cardioКардиологияKardiologiia0022-90402412-5660Kardiomag10.18087/cardio.2021.2.n1356cardio-1356Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИRESEARCH ARTICLESВыбор оптимального режима тренировок дыхательных мышц у пациентов с хронической сердечной недостаточностью II-III функциональных классовSelection of the optimal respiratory muscle training mode in patients with class II-III chronic heart failureАрутюновА. Г.ArutyunovA. G.

Professor of the Department of propaedeutics of internal diseases of the faculty of Pediatrics

agarutyunov@mail.ruКолесниковаЕ. А.KolesnikovaE. A.

к.м.н., доцент кафедры пропедевтики внутренних болезней педиатрического факультета РНИМУ

associate Professor of the Department of propaedeutics of internal diseases of the faculty of Pediatrics

e_kolesnikova@inbox.ruИльинаК. В.IlyinaK. V.

Ассистент кафедры  пропедевтики внутренних болезней педиотрического факультета РНИМУ, врач кардиолог  ГБУЗ ГКБ №4 ДЗМ. 

cardiologist cardiology department 2 

Assistant of the Department of propaedeutics of internal diseases of the faculty of Pediatrics

doc.ksenia@gmai.comРыловаА. К.RylovaA. K.

Professor of the department of propaedeutics of internal diseases of the faculty of Pediatrics

rylova@ossn.ruАрутюновГ. П.ArutyunovG. P.

д.м.н. профессор кафедры пропедевтики внутренних болезней педиатрического факультета РНИМУ.

Professor of the department of propaedeutics of internal diseases of the faculty of Pediatrics

arut@ossn.ruЩербаковаН. В.ScherbacovaN. V.

assistant of the Department of propaedeutics of internal diseases of the faculty of Pediatrics

smumrik1979@mail.ruКулагинаН. П.KulaginaN. P.

Зав. отд.  кардиологическим отделением  2

head of cardiology department 2

sccorpio66@mail.ruФГБОУ ВО Российский национальный исследовательский медицинский университет имени Н.И. Пирогова Минздрава РФ, Москва, РоссияРоссияPirogov Russian National Research Medical University (RNRMU), Moscow, RussiaRussian FederationФГБОУ ВО Российский национальный исследовательский медицинский университет имени Н.И. Пирогова Минздрава РФ, Москва, Россия ГБУЗ «Городская клиническая больница №4», Москва, РоссияРоссияPirogov Russian National Research Medical University (RNRMU), Moscow, Russia Сity clinical hospital №4, Moscow, RussiaRussian FederationГБУЗ «Городская клиническая больница №4», Москва, РоссияРоссияСity clinical hospital №4, Moscow, RussiaRussian Federation2021060320216126975Copyright © Kardiomag, 20212021KardiomagKardiomaghttps://cardio.elpub.ru/jour/about/submissions#copyrightNoticehttps://cardio.elpub.ru/jour/article/view/1356

Цель Изучение влияния различных видов тренировок дыхательной мускулатуры (ТДМ) у пациентов с хронической сердечной недостаточностью (ХСН) II–III функциональных классов (ФК) и сохранной мышечной массой диафрагмы более 70 %.Материал и методы В исследовании 53 больных (28 мужчин и 25 женщин) ишемической болезнью сердца (ИБС) и гипертонической болезнью с ХСН II–III ФК по NYHA в возрасте от 50 до 75 лет с сохранной мышечной массой диафрагмы более 70 % были рандомизированы для занятий одним из 4‑х вариантов ТДМ: статические нагрузки, динамические нагрузки, их сочетание, дыхание без создаваемого сопротивления – контрольная группа. Пиковое потребление кислорода (VO2 peak), максимальное инспираторное давление (MIP) оценивали исходно и через 6 месяцев.Результаты Во всех исследуемых группах отмечалось улучшение показателей физической выносливости, статистически значимое по сравнению с исходными значениями (р<0,05). При попарном сравнении группы достоверно отличались между собой (р<0,01). Наибольшее улучшение продемонстрировали пациенты из группы динамических и сочетанных тренировок. При этом результаты в группе сочетанных тренировок были значимо выше, чем в группе только динамических нагрузок. Наибольшая статистически значимая (р <0,01) положительная динамика силы мышц вдоха отмечалась в группах с динамическими и смешанными тренировками, причем лучшие результаты получены у пациентов группы сочетанных тренировок.Заключение При сохранении более чем 70 % мышечной ткани диафрагмы (по данным MIP более 60 см вод. ст.) наиболее эффективно сочетание статических и динамических ТДМ у больных ХСН II–III ФК.

Aim To study the effect of various types of respiratory muscle training (RMT) in patients with functional class (FC) II-III chronic heart failure (CHF) and more than 70% preserved diaphragm muscle mass.Material and methods 53 patients (28 men and 25 women) aged 50-75 years with NYHA FC II-III ischemic heart disease (IHD) and arterial hypertension with more than 70% preserved diaphragm muscle mass of >70% were randomized to one of four RMT types: static loads, dynamic loads, their combination, and breathing without applied resistance as a control. Peak oxygen consumption (VO2 peak) and maximum inspiratory pressure (MIP) were evaluated at baseline and in 6 months.Results All study groups showed significant improvement of physical endurance indexes compared to baseline values (р<0.05). In pairwise comparison, the groups significantly differed (р<0.01). The greatest improvement was observed for patients of dynamic and combined training groups. Furthermore, in the combined training group, results were significantly higher than in the group of isolated dynamic loads. The most significant (р <0.01), positive changes in the force of inspiratory muscles were observed in groups of dynamic and combined trainings with the best results displayed by patients of the combined training group.Conclusion With preserving more than 70 % of diaphragm muscle tissue (as determined by MIP >60 cm H2O), a combination of static and dynamic RMT is most effective for patients with FC II-III CHF.

Хроническая сердечная недостаточностьФК ХСНдиафрагмамаксимальное инспираторное давлениетренировки дыхательной мускулатурыChronic heart failureCHF FCdiaphragmmaximum inspiratory pressurerespiratory muscle trainingКонфликт интересов не заявлен.No conflict of interest is reported.ReferencesMancini DM, Henson D, La Manca J, Donchez L, Levine S. Benefit of selective respiratory muscle training on exercise capacity in patients with chronic congestive heart failure. Circulation. 1995;91(2):320–9. PMID: 7805234Mancini DM, Henson D, La Manca J, Donchez L, Levine S. Benefit of selective respiratory muscle training on exercise capacity in patients with chronic congestive heart failure. Circulation. 1995;91(2):320–9. PMID: 7805234Weiner P, Magadle R, Berar-Yanay N, Pelled B. The effect of specific inspiratory muscle training on the sensation of dyspnea and exercise tolerance in patients with congestive heart failure. Clinical Cardiology. 1999;22(11):727–32. DOI: 10.1002/clc.4960221110Weiner P, Magadle R, Berar-Yanay N, Pelled B. The effect of specific inspiratory muscle training on the sensation of dyspnea and exercise tolerance in patients with congestive heart failure. Clinical Cardiology. 1999;22(11):727–32. DOI: 10.1002/clc.4960221110Piepoli MF, Conraads V, Corrà U, Dickstein K, Francis DP, Jaarsma T et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure. 2011;13(4):347–57. DOI: 10.1093/eurjhf/hfr017Piepoli MF, Conraads V, Corrà U, Dickstein K, Francis DP, Jaarsma T et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure. 2011;13(4):347–57. DOI: 10.1093/eurjhf/hfr017Smart NA, Giallauria F, Dieberg G. Efficacy of inspiratory muscle training in chronic heart failure patients: A systematic review and meta-analysis. International Journal of Cardiology. 2013;167(4):1502–7. DOI: 10.1016/j.ijcard.2012.04.029Smart NA, Giallauria F, Dieberg G. Efficacy of inspiratory muscle training in chronic heart failure patients: A systematic review and meta-analysis. International Journal of Cardiology. 2013;167(4):1502–7. DOI: 10.1016/j.ijcard.2012.04.029Арутюнов Г.П., Колесникова Е.А., Беграмбекова Ю.Л., Орлова Я.А., Рылова А.К., Аронов Д.М. и др. Рекомендации по назначению физических тренировок пациентам с хронической сердечной недостаточностью. Журнал Сердечная Недостаточность. 2017;18(1):41–66.. DOI: 10.18087/rhfj.2017.1.2339Arutyunov G.P., Kolesnikova E.A., Begrambekova Yu.L., Orlova Ya.A., Rylova A.K., Aronov D.M. et al. Exercise training in chronic heart failure: practical guidance of the Russian Heart Failure Society. Russian Heart Failure Journal. 2017;18(1):41–66. DOI: 10.18087/rhfj.2017.1.2339Souza H, Rocha T, Pessoa M, Rattes C, Brandao D, Fregonezi G et al. Effects of Inspiratory Muscle Training in Elderly Women on Respiratory Muscle Strength, Diaphragm Thickness and Mobility. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2014;69(12):1545–53. DOI: 10.1093/gerona/glu182Souza H, Rocha T, Pessoa M, Rattes C, Brandao D, Fregonezi G et al. Effects of Inspiratory Muscle Training in Elderly Women on Respiratory Muscle Strength, Diaphragm Thickness and Mobility. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2014;69(12):1545–53. DOI: 10.1093/gerona/glu182Арутюнов А.Г., Ильина К.В., Арутюнов Г.П., Колесникова Е.А., Пчелин В.В., Кулагина Н.П. и др. Морфофункциональные особенности диафрагмы у больных с хронической сердечной недостаточностью. Кардиология. 2019;59(1):12-21. DOI: 10.18087/cardio.2019.1.2625Arutyunov A.G., Ilyina K.V., Arutyunov G.P., Kolesnikova E.A., Pchelin V.V., Kulagina N.P. et al. Morphofunctional Features of The Diaphragm in Patients With Chronic Heart Failure. Kardiologiia. 2019;59(1):12–21. DOI: 10.18087/cardio.2019.1.2625Tucker WJ, Lijauco CC, Hearon CM, Angadi SS, Nelson MD, Sarma S et al. Mechanisms of the Improvement in Peak VO2 With Exercise Training in Heart Failure With Reduced or Preserved Ejection Fraction. Heart, Lung and Circulation. 2018;27(1):9–21. DOI: 10.1016/j.hlc.2017.07.002Tucker WJ, Lijauco CC, Hearon CM, Angadi SS, Nelson MD, Sarma S et al. Mechanisms of the Improvement in Peak VO2 With Exercise Training in Heart Failure With Reduced or Preserved Ejection Fraction. Heart, Lung and Circulation. 2018;27(1):9–21. DOI: 10.1016/j.hlc.2017.07.002Tucker WJ, Haykowsky MJ, Seo Y, Stehling E, Forman DE. Impaired Exercise Tolerance in Heart Failure: Role of Skeletal Muscle Morphology and Function. Current Heart Failure Reports. 2018;15(6):323– 31. DOI: 10.1007/s11897-018-0408-6Tucker WJ, Haykowsky MJ, Seo Y, Stehling E, Forman DE. Impaired Exercise Tolerance in Heart Failure: Role of Skeletal Muscle Morphology and Function. Current Heart Failure Reports. 2018;15(6):323– 31. DOI: 10.1007/s11897-018-0408-6Meyer FJ, Borst MM, Zugck C, Kirschke A, Schellberg D, Kübler W et al. Respiratory Muscle Dysfunction in Congestive Heart Failure: Clinical Correlation and Prognostic Significance. Circulation. 2001;103(17):2153–8. DOI: 10.1161/01.CIR.103.17.2153Meyer FJ, Borst MM, Zugck C, Kirschke A, Schellberg D, Kübler W et al. Respiratory Muscle Dysfunction in Congestive Heart Failure: Clinical Correlation and Prognostic Significance. Circulation. 2001;103(17):2153–8. DOI: 10.1161/01.CIR.103.17.2153Мареев В.Ю., Агеев Ф.Т., Арутюнов Г.П., Коротеев А.В., Мареев Ю.В., Овчинников А.Г. и др. Национальные рекомендации ОССН, РКО и РНМОТ по диагностике и лечению ХСН (четвертый пересмотр). Утверждены на Конгрессе ОССН 7 декабря 2012 года, на Правлении ОССН 31 марта 2013 и Конгрессе РКО 25 сентября 2013 года. Журнал Сердечная Недостаточность. 2013;14(7):379-472.Mareev V.Yu., Ageev F.T., Arutyunov G.P., Koroteev A.V., Mareev Yu.V., Ovchinnikov A.G. et al. SEHF, RSC and RSMSIM national guidelines on CHF diagnostics and treatment (fourth revision) Approved at the SEHF Congress on December 7, 2012, at the SEHF Board of Directors meeting on March 31, 2013, and at the RSC Congress on September 25, 2013. Russian Heart Failure Journal. 2013;14(7):379– 472.Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF et al. Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement From the American Heart Association. Circulation. 2010;122(2):191–225. DOI: 10.1161/CIR.0b013e3181e52e69Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF et al. Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement From the American Heart Association. Circulation. 2010;122(2):191–225. DOI: 10.1161/CIR.0b013e3181e52e69Froelicher VF, Myers J. Manual of exercise testing. – US: Mosby;2007. – 349 p. ISBN 0-323-03302-4Froelicher VF, Myers J. Manual of exercise testing. – US: Mosby;2007. – 349 p. ISBN 0-323-03302-4Kolesnikova E.A., Arutyunov G.P., Rylova A.K., Rylova N.V. P490. Long-term effects of respiratory muscle trainings started in acute period of complicated myocardial infarction. Poster session 3. European Journal of Preventive Cardiology. 2012;19(1 Suppl 1):S93. DOI: 10.1177/2047487312448008Kolesnikova E.A., Arutyunov G.P., Rylova A.K., Rylova N.V. P490. Long-term effects of respiratory muscle trainings started in acute period of complicated myocardial infarction. Poster session 3. European Journal of Preventive Cardiology. 2012;19(1 Suppl 1):S93. DOI: 10.1177/2047487312448008Kolesnikova EA, Arutyunov GP, Rylova AK, Lobzeva V. P385. Physical rehabilitation in patients with severe heart failure. Circulation. 2015;131(Suppl 1):AP385. [Av. at: https://www.ahajournals.org/doi/10.1161/circ.131.suppl_1.p385]Kolesnikova EA, Arutyunov GP, Rylova AK, Lobzeva V. P385. Physical rehabilitation in patients with severe heart failure. Circulation. 2015;131(Suppl 1):AP385. [Av. at: https://www.ahajournals.org/doi/10.1161/circ.131.suppl_1.p385]Арутюнов Г.П., Колесникова Е.А., Рылова А.К. Современные подходы к реабилитации больных c хронической сердечной недостаточностью. CardioСоматика. 2010;1:20–4Arutyunov G.P., Kolesnikova E.A., Rylova A.K. Current approaches to rehabilitation of patients with chronic heart failure. CardioSomatika. 2010;1:20–4.Cahalin LP, Arena R, Guazzi M, Myers J, Cipriano G, Chiappa G et al. Inspiratory muscle training in heart disease and heart failure: a review of the literature with a focus on method of training and outcomes. Expert Review of Cardiovascular Therapy. 2013;11(2):161–77. DOI: 10.1586/erc.12.191 18. Cahalin LP, Arena RA. Breathing Exercises and Inspiratory Muscle Training in Heart Failure. Heart Failure Clinics. 2015;11(1):149–72. DOI: 10.1016/j.hfc.2014.09.002Cahalin LP, Arena R, Guazzi M, Myers J, Cipriano G, Chiappa G et al. Inspiratory muscle training in heart disease and heart failure: a review of the literature with a focus on method of training and outcomes. Expert Review of Cardiovascular Therapy. 2013;11(2):161–77. DOI: 10.1586/erc.12.191 18. Cahalin LP, Arena RA. Breathing Exercises and Inspiratory Muscle Training in Heart Failure. Heart Failure Clinics. 2015;11(1):149–72. DOI: 10.1016/j.hfc.2014.09.002Sadek Z, Salami A, Joumaa WH, Awada C, Ahmaidi S, Ramadan W. Best mode of inspiratory muscle training in heart failure patients: a systematic review and meta-analysis. European Journal of Preventive Cardiology. 2018;25(16):1691–701. DOI: 10.1177/2047487318792315Sadek Z, Salami A, Joumaa WH, Awada C, Ahmaidi S, Ramadan W. Best mode of inspiratory muscle training in heart failure patients: a systematic review and meta-analysis. European Journal of Preventive Cardiology. 2018;25(16):1691–701. DOI: 10.1177/2047487318792315Wu J, Kuang L, Fu L. Effects of inspiratory muscle training in chronic heart failure patients: A systematic review and meta-analysis. Congenital Heart Disease. 2018;13(2):194–202. DOI: 10.1111/chd.12586Wu J, Kuang L, Fu L. Effects of inspiratory muscle training in chronic heart failure patients: A systematic review and meta-analysis. Congenital Heart Disease. 2018;13(2):194–202. DOI: 10.1111/chd.12586Gomes Neto M, Ferrari F, Helal L, Lopes AA, Carvalho VO, Stein R. The impact of high-intensity inspiratory muscle training on exercise capacity and inspiratory muscle strength in heart failure with reduced ejection fraction: a systematic review and meta-analysis. Clinical Rehabilitation. 2018;32(11):1482–92. DOI: 10.1177/0269215518784345Gomes Neto M, Ferrari F, Helal L, Lopes AA, Carvalho VO, Stein R. The impact of high-intensity inspiratory muscle training on exercise capacity and inspiratory muscle strength in heart failure with reduced ejection fraction: a systematic review and meta-analysis. Clinical Rehabilitation. 2018;32(11):1482–92. DOI: 10.1177/0269215518784345Jugdutt BI, Michorowski BL, Kappagoda CT. Exercise training after anterior Q wave myocardial infarction: Importance of regional left ventricular function and topography. Journal of the American College of Cardiology. 1988;12(2):362–72. DOI: 10.1016/07351097(88)90407-XJugdutt BI, Michorowski BL, Kappagoda CT. Exercise training after anterior Q wave myocardial infarction: Importance of regional left ventricular function and topography. Journal of the American College of Cardiology. 1988;12(2):362–72. DOI: 10.1016/07351097(88)90407-XPrinciples and practice of pulmonary rehabilitation. Killian K. Dyspnеa: implications for rеhabilitation. P. 103-114. Casaburi R, Petty TL, editors -Philadelphia: Saunders;1993. 508 p. ISBN 978-07216-3304-6Principles and practice of pulmonary rehabilitation. Killian K. Dyspnеa: implications for rеhabilitation. P. 103-114. Casaburi R, Petty TL, editors -Philadelphia: Saunders;1993. 508 p. ISBN 978-07216-3304-6Johnson P. A randomized controlled trial of inspiratory muscle training in stable chronic heart failure. European Heart Journal. 1998;19(8):1249–53. DOI: 10.1053/euhj.1998.1024Johnson P. A randomized controlled trial of inspiratory muscle training in stable chronic heart failure. European Heart Journal. 1998;19(8):1249–53. DOI: 10.1053/euhj.1998.1024Dall’Ago P, Chiappa GRS, Guths H, Stein R, Ribeiro JP. Inspiratory muscle training in patients with heart failure and inspiratory muscle weakness: a randomized trial. Journal of the American College of Cardiology. 2006;47(4):757–63. DOI: 10.1016/j.jacc.2005.09.052Dall’Ago P, Chiappa GRS, Guths H, Stein R, Ribeiro JP. Inspiratory muscle training in patients with heart failure and inspiratory muscle weakness: a randomized trial. Journal of the American College of Cardiology. 2006;47(4):757–63. DOI: 10.1016/j.jacc.2005.09.052Bosnak-Guclu M, Arikan H, Savci S, Inal-Ince D, Tulumen E, Aytemir K et al. Effects of inspiratory muscle training in patients with heart failure. Respiratory Medicine. 2011;105(11):1671–81. DOI: 10.1016/j.rmed.2011.05.001Bosnak-Guclu M, Arikan H, Savci S, Inal-Ince D, Tulumen E, Aytemir K et al. Effects of inspiratory muscle training in patients with heart failure. Respiratory Medicine. 2011;105(11):1671–81. DOI: 10.1016/j.rmed.2011.05.001Laoutaris I, Dritsas A, Brown MD, Manginas A, Alivizatos PA, Cokkinos DV. Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure. European Journal of Cardiovascular Prevention & Rehabilitation. 2004;11(6):489–96. DOI: 10.1097/01.hjr.0000152242.51327.63Laoutaris I, Dritsas A, Brown MD, Manginas A, Alivizatos PA, Cokkinos DV. Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure. European Journal of Cardiovascular Prevention & Rehabilitation. 2004;11(6):489–96. DOI: 10.1097/01.hjr.0000152242.51327.63Chiappa GR, Roseguini BT, Vieira PJC, Alves CN, Tavares A, Winkelmann ER et al. Inspiratory muscle training improves blood flow to resting and exercising limbs in patients with chronic heart failure. Journal of the American College of Cardiology. 2008;51(17):1663– 71. DOI: 10.1016/j.jacc.2007.12.045Chiappa GR, Roseguini BT, Vieira PJC, Alves CN, Tavares A, Winkelmann ER et al. Inspiratory muscle training improves blood flow to resting and exercising limbs in patients with chronic heart failure. Journal of the American College of Cardiology. 2008;51(17):1663– 71. DOI: 10.1016/j.jacc.2007.12.045Winkelmann ER, Chiappa GR, Lima COC, Viecili PRN, Stein R, Ribeiro JP. Addition of inspiratory muscle training to aerobic training improves cardiorespiratory responses to exercise in patients with heart failure and inspiratory muscle weakness. American Heart Journal. 2009;158(5):768.e1-768.e7. DOI: 10.1016/j.ahj.2009.09.005Winkelmann ER, Chiappa GR, Lima COC, Viecili PRN, Stein R, Ribeiro JP. Addition of inspiratory muscle training to aerobic training improves cardiorespiratory responses to exercise in patients with heart failure and inspiratory muscle weakness. American Heart Journal. 2009;158(5):768.e1-768.e7. DOI: 10.1016/j.ahj.2009.09.005Floras JS. Sympathetic activation in human heart failure: diverse mechanisms, therapeutic opportunities. Acta Physiologica Scandinavica. 2003;177(3):391–8. DOI: 10.1046/j.1365201X.2003.01087.xFloras JS. Sympathetic activation in human heart failure: diverse mechanisms, therapeutic opportunities. Acta Physiologica Scandinavica. 2003;177(3):391–8. DOI: 10.1046/j.1365201X.2003.01087.xOpasich C, Ambrosino N, Fеlicеtti G, Aquilani R, Pasini E, Bergitto D et al. Heart failure-related myopathy. Clinical and pathophysiological insights. European Heart Journal. 1999;20(16):1191–200. DOI: 10.1053/euhj.1999.1523Opasich C, Ambrosino N, Fеlicеtti G, Aquilani R, Pasini E, Bergitto D et al. Heart failure-related myopathy. Clinical and pathophysiological insights. European Heart Journal. 1999;20(16):1191–200. DOI: 10.1053/euhj.1999.1523Cahalin LP, Semigran MJ, Dec GW. Inspiratory Muscle Training in Patients With Chronic Heart Failure Awaiting Cardiac Transplantation: Results of a Pilot Clinical Trial. Physical Therapy. 1997;77(8):830–8. DOI: 10.1093/ptj/77.8.830Cahalin LP, Semigran MJ, Dec GW. Inspiratory Muscle Training in Patients With Chronic Heart Failure Awaiting Cardiac Transplantation: Results of a Pilot Clinical Trial. Physical Therapy. 1997;77(8):830–8. DOI: 10.1093/ptj/77.8.830Martínez A, Lisboa C, Jalil J, Muñoz V, Díaz O, Casanegra P et al. Selective training of respiratory muscles in patients with chronic heart failure. Revista Medica De Chile. 2001;129(2):133–9. PMID: 11351463Martínez A, Lisboa C, Jalil J, Muñoz V, Díaz O, Casanegra P et al. Selective training of respiratory muscles in patients with chronic heart failure. Revista Medica De Chile. 2001;129(2):133–9. PMID: 11351463Laoutaris ID, Dritsas A, Brown MD, Manginas A, Kallistratos MS, Degiannis D et al. Immune response to inspiratory muscle training in patients with chronic heart failure. European Journal of Cardiovascular Prevention & Rehabilitation. 2007;14(5):679–86. DOI: 10.1097/HJR.0b013e3281338394Laoutaris ID, Dritsas A, Brown MD, Manginas A, Kallistratos MS, Degiannis D et al. Immune response to inspiratory muscle training in patients with chronic heart failure. European Journal of Cardiovascular Prevention & Rehabilitation. 2007;14(5):679–86. DOI: 10.1097/HJR.0b013e3281338394Laoutaris ID, Dritsas A, Brown MD, Manginas A, Kallistratos MS, Chaidaroglou A et al. Effects of Inspiratory Muscle Training on Autonomic Activity, Endothelial Vasodilator Function, and N-Terminal Pro-brain Natriuretic Peptide Levels in Chronic Heart Failure. Journal of Cardiopulmonary Rehabilitation and Prevention. 2008;28(2):99– 106. DOI: 10.1097/01.HCR.0000314203.09676.b9Laoutaris ID, Dritsas A, Brown MD, Manginas A, Kallistratos MS, Chaidaroglou A et al. Effects of Inspiratory Muscle Training on Autonomic Activity, Endothelial Vasodilator Function, and N-Terminal Pro-brain Natriuretic Peptide Levels in Chronic Heart Failure. Journal of Cardiopulmonary Rehabilitation and Prevention. 2008;28(2):99– 106. DOI: 10.1097/01.HCR.0000314203.09676.b9Padula CA, Yeaw E, Mistry S. A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research. 2009;22(1):18–25. DOI: 10.1016/j.apnr.2007.02.002Padula CA, Yeaw E, Mistry S. A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research. 2009;22(1):18–25. DOI: 10.1016/j.apnr.2007.02.002Laoutaris ID, Adamopoulos S, Manginas A, Panagiotakos DB, Kallistratos MS, Doulaptsis C et al. Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study. International Journal of Cardiology. 2013;167(5):1967–72. DOI: 10.1016/j.ijcard.2012.05.019Laoutaris ID, Adamopoulos S, Manginas A, Panagiotakos DB, Kallistratos MS, Doulaptsis C et al. Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study. International Journal of Cardiology. 2013;167(5):1967–72. DOI: 10.1016/j.ijcard.2012.05.019

The authors declare that there are no conflicts of interest present.