Selection of the optimal respiratory muscle training mode in patients with class II-III chronic heart failure

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.

1. Mancini 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: 7805234

2. Weiner 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.4960221110

3. Piepoli 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/hfr017

4. Smart 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.2012.04.029

5. Arutyunov 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.2017.1.2339

6. Souza 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/glu182

7. Arutyunov 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.2019.1.2625

8. Tucker 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.2017.07.002

9. Tucker 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/s11897-018-0408-6

10. Meyer 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.103.17.2153

11. 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.

12. 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.0b013e3181e52e69

13. Froelicher VF, Myers J. Manual of exercise testing. – US: Mosby;2007. – 349 p. ISBN 0-323-03302-4

14. Kolesnikova 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: 10.1177/2047487312448008

15. 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]

16. Arutyunov G.P., Kolesnikova E.A., Rylova A.K. Current approaches to rehabilitation of patients with chronic heart failure. CardioSomatika. 2010;1:20–4.

17. 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.2014.09.002

18. Sadek 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: 10.1177/2047487318792315

19. Wu 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.12586

20. Gomes 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: 10.1177/0269215518784345

21. Jugdutt 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-X

22. Principles 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 978-07216-3304-6

23. Johnson 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.1998.1024

24. Dall’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.2005.09.052

25. Bosnak-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.2011.05.001

26. Laoutaris 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.0000152242.51327.63

27. Chiappa 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.2007.12.045

28. Winkelmann 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.2009.09.005

29. Floras 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.x

30. Opasich 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.1999.1523

31. Cahalin 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/77.8.830

32. Martínez 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: 11351463

33. Laoutaris 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.0b013e3281338394

34. Laoutaris 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.b9

35. Padula 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.2007.02.002

36. Laoutaris 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