI, -0.34 to -0.07); I2 = 0%; p = 0,002] the risk of COVID-19 infection, but the quality of evidence was low. Regarding case-control studies, wearing a surgical mask reduced the chance of COVID-19 infection [OR = 0.51 (95% CI, 0.37-0.70); I2 = 47%; p = 0.0001], as did wearing an N95 respirator mask [OR = 0.31 (95% CI, 0.20-0.49); I2 = 0%; p = 0.00001], both with low quality of evidence. Conclusions: In this systematic review with meta-analysis, we showed the effectiveness of wearing masks in the prevention of SARS-CoV-2 infection regardless of the type of mask (disposable surgical mask, common masks, including cloth masks, or N95 respirators), although the studies evaluated presented with low quality of evidence and important biases.

Keywords: Antiviral agents; COVID-19; SARS-CoV-2; Masks.

Objective: Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. Methods: This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. Results: The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. Conclusions: The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.

Keywords: Intermittent positive-pressure ventilation; Masks/adverse effects; Respiratory insufficiency;Equipment failure analysis.

Objective: To evaluate the effects of high-intensity interval training (HIIT), in comparison with those of continuous exercise, on functional capacity and cardiovascular variables in patients with COPD, through a systematic review and meta-analysis of randomized controlled trials. Methods: We searched PubMed, the Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, and EMBASE, as well as performing hand searches, for articles published up through January of 2017. We included studies comparing exercise regimens of different intensities, in terms of their effects on functional capacity and cardiovascular variables in patients with COPD. Results: Of the 78 articles identified, 6 were included in the systematic review and meta-analysis. Maximal oxygen consumption (VO2max) did not differ significantly between HIIT and control interventions. That was true for relative VO2max (0.03 mL/kg/min; 95% CI: −3.05 to 3.10) and absolute VO2max (0.03 L/min, 95% CI: −0.02 to 0.08). Conclusions: The effects of HIIT appear to be comparable to those of continuous exercise in relation to functional and cardiovascular responses. However, our findings should be interpreted with caution because the studies evaluated present a high risk of bias, which could have a direct influence on the results.

Keywords: Pulmonary disease, chronic obstructive; Exercise; Oxygen consumption.

Objective: To investigate the efficacy of upper limb exercise training (ULExT) in improving the performance of activities of daily living (ADL) that involve the upper limbs (UL) in patients with COPD. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review. PubMed and EBSCOhost databases were searched to identify randomized controlled trials involving adults with COPD who underwent ULExT, compared with those who underwent other types of exercise or no exercise, in order to assess the performance of ADL that involve the UL. The methodological quality of the selected studies was assessed using the Physiotherapy Evidence Database scale. Results: Five studies, with a total sample of 173 subjects, met the inclusion criteria. The results of the selected studies showed that ULExT is safe and can significantly improve the performance of ADL that involve the UL in patients with COPD. However, there were inconsistencies in the results, especially regarding the perception of symptoms during ADL. The small number of studies included and their methodological quality do not allow for firm conclusions. Conclusions: The findings of this review revealed that ULExT is a safe therapeutic approach and can improve the performance of ADL that involve the UL in patients with COPD, but the results are unclear. Further investigation through well-designed randomized trials is warranted to determine the effectiveness of ULExT in improving the performance of ADL that involve the UL in patients with COPD.

Keywords: Upper extremity; Pulmonary disease, chronic obstructive; Activities of daily living, Exercise therapy.

Objective: To evaluate the effect size of oral corticosteroid treatment on eosinophilic bronchitis in asthma, through systematic review and meta-analysis. Methods: We systematically reviewed articles in the Medline, Cochrane Controlled Trials Register, EMBASE, and LILACS databases. We selected studies meeting the following criteria: comparing at least two groups or time points (prednisone vs. control, prednisone vs. another drug, or pre- vs. post-treatment with prednisone); and evaluating parameters before and after prednisone use, including values for sputum eosinophils, sputum eosinophil cationic protein (ECP), and sputum IL-5-with or without values for post-bronchodilator FEV1-with corresponding 95% CIs or with sufficient data for calculation. The independent variables were the use, dose, and duration of prednisone treatment. The outcomes evaluated were sputum eosinophils, IL-5, and ECP, as well as post-bronchodilator FEV1. Results: The pooled analysis of the pre- vs. post-treatment data revealed a significant mean reduction in sputum eosinophils (8.18%; 95% CI: 7.69-8.67; p < 0.001), sputum IL-5 (83.64 pg/mL; 95% CI: 52.45-114.83; p < 0.001), and sputum ECP (267.60 µg/L; 95% CI: 244.57-290.63; p < 0.0001), as well as a significant mean increase in post-bronchodilator FEV1 (8.09%; 95% CI: 5.35-10.83; p < 0.001). Conclusions:In patients with moderate-to-severe eosinophilic bronchitis, treatment with prednisone caused a significant reduction in sputum eosinophil counts, as well as in the sputum levels of IL-5 and ECP. This reduction in the inflammatory response was accompanied by a significant increase in post-bronchodilator FEV1.

Keywords: Meta-analysis; Bronchitis; Asthma; Pulmonary eosinophilia; Evidence-based medicine; Prednisone.

Objective: To evaluate the effect of treatment with the combination of three cystic fibrosis transmembrane conductance regulator (CFTR) modulators-elexacaftor+tezacaftor+ivacaftor (ETI)-on important clinical endpoints in individuals with cystic fibrosis. Methods: This was a systematic review and meta-analysis of randomized clinical trials that compared the use of ETI in individuals with CF and at least one F508del allele with that of placebo or with an active comparator such as other combinations of CFTR modulators, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) methodology. We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception to December 26th, 2022. The risk of bias was assessed using the Cochrane risk-of-bias tool, and the quality of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: We retrieved 54 studies in the primary search. Of these, 6 met the inclusion criteria and were analyzed (1,127 patients; 577 and 550 in the intervention and control groups, respectively). The meta-analysis revealed that the use of ETI increased FEV1% [risk difference (RD), +10.47%; 95% CI, 6.88-14.06], reduced the number of acute pulmonary exacerbations (RD, -0.16; 95% CI, -0.28 to -0.04), and improved quality of life (RD, +14.93; 95% CI, 9.98-19.89) and BMI (RD, +1.07 kg/m2; 95% CI, 0.90-1.25). Adverse events did not differ between groups (RD, -0.03; 95% CI, -0.08 to 0.01), and none of the studies reported deaths. Conclusions: Our findings demonstrate that ETI treatment substantially improves clinically significant, patient-centered outcomes.

Keywords: Cystic fibrosis/therapy; Cystic fibrosis transmembrane conductance regulator; Membrane transport modulators.

Objective: To determine whether airway narrowing during obstructive events occurs predominantly at the retropalatal level and results from dynamic changes in the lateral pharyngeal walls and in tongue position. Methods: We evaluated 11 patients with severe obstructive sleep apnea (OSA) and 7 healthy controls without OSA during wakefulness and during natural sleep (documented by full polysomnography). Using fast multidetector CT, we obtained images of the upper airway in the waking and sleep states. Results: Upper airway narrowing during sleep was significantly greater at the retropalatal level than at the retroglossal level in the OSA group (p < 0.001) and in the control group (p < 0.05). The retropalatal airway volume was smaller in the OSA group than in the control group during wakefulness (p < 0.05) and decreased significantly from wakefulness to sleep only among the OSA group subjects. Retropalatal pharyngeal narrowing was attributed to reductions in the anteroposterior diameter (p = 0.001) and lateral diameter (p = 0.006), which correlated with an increase in lateral pharyngeal wall volume (p = 0.001) and posterior displacement of the tongue (p = 0.001), respectively. Retroglossal pharyngeal narrowing during sleep did not occur in the OSA group subjects. Conclusions: In patients with OSA, upper airway narrowing during sleep occurs predominantly at the retropalatal level, affecting the anteroposterior and lateral dimensions, being associated with lateral pharyngeal wall enlargement and posterior tongue displacement.

Keywords: Multidetector computed tomography; Oropharynx; Sleep apnea, obstructive; Polysomnography; Diagnostic imaging; Sleep.

Objective: To evaluate and correlate the quality of life (QoL) of COPD patients on long-term home oxygen therapy (LTOT) with their sociodemographic/clinical characteristics and level of dependence. Methods: This was a cross-sectional analytical study involving COPD patients on LTOT followed at the Oxygen Therapy Outpatient Clinic of the Federal University of São Paulo Hospital São Paulo, in the city of São Paulo, Brazil. Sociodemographic, clinical, and biochemical data were collected. We assessed QoL and level of dependence using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Katz index, respectively. Multiple linear regression models were constructed in order to determine the influence of these variables on QoL. Results: We included 80 patients in the study. The mean age was 69.6 ± 9.1 years, and 51.3% were female. The lowest SF-36 scores were for the physical functioning and role-physical domains. All sociodemographic characteristics (except gender) were found to correlate significantly with the SF-36 domains mental health, vitality, role-physical, and social functioning. We also found that body mass index, PaO2, post-bronchodilator FEV1, hemoglobin, and Katz index correlated significantly with the physical functioning, mental health, role-physical, and bodily pain domains. In addition, oxygen flows were found to correlate negatively with the physical functioning, mental health, vitality, and role-emotional domains. Conclusions: Low scores for SF-36 domains, as well as the variables that negatively influence them, should be considered and analyzed during the development and implementation of strategies for improving the QoL of COPD patients on LTOT.

Keywords: Pulmonary disease, chronic obstructive; Quality of life; Oxygen inhalation therapy.

Objective: To analyze the available evidence regarding the effect that corticosteroids have on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture. Methods: In March of 2007, we performed a search of various electronic databases, including Medline, the Excerpta Medica database, the Cochrane Library, the Latin American and Caribbean Health Sciences Literature database and the Scientific Electronic Library Online. We selected randomized controlled trials that compared the effect of corticosteroids with that of placebo (or standard care) on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture. References from the studies included were also reviewed. Results: Six studies were included. The pooled relative risk for developing fat embolism syndrome was 0.16 (95% CI: 0.08-0.35) in the corticosteroid group as compared with the control group. The pooled relative risk for developing hypoxemia was 0.34 (95% CI: 0.19-0.59) in the corticosteroid group as compared with the control group. Conclusion: The analysis of evidence showed that corticosteroids decrease the risk of developing fat embolism syndrome and hypoxemia after long bone fracture of the lower limbs.

Keywords: Embolism, Fat; Adrenal Cortex Hormones; Meta-Analysis.

Objective: Physiologically, VC can vary according to gender, age, body weight and posture, as well as ethnic and anthropometric characteristics. In addition, various diseases can alter VC. In order to measure VC, it is necessary to motivate the patient, to make the instructions understandable, to provide clear information and to have a capable examiner. The objective of this study was to determine the impact that positive reinforcement during spirometry has on the measurement of VC in healthy volunteers. Methods: A randomized clinical trial involving 105 healthy volunteers, randomly allocated to one of two groups: control and intervention. In both groups, VC was assessed as baseline (VC1) and again 15 days later (VC2). Positive reinforcement was provided only to patients in the intervention group and only during the determination of VC2. Results: There were no significant differences between the groups regarding the baseline characteristics. Females predominated in both groups. There was an increase in VC2 in both groups (p < 0.01), and VC2 was higher in the intervention group than in the control group (p < 0.01). Conclusions: These findings demonstrate the importance of using the behavioral strategy in combination with traditional practice in order to obtain better results. The use of positive reinforcement during the determination of VC has proven to be an effective, simple and easily applied strategy.

Keywords: Vital capacity; Reinforcement, verbal; Respiratory function tests.

Step tests are typically used to assess exercise capacity. Given the diversity of step tests, the aim of this review was to describe the protocols that have been used in healthy subjects and in patients with chronic lung disease. Step tests for use in healthy subjects have undergone a number of modifications over the years. In most step tests, the duration is variable (90 s-10 min), but the step height (23.0-50.8 cm) and stepping rate (22.5-35.0 steps/min) remain constant throughout the test. However, the use of a fixed step height and constant stepping rate might not provide adequate work intensity for subjects with different levels of fitness, the workload therefore being above or below individual capacity. Consequently, step test protocols have been modified by introducing changes in step heights and stepping rates during the test. Step tests have been used in patients with chronic lung diseases since the late 1970s. The protocols are quite varied, with adjustments in step height (15-30 cm), pacing (self-paced or externally paced), and test duration (90 s-10 min). However, the diversity of step test protocols and the variety of outcomes studied preclude the determination of the best protocol for use in individuals with chronic lung disease. Shorter protocols with a high stepping rate would seem to be more appropriate for assessing exercise-related oxygen desaturation in chronic lung disease. Symptom-limited testing would be more appropriate for evaluating exercise tolerance. There is a need for studies comparing different step test protocols, in terms of their reliability, validity, and ability to quantify responses to interventions, especially in individuals with lung disease.

Keywords: Pulmonary disease, chronic obstructive; Asthma; Cystic fibrosis; Idiopathic pulmonary fibrosis; Exercise tolerance; Exercise test.

Objective: Studies in the literature regarding the use of remdesivir to treat COVID-19 patients have shown conflicting results. This study sought to answer questions related to the use of remdesivir for the treatment of patients hospitalized with moderate to severe COVID-19. Methods: This was a systematic review and meta-analysis including phase 3 randomized clinical trials (RCTs) and observational cohort studies selected from various databases, comparing patients hospitalized with moderate to severe COVID-19 receiving remdesivir and controls. Results: A total of 207 studies were retrieved, 9 of which met the eligibility criteria and were included in the study. The meta-analysis using RCTs alone showed no statistically significant differences regarding mortality or use of mechanical ventilation/extracorporeal membrane oxygenation between remdesivir and control groups, and the quality of evidence was moderate and low, respectively. The use of remdesivir increased the recovery rate by 6% (95% CI, 3-9); p = 0.004) and the clinical improvement rate by 7% (95% CI, 1-14); p = 0.02). Additionally, no significant differences in mortality were found between remdesivir and control groups when the meta-analysis used observational cohort studies alone (risk difference = -0.01 (95% CI, -0.02 to 0.01; p = 0.32), the quality of evidence being moderate, and the risk of adverse events was 4% ([95% CI, -0.08 to 0.01]; p = 0.09). Conclusions: The use of remdesivir for the treatment of patients with moderate to severe COVID-19 had no significant impact on clinically important outcomes.

Keywords: Antiviral agents; COVID-19; SARS-CoV-2.

Objective: To answer questions related to the use of anticoagulants in the treatment of COVID-19 patients. Methods: This was a systematic review and meta-analysis of phase 3 randomized controlled trials comparing the use of anticoagulants in non-hospitalized and hospitalized COVID-19 patients. We searched the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception to January 22, 2022. The risk of bias was assessed by the Cochrane risk-of-bias tool, and the quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 401 studies were initially selected. Of those, 9 met the inclusion criteria and were therefore analyzed (a total of 6,004 patients being analyzed). In non-hospitalized COVID-19 patients, no significant difference was found between post-discharge prophylactic anticoagulation and no intervention regarding venous thromboembolism or bleeding at 30 days. In hospitalized COVID-19 patients, full anticoagulation resulted in a slight reduction in thrombotic events at 30 days (risk difference, -0.03; 95% CI, -0.06 to -0.00; p = 0.04; I2 = 78%), the quality of evidence being moderate. However, no significant difference was found between full anticoagulation and no intervention regarding the risk of major bleeding, the quality of evidence being very low. No significant difference was found between intermediate- and standard-dose prophylactic anticoagulation (risk difference, -0.01; 95% CI, -0.07 to 0.06; p = 0.81; I2 = 0%), the quality of evidence being very low. Conclusions: Therapeutic anticoagulation appears to have no effect on mortality in COVID-19 patients, resulting in a slight reduction in venous thromboembolism in hospitalized patients.

Keywords: Anticoagulants; COVID-19; SARS-CoV-2.

Objective: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. Methods: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. Results: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. Conclusions: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects.

Keywords: Lung/metabolism; Technetium Tc 99m pentetate/pharmacokinetics; Radiopharmaceuticals; Positive-pressure respiration.

Objective: Although lean body mass (LBM) has been associated with mortality in patients with COPD, its influence on functional limitation is not clear. The objective of this study was to analyze the cardiopulmonary variables in COPD patients with or without LBM depletion, prior to and after the six-minute walk test (6MWT). Methods: We evaluated COPD patients, 32 with LBM depletion and 36 without. All patients underwent clinical evaluation, spirometry, evaluation of body mass composition and 6MWT, as well as completing questionnaires related to quality of life and perception of dyspnea. Results: No significant differences in the severity of airway obstruction, perception of dyspnea and quality of life scores were found between the groups. The distance covered on the 6MWT was similar in COPD patients with and without LBM depletion (470.3 ± 68.5 m vs. 448.2 ± 89.2 m). However, patients with LBM depletion presented significantly greater differences between baseline and final values in terms of heart rate and Borg scale index for lower limb fatigue. There was a significant positive correlation between distance covered on the 6MWT and FEV1 (r = 0.381, p = 0.01).Conclusions: In the patients studied, functional exercise tolerance and quality of life were unaffected by LBM depletion. However, the patients with LBM depletion presented more pronounced lower limb fatigue during the 6MWT, which underscores the importance of the evaluation and treatment of systemic manifestations in COPD patients.

Keywords: Body mass index; Pulmonary disease, chronic obstructive; Exercise tolerance.

Despite the considerable efforts made in the fight against smoking in the last decades, there are still substantial numbers of people who, in full knowledge of the health hazards, begin smoking or continue smoking. Recent studies have focused on the genetic bases of the nicotine addiction. Various genetic polymorphisms have been associated with smoking. However, environmental factors have also been shown to play a role. In this review, we present some of the principal data collected in genetic studies of smoking behavior. The results obtained through this line of research will eventually aid clinicians in individualizing the type, dosage and duration of treatment for patients with nicotine dependence in accordance with the genotype of each smoker, thereby maximizing the efficacy of the proposed treatment regimen.

Keywords: Smoking; Tobacco use cessation; Nicotine; Tobacco use disorder

Objective: To evaluate lung function and inspiratory muscle strength, correlating them with exercise tolerance, in obese individuals with obstructive sleep apnea syndrome (OSAS). Methods: The sample comprised 31 adult subjects with moderate-to-severe OSAS diagnosed by polysomnography. We used spirometry to measure FVC, FEV1, and FVC/FEV1 ratio, using pressure manometry to measure MIP and MEP. The incremental shuttle walk test (ISWT) and the six-minute walk test (6MWT) were used in order to determine functional exercise capacity. Results: In this sample, the mean values for FVC (% of predicted), FEV1 (% of predicted): MIP, and MEP were 76.4 ± 12.3%, 80.1 ± 6.3%, 60.0 ± 21.9 cmH2O, and 81.3 ± 22.2 cmH2O, respectively. The mean distances covered on the ISWT and 6MWT were 221 ± 97 m and 480.8 ± 67.3 m, respectively. The ISWT distance showed moderate positive correlations with FVC (r = 0.658; p = 0.001) and FEV1 (r = 0.522; p = 0.003). Conclusions: In this sample of obese subjects with untreated OSAS, lung function, inspiratory muscle strength, and exercise tolerance were all below normal. In addition, we found that a decline in lung function, but not in respiratory muscle strength, was associated with exercise tolerance in these patients.

Keywords: Sleep apnea syndromes; Exercise tolerance; Respiratory function tests; Respiratory muscles.