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COPD patients with severe diffusion defect in carbon monoxide diffusing capacity predict a better outcome for pulmonary rehabilitation
a Dr Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital, Pulmonary Rehabilitation Unit, Izmir, Turkey
b Katip Celebi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation
c Dr Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital, Department of Chest Diseases, Izmir, Turkey
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Quintas-Neves, J. Preto, M. Drummond" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Quintas-Neves" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Preto" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Drummond" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351151630046X?idApp=UINPBA00004E" "url" => "/21735115/0000002200000006/v1_201612110145/S217351151630046X/v1_201612110145/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173511516300410" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2016.05.005" "estado" => "S300" "fechaPublicacion" => "2016-11-01" "aid" => "1176" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2016;22:315-22" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1545 "formatos" => array:3 [ "EPUB" => 217 "HTML" => 787 "PDF" => 541 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Acute exercise amplifies inflammation in obese patients with COPD" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "315" "paginaFinal" => "322" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 394 "Ancho" => 2271 "Tamanyo" => 27976 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Blood sampling scheme and maximal exercise test.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Rodrigues, A.L. Papoila, D. Ligeiro, M.J.M. Gomes, H. Trindade" "autores" => array:5 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "A.L." "apellidos" => "Papoila" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Ligeiro" ] 3 => array:2 [ "nombre" => "M.J.M." "apellidos" => "Gomes" ] 4 => array:2 [ "nombre" => "H." "apellidos" => "Trindade" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511516300410?idApp=UINPBA00004E" "url" => "/21735115/0000002200000006/v1_201612110145/S2173511516300410/v1_201612110145/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "COPD patients with severe diffusion defect in carbon monoxide diffusing capacity predict a better outcome for pulmonary rehabilitation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "323" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "H. Sahin, I. Naz, Y. Varol, N. Aksel, F. Tuksavul, A. Ozsoz" "autores" => array:6 [ 0 => array:3 [ "nombre" => "H." "apellidos" => "Sahin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Naz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0015" ] ] ] 2 => array:4 [ "nombre" => "Y." "apellidos" => "Varol" "email" => array:1 [ 0 => "yeldavatansever@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "N." "apellidos" => "Aksel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "F." "apellidos" => "Tuksavul" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Ozsoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Dr Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital, Pulmonary Rehabilitation Unit, Izmir, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Katip Celebi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation" "etiqueta" => "b" "identificador" => "aff0015" ] 2 => array:3 [ "entidad" => "Dr Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital, Department of Chest Diseases, Izmir, Turkey" "etiqueta" => "c" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1080 "Ancho" => 1532 "Tamanyo" => 87851 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Exercise capacity (6<span class="elsevierStyleHsp" style=""></span>minute walk test) of the patients before and after pulmonary rehabilitation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 for within group change, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.16 between groups).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) is defined by airflow limitation and is a complex pathological condition. COPD is associated with an important reduction in physical activity that contributes to the patient's disability and poor health-related quality of life. Pulmonary rehabilitation (PR) is aimed to eliminate or at least attenuate these difficulties.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1,2</span></a> Therefore, PR has been recommended as an integral part of management for patients with COPD.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">3,4</span></a> However, the responses to PR may vary significantly among individuals. Although there are many studies mentioning changes of FEV1, FVC, FEV1/FVC after PR, in some studies, significant changes in forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and FEV1/FVC values were not detected after PR.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">5–8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diffusing capacity for carbon monoxide (D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>) is a common and clinically useful test that provides a quantitative measure of gas transfer in the lungs.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">9</span></a> The decrease in Dl<span class="elsevierStyleInf">CO</span>, one of the first signs of disease progression, can point out the arterial O<span class="elsevierStyleInf">2</span> desaturation during exercise. For COPD patients with low D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> values pose a high risk for poor survival.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">10</span></a> Although PR is known to have many effects on functional outcomes of COPD patients, there is not enough information about the diffusion capacity in terms of PR outcome.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">2</span></a> Also in a recent study authors suggest that diffusing capacity was the strongest predictor of exercise capacity in all subjects with COPD.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">11</span></a> Therefore can CO diffusion capacity be used to evaluate which patient will benefit more from PR program? Moreover will there be a significant change in CO diffusion capacity after PR program in patients with COPD?</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of our study was to compare the results of PR program on exercise capacity (6mWT) between COPD patients with moderate and severe diffusion defect detected by D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>. Our secondary aims were comparing the results of the program on arterial blood gas analysis, dyspnea sensation, exercise capacity, quality of life and psychological symptoms between two groups.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a prospective cohort study to compare the effectiveness of exercise training in COPD patients with moderate and severe diffusion defect. The study was approved by the local institutional review board. Patients included in the study completed an informed written consent form.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Subject selection</span><p id="par0025" class="elsevierStylePara elsevierViewall">We recruited COPD patients diagnosed according to Global initiative for Chronic Obstructive Lung Disease (GOLD) definition, stable from exacerbations (with no worsening of respiratory symptoms, no increase in the use of rescue medication, and no unscheduled visits due to COPD worsening) for at least 4 weeks. All patients were suffering from dyspnea, reduced exercise tolerance and limitation of daily living activities. The recruitment criteria included a minimum age of 40 years old, a history of 10 or more pack-years of smoking, a FEV1 of less than 80% of the predicted value after bronchodilator use and a ratio of FEV1 to FVC of 0.7 or less after bronchodilator use.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">12</span></a> The condition of the patients was graded according to the stages of disease defined by the GOLD.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">13</span></a> The patients’ self-reported respiratory symptoms, medications, smoking history, and coexisting medical conditions were documented at the beginning of the study. Comorbid diagnoses were established using the clinical history and physical examination findings during the visit and were supported by a review of the available medical records. We excluded patients who were suffering from acute exacerbation, history of other lung diseases, (pneumoconiosis, pulmonary tuberculosis, interstitial lung disease); and orthopedic, neurologic, or cardiovascular impairment that might render the subject incapable of completing the exercise training. Also subjects with lack of motivation, poor compliance (not attending the program more than 2 times) or having transport problems were excluded from the study. We grouped patients; those with diffusion capacity between 41 and 60% of predicted as moderate (group 1) and under 40% of predicted as severe (group 2) diffusion defect.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Measurement of pulmonary parameters and questionnaires</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients underwent cardiac and respiratory system examinations and were evaluated by chest X-rays and blood gases analysis. Pulmonary functions were assessed by measuring body plethysmography (Zan 500, Germany) and carbon monoxide diffusing capacity test (Zan 300, Germany). The DLCO maneuver begins with a full exhalation to residual volume (RV), the mouthpiece is then connected to the test gas (0.3 percent carbon monoxide [CO], 10 percent helium), and the subject inhales rapidly to total lung capacity. Following a 10<span class="elsevierStyleHsp" style=""></span>s breath hold, the subject exhales quickly and completely to RV. An alveolar sample of the exhaled gas is then analyzed for calculation of the dilution of helium and the uptake of CO. Dyspnea was assessed by Modified Medical Research Council (MMRC) dyspnea scale and modified BORG scales.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">3</span></a> Quality of life was assessed using disease specific St. George Respiratory Questionnaire and SF-36 health related quality of life questionnaire.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">15,16</span></a> Psychological symptoms were assessed by Hospital Anxiety and Depression Questionnaires.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">17,18</span></a> 6-Minute walking test was used which was defined by American Thoracic Society (ATS) standards.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> All measurements were assessed at admission and at the end of the PR.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pulmonary rehabilitation parameters</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients underwent an 8-week hospital based out-patient pulmonary rehabilitation program twice a week in our hospital's Pulmonary Rehabilitation Unit. Pulmonary rehabilitation was completely tailored to suit the needs of the individual. PR program consists of education, supervised exercise training, nutritional intervention and psychological counseling, if needed. Exercises were chosen for each patient for their ability to tolerate exercise and their disease severity. Exercises included; breathing exercises, treadmill (at least 15<span class="elsevierStyleHsp" style=""></span>minutes) and cycle training (at least 15<span class="elsevierStyleHsp" style=""></span>minutes), peripheral muscle training, and stretching exercises. Also we informed patients about medication advices, bronchial hygiene techniques, energy conservation, relaxation techniques for reducing dyspnea and home exercises.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">3</span></a> After respiratory physiotherapy education, upper and lower extremity stretching and strengthening exercises were performed. All strengthening exercises were started without a weight. During PR program according to the BORG scale<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">4–6</span></a> half a kilogram weight is added in every 4 periods of exercises. The treadmill and bicycle/arm ergometer were used for aerobic exercises. We calculated both workloads for cycling and walking speed for treadmill from six minutes’ walk test.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> Treadmill walking speed is calculated by 80% of average 6MWT speed using formula: (6mWT distance<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10)/1000<span class="elsevierStyleHsp" style=""></span>km/h. Cycling workload was calculated with the formula (Watt<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>103.217<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>(30.500<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>Sex)<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>(−1.613<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>age)<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>[(0.002<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>distance<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>weight)] sex; male<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1 female<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0). Patients were trained at 60–90% of maximum heart rate. Also we used BORG dyspnea scores for regulation of exercise.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">3–20</span></a> Exercise intensity increased according to the patient progress. During exercise we used pulse oximetry to supervise patients and if the SpO<span class="elsevierStyleInf">2</span> fell below 90% oxygen supplementation was provided.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">We performed statistical analyses using the SPSS 17.0 (Statistical Package for the Social Sciences, Chicago, Illinois). Descriptive statistics were performed for all the recorded variables. The normality of the data was evaluated by Kolmogorov Smirnow test. We used Mann Whitney-<span class="elsevierStyleItalic">U</span> test to compare baseline characteristics and changing outcomes as shown Δ values before and after PR. We used Wilcoxon test to compare variables between before and after PR. <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 value is considered as significant.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Demographic data</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 68 patients (61 men %90) participated in this study. Thirty-two (47%) patients had moderate diffusion defect [T<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>; 57 (47–61)<span class="elsevierStyleHsp" style=""></span>mmol/kPa] (group 1) and 36 (53%) patients had severe diffusion defect [T<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>; 29 (22–34)<span class="elsevierStyleHsp" style=""></span>mmol/kPa] (group 2). All patients had smoking history. Groups were similar in terms of age, gender and cigarette consumption (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). Body mass index (BMI) was significantly lower in patients with severe diffusion defect (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Initial measurements before PR</span><p id="par0050" class="elsevierStylePara elsevierViewall">When comparing initial measurements; exercise capacity, quality of life, FEV1, FEV1/FVC, PaO<span class="elsevierStyleInf">2</span>, SaO<span class="elsevierStyleInf">2</span> were significantly lower in group 2 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) before PR in comparison with group 1 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Also dyspnea sensation and anxiety levels were significantly higher in group 2 compared with group 1 before PR.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Initial measurements after PR</span><p id="par0055" class="elsevierStylePara elsevierViewall">After PR program there was a statistically significant increase in 6mWT in both groups (401–443<span class="elsevierStyleHsp" style=""></span>m for group 1, 328–388<span class="elsevierStyleHsp" style=""></span>m for group 2, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001, both) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In both groups PaO<span class="elsevierStyleInf">2</span> significantly increased after rehabilitation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05, both). After rehabilitation, significant improvement recorded in dyspnea sensation (mMRC scores) and SGRQ scores (−9 for group 1, −7 for group 2) in both groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There was no significant difference in both groups in term of <span class="elsevierStyleItalic">Δ</span>FEV1/FVC, <span class="elsevierStyleItalic">Δ</span>IC, <span class="elsevierStyleItalic">Δ</span>VC, <span class="elsevierStyleItalic">Δ</span>pH, <span class="elsevierStyleItalic">Δ</span>PaCO<span class="elsevierStyleInf">2</span>, <span class="elsevierStyleItalic">Δ</span>Role emotional scores (SF-36) and <span class="elsevierStyleItalic">Δ</span>mental health score (SF-36) after PR program.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Differences between groups 1 and 2</span><p id="par0060" class="elsevierStylePara elsevierViewall">When comparing changes between groups; in group 1 the average change in 6mWT was 40 (min 21, max 50) meters, while in group 2 the change was 50 (min 30, max 70) meters (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There was no significant difference between groups in terms of 6mWT change. The changes in PaO<span class="elsevierStyleInf">2</span> levels were significantly higher in group 2, compared to group 1 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Improvement of dyspnea sensation was significantly higher in patients with severe diffusion defect compared to group 1 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There was no difference in SGRQ scores, SF-36 and HAD scores between groups 1 and 2 comparing changes in QoL parameters (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In addition; FEV<span class="elsevierStyleInf">1</span>% and D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> increased in patients with only severe diffusion defect (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">In this study we found significant improvement in oxygenation (PaO<span class="elsevierStyleInf">2</span>), severity of dyspnea, exercise capacity and quality of life parameters in patents with moderate and severe diffusion defect after PR program. Additionally FEV<span class="elsevierStyleInf">1</span> and D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> increased significantly in patients with severe diffusion defect. When comparing changes between groups; improvement in dyspnea sensation was significantly higher in patients with severe diffusion defect.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All studies about effects of pulmonary rehabilitation on lung function have investigated FEV<span class="elsevierStyleInf">1</span>, FVC, FEV<span class="elsevierStyleInf">1</span>/FVC and blood gas analysis. There are few studies conducted on investigating the effect of PR program on different D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> groups.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">21,22</span></a> COPD is characterized by high morbidity and mortality. It remains unknown which aspect of lung function carries the most prognostic information. In a study of 604 COPD patients which were clinically stable it was concluded that D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> was the most powerful predictor of survival.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> In another study in patients with COPD it was emphasized that FEV1, IC and D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> were higher predictive regarding exercise capacity and D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> was the strongest predictor.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">11</span></a> In a 5-year follow up study it was found that decline in 12-minute walk test was mainly explained by deterioration in D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> and this measurements at baseline were the most important predictors of declining exercise capacity in COPD patients.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Single measurements of D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> in patients with COPD have shown that a reduced value in early disease is associated with accelerated decline in FEV1 and in advanced disease it predicts exercise capacity and mortality. In population studies a reduced D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> predicts all-cause mortality more strongly than a reduced FEV1. It also stated that repeated measurements of CO transfer in individuals were needed to increase the present poor knowledge of the natural history of the contribution of alveolar disease to the progression of COPD.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a> In a study performed in heavy smokers lower diffusing capacity was found to be directly correlated with decline FEV1/FVC ratio and a greater progression of CT – quantified emphysema.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a> Mohsenifar et al. demonstrated that patients with reduced D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>, particularly when <20% of predicted, were more likely to have reduced PaO<span class="elsevierStyleInf">2</span> at rest and were more likely to require supplemental oxygen with low levels of activity. They pointed out D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> was useful in evaluating whether supplemental oxygen is required for exercise.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a> In our study, consistent with the other studies, FEV1, FEV1/FVC, PaO<span class="elsevierStyleInf">2</span>, SaO<span class="elsevierStyleInf">2</span>, exercise capacity and quality of life scores were significantly lower in patients with severe diffusion defect before pulmonary rehabilitation.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">1,28</span></a> It has been demonstrated to improve exercise capacity, reduce symptoms of dyspnea and increase health-related quality of life.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28,32</span></a> Pulmonary function tests showed different results after pulmonary rehabilitation in previous studies. In most of them, significant changes in FEV1, FVC and FEV1/FVC values<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">5–8</span></a> were not detected. Because rehabilitation is a multicomponent intervention the results are controversial. In a study of 24 patients with COPD who carried out at least half an hour of pranayama breathing exercises for 3 months, despite significant increase in PEF values, there was no significant increase in FEV1 and FVC.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">33</span></a> Cecily et al. had observed that as well as FEV1 and FVC the value of PEFR (peak expiratory flow rate) significantly had increased in 100 patients with COPD.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">34</span></a> Shebl et al. concluded that FEV1 increased only in severe COPD but FVC and FEV1/FVC ratio was increased in the medium and severe COPD after the supervised two- month home based exercise program. However, these increases were not statistically significant.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">35</span></a> In a study comparing differences of improvement by gender, FEV1 and FVC increased in both; however they were greater in males after pulmonary rehabilitation program.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">36</span></a> When 225 patients were assessed according to severity of COPD; FEV1 increased significantly in stage 3 and 4, VC (vital capacity) increased significantly to 2.3 and 4, TLC (total lung capacity) decreased significantly only in stage 3, RV (residual volume) were significantly decreased in stage 3 and 4 after pulmonary rehabilitation program.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">37</span></a> Unlike other studies, after pulmonary rehabilitation for 3 years, there was not a significant fall in FEV1 at the end of the 3rd year.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Changes in arterial blood gas were evaluated less and the results vary in previous studies. In some of the studies PaO<span class="elsevierStyleInf">2</span>, PaCO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span> did not change<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6,29</span></a> but in some other studies both PaO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span> increased significantly after pulmonary rehabilitation.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">21–39</span></a> A study that assessed blood gas analysis according to severity of COPD showed that PaO<span class="elsevierStyleInf">2</span> increased significantly with stage 3 and 4, PaCO<span class="elsevierStyleInf">2</span> decreased significantly in stage 4 diseases after PR.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">37</span></a> There are few studies evaluating changes in diffusing capacity after PR. In a previous study conducted in our clinic there was a significant increase in D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> level after 8 week outpatient rehabilitation program in 44 patients with COPD.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Zanini et al. divided moderate to severe COPD patients (<span class="elsevierStyleItalic">n</span>: 75) into two groups depending on the change in 6MWT (responders >30<span class="elsevierStyleHsp" style=""></span>m and no responders ≤30<span class="elsevierStyleHsp" style=""></span>m). They showed that FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>50% pred. and TLCO<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>50% pred. were independent predictors of PR efficacy. They also found that complex COPD patients with poor lung function got more benefit from PR.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">39</span></a> Sixty patients were stratified into subgroups according to airway obstruction (FEV(1)<span class="elsevierStyleHsp" style=""></span>>= or <50% predicted), pulmonary hyperinflation (TLC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>or < or =120% predicted), BMI value (BMI > or < or =25), cardiovascular (CV) comorbidity, and resting PaO(2) (PaO(2)<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>= or <60<span class="elsevierStyleHsp" style=""></span>mmHg) levels, suggesting that subjects with poorer exercise capacity or quality of life had greater room for improvement.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">40</span></a> An observational study, which included 102 COPD patients who followed PR showed that patients with worse disease status (i.e. a combination of lower FEV1, more hyperinflation, lower exercise capacity and worse quadriceps force) improved most in endurance exercise capacity.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">41</span></a> Our results were similar to the results of these studies; although it did not reach statistical difference, there was an improvement in the exercise capacity of the patients with severe diffusion defect when comparing with the patients having moderate diffusion defect. It is possible that the improvement in 6MWT partially reflects the gain in DLCO and lung function or simply reflects the fact that subjects with worse COPD have more room for improvement than those with mild COPD. It may also indicate that emphysematous COPD subjects have a better chance of improvement from rehabilitation than chronic bronchitis. In addition, PaO<span class="elsevierStyleInf">2</span> and O<span class="elsevierStyleInf">2</span> saturation values were significantly increased in both groups with a little difference in favor of the patients with severe diffusion defect. In COPD patients, exercise capacity may decrease as a result of exercise intolerance, ventilation and gas exchange impairment, cardiac failure and pulmonary muscle dysfunction or combination of them. Hypoxia due to gas exchange dysfunction may directly or indirectly decrease exercise tolerance.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a> D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> which is a good predictor of gas exchange dysfunction can also predict exercise restriction perfectly.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">11</span></a> Older textbooks suggest that thickening of the alveolar-capillary membrane (in interstitial lung disease) and loss of alveolar membrane surface area (in emphysema) are the primary causes of a low DLCO.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">42</span></a> However, new experimental data suggest that diseases that influence the DLCO do so by reducing the volume of red blood cells in the pulmonary capillaries.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a> In healthy adults total volume of blood in lungs is less than 150<span class="elsevierStyleHsp" style=""></span>ml at rest.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a> Diseases which reduce alveolar-capillary surface area cause a reduction in the blood volume in the lungs. The blood volume in the pulmonary capillaries and the DLCO are increased during exercise.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">42</span></a> Therefore, we hypotheses that the increase in DLCO after PR may be due to the recruitment of pulmonary capillaries after exercise.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Patients with severe diffusion defects usually avoid exercise in daily life. However, PR program including aerobic and reinforcement exercise combination may improve their muscle power, exercise performance and quality of life, and may give them the courage to compete with their dyspnea symptom.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">44</span></a> Improvement in D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> and FEV1 in this group of patients may reflect the success in muscle exercise as a result of recruitment of pulmonary capillaries. Also by breathing exercises it is possible that the exercise may reverse some dead space ventilation, and make new areas of alveolar more available to gas exchange.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Seventy-four stable COPD patients were grouped according to MMRC dyspnea scale and evaluated after PR. There was an improvement in 6-minute walking test and SGRQ only in the patients with dyspnea score: grade 1/2 and grade 3/4 while the improvement in grade 5 patients was very limited. The authors suggested that baseline state is a poor predictor of response to rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> Despite that, in our study, baseline D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> levels were good predictors for better PR outcome. Although the MMRC and BORG scores were higher in patients with severe diffusion defect, these scores significantly decreased after PR. Also walking distance within group 2 (not statistically significant between groups) was increased significantly after PR. When the two groups were compared in terms of MMRC and BORG dyspnea score changes, the augmentation of MMRC and BORG score was significantly higher in patients with severe diffusion defect. Additionally, anxiety score was the only parameter decreased in patients with moderate diffusion defect whereas both anxiety score and depression score were decreased in patients with severe diffusion defect.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">We concluded that pulmonary rehabilitation improves oxygenation, severity of dyspnea, exercise capacity and quality of life in patents with COPD independent of carbon monoxide diffusion capacity levels. Furthermore pulmonary rehabilitation may improve D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> and FEV1 values in COPD patients with severe diffusion defect. However long-term follow up studies are needed to have the best results from rehabilitation programs.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no declarations of interest to report.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical responsibilities</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres771347" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec772533" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Subject selection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Measurement of pulmonary parameters and questionnaires" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Pulmonary rehabilitation parameters" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 4 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Demographic data" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Initial measurements before PR" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Initial measurements after PR" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Differences between groups 1 and 2" ] ] ] 5 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusion" ] 7 => array:3 [ "identificador" => "sec0070" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-07" "fechaAceptado" => "2016-03-06" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec772533" "palabras" => array:6 [ 0 => "6-Minute walk test" 1 => "Pulmonary rehabilitation" 2 => "Pulmonary function tests" 3 => "DLCO" 4 => "Quality of life" 5 => "Dyspnea" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to compare the effects of pulmonary rehabilitation (PR) on six-minute walk test (6mWT) between chronic obstructive pulmonary disease (COPD) patients with moderate or severe carbon monoxide diffusion defects. We also evaluated dyspnea sensation, pulmonary functions, blood gases analysis, quality of life parameters and psychological symptoms in both groups before and after pulmonary rehabilitation.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients with COPD underwent a comprehensive 8-week out-patient PR program participated in this study. Patients grouped according to diffusion capacity as moderate or severe. Outcome measures were exercise capacity (6mWT), dyspnea sensation, pulmonary function tests, blood gases analysis, quality of life (QoL) and psychological symptoms.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 68 patients enrolled in the study. Thirty-two (47%) of them had moderate diffusion defect [T<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>; 52 (47–61)<span class="elsevierStyleHsp" style=""></span>mmol/kPa] and 36 (53%) of them had severe diffusion defect [T<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span>; 29 (22–34)<span class="elsevierStyleHsp" style=""></span>mmol/kPa]. At the end of the program, PaO<span class="elsevierStyleInf">2</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001), Modified Medical Research Council dyspnea scale (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001), 6mWT (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and quality of life parameters improved significantly in both groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). Also the improvement in D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04) value and FEV<span class="elsevierStyleInf">1</span>% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01) reached a statistically significant level in patients with severe diffusion defect. When comparing changes between groups, dyspnea reduced significantly in patients with severe diffusion defect (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pulmonary rehabilitation improves oxygenation, severity of dyspnea, exercise capacity and quality of life independent of level of carbon monoxide diffusion capacity in patents with COPD. Furthermore pulmonary rehabilitation may improve D<span class="elsevierStyleSmallCaps">l</span><span class="elsevierStyleInf">CO</span> values in COPD patients with severe diffusion defect.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1080 "Ancho" => 1532 "Tamanyo" => 87851 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Exercise capacity (6<span class="elsevierStyleHsp" style=""></span>minute walk test) of the patients before and after pulmonary rehabilitation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 for within group change, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.16 between groups).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Data are expressed as median (interquartile range) or %, BMI: body mass index, FEV<span class="elsevierStyleInf">1</span>: forced expiratory volume in the 1<span class="elsevierStyleHsp" style=""></span>s, FVC: forced vital capacity, IC: inspiratory capacity, VC: vital capacity, PaCO<span class="elsevierStyleInf">2</span>: partial arterial carbon dioxide pressure. SaO<span class="elsevierStyleInf">2</span>: arterial oxygen saturation, 6MWD: six minutes walk distance, MMRC: Medical Research Council Dyspnea Scale, HAD: Hospital Anxiety and Depression Scale, SGRQ: St. George Respiratory Questionnaire, SF-36: Short-Form Health Survey.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>32) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (55, 66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (57, 67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.168 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI (kg/m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (26, 31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (20, 28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male gender n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (93.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (86.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.434 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking (p/years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (33, 70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (47, 80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.308 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FEV1 (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (37, 63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (25, 50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FEV1/FVC</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (54, 72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (41, 65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IC (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 (41, 86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (37, 65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.052 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">VC (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (56, 77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (46, 79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.212 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">DLCO</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (47–61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (22–34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.41 (7.39, 7.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.40 (7.38, 7.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.912 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 (67, 83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (58, 75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.020 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (38, 43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (36, 47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.483 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SaO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (93, 96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 (90, 95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.009 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">6MWD (meters)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">414 (352, 464) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">340 (300, 380) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔBORG</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.5, 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1, 3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.014 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">MMRC</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2, 3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3, 4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HADa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 (3, 8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (6, 14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HADd</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3, 9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 (5, 11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.095 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">SGRQ</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (30, 58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (51, 79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 (42, 67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (59, 92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Impact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (27, 46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (35, 69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 (31, 55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (46, 72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">SF36</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Physical functioning (PF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (40, 85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (20, 65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.023 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Social functioning (SF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 (62, 100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (25, 75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Role physical (RF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (0, 100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0, 50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.151 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Role emotional (RE) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (0, 100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (0, 100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.091 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>General health (GH) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (30, 67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (20, 52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.024 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mental health (MH) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 (64, 88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (50, 76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.066 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bodily pain (BP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 (42, 100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (32, 88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.038 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitality (VT) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 (45, 80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (29, 60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.020 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1276943.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Baseline demographic and clinical features of patients.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Data are expressed as median (interquartile range), Results are shown as change between post-treatment and baseline levels (Δ values).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>32) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Δ6MWTD (meter)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (21, 50)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (30, 70)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.160 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔBORG</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.05 (−1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.05 (−1.5, 0)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.587 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔMMRC</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−1.0)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1 (−1.0)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.044 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔFEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">(% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.5 (−2.7, 6.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (−1, 6.8)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.413 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔFEV1/FVC</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−8.7, 3.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.5 (−5, 9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.214 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔIC (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (−16.5, 15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (−9, 30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.513 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔVC (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (−4.5, 11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (−9, 18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.212 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔDLCO (% predicted)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1 (−7, 7.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 (−4, 13)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔpH</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 (−0.01, 0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 (−0.02, 0.03) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.965 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔPaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">(mmHg)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1, 9)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 (3, 11)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.035<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔPaCO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">(mmHg)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−4.5, 4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.5 (−5.5, 1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.235 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔSaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0, 2)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0, 3)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.656 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">SGRQ</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔSymptom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7 (−15, 5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8 (−15, 1)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.495 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔActivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7 (−18, −0.03)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−6 (−18, 0.2)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.901 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔImpact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8 (−18, −3)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7 (−17, 0.8)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.636 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔTotal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−9 (−15, −2)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7 (−15, −3)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.953 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">SF-36</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔPhysical functioning (PF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (−10, 30)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (0, 21)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.979 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔSocial functioning (SF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0, 25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (0, 25)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.401 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔRole physical (RF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (−10, 30)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0, 50)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.946 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔRole emotional (RE) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0, 33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0, 66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.586 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔGeneral health (GH) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 (−4, 16)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (−5, 17)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.746 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔMental health (MH) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−8, 8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (−9, 16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.838 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔBodily pain (BP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−10, 20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (0, 34)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.293 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ΔVitality (VT) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (−5, 25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (0, 25)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.424 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔHAD</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">anxiety</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.5 (−4, 0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−3 (−5, −1)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.069 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ΔHAD</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">depression</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (−3, 2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2 (−5, 0.2)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.075 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1276944.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 for within group change, 6MWD: six minutes walk distance, MMRC: Medical Research Council Dyspnea Scale, FEV<span class="elsevierStyleInf">1</span>: forced expiratory volume in the 1<span class="elsevierStyleHsp" style=""></span>s, FVC: forced vital capacity, IC: inspiratory capacity, VC: vital capacity, DL<span class="elsevierStyleInf">CO</span>: carbon monoxide diffusing capacity. 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| Year/Month | Html | Total | |
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