Inspiratory Muscle Training in Patients with Heart Failure

Hugo Fernandez-Rubio, Ricardo Becerro-de-Bengoa-Vallejo, David Rodríguez-Sanz, César Calvo-Lobo, Davinia Vicente-Campos, J L Chicharro, Hugo Fernandez-Rubio, Ricardo Becerro-de-Bengoa-Vallejo, David Rodríguez-Sanz, César Calvo-Lobo, Davinia Vicente-Campos, J L Chicharro

Abstract

Background: Prior systematic reviews and meta-analysis addressed that inspiratory muscle training (IMT) improved inspiratory muscle weakness, cardiorespiratory fitness and quality of life similar to conventional exercise training as a first alternative in deconditioned patients with heart failure (HF) lead to a better adaptation to posterior exercise training. The heterogeneity and variability in a wide range of new studies about this topic led to the necessity of an updated and comprehensive narrative review. The present review aimed to analyze and update the most relevant studies about IMT in patients who suffer from HF.

Methods: A narrative review was carried out about IMT in HF patients including 26 experimental studies divided into 21 clinical trials and 5 quasi-experimental studies identified through database searching in PubMed, Cochrane and PEDro.

Results: There is enough evidence to state that IMT produces improvements in functional capacity of patients with HF. Nevertheless, there is not enough evidence to support that IMT could improve cardiovascular parameters, blood biomarkers or quality of life in these patients.

Conclusions: Thus, IMT may be recommended to improve functional capacity in patients who suffer from HF; nevertheless, more evidence is needed regarding cardiovascular parameters, biomarkers and quality of life. Furthermore, mortality or HF hospitalization was not evaluated and most studies were not longer than 3 months. According to IMT protocols and study designs heterogeneity and mid-term follow-up, further investigations through high-quality long-term randomized clinical trials should be performed to achieve systematic reviews and meta-analysis to support strong evidence for IMT in HF patients.

Keywords: heart failure; maximal respiratory pressures; resistance training; respiration.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of the narrative review.

References

    1. Chaudhry S.P., Stewart G.C. Advanced Heart Failure: Prevalence, Natural History and Prognosis. Heart Fail. Clin. 2016;12:323–333. doi: 10.1016/j.hfc.2016.03.001.
    1. Tanai E., Frantz S. Comprehensive Physiology. Volume 6. John Wiley & Sons, Inc.; Hoboken, NJ, USA: 2015. Pathophysiology of Heart Failure; pp. 187–214.
    1. Dickstein K., Cohen-Solal A., Filippatos G., McMurray J.J.V., Ponikowski P., Poole-Wilson P.A., Strömberg A., Van Veldhuisen D.J., Atar D., Hoes A.W., et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur. Heart J. 2008;29:2388–2442.
    1. Lloyd-Jones D., Adams R.J., Brown T.M., Carnethon M., Dai S., De Simone G., Ferguson T.B., Ford E., Furie K., Gillespie C., et al. Executive summary: Heart disease and stroke statistics—2010 update: A report from the american heart association. Circulation. 2010;121:948–954.
    1. Fisher J.D. New York Heart Association Classification. Arch. Intern. Med. 1972;129:836. doi: 10.1001/archinte.1972.00320050160023.
    1. Lalande S., Cross T.J., Keller-Ross M.L., Morris N.R., Johnson B.D., Taylor B.J. Exercise Intolerance in Heart Failure: Central Role for the Pulmonary System. Exerc. Sport Sci. Rev. 2020;48:11–19. doi: 10.1249/JES.0000000000000208.
    1. Nakagawa N.K., Diz M.A., Kawauchi T.S., de Andrade G.N., Umeda I.I.K., Murakami F.M., Oliveira-Maul J.P., Nascimento J.A., Nunes N., Takada J.Y., et al. Risk Factors for Inspiratory Muscle Weakness in Chronic Heart Failure. Respir. Care. 2020;65:507–516. doi: 10.4187/respcare.06766.
    1. Clark A.L., Poole-Wilson P.A., Coats A.J.S. Exercise limitation in chronic heart failure: Central role of the periphery. J. Am. Coll. Cardiol. 1996;28:1092–1102. doi: 10.1016/S0735-1097(96)00323-3.
    1. Hammond M.D., Bauer K.A., Sharp J.T., Rocha R.D. Respiratory muscle strength in congestive heart failure. Chest. 1990;98:1091–1094. doi: 10.1378/chest.98.5.1091.
    1. Walsh J.T., Andrews R., Johnson P., Phillips L., Cowley A.J., Kinnear W.J.M. Inspiratory muscle endurance in patients with chronic heart failure. Heart. 1996;76:332–336. doi: 10.1136/hrt.76.4.332.
    1. Laoutaris I.D. The ‘aerobic/resistance/inspiratory muscle training hypothesis in heart failure’. Eur. J. Prev. Cardiol. 2018;25:1257–1262. doi: 10.1177/2047487318776097.
    1. Mancini D.M., Henson D., Lamanca J., Levine S. Evidence of reduced respiratory muscle endurance in patients with heart failure. J. Am. Coll. Cardiol. 1994;24:972–981. doi: 10.1016/0735-1097(94)90858-3.
    1. Nilsson Jr. K., Duscha B., Hranitzky P., Kraus W. Chronic Heart Failure and Exercise Intolerance: The Hemodynamic Paradox. Curr. Cardiol. Rev. 2008;4:92–100. doi: 10.2174/157340308784245757.
    1. Clark A.L. Origin of symptoms in chronic heart failure. Heart. 2006;92:12–16. doi: 10.1136/hrt.2005.066886.
    1. Boushel R. Muscle metaboreflex control of the circulation during exercise. Acta Physiol. 2010;199:367–383. doi: 10.1111/j.1748-1716.2010.02133.x.
    1. Katayama K., Saito M. Muscle sympathetic nerve activity during exercise. J. Physiol. Sci. 2019;69:589–598. doi: 10.1007/s12576-019-00669-6.
    1. Vissing J., Vissing S.F., MacLean D.A., Saltin B., Quistorff B., Haller R.G. Sympathetic activation in exercise is not dependent on muscle acidosis: Direct evidence from studies in metabolic myopathies. J. Clin. Invest. 1998;101:1654–1660. doi: 10.1172/JCI555.
    1. Fisher J.P., Young C.N., Fadel P.J. Autonomic adjustments to exercise in humans. Compr. Physiol. 2015;5:475–512.
    1. Romer L.M., Polkey M.I. Exercise-induced respiratory muscle fatigue: Implications for performance. J. Appl. Physiol. 2008;104:879–888. doi: 10.1152/japplphysiol.01157.2007.
    1. Moreno A.M., Toledo-Arruda A.C., Lima J.S., Duarte C.S., Villacorta H., Nóbrega A.C.L. Inspiratory Muscle Training Improves Intercostal and Forearm Muscle Oxygenation in Patients With Chronic Heart Failure: Evidence of the Origin of the Respiratory Metaboreflex. J. Card. Fail. 2017;23:672–679. doi: 10.1016/j.cardfail.2017.05.003.
    1. Yamada K., Kinugasa Y., Sota T., Miyagi M., Sugihara S., Kato M., Yamamoto K. Inspiratory Muscle Weakness is Associated with Exercise Intolerance in Patients with Heart Failure with Preserved Ejection Fraction: A Preliminary Study. J. Card. Fail. 2016;22:38–47. doi: 10.1016/j.cardfail.2015.10.010.
    1. 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;16:261–268. doi: 10.1590/S1413-35552012005000034.
    1. Taylor B.J., Bowen T.S. Respiratory Muscle Weakness in Patients with Heart Failure: Time to Make It a Standard Clinical Marker and a Need for Novel Therapeutic Interventions? J. Card. Fail. 2018;24:217–218. doi: 10.1016/j.cardfail.2018.02.007.
    1. Ribeiro J.P., Chiappa G.R., Neder A.J., Frankenstein L. Respiratory muscle function and exercise intolerance in heart failure. Curr. Heart Fail. Rep. 2009;6:95–101. doi: 10.1007/s11897-009-0015-7.
    1. Guazzi M. Alveolar Gas Diffusion Abnormalities in Heart Failure. J. Card. Fail. 2008;14:695–702. doi: 10.1016/j.cardfail.2008.06.004.
    1. Meyer F.J., Zugck C., Haass M., Otterspoor L., Strasser R.H., Kubler W., Borst M.M. Inefficient ventilation and reduced respiratory muscle capacity in congestive heart failure. Basic Res. Cardiol. 2000;95:333–342. doi: 10.1007/s003950070053.
    1. Cahalin L.P., Arena R., Guazzi M., Myers J., Cipriano G., Chiappa G., Lavie C.J., Forman D.E. Inspiratory muscle training in heart disease and heart failure: A review of the literature with a focus on method of training and outcomes. Expert Rev. Cardiovasc. Ther. 2013;11:161–177. doi: 10.1586/erc.12.191.
    1. Ross Arena; Marco Guazzi; Jonathan Myers Ventilatory Abnormalities During Exercise in Heart Failure: A Mini Review. Curr. Respir. Med. Rev. 2007;3:179–187. doi: 10.2174/157339807781387517.
    1. Wasserman K., Zhang Y.Y., Gitt A., Belardinelli R., Koike A., Lubarsky L., Agostoni P.G. Lung function and exercise gas exchange in chronic heart failure. Circulation. 1997;96:2221–2227. doi: 10.1161/01.CIR.96.7.2221.
    1. Dall’Ago P., Chiappa G.R.S., Guths H., Stein R., Ribeiro J.P. Inspiratory muscle training in patients with heart failure and inspiratory muscle weakness: A randomized trial. J. Am. Coll. Cardiol. 2006;47:757–763. doi: 10.1016/j.jacc.2005.09.052.
    1. Padula C.A., Yeaw E., Mistry S. A home-based nurse-coached inspiratory muscle training intervention in heart failure. Appl. Nurs. Res. 2009;22:18–25. doi: 10.1016/j.apnr.2007.02.002.
    1. Meyer F.J., Borst M.M., Zugck C., Kirschke A., Schellberg D., Kübler W., Haass M. Respiratory muscle dysfunction in congestive heart failure: Clinical correlation and prognostic significance. Circulation. 2001;103:2153–2158. doi: 10.1161/01.CIR.103.17.2153.
    1. Montemezzo D., Fregonezi G.A., Pereira D.A., Britto R.R., Reid W.D. Influence of inspiratory muscle weakness on inspiratory muscle training responses in chronic heart failure patients: A systematic review and meta-analysis. Arch. Phys. Med. Rehabil. 2014;95:1398–1407. doi: 10.1016/j.apmr.2014.02.022.
    1. Plentz R.D.M., Sbruzzi G., Ribeiro R.A., Ferreira J.B., Dal Lago P. Inspiratory muscle training in patients with heart failure: Meta-analysis of randomized trials. Arq. Bras. Cardiol. 2012;99:762–771. doi: 10.1590/S0066-782X2012001100011.
    1. Weiner P., Waizman J., 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. Clin. Cardiol. 1999;22:727–732. doi: 10.1002/clc.4960221110.
    1. Hamazaki N., Masuda T., Kamiya K., Matsuzawa R., Nozaki K., Maekawa E., Noda C., Yamaoka-Tojo M., Ako J. Respiratory muscle weakness increases dead-space ventilation ratio aggravating ventilation–perfusion mismatch during exercise in patients with chronic heart failure. Respirology. 2019;24:154–161. doi: 10.1111/resp.13432.
    1. McParland C., Krishnan B., Wang Y., Gallagher C.G. Inspiratory muscle weakness and dyspnea in chronic heart failure. Am. Rev. Respir. Dis. 1992;146:467–472. doi: 10.1164/ajrccm/146.2.467.
    1. Tikunov B., Levine S., Mancini D. Chronic congestive heart failure elicits adaptations of endurance exercise in diaphragmatic muscle. Circulation. 1997;95:910–916. doi: 10.1161/01.CIR.95.4.910.
    1. Hart N., Kearney M.T., Pride N.B., Green M., Lofaso F., Shah A.M., Moxham J., Polkey M.I. Inspiratory muscle load and capacity in chronic heart Failure. Thorax. 2004;59:477–482. doi: 10.1136/thx.2003.007724.
    1. Giallauria F., Piccioli L., Vitale G., Sarullo F.M. Exercise training in patients with chronic heart failure: A new challenge for cardiac rehabilitation community. Monaldi Arch. Chest Dis. 2018;88:38–44. doi: 10.4081/monaldi.2018.987.
    1. Cahalin L.P., Arena R.A. Breathing exercises and inspiratory muscle training in heart failure. Heart Fail. Clin. 2015;11:149–172. doi: 10.1016/j.hfc.2014.09.002.
    1. Reis M.S., Arena R., Archiza B., De Toledo C.F., Catai A.M., Borghi-Silva A. Deep breathing heart rate variability is associated with inspiratory muscle weakness in chronic heart failure. Physiother. Res. Int. 2014;19:16–24. doi: 10.1002/pri.1552.
    1. Freeman A.M., Taub P.R., Lo H.C., Ornish D. Intensive Cardiac Rehabilitation: An Underutilized Resource. Curr. Cardiol. Rep. 2019;21:19. doi: 10.1007/s11886-019-1104-1.
    1. 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;167:1502–1507. doi: 10.1016/j.ijcard.2012.04.029.
    1. Moher D., Liberati A., Tetzlaff J., Altman D.G. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int. J. Surg. 2010;8:336–341. doi: 10.1016/j.ijsu.2010.02.007.
    1. Wong E., Selig S., Hare D.L. Respiratory muscle dysfunction and training in chronic heart failure. Heart Lung Circ. 2011;20:289–294. doi: 10.1016/j.hlc.2011.01.009.
    1. Lin S.-J., McElfresh J., Hall B., Bloom R., Farrell K. Inspiratory Muscle Training in Patients with Heart Failure: A Systematic Review. Cardiopulm. Phys. Ther. J. 2012;23:29–36. doi: 10.1097/01823246-201223030-00005.
    1. Chiappa G.R., Roseguini B.T., Vieira P.J.C., Alves C.N., Tavares A., Winkelmann E.R., Ferlin E.L., Stein R., Ribeiro J.P. Inspiratory Muscle Training Improves Blood Flow to Resting and Exercising Limbs in Patients With Chronic Heart Failure. J. Am. Coll. Cardiol. 2008;51:1663–1671. doi: 10.1016/j.jacc.2007.12.045.
    1. Stein R., Chiappa G.R., Güths H., Dall’Ago P., Ribeiro J.P. Inspiratory muscle training improves oxygen uptake efficiency slope in patients with chronic heart failure. J. Cardiopulm. Rehabil. Prev. 2009;29:392–395. doi: 10.1097/HCR.0b013e3181b4cc41.
    1. Winkelmann E.R., Chiappa G.R., Lima C.O.C., Viecili P.R.N., Stein R., Ribeiro J.P. 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;158:768.e1–768.e7. doi: 10.1016/j.ahj.2009.09.005.
    1. Bosnak-Guclu M., Arikan H., Savci S., Inal-Ince D., Tulumen E., Aytemir K., Tokgözoglu L. Effects of inspiratory muscle training in patients with heart failure. Respir. Med. 2011;105:1671–1681. doi: 10.1016/j.rmed.2011.05.001.
    1. Laoutaris I.D., Adamopoulos S., Manginas A., Panagiotakos D.B., Kallistratos M.S., Doulaptsis C., Kouloubinis A., Voudris V., Pavlides G., Cokkinos D.V., 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;167:1967–1972. doi: 10.1016/j.ijcard.2012.05.019.
    1. Adamopoulos S., Schmid J.P., Dendale P., Poerschke D., Hansen D., Dritsas A., Kouloubinis A., Alders T., Gkouziouta A., Reyckers I., et al. Combined aerobic/inspiratory muscle training vs. aerobic training in patients with chronic heart failure: The Vent-HeFT trial: A European prospective multicentre randomized trial. Eur. J. Heart Fail. 2014;16:574–582. doi: 10.1002/ejhf.70.
    1. Marco E., Ramírez-Sarmiento A.L., Coloma A., Sartor M., Comin-Colet J., Vila J., Enjuanes C., Bruguera J., Escalada F., Gea J., et al. High-intensity vs. sham inspiratory muscle training in patients with chronic heart failure: A prospective randomized trial. Eur. J. Heart Fail. 2013;15:892–901. doi: 10.1093/eurjhf/hft035.
    1. Mello P.R., Guerra G.M., Borile S., Rondon M.U., Alves M.J., Negrão C.E., Dal Lago P., Mostarda C., Irigoyen M.C., Consolim-Colombo F.M. Inspiratory muscle training reduces sympathetic nervous activity and improves inspiratory muscle weakness and quality of life in patients with chronic heart failure. J. Cardiopulm. Rehabil. Prev. 2012;32:255–261. doi: 10.1097/HCR.0b013e31825828da.
    1. Palau P., Domínguez E., Núñez E., Schmid J.P., Vergara P., Ramón J.M., Mascarell B., Sanchis J., Chorro F.J., Núñez J. Effects of inspiratory muscle training in patients with heart failure with preserved ejection fraction. Eur. J. Prev. Cardiol. 2014;21:1465–1473. doi: 10.1177/2047487313498832.
    1. Palau P., Domínguez E., López L., Ramón J.M., Heredia R., González J., Santas E., Bodí V., Miñana G., Valero E., et al. Inspiratory Muscle Training and Functional Electrical Stimulation for Treatment of Heart Failure With Preserved Ejection Fraction: The TRAINING-HF Trial. Rev. Española Cardiol. 2019;72:288–297. doi: 10.1016/j.recesp.2018.01.024.
    1. Palau P., Domínguez E., Ramón J.M., López L., Briatore A.E., Tormo J.P., Ventura B., Chorro F.J., Núñez J. Home-based inspiratory muscle training for management of older patients with heart failure with preserved ejection fraction: Does baseline inspiratory muscle pressure matter? Eur. J. Cardiovasc. Nurs. 2019;18:621–627. doi: 10.1177/1474515119855183.
    1. Taya M., Amiya E., Hatano M., Maki H., Hosoya Y., Ishida J., Bujo C., Tsuji M., Konishi Y., Yokota K., et al. Inspiratory muscle training for advanced heart failure with lamin-related muscular dystrophy. J. Cardiol. Cases. 2019;20:232–234. doi: 10.1016/j.jccase.2019.09.007.
    1. Kawauchi T.S., Umeda I.I.K., Braga L.M., Mansur A. de P.; Rossi-Neto, J.M.; Guerra de Moraes Rego Sousa, A.; Hirata, M.H.; Cahalin, L.P.; Nakagawa, N.K. Is there any benefit using low-intensity inspiratory and peripheral muscle training in heart failure? A randomized clinical trial. Clin. Res. Cardiol. 2017;106:676–685. doi: 10.1007/s00392-017-1089-y.
    1. Hossein Pour A.H., Gholami M., Saki M., Birjandi M. The effect of inspiratory muscle training on fatigue and dyspnea in patients with heart failure: A randomized, controlled trial. Jpn. J. Nurs. Sci. 2019 doi: 10.1111/jjns.12290.
    1. Hornikx M., Buys R., Cornelissen V., Deroma M., Goetschalckx K. Effectiveness of high intensity interval training supplemented with peripheral and inspiratory resistance training in chronic heart failure: A pilot study. Acta Cardiol. 2019 doi: 10.1080/00015385.2019.1591676.
    1. Martínez A., Lisboa C., Jalil J., Muñoz V., Díaz O., Casanegra P., Corbalán R., Vásquez A.M., Leiva A. [Selective training of respiratory muscles in patients with chronic heart failure] Rev. Med. Chil. 2001;129:133–139.
    1. Mancini D.M., 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;91:320–329. doi: 10.1161/01.CIR.91.2.320.
    1. Cahalin L.P., Semigran M.J., Dec G.W. Inspiratory muscle training in patients with chronic heart failure awaiting cardiac transplantation: Results of a pilot clinical trial. Phys. Ther. 1997;77:830–838. doi: 10.1093/ptj/77.8.830.
    1. Johnson P. A randomized controlled trial of inspiratory muscle training in stable chronic heart failure. Eur. Heart J. 1998;19:1249–1253. doi: 10.1053/euhj.1998.1024.
    1. Laoutaris I., Dritsas A., Brown M.D., Manginas A., Alivizatos P.A., Cokkinos D.V. Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure. Eur. J. Prev. Cardiol. 2004;11:489–496. doi: 10.1097/00149831-200412000-00008.
    1. Laoutaris I.D., Dritsas A., Brown M.D., Manginas A., Kallistratos M.S., Degiannis D., Chaidaroglou A., Panagiotakos D.B., Alivizatos P.A., Cokkinos D.V. Immune response to inspiratory muscle training in patients with chronic heart failure. Eur. J. Prev. Cardiol. 2007;14:679–686. doi: 10.1097/HJR.0b013e3281338394.
    1. Laoutaris I.D., Dritsas A., Brown M.D., Manginas A., Kallistratos M.S., Chaidaroglou A., Degiannis D., Alivizatos P.A., Cokkinos D.V. Effects of inspiratory muscle training on autonomic activity, endothelial vasodilator function, and N-terminal pro-brain natriuretic peptide levels in chronic heart failure. J. Cardiopulm. Rehabil. Prev. 2008;28:99–106. doi: 10.1097/01.HCR.0000314203.09676.b9.
    1. Olson T.P., Joyner M.J., Dietz N.M., Eisenach J.H., Curry T.B., Johnson B.D. Effects of respiratory muscle work on blood flow distribution during exercise in heart failure. J. Physiol. 2010;588:2487–2501. doi: 10.1113/jphysiol.2009.186056.
    1. Palau P., Domínguez E., Núñez E., Ramón J.M., López L., Melero J., Bellver A., Chorro F.J., Bodí V., Bayés-Genis A., et al. Inspiratory Muscle Function and Exercise Capacity in Patients With Heart Failure With Preserved Ejection Fraction. J. Card. Fail. 2017;23:480–484. doi: 10.1016/j.cardfail.2017.04.016.
    1. Llàcer P., Bayés-Genís A., Núñez J. Carbohydrate antigen 125 in heart failure. New era in the monitoring and control of treatment. Med. Clin. 2019;152:266–273. doi: 10.1016/j.medcli.2018.08.020.

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