Respiratory Physiology & Neurobiology 188 (2013) 15–20

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Respiratory Physiology & Neurobiology

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Chest wall volumes during inspiratory loaded breathing in COPD patients

Mariana Alves Coutinho Myrrha a , Danielle Soares Rocha Vieira a , Karoline Simões Moraes a ,
Susan Martins Lage a , Verônica Franco Parreira a,b , Raquel Rodrigues Britto a,b,∗
a
Rehabilitation Science Graduation Program, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
b
Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Chest wall volumes and breathing patterns of 13 male COPD patients were evaluated at rest and during
Accepted 15 April 2013 inspiratory loaded breathing (ILB). The sternocleidomastoid (SMM) and abdominal muscle activity was
also evaluated. The main compartment responsible for the tidal volume at rest and during ILB was the
Keywords: abdomen. During ILB patients exhibited, in addition to increases in the ratio of inspiratory time to total
Chest wall time of the respiratory cycle and minute ventilation, increases (p < 0.05) in the chest wall tidal volume
Breathing exercises
by an increase in abdomen tidal volume as a result of improvement of end chest wall inspiratory vol-
Chronic obstructive pulmonary disease
ume without changing on end chest wall expiratory volume. The SMM and abdominal muscle activity
Electromyography
Optoelectronic plethysmography
increased 63.84% and 1.94% during ILB. Overall, to overcome the load imposed by ILB, COPD patients
Respiratory muscle training improve the tidal volume by changing the inspiratory chest wall volume without modifying the pre-
dominant mobility of the abdomen at rest and without affecting the end chest wall expiratory volume.

© 2013 Elsevier B.V. All rights reserved.

1. Introduction To reduce these consequences, the Joint American College of

The breathing patterns of patients with chronic obstructive pul-
monary disease (COPD) are abnormal, especially in patients with
pulmonary hyperinflation (Aliverti et al., 2004; McKenzie et al.,
2009). Airflow obstructions and mechanical disadvantages of the
diaphragm contribute to the changes in the breathing pattern
and thoracoabdominal motion observed in these patients (Sackner
et al., 1984; Tobin et al., 1983). Most of these abnormalities suggest
a malfunction of respiratory muscles, especially the diaphragm,
with the use of sternocleidomastoid (SMM) and abdominal mus-
cle (ABD) being enhanced (Decramer, 1997; McKenzie et al.,
2009). These patients also exhibit other adaptations, such as mod-
ified chest wall and diaphragm shapes, which accommodate the
increased volume and adaptations of muscles fibers to preserve
strength and increase endurance (Loring et al., 2009; McKenzie
et al., 2009). These abnormalities are associated with poor exer-
cise tolerance, dyspnea and lower functional capacity (Loring et al.,
2009).
∗ Corresponding author at: Department of Physical Therapy, Universidade Federal
de Minas Gerais, Av. Antônio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais
31270-901, Brazil. Tel.: +55 31 34094783; fax: +55 31 3409 4783.
E-mail addresses: marianaacoutinho@gmail.com (M.A. Coutinho Myrrha),
danisrvieira@yahoo.com.br (D.S.R. Vieira), karolinesimoes@yahoo.com.br
(K.S. Moraes), susanfisio@yahoo.com.br (S.M. Lage),
veronicaparreira@yahoo.com.br (V.F. Parreira), rbrito@ufmg.br,
r3britto@gmail.com (R.R. Britto).
Chest Physicians/American Association of Cardiovascular and Pul-
monary Rehabilitation recommend inspiratory muscle training
(IMT) with inspiratory loaded breathing at least 30% of the maximal
inspiratory pressure (MIP) (Lotters et al., 2002) as part of rehabil-
itation programs for patients with COPD (American Association of
Cardiovascular and Pulmonary Rehabilitation, 1997). The benefits
of IMT have been described by many authors and include increased
strength and endurance of the inspiratory muscles, reduced dys-
pnea and fatigue, increased exercise tolerance and distance walked
during the six minute walk test, improved performance in daily
activities and an improved quality of life (Geddes et al., 2008;
Gosselink et al., 2011; Shoemaker et al., 2009).
Optoelectronic plethysmography (OEP) (Cala et al., 1996) can be
used to elucidate which chest wall (CW) compartment contributes
the most to the tidal volume and breathing pattern in different
situations. Recent reviews summarized the use of OEP in COPD
patients (Parreira et al., 2012; Romagnoli et al., 2008). Aliverti et al.
(2004) found different behavior to increase the tidal volume dur-
ing exercise: a decrease of end expiratory abdominal volume in
euvolemics patients and an increase of end inspiratory abdominal
and rib cage volume in hyperinflated patients. Bianchi et al. (2004)
also identified during pursed-lip breathing an increased tidal vol-
ume associated with increasing end inspiratory rib cage volume
and reducing end expiratory rib cage and abdominal volumes.
Hostettler et al. (2011) assessed the effect of ILB and identified asso-
ciation between chest wall volume changes and respiratory muscle
strength in 12 healthy subjects. To the best of our knowledge no

1569-9048/$ – see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.resp.2013.04.017
16 M.A. Coutinho Myrrha et al. / Respiratory Physiology & Neurobiology 188 (2013) 15–20
previous studies evaluated the chest wall volumes and breathing
pattern of COPD patients during inspiratory loaded breathing (ILB).
We hypothesized that COPD patients to overcome the load
imposed by the ILB will present an increase of chest wall tidal vol-
ume as a result of an increase of chest wall end inspiratory volume
by both compartments (rib cage and abdomen). We also hypoth-
esized that these changes will occur associated with increase
activation of inspiratory accessories muscles.
Therefore, the primary aim of this study was to evaluate the
changes in the chest wall volumes and breathing patterns in COPD
patients during ILB at 30% of MIP. As a secondary aim we also eval-
uate the activity of accessories respiratory muscles.
2. Methods
2.1. Participant characteristics
This cross-sectional study was approved by the institutional
ethics committee, and all of the participants gave written informed
consent.
The participants in the study met the following inclusion crite-
ria: male, an age between 45 and 75 years, a body mass index
between 18 and 30 kg/m2 , a clinical diagnosis of moderate to very
severe COPD (FEV1 /FVC < 0.70; FEV1 < 0.80) (GOLD, 2008), clinical
stability with no exacerbations in the last four weeks, a history of
smoking, the absence of any respiratory disease that could con-
tribute to dyspnea, no cardiovascular, neurological or psychiatric
disorders, and no participation in a pulmonary rehabilitation pro-
gram. Participants were excluded if they were unable to understand
and follow the procedures.
2.2. Protocol
Data were collected on two occasions within a one-week period.
On the first day, lung function and muscle strength were evaluated.
On the second day, the chest wall volumes, breathing pattern and
respiratory muscle activity were simultaneously recorded at two
situations: (1) quiet breathing (resting), divided into three sets of
two minutes with a one-minute interval between sets, totaling six
minutes; (2) ILB at 30% of MIP for five minutes, without any specific
requirements regarding the breathing pattern to be adopted.
2.2.1. Lung function and respiratory muscle strength
A calibrated spirometer (Vitalograph 2120, Buckingham,
England) was used to evaluate lung function according to the Brazil-
ian recommendations (Sociedade Brasileira de Pneumolologia e
Tisiologia, 2004) and predicted values proposed for Brazilian
subjects (Pereira, 2007). Inspiratory muscle strength was evalu-
ated using a calibrated manometer (GERAR® Classe B – SP/Brazil)
connected to corrugated plastic tube and a mouthpiece with a
2-mm air leak orifice (Neder et al., 1999). Each patient performed
at least five maneuvers (considering a variation of up to 10%)
to achieve MIP from residual volume to total lung capacity. The
highest value observed was recorded, as long as this value was not
the last to be obtained.
2.2.2. Inspiratory loaded breathing (ILB)
ILB was performed using a threshold device (Threshold Inspira-
tory Muscle Trainer, New Jersey, USA), which imposes a workload
on the inspiratory muscles, maintains a constant load during
inspiration, and is flow-independent, with no resistance during
expiration. The patients breathed through the mouthpiece with
their nose occluded by a noseclip for five minutes with a work-
load of 30% of the MIP, the load frequently used in most studies
(Lotters et al., 2002). The patients were instructed to breathe deeply
to overcome the load. There were no requirements for the breath-
ing pattern or the breathing frequency to be adopted during the
ILB.
2.2.3. Chest wall volumes and breathing pattern
The chest wall volumes and breathing pattern were measured
by optoelectronic plethysmography (OEP-BTS, Milan, Italy) with a
sampling frequency of 60 Hz. This non-invasive technique meas-
ures breath-by-breath changes in the volume of chest wall and
its compartments (Aliverti and Pedotti, 2003; Aliverti et al., 2009).
Eighty-nine reflecting markers were placed over the front and back
of the trunk along pre-defined horizontal and vertical lines. The
landmark coordinates were measured with a system consisting of
six infrared cameras, three of which were positioned in front of the
participants and three of which were positioned behind the partici-
pants (Aliverti and Pedotti, 2003; Aliverti et al., 2009). The recorded
images were transmitted to a computer, where a 3-D geometric
model was formed (Cala et al., 1996). The chest wall was modeled
from the compartments: pulmonary rib cage (RCP), abdominal rib
cage (RCA) and abdomen (AB). For this study, we considered the rib
cage (RC) as the sum of the RCP and the RCA.
The participants remained seated on a backless bench with their
feet flat on the floor and their upper limps abducted, externally
rotated and flexed (for the visualization of the lateral markers) and
comfortably supported to minimize the activity of the accessory
respiratory muscles both at rest and during ILB. The participants
were instructed to look forward. To allow the cameras to capture
the lateral chest wall markers, the examiner held the inspiratory
threshold device at the participant’s right side.
The chest wall volumes were determined by analyzing the tidal
volumes based on the difference (VT) between the end-inspiratory
volume (Vei) and end-expiratory volume (Vee) of each compart-
ment. The chest wall tidal volume (VTcw ) was the sum of rib cage
tidal volume (VTrc ) and abdomen tidal volume (VTab ). The breath-
ing pattern was analyzed by the contribution of each compartment
to the chest wall volume. The ratio of the inspiratory time to the
total time of the respiratory cycle, the respiratory frequency and the
minute ventilation were also assessed. These ventilator parameters
were obtained from chest wall volume variations measurements.
2.2.4. Respiratory muscle activity
Surface electromyography (EMG System do Brazil Ltd, São Paulo,
Brazil) was used to record the muscle respiratory activity. Because
a wireless device was not available, to avoid covering the OEP
markers by EMG electrodes and cables we evaluated only the ster-
nocleidomastoid (SMM) and abdominal (ABD) muscles. An EMG
system with a biological signal acquisition module consisting of
eight channels, an amplifier gain of 1000× and a common mode
rejection ratio >120 db was used for data acquisition. The data
were processed using specific acquisition and analysis software
(WinDaq® Acquisition Software, Akron, OH, USA) and an A/D 12
bit signal converting plate, which was used to convert analog sig-
nals to digital signals with an anti-aliasing sampling frequency of
2000 Hz for each channel and an input range of 5 mV. Active bipolar
superficial electrodes consisting of two parallel rectangular Ag/AgCl
bars (1 cm in length, 0.78 cm2 of contact area) were used with an
internal amplifier to reduce the effects of electromagnetic interfer-
ence and other noise. For SMM, the electrodes were fastened to the
lower third of the muscle belly, which was identified by palpation
during manually resisted flexion of the neck (Falla et al., 2002).
For ABD, the electrodes were placed 2 cm away from the umbili-
cus on the rectus abdominal muscle (Duiverman et al., 2004). The
ground electrode was fixed on the ulnar styloid process. All of the
electrodes were fixed on the right side. The EMG signal collection
and analysis were carried out as recommend by the International
Society for Electrophysiology and Kinesiology (Merletti, 1999). The
 M.A. Coutinho Myrrha et al. / Respiratory Physiology & Neurobiology 188 (2013) 15–20 17

activity of the respiratory muscles was analyzed by the root mean Table 1
Participant characteristics.
square (RMS) method.
Characteristic n = 13
2.2.5. Dyspnea Age (yr) 65.15 (7.09)
The participants were asked to quantify their sensation of dys- Weight (kg) 62.88 (8.59)
pnea at rest and immediately after ILB on a scale of 0–10 using the Height (m) 1.64 (0.06)
modified Borg scale. BMI (kg/m2 ) 23.37 (2.61)
MIP (cm H2 O) 86.92 (29.97)
MIP (% pred) 81.13 (28.03)
3. Statistical analyses FEV1 (L) 1.07 (0.44)
FEV1 (% pred) 33.18 (10.91)
3.1. Sample size calculation FEV1 /FVC 0.46 (0.07)
MRC (a.u.) 2.31 (0.75)

The sample size was based on being able to detect at least a
difference of 300 ml in the chest wall tidal volume (Romagnoli et al.,
2011). Considering our data of pilot study with six subjects (mean
and standard deviation), a two-sided alpha of 0.05 and a statistical
power of 0.80, the target sample size was set at 13 individuals. Thus,
15 patients were selected to account for the possibility of dropouts.
3.2. Data analysis
The chest wall volumes measured during the six minutes at rest
and two minutes of ILB (90–210 s) were analyzed using specific
software. The mean rest values were compared to the ILB values
with Student’s t-test or Wilcoxon’s test, depending on the data
distribution.
The EMG signals were processed according to the time-domain.
One minute of the signal (30–90 s) from the second set of two
minutes at rest and one minute of the signal from the ILB
(120–180 s) were analyzed. We evaluated the change from rest to
ILB period expressed as percentage (relative change) analyzing by
the Mann–Whitney test.
All of the statistical procedures were carried out using the Sta-
tistical Package for Social Science (SPSS, 15.0, Chicago, IL, USA). The
level of significance was set at p < 0.05.
4. Results
The data are presented as the mean and standard deviation (in parentheses). BMI:
body mass index, MIP: maximal inspiratory pressure, FEV1 : forced expired volume
in the first second, FVC: forced vital capacity, MRC: medical research council scale,
a.u.: arbitrary unit.
correlation was calculated from 12 participants, as artifacts in the
EMG signal analyses precluded the use of the data from another
participant. Table 1 presents the anthropometric characteristics,
lung function and inspiratory muscle strength of the 13 patients
included in the study.
4.2. Chest wall volumes and breathing pattern
Table 2 and Fig. 1 show the changes in the patients’ chest
wall volumes and breathing pattern during ILB. The VTcw signifi-
cantly increased from rest to ILB (p < 0.05) mainly by the increase
of the VTab (Table 2). There was also a significant increase in
Veicw and Veirc . Regarding to end expiratory volumes, only the
Veerc increased during ILB, but it was not sufficient to significantly
increase the Veecw .
The main compartment contribution for the VTcw at rest and
during ILB was the abdomen, without difference in the two situa-
tions analyzed. The inspiratory time, the ratio of inspiratory time
to total time of the respiratory cycle and the minute ventilation
increased (p < 0.05) during ILB (Table 2).

4.1. Participants 4.3. Muscle activity and dyspnea

Fifteen patients with COPD were initially evaluated. Two of the From rest to ILB it was observed an improvement of 63.84%
patients were excluded because they were not able to complete (25.22 to 125.06) of the SMM muscle activity and 1.94% (−13.84
five minutes of ILB. Therefore, 13 participants were included in the to 21.96) of the ABD muscle activity (median, interquartile range,
analysis. However, the chest wall volume and muscular activity Fig. 2). The sensation of dyspnea according to the modified

Table 2
Chest wall volume and breathing pattern data obtained at rest and during inspiratory loaded breathing (n = 13).

Rest ILB ILB–Rest 95% CI P

VTcw (L) 0.51 (0.11) 0.84 (0.31) 0.34 0.16 to 0.51 0.002a
VTrc (L) 0.20 (0.05) 0.31 (0.20) 0.11 −0.22 to 0.002 0.046
VTab (L) 0.31 (0.10) 0.53 (0.20) 0.22 0.14 to 0.31 0.0001
%AB 60.33 (11.41) 64.32 (15.46) 3.99 −2.88 to 10.85 0.23
Ttot (s) 3.49 (0.64) 4.34 (1.40) 0.85 −0.09 to 1.78 0.071
Ti /Ttot 0.40 (0.28) 0.48 (0.08) 0.09 0.03 to 0.14 0.005
f (min−1 ) 18.55 (3.26) 15.53 (4.66) −3.02 −6.92 to 0.88 0.117
VE (L min−1 ) 8.85 (1.69) 12.30 (3.94) 3.46 0.79 to 6.13 0.015
Veecw (L) 22.53 (3.76) 22.74 (3.80) 0.21 −0.08 to 0.48 0.144
Veerc (L) 16.55 (2.31) 16.84 (2.31) 0.28 −0.50 to −0.07 0.012
Veeab (L) 5.99 (1.55) 5.90 (1.60) −0.09 −0.24 to 0.06 0.228
Veicw (L) 23.04 (3.79) 23.58 (3.93) 0.54 0.14 to 0.93 0.011
Veirc (L) 16.75 (2.30) 17.15 (2.33) 0.40 0.22 to 1.29 0.010
Veiab (L) 6.29 (1.60) 6.43 (1.73) 0.13 −0.06 to 0.33 0.156

The data are presented as the mean and standard deviation (in parentheses). ILB: inspiratory loaded breathing, CI: confidence interval, VTcw : tidal volume of the chest wall,
VTrc : tidal volume of rib cage, VTab : tidal volume of abdominal volume, %AB: contribution of abdominal compartment, Ti : inspiratory time, Ttot : total time of the respiratory
cycle, f: respiratory frequency, VE: minute ventilation, Veecw : chest wall end-expiratory volume, Veerc : rib cage end-expiratory volume, Veeab : abdomen end-expiratory
volume, Veicw : chest wall end-inspiratory volume, Veirc : rib cage end-inspiratory volume, Veirca : abdomen end-inspiratory volume.
a
Non-parametric variable. p values < 0.05 were considered significant.
18 M.A. Coutinho Myrrha et al. / Respiratory Physiology & Neurobiology 188 (2013) 15–20

1,6
1,4
1,2
1
0,8 *
∆Vcw (L)

0,6
0,4
0,2
0
- 0,2 Rest ILB

- 0,4

1,6
1,4
1,2
1 Fig. 2. Percentage (%) of changes on root mean square values from rest to inspiratory
load breathing for the sternocleidomastoid and abdominal muscles.
∆Vrc (L)

0,8
RMS: root mean square, SMM: sternocleidomastoid, ABD: abdominal, (䊉): outliers,
0,6 Mann–Whitney test.

0,4 *
0,2 5.2. Study limitations
*
0
While inspiratory muscle weakness was not considered as an
- 0,2 Rest ILB
inclusion criterion in this study, the inspiratory muscle strength
- 0,4 of the COPD patients was preserved, matching the predicted values
corrected for age and gender (Neder et al., 1999). There may be sev-
eral explanations for this observation: (1) the chronic adaptations
1,6
of COPD may reduce the length of the sarcomeres and increase the
1,4
oxidative capacity of mitochondria (Duiverman et al., 2004), (2) the
1,2
accessory respiratory muscles may adapt to overcome the load dur-
1 ing the respiratory cycle due to the diaphragm weakness (Souza,
∆Vab (L)

0,8 2002) and (3) the manovacuometer assesses the global inspira-
0,6 tory muscles, not solely diaphragm strength. Considering this, it
0,4 is possible that the load was not enough to change the breathing
0,2 patterns.
0
Another important limitation of the study is the EMG results.
The evaluation of only two respiratory muscles, considering both
- 0,2
inspiration and expiration for the quantitative evaluation of EMG,
- 0,4
reduces the specificity of the measurement and does not allow
Rest ILB studying the mechanisms underlying the variations in the displace-
ment of the different compartments of the chest wall. Also we did
Fig. 1. Changes in the chest wall and compartment volumes during inspiratory
not normalize the EMG using a maximal contraction as reference.
loaded breathing. The distance between two corresponding point is the tidal volume
of the considered compartment. We reported the EMG results as change of absolute values from
CW: chest wall, RC: rib cage, AB: abdomen, ILB: inspiratory loaded breathing, closed rest to ILB condition. Aware of these limitations we decided to
symbols: end-expiratory volume, open symbols: end-inspiratory volume. Dotted report the results to encourage future studies with more advanced
line: functional respiratory capacity. The bars indicate means ± SD. *p < 0.05.
technology.

Borg scale expressed as media (minimum–maximum) increased
(p = 0.005) from rest 0.4 (0.0–2.0) to after ILB 1.1 (0.5–3.0).
5. Discussion
5.1. Major finding
This mainly results of this study are that (1) to overcome
the inspiratory load COPD patients improve the tidal volume by
increasing the end inspiratory chest wall volume without change
the end expiratory chest wall volume, (2) this action did not affect
the predominant displacement of the abdomen found in rest con-
ditions and (3) it was also observed an improvement of the SMM
muscle activity.
5.3. Chest wall volumes and breathing pattern
In our study, the abdominal compartment was responsible for
approximately 60% of the tidal volume in both situations. Our find-
ings are in accordance with other studies, which have also found
a major abdominal contribution to tidal volume (60%) at rest in
patients with COPD (Aliverti et al., 2009; Bianchi et al., 2004, 2007;
Romagnoli et al., 2011). On the other hand, other studies found a
lower abdominal contribution to tidal volume (40%) at functional
residual capacity (Binazzi et al, 2008) and during exercise (Vogiatzis
et al., 2005). The ratio of the inspiratory time to total time of the
respiratory cycle increased during ILB indicates more work from
the inspiratory muscles (Decramer et al., 2005). The reduction of
the expiratory time usually increases the hyperinflation in COPD
patients. However, although it was observed a higher rib cage end
 M.A. Coutinho Myrrha et al. / Respiratory Physiology & Neurobiology 188 (2013) 15–20
expiratory volume during ILB, it did not lead to an increase on chest
wall end expiratory volume, probably because of the concomitant
tendency to decrease the end-expiratory abdominal volume. The
improvement of the elastic recoil of the lung tissue would also
be related to this result; however it needs to be evaluated by a
systematic research.
Studies about the chest wall volumes behavior of COPD patients
during exercise and respiratory exercise showed that the responses
could be different depending on the characteristics of the patients
in regard to dynamic hyperinflation response (Aliverti et al., 2004;
Bianchi et al., 2007; Vogiatzis et al., 2005). Brandão et al. (2012)
using ILB at 30% MIP in health and heart failure subjects observed
also an increase of tidal volume, however by increasing the rib cage
and abdomen tidal volume and with a reduced mobility in lower
left part of the rib cage in heart failure. Therefore, it seems that
each population adopts specific changes in chest wall volumes and
breathing pattern to adapt to different kind of interventions.
5.4. Respiratory muscle activity
The signal of EMG can be influenced by the distance between
the muscle and the electrode, being easily confounded with non-
physiological cross-talk. The absolute values of the EMG signals
suffer the effects of individual constitution and adjacent muscles,
complicating the comparison of values. To overcome this con-
straint, the EMG amplitudes were normalized based on individual
differences (De Andrade et al., 2005). Duiverman et al. (2004)
evaluated the reproducibility and sensitivity of surface EMG for
respiratory muscles during ILB, concluding that EMG is repro-
ducible and sensitive enough to assess the breathing pattern of
healthy subjects and patients with COPD. Our findings suggested
that COPD patients activate accessory muscles such as the SMM to
overcome the load. De Andrade et al. (2005) also using 30% MIP of
ILB in COPD patients observed that the RMS for the SMM increased
significantly during ILB in the COPD group (p = 0.04), while the RMS
of the diaphragm remained constant.
5.5. Clinical implications
It is well known that COPD patients exhibit abnormal breathing
patterns. However, the implications of these abnormalities dur-
ing ILB are poorly understood. The COPD patients evaluated in the
present study modified their chest wall volumes, breathing pattern
and sternocleidomastoid activity during ILB at 30% MIP without
presenting dynamic hyperinsuflation and while maintaining low
Borg scale dyspnea scores. These findings can corroborate the fea-
sibility of including IMT in rehabilitation programs for patients with
COPD. Moreover, our study can be used as a starting point for clini-
cians to analyze the effects of ILB on the redistribution of chest wall
volumes in this patient population.
5.6. Suggestion for future studies
The evaluation of COPD patients with different clinical charac-
teristics including hyperinflation, inspiratory muscle weaknesses
and severity of COPD synchronizing OEP and respiratory muscles
activity could contribute to understand the responses during the
use of ILB and also identify the behavior when the diaphragmatic
breathing is associated.
6. Conclusions
Overall, to overcome the load imposed by ILB, COPD patients
improve the tidal volume by changing the inspiratory chest
wall volume without modifying the predominant mobility of the
abdomen at rest and without affecting the end chest wall expiratory
19
volume. This action seems to be related to inspiratory accessory
muscle activity.
Acknowledgements
This study was supported by grants from CNPq (Conselho
Nacional de Desenvolvimento Científico e Tecnológico, number
302913/2008-4), FAPEMIG (Fundação de Amparo à Pesquisa do
estado de Minas Gerais, PPM00072-09) and PRPq (Pró-Reitoria de
Pesquisa – UFMG).
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