Respiratory Muscles Training in the Complex Treatment of Patients with Acute Decompensated Heart Failure

The aim: to evaluate the efficacy of respiratory muscles training in the complex treatment of patients with acute decompensated heart failure. Material and methods. A prospective randomized study included 120 patients (71 men and 49 women, mean age 73,6±5,8 years) hospitalized with acute decompensated heart failure. The main exclusion criteria were: requirement for treatment in intensive care unit; hemodynamic instability; severe pulmonary and other concomitant pathology. After initial procedures all patients were randomized to breathing exercises performed in addition to standard therapy (main group, n=60) or to standard therapy only (control group, n=60). Patients of the main group were trained in the technique of complete yogic breathing, which consists of three successive phases: abdominal, thoracic and clavicular. The participants practiced full breathing daily at least 3 times a day for 10 minutes under the supervision of instructor. The primary endpoint of the study was the change in dyspnea according to the modified Borg scale (modified by V.Yu. Mareev) on the 7th day of treatment. Results. During treatment the severity of dyspnea decreased in both groups, more significantly in the main group (from 6 (5; 6) to 3 (2; 3) points) compared to control (from 6 (5; 6) to 4 (3; 4) points, p <0,05). Significant differences between the groups were also obtained for the secondary variables of efficacy: six-minute walk distance, heart rate and breathing rate at rest, blood oxygen saturation (p ><0,05). In patients who performed breathing exercises, body weight decreased faster (0,72±0,06 kg/day versus 0,53±0,06 kg/day, p ><0,001), although the volumes of excreted fluid did not differ between the groups. In the main group moist rales in the lungs were stopped by the sixth day of hospitalization (interquartile range of 5-7 days), and in the control group — by the eighth (interquartile range of 7-9 days), p=0,024. The duration of active diuretic phase and the average daily doses of diuretics were lower in main group compared to control (p ><0,05). During hospitalization quality of life improved in both groups, more significantly in respiratory muscles training group (p ><0,01). In-hospital mortality and the rate of transfers to the intensive care unit did not differ between groups. The average hospital stay in surviving patients was significantly shorter in main group than in control (14,2±2,5 versus 17,3±2,9 days, p ><0,001). >Conclusion. Respiratory muscles training with full yogic breathing in addition to standard medical therapy for patients with acute decompensated heart failure leads to a more significant reduction in the severity dyspnea, increased exercise tolerance, improved blood oxygen saturation, and reduced need for diuretics. The use of full breathing is associated with significant improvement in the quality of life and decrease in the length of hospital stay, but does not lead to improvement in hospital outcomes.

1. Chaudhry S-P., Stewart G.C. Advanced Heart Failure: Prevalence, Natural History, and Prognosis. Heart Fail Clin. 2016; 12(3): 323-333. doi:10.1016/j.hfc.2016.03.001

2. Lalande S., Cross T.J., Keller-Ross M.L. et al. Exercise Intolerance in Heart Failure: Central Role for the Pulmonary System. Exercise and Sport Sciences Reviews. 2020; 48(1): 11-19. doi:10.1249/JES.0000000000000208

3. Nakagawa N.K., Diz M.A., Kawauchi T.S. et al. Risk Factors for Inspiratory Muscle Weakness in Chronic Heart Failure. Respir Care. 2020; 65(4): 507-516. doi:10.4187/respcare.06766

4. Laoutaris I.D. The “aerobic/resistance/inspiratory muscle training hypothesis in heart failure.” Eur J Prev Cardiol. 2018; 25(12): 1257-1262. doi:10.1177/2047487318776097

5. Argilés J.M., Busquets S., Stemmler B. et al. Cachexia and sarcopenia: mechanisms and potential targets for intervention. Curr Opin Pharmacol. 2015; 22: 100-106. doi:10.1016/j.coph.2015.04.003

6. Dos Santos M.R., Saitoh M., Ebner N. et al. Sarcopenia and Endothelial Function in Patients With Chronic Heart Failure: Results From the Studies Investigating Comorbidities Aggravating Heart Failure (SICA-HF). J Am Med Dir Assoc. 2017; 18(3): 240-245. doi:10.1016/j.jamda.2016.09.006

7. Okwose N.C., Avery L., O’Brien N. et al. Acceptability, Feasibility and Preliminary Evaluation of a Novel, Personalised, Home-Based Physical Activity Intervention for Chronic Heart Failure (Active-at-Home-HF): a Pilot Study. Sports Medicine — Open. 2019; 5(1): 45. doi:10.1186/s40798-019-0216-x

8. Cattadori G., Segurini C., Picozzi A. et al. Exercise and heart failure: an update. ESC Heart Fail. 2018; 5(2): 222-232. doi:10.1002/ehf2.12225

9. Oz Alkan H., Uysal H., Enç N. et al. Influence of Breathing Exercise Education Applied on Patients with Heart Failure on Dyspnoea and Quality of Sleep: A Randomized Controlled Study. International Journal of Medical Research & Health Sciences. 2017; 6(9): 107-113

10. Belardinelli R., Georgiou D., Cianci G. et al. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999; 99(9): 1173-1182. doi:10.1161/01.cir.99.9.1173

11. Arutyunov G.P., Kolesnikova E.A., Begrambekova Yu.L. et al. Exercise training in chronic heart failure: practical guidance of the Russian Heart Failure Society. Russian journal of heart failure. 2017;18(1): 41-66. doi:10.18087/rhfj.2017.1.2339 [In Russian]

12. Troitsky M.S., Fedorov S.Yu., Borisova O.N. et al. Innovations in the training of the respiratory muscles (Literature Review). Russian journal of New Medical Technologies. Electronic edition. 2015; 2: 3-7. [In Russian]

13. Udupa K., Madanmohan N., Bhavanani A.B. et al. Effect of pranayam training on cardiac function in normal young volunteers. Indian J Physiol Pharmacol. 2003; 47(1): 27-33.

14. Ponikowski P., Voors A.A., Anker S.D. et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016; 18(8): 891-975. doi:10.1002/ejhf.592

15. Saitoh M., Ishida J., Doehner W. et al. Sarcopenia, cachexia, and muscle performance in heart failure: Review update 2016. Int J Cardiol. 2017; 238: 5-11. doi:10.1016/j.ijcard.2017.03.155

16. Giallauria F., Piccioli L., Vitale G. et al. Exercise training in patients with chronic heart failure: A new challenge for Cardiac Rehabilitation Community. Monaldi Arch Chest Dis. 2018; 88(3): 987. doi:10.4081/monaldi.2018.987

17. Ribeiro J.P., Chiappa G.R., Callegaro C.C. The contribution of inspiratory muscles function to exercise limitation in heart failure: pathophysiological mechanisms. Rev Bras Fisioter. 2012; 16(4): 261-267. doi:10.1590/s1413-35552012005000034

18. Boushel R. Muscle metaboreflex control of the circulation during exercise. Acta Physiol (Oxf). 2010; 199(4): 367-383. doi:10.1111/j.1748-1716.2010.02133.x

19. Begrambekova Yu.L., Karanadze N.A., Orlova Y.A. Alterations of the respiratory system in heart failure. Kardiologiia. 2019; 59(2S): 15-24. doi:10.18087/cardio.2626 [In Russian]

20. Meyer F.J., Borst M.M., Zugck C. et al. Respiratory muscle dysfunction in congestive heart failure: clinical correlation and prognostic significance. Circulation. 2001; 103(17): 2153-2158. doi:10.1161/01.cir.103.17.2153

21. Winkelmann E.R., Chiappa G.R., Camila O.C. Lima. et al. Addition of inspiratory muscle training to aerobic training improves cardiorespiratory responses to exercise in patients with heart failure and inspiratory muscle weakness. Am Heart J. 2009; 158(5): 768.e1-7. doi:10.1016/j.ahj.2009.09.005

22. Stein R., Chiappa G.R., Güths H. et al. Inspiratory muscle training improves oxygen uptake efficiency slope in patients with chronic heart failure. J Cardiopulm Rehabil Prev. 2009; 29(6): 392-395. doi:10.1097/HCR.0b013e3181b4cc41

23. Laoutaris I.D., Adamopoulos S., Manginas A. et al. Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study. Int J Cardiol. 2013; 167(5): 1967-1972. doi:10.1016/j.ijcard.2012.05.019

24. Montemezzo D., Fregonezi G.A., Pereira D.A. et al. Influence of inspiratory muscle weakness on inspiratory muscle training responses in chronic heart failure patients: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2014; 95(7): 1398-1407. doi:10.1016/j.apmr.2014.02.022

25. Passino C., Giannoni A., Milli M. et al. Recent knowledges on chemosensitivity to hypoxia and hypercapnia in cardiovascular disease. Recenti Prog Med. 2010; 101(7-8): 308-313.

26. Novaes M.M., Palhano-Fontes F., Onias H. et al. Effects of Yoga Respiratory Practice (Bhastrika pranayama) on Anxiety, Affect, and Brain Functional Connectivity and Activity: A Randomized Controlled Trial. Front Psychiatry. 2020; 11: 467. doi:10.3389/fpsyt.2020.00467

27. Shinba T., Inoue T., Matsui T. et al. Changes in Heart Rate Variability after Yoga are Dependent on Heart Rate Variability at Baseline and during Yoga: A Study Showing Autonomic Normalization Effect in Yoga-Naïve and Experienced Subjects. Int J Yo ga. 2020; 13(2): 160-167. doi:10.4103/ijoy.IJOY_39_19

28. Garcia A.J., Koschnitzky J.E., Dashevskiy T. et al. Cardiorespiratory Coupling in Health and Disease. Auton Neurosci. 2013; 175(0): 26-37. doi:10.1016/j.autneu.2013.02.006

29. Pokrovskiy V.M., Korotko G.F. Human physiology. 2003; 656 р. [Electronic resource]. URL: https://www.booksmed.com/fiziologiya/565-fiziologiya-cheloveka-pokrovskij-uchebnik.html. (Date of the application: 12.06.2020) [In Russian]

30. Smart N.A., Giallauria F., Dieberg G. Efficacy of inspiratory muscle training in chronic heart failure patients: a systematic review and meta-analysis. Int J Cardiol. 2013; 167(4): 1502-1507. doi:10.1016/j.ijcard.2012.04.029