The impact of weight loss beyond lung function: benefit with respect to asthma outcomes

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(B) Type of disease in patients with locoregional TBs (n=599)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Meira, C. Chaves, D. Araújo, L. Almeida, R. Boaventura, A. Ramos, T. Carvalho, N.S. Osório, A.G. Castro, F. Rodrigues, J.T. Guimarães, M. Saraiva, H.N. Bastos" "autores" => array:13 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Meira" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Chaves" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Araújo" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Almeida" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Boaventura" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Ramos" ] 6 => array:2 [ "nombre" => "T." "apellidos" => "Carvalho" ] 7 => array:2 [ "nombre" => "N.S." "apellidos" => "Osório" ] 8 => array:2 [ "nombre" => "A.G." "apellidos" => "Castro" ] 9 => array:2 [ "nombre" => "F." "apellidos" => "Rodrigues" ] 10 => array:2 [ "nombre" => "J.T." 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respiratory therapies in Portugal: it is time to move forward" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "311" "paginaFinal" => "312" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cátia Caneiras, Cristina Jácome, Sagrario Mayoralas-Alises, José Ramon-Calvo, João Almeida Fonseca, Salvador Diaz-Lobato, Joan Escarrabill, João Carlos Winck" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Cátia" "apellidos" => "Caneiras" ] 1 => array:2 [ "nombre" => "Cristina" "apellidos" => "Jácome" ] 2 => array:2 [ "nombre" => "Sagrario" "apellidos" => "Mayoralas-Alises" ] 3 => array:2 [ "nombre" => "José" "apellidos" => "Ramon-Calvo" ] 4 => array:2 [ "nombre" => "João Almeida" "apellidos" => "Fonseca" ] 5 => array:2 [ "nombre" => "Salvador" "apellidos" => "Diaz-Lobato" ] 6 => array:2 [ "nombre" => "Joan" "apellidos" => "Escarrabill" ] 7 => array:2 [ "nombre" => "João Carlos" "apellidos" => "Winck" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043719301679?idApp=UINPBA00004E" "url" => "/25310437/0000002500000006/v1_201911020923/S2531043719301679/v1_201911020923/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "The impact of weight loss beyond lung function: benefit with respect to asthma outcomes" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "313" "paginaFinal" => "319" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Lília Maia Santos, Bárbara Ramos, João Almeida, Cláudia Chaves Loureiro, Carlos Robalo Cordeiro" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Lília Maia" "apellidos" => "Santos" "email" => array:1 [ 0 => "lilasantos87@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Bárbara" "apellidos" => "Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "João" "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Cláudia Chaves" "apellidos" => "Loureiro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Carlos Robalo" "apellidos" => "Cordeiro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pulmonology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "General Surgery Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Clinical Academic Center of Coimbra, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Serviço de Pneumologia A, Centro Hospitalar e Universitário de Coimbra Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 975 "Ancho" => 2086 "Tamanyo" => 147983 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Flowchart of patients who underwent bariatric surgery." ] ] ] "textoCompleto" => "IntroductionApproximately 30% of the population worldwide is overweight or obese, due to physical inactivity and increased intake of energy-dense foods that are high in fat.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The percentage of overweight and obese individuals is estimated to double by the year 2020.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The prevalence of morbid obesity is also estimated to increase to 11% by the year 2030.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> These factors make obesity, defined by the WHO as a body mass index (BMI) ≥30 kg/m2, the third largest social burden created by human beings, only surpassed by smoking and armed violence.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> According to the WHO, obesity is subdivided into three classes: class I (BMI = 30–34.9 kg/m2), class II (BMI = 35–39.9 kg/m2) and class III (BMI ≥ 40 kg/m2).<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>Being overweight promotes metabolic and structural changes in the body; therefore, obese individuals present with several co-morbidities, such as cardiovascular disease, hypertension, type 2 diabetes mellitus, musculoskeletal disorders, and some forms of cancer.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,4,5</a> A higher BMI is also associated with a higher risk of developing obesity-related diseases.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>Respiratory disorders are one of the co-morbidities associated with obesity.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6</a> The mechanism of such diseases is primarily mechanical, pertaining to the excess adipose tissue that covers the thorax and abdomen. The adipose tissue encumbers normal ventilation through limitation of two primary inspiratory movements: contraction of the diaphragm, which results in projection of the abdominal content in a downward and forward direction, and an increase in chest diameter due to the movement of the ribs.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4,6–8</a> This results in stiffening of the total respiratory system and an increase in the mechanical work required to breathe.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a>Additionally, adipose tissue has endocrine and paracrine functions, producing a large number of cytokines and bioactive mediators that generate a pro-inflammatory state in obese individuals associated with atopy, bronchial hyperactivity, and increased risk and severity of asthma, as well as endotypic modifications of asthma.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4–8,10,11</a>Asthma is a common heterogeneous respiratory disease, characterized by chronic airway inflammation, with a substantially increasing prevalence in the later part of the 20th century.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> Recent data suggest that ≥15% of the general population in multiple countries suffer from asthma.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a>The association between obesity and asthma is not well understood.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,5,7</a>,<a class="elsevierStyleCrossRefs" href="#bib0055">11,14</a> Obese asthmatic (OA) patients have more symptoms, difficulty in controlling disease, more frequent and severe exacerbations, decreased response to both reliever and control medications, and worse quality of life.<a class="elsevierStyleCrossRefs" href="#bib0025">5,7,10–12,14</a>The obesity-related phenotype of asthma shows distinct characteristics and there is growing evidence that weight loss (WL) leads to an improvement in the control of asthma, quality of life, and lung function (LF), as well as a reduction in the use of medication.<a class="elsevierStyleCrossRefs" href="#bib0035">7,10,12,14</a> Asthma control is evaluated on the basis of the combination of the frequency and severity of day- and night-time symptoms, future risk of adverse outcomes such as exacerbations, use of rescue medication, and limitation of day-time activities.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> As the above-mentioned aspects constitute the aim of asthma management,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> a combination of both pharmacological and non-pharmacological therapies, such as WL, in the obesity-related phenotype, may be advantageous.The treatment of obesity requires a multidisciplinary approach that includes behavioral modifications, a calorie-restricted diet, and physical exercise.<a class="elsevierStyleCrossRefs" href="#bib0050">10,14</a> However, bariatric surgery is the most effective intervention for producing sustained and significant WL.<a class="elsevierStyleCrossRefs" href="#bib0035">7,15</a> All studies describing the effect of bariatric surgery reported highly significant improvements in LF, control and exacerbations of asthma.<a class="elsevierStyleCrossRefs" href="#bib0035">7,14</a> Most of them include data from one year, but few demonstrate the effect of the significant improvement of all these outcomes associated with a significant reduction in controller medication.Therefore, the aim of the present study was to evaluate the impact of WL on LF in obese individuals who had undergone bariatric surgery, and on control of asthma, quality of life, LF, and controller medication requirements in a sub-group of OA patients.MethodsThe current work was a prospective, longitudinal study performed on obese patients undergoing bariatric surgery at the Surgical Obesity Treatment Unit of the General Surgery Department of Centro Hospitalar e Universitário de Coimbra (CHUC), Portugal, between July 2015 and July 2017. The CHUC Research Ethics Committee (CHUC-088-15) approved the study protocol.Patients over 18 years of age who were scheduled to undergo bariatric surgery were invited to participate in the present study. Patients who consented to participate were questioned about their smoking habits, presence of respiratory disease, and medication use. This study included patients with no history of any respiratory disease rather than asthma or obstructive sleep apnea (OSA), who consented to participate.All included patients signed an informed consent form. Classification of obesity was done according to the WHO criteria.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Patients were divided into two groups based on the presence or absence of asthma: OA and obese non-asthmatics (O-NA). OA patients had a previous diagnosis of asthma according to Global Initiative of Asthma (GINA) diagnostic criteria in adults, confirmed retrospectively from their clinical charts, or showed a clinically significant response to bronchodilator medications, defined by an increase of >12% and >200 ml in forced expiratory volume in first second (FEV1) and/or forced vital capacity (FVC) from baseline, during assessment of LF before surgery.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> O-NA patients had no previous diagnosis of asthma by any physician and did not respond in a clinically significant manner to bronchodilator.LF of all included patients was assessed the day before bariatric surgery (first day inward). In OA patients, control of asthma, quality of life and level of treatment were also evaluated on the same day.LF (plethysmography and bronchodilation test) was evaluated in the Pulmonology Department of CHUC using plethysmograph MasterScreen™ Body, Vyaire, Germany, and the follow parameters were taken into account: FVC, FEV1, vital capacity (VC), total lung capacity (TLC), total lung resistance (Rtot), forced expiratory flow at 25–75% of FVC (FEF25–75%), flow when 75% of FVC had been exhaled (FEF75%). Control of asthma was evaluated using the Control of Allergic Rhinitis and Asthma Test (CARAT), and quality of life using Asthma Life Quality (ALQ) questionnaire. Level of treatment was assessed according to GINA treatment steps.<a class="elsevierStyleCrossRefs" href="#bib0060">12,16,17</a>CARAT is a brief self-administered Portuguese questionnaire divided into two sections: the first evaluates the symptoms of allergic rhinitis through four questions, in which a total >8 means good control; and the second section evaluates the symptoms of asthma in six questions, with good control defined as values >16.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> ALQ is a questionnaire comprised of 20 items with a Yes/No response, wherein all questions are equally weighted and the total score is the sum of all positive answers, ranging from 0 to 20.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Patients underwent gastric bypass or vertical gastrectomy by laparoscopy. Before discharge, a new LF assessment was scheduled for all patients included after six to nine months, when patients returned to the hospital for follow-up (Surgical Obesity Treatment Unit protocol follow-up schedule). Control of asthma, quality of life, and GINA treatment step were re-evaluated in OA patients at the same time as the second LF assessment.Patients who did not consent to continue to participate, those who did not undergo bariatric surgery, those who did not undergo LF assessment in the second follow-up, or those who died were excluded from the study.Clinical (gender, age, weight, BMI, smoking habits, asthma control, quality of life, asthma treatment step) and functional parameters obtained were registered on a database. Statistical analyses were carried out using SPSS®, version 24.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). The data of the patients are presented using descriptive statistics: categorical data as frequencies (percentages) and continuous variables as mean and standard deviation (SD). Comparisons between the two groups, OA and O-NA, were performed using the Mann–Whitney U test, while comparisons between BMI, functional parameters, asthma control, quality of life, and asthma treatment step before and after bariatric surgery were performed using the Wilcoxon test. The normality of the distribution of variables was analyzed using the Kolmogorov-Smirnov test. P < 0.05 was considered significant.ResultsResults from 26 patients (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), with a median age of 44 years (SD = ±9.7), and who were predominantly female (n = 19, 73.1%) and non-smokers (n = 18, 69.2%) were analyzed. Before surgery, all patients were obese, with class III obesity (n = 22, 84.6%) in the majority of cases.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>With respect to bariatric surgery, 65.4% of the patients underwent gastric bypass and 34.6% vertical gastrectomy surgeries. The initial mean value for BMI was 44.7 kg/m2 (SD = ±5.9), with a significant mean decrease of 11.3 kg/m2 (SD = ±3.8), p < 0.001, after 6–9 months of WL.No significant differences were observed between genders (p = 0.935), age (p = 0.196), smoking habits (p = 0.849), or initial mean value (p = 0.531) and subsequent decrease (p = 0.892) of BMI between OA and O-NA patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Regarding the initial LF, only FEV1/FVC (p = 0.022), Rtot (p = 0.019), FEF25–75% (p = 0.030), and FEF75% (p = 0.047) were significantly worse in OA patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>O-NA patients showed an increase in TLC (137 mL, p = 0.199), as well as a significant increase in VC (199 mL, p = 0.005), FVC (249 mL, p = 0.011) and FEV1 (228 mL, p = 0.002) following WL. A significant improvement in Rtot (−0.090 kPa*s/L, p = 0.003) and increase of FEF75% and FEF25–75% of 316 mL (p = 0.002) and 358 mL (p = 0.014), respectively, were observed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Before surgery, OA patients showed a mean CARAT score of 6.1 (SD = ±3.1) in the upper airways and 13.4 (SD = ±4.1) in the lower airways, with mean of total CARAT score of 19.6 ± 6.7. 25% of the patients were on Step 3 and 75% on Step 4 of the GINA treatment.After WL, OA patients showed an increase in VC (268 mL, p = 0.107), as well as a significant increase FVC (303 mL, p = 0.040), FEV1 (295 mL, p = 0.017), and TLC (659 mL, p = 0.036). Significant improvement was also observed in FEF75% (291 mL, p = 0.018), FEF25–75% (428 mL, p = 0.012), and Rtot (−0.17 kPa*s/L, p = 0.035) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Improvement in LF was accompanied by a significant increase in CARAT score of the upper airways by 3.9 (SD = ±1.9, p = 0.017) and of the lower airways by 4.2 (SD = ±4.4, p = 0.027), as well as a significant mean decrease of 1.8 (SD = ±1.0, p = 0.017) in the GINA treatment step. After surgery, all OA decrease the step of treatment: 37.5% were on Step 3, 12.5% were on Step 2, and 50% were on Step 1 of the GINA treatment, with a mean of total CARAT score was 27.6 ± 1.5. The initial mean value for ALQ was 9.6 (SD = ±5.3), which improved significantly with WL to 4.1 (SD = ±2.6, p = 0.017).The results showed no significant difference in improvement of LF between OA and O-NA patients with respect to VC (p = 1.000), FVC (p = 0.849), FEV1 (p = 0.495), TLC (p = 0.54), FEF75% (p = 0.849), FEF25–75% (p = 0.567), or Rtot (p = 0.397).DiscussionThe present study demonstrates an early significant improvement in LF, control of asthma, and quality of life together with a significant reduction in controller medication, in OA after WL.Before surgery, symptoms of allergic rhinitis and asthma were not controlled in OA patients despite step 4 or 5 of the GINA treatment. Data published by Esteban-Gorgojo et al. showed that obesity-related asthma is predominantly non-eosinophilic and, although obesity can be either a cause or consequence, it seems more plausible that it is caused by increased asthma severity.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> In addition to the mechanical effect of excessive fat accumulation in the thoracic and abdominal cavities, obesity induces a state of low-grade inflammation.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7,11,15</a>,<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> In OA patients, overproduction of leptin in the adipose tissue stimulates the production of pro-inflammatory mediators, such as TNF-α, IL-6, and IFN-γ, which can all cause bronchial hyperactivity, pulmonary inflammation, and a poor response to inhaled corticosteroids.<a class="elsevierStyleCrossRefs" href="#bib0025">5–8,15,18,20</a>,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> IL-6 has also been associated with smooth muscle proliferation and epithelial damage in the airways, leading to its remodeling.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Abnormalities in surfactant function leading to increased alveolar instability and collapse, as well as increased oxidative stress with reduced bioavailability of the endogenous bronchodilator NO, also have a negative effect on asthma outcomes.<a class="elsevierStyleCrossRefs" href="#bib0035">7,21</a> In the obesity-related phenotype of asthma a worse response to standard controller and reliever medications may also be due to associated comorbidities, such as OSA and gastroesophageal reflux disease (GERD).<a class="elsevierStyleCrossRefs" href="#bib0025">5,8,12,14</a>,<a class="elsevierStyleCrossRefs" href="#bib0110">22,23</a> Obesity is a well-established risk factor for the development of GERD that, in turn, hinders the control of asthma.<a class="elsevierStyleCrossRefs" href="#bib0005">1,5,8,12</a>,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Some studies have reported that the asthma medication required before bariatric surgery is strongly influenced by BMI and GERD.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>After surgery, a significant decrease was observed in the mean value of BMI along with a significant improvement in the control of asthma and quality of life, which was accompanied by a significant decrease in the step of GINA treatment. Previous studies have also reported an improvement in asthma outcomes and a decrease in the use of medications with WL.<a class="elsevierStyleCrossRefs" href="#bib0050">10,24</a> Guerron et al. reported that this reduction was observed as early as 30 days post-bariatric surgery and progressed over time, regardless of the type of procedure.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> However, as far as we know, very few studies assessed all these outcomes together with these significant results within a short period of time. It must be noted that after 6–9 months of follow-up, despite the fact that half of them were on Step 1 of GINA treatment and none needed controller medication on Step 4, they achieved a good control. The primary goal of asthma treatment is to control symptoms with minimal side effects.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> It must be understood that all pharmacological therapies may be associated with side effects, which in the case of asthma, are higher when a high dose of inhalational corticosteroids are used, as observed in more severe asthmatic individuals, such as OA.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> It may be speculated that WL could lead to a reduction in bronchial inflammation and consequently, better control of asthma and quality of life, even with a reduction in the step of GINA treatment. However, better control of comorbidities, such as GERD and OSA, may also play an important role. Regarding the quality of life, the worst values before surgery may also be related to the greater limitations in the activities of daily living with more symptoms following mild efforts, as a consequence of being overweight.The mechanism by which obesity causes disorders of LF has not been completely established.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> A review conducted by Melo et al. demonstrated a reduction in FEV1, FVC, VC, and TLC in obese individuals and some studies reported such changes even in cases with a minimal degree of obesity.<a class="elsevierStyleCrossRefs" href="#bib0020">4,25</a> However, it must be noted that extremely obese individuals may have normal LF, as observed in O-NA patients prior to surgery in the present study.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6</a> A review conducted by Cheryl et al. reported that despite many studies describing an association between an increase in BMI and decreased TLC, the effects of obesity on TLC are modest and this LF parameter is usually maintained within a normal range even in patients with severe obesity.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a> Similarly, the authors have reported that although FEV1 and FVC tend to decrease with an increase in BMI, the effects of obesity are minimal and the LF parameters mentioned are usually within the normal range in healthy obese adults.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a>Preliminary studies suggested a reduction in the diameter of small airways; however, the results are not consistent.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9,25</a> In the present study, O-NA patients showed no impairment in the baseline dynamic volumes of small airways. Similarly, Cheryl et al. reported an increase in lung resistance in obese individuals, indicating that the caliber of the airway is reduced throughout the tidal breathing cycle.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> However, the authors also stated that specific airway resistance, adjusted for the lung volume at which the measurement was made, was within the normal range, which could explain the reason for the normal baseline Rtot value in O-NA patients in the present study.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Although obesity has a tendency to induce restrictive disorders, obese patients breathe at low lung volumes and the tidal volume is typically approximately the same as the closing volume.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The consequent repeated opening and closing of peripheral airways may lead to rupture of alveolar attachments to bronchioles, uncoupling the airways from the retractile forces of the parenchyma and worsening the limitation of airflow.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> FEF75% and FEF25–75% were described as being more reproducible and sensitive to detecting limitations in the small airways than FEV1.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> However, when FVC and TLC are affected by disease, forced expiratory flows are measured in different lung volumes than in healthy subjects, making the use of predicted values calculated from healthy subjects problematic.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Thus, the reduction, in the absence of airway obstruction, may result from reduced lung volume rather than from airway disease.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> This may explain the reduced FEF75% and FEF25–75% in OA patients in the present study and the significant improvement with WL.Despite the fact that obesity chiefly affects lung volume, with the preservation of dynamic volumes, improvement was observed in all capacities and dynamic volumes in the population included in the present study, with significant changes in FEV1, FVC, FEF75%, and FEF25–75%, as well as Rtot, in both groups after WL.1 The improvement was higher in OA patients; however, the difference between the groups was not significant. The improvement in TLC with WL supports the hypothesis concerning the mechanical effect of adipose tissue on LF in obese individuals.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Additionally, a significant increase in TLC was observed only in OA patients, refuting the hypothesis that the parenchyma of these patients were more compliant than in O-NA—, causing them to collapse more easily due to lung compression.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Improvement in FEV1, FVC, FEF75%, and FEF25–75%, even in O-NA patients, suggested the relative effect of WL on the diameter of airways. Similarly, a significant decrease in Rtot was probably due to a reduction in the stiffness of the chest wall with WL and recruitment of airways that were previously closed due to compression by excess adipose tissue. In O-NA patients, the decrease in Rtot supports the hypothesis that the increase in the value with obesity could be attributed to a reduction in lung volume rather than airway obstruction.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The sample in the present study is comprised of patients who underwent bariatric surgery; however, in general, not all OA patients meet the criteria for surgical intervention. Previous studies have evaluated the effect of nonsurgical WL in patients with asthma and reported a significant improvement in LF, use of rescue medications, and frequency and severity of symptoms, as well as the number of exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0050">10,15</a> A study by Scott et al. suggested that WL of 5–10% may be associated with significant improvements in asthma outcomes.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> The superiority of surgical WL lies in the higher rate of success, larger reduction in BMI (±15 kg/m2), and lasting results.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>The present study has some limitations. First, the sample size was small reducing the ability to analyze certain effects, such as the differences in the effect of WL on pre-existing asthma complicated by the subsequent development of obesity and symptoms of asthma that developed as a consequence of obesity. On the other hand, BMI was considered a measure of obesity, which has some limitations, such as the inability to describe the distribution of fat. Fat distribution has distinct implications concerning normal physiological changes in the respiratory system, as well as on metabolic inflammation.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6,25</a> Control of comorbidities such as OSA and GERD were not assessed at baseline and after WL despite the fact that control of these factors may contribute to better control of asthma and improved quality of life.<a class="elsevierStyleCrossRefs" href="#bib0040">8,22,28</a> Additionally, levels of serum eosinophils, exhaled NO, or airway responsiveness to methacholine were not assessed prior to and 6–9 months after surgery. Therefore, conclusive information cannot be provided pertaining to changes in inflammatory status that may contribute to symptoms of asthma.ConclusionsWeight loss proved to be effective in the improvement of LF in both OA and O-NA patients. Additionally, significant improvement in the control of asthma and quality of life was recorded in OA patients, which was accompanied by a significant decrease in the GINA treatment step. Thus, it is important to implement healthcare programs for the obese population, in order to improve LF and, consequently, quality of life. Regarding OA patients, the therapeutic approach should combine pharmacological therapies with WL, rather than primarily focusing on disease control by stepping up asthma therapy.FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Declarations of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1261478" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1168227" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1168228" "titulo" => "Abbreviations" ] 3 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Declarations of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-10" "fechaAceptado" => "2019-07-31" "PalabrasClave" => array:1 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1168227" "palabras" => array:7 [ 0 => "Obesity" 1 => "Weight loss" 2 => "Lung function" 3 => "Asthma control" 4 => "Asthma quality of life" 5 => "Treatment step" 6 => "Bariatric surgery" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1168228" "palabras" => array:19 [ 0 => "BMI" 1 => "OA" 2 => "WL" 3 => "LF" 4 => "CHUC" 5 => "OSA" 6 => "O-NA" 7 => "GINA" 8 => "FEV1" 9 => "FVC" 10 => "VC" 11 => "TLC" 12 => "Rtot" 13 => "FEF25–75%" 14 => "FEF75%" 15 => "CARAT" 16 => "ALQ" 17 => "SD" 18 => "GERD" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveWe evaluated the effect of weight loss (WL) on lung function (LF) in obese individuals who underwent bariatric surgery, and on asthma control, quality of life, LF, and controller medication in a sub-group of obese asthma (OA) patients. Materials and methodsObese individuals who underwent bariatric surgery between July 2015 and July 2017 were included in this prospective longitudinal study. They were classified as OA or obese non-asthmatics (O-NA). LF was assessed preoperatively and 6–9 months postoperatively. In OA patients, asthma control, quality of life, and treatment step were evaluated. P < 0.05 was considered significant. ResultsTwenty-six patients (OA: n = 8; O-NA: n = 18), 84.6% with class III obesity were enrolled. Preoperatively, OA patients showed worse values of LF parameters, with upper and lower airway CARAT scores of 6.1 ± 3.1 and 13.4 ± 4.1, respectively, and 75% were in step 4 of treatment. After WL, improvements in dynamic volumes, lung capacities, and total resistance were observed in both groups. Despite greater increases in OA patients, no significant differences were observed between groups. In OA patients, improvements in CARAT score of upper (3.9 ± 1.9, p = 0.017) and lower (4.2 ± 4.4, p = 0.027) airways, and in Asthma Life Quality scores (8.1 ± 5.6, p = 0.017) were observed along with a decrease (−1.8 ± 1.0, p = 0.017) in treatment step. ConclusionsAll LF parameters improved after WL. Although the improvement was greater in OA patients, the difference between groups was not significant. Significant improvement from baseline in uncontrolled symptoms of OA patients and quality of life was observed after WL, along with a significant decrease in treatment step." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 975 "Ancho" => 2086 "Tamanyo" => 147983 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Flowchart of patients who underwent bariatric surgery." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Legend: SD = standard deviation; BMI = body mass index; FEV1 = forced expiratory volume in first second; FVC = forced vital capacity; VC = vital capacity; FEF75% =  forced expiratory flow when 75% of FVC has been exhaled; FEF25–75% = forced expiratory flow at 25–75% of FVC; TLC = total lung capacity; RV = residual volume; Rtot = total lung resistance." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obese with no pulmonary disease n (%) or mean ± SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obese asthmatic n (%) or mean ± SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (27.8) / 13 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (25) / 6 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.935 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 ± 8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 ± 11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.196 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">122.7 ± 23.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">112 ± 23.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.261 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.5 ± 6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 ± 5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.531 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI decrease (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3 ± 3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3 ± 4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.892 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking habits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Non-smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (62.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Current smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.849 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Former smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial lung function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEV1 /FVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.7 ± 7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.7 ± 7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.022 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VC (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103.6 ± 13.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100.1 ± 12.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.807 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FVC (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102.7 ± 13.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.7 ± 10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.724 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pre-bronchodilator FEV1 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100.5 ± 17.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89.6 ± 12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.102 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-bronchodilator FEV1 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104.7 ± 16.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.8 ± 16.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.311 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF75% (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.5 ± 36.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.5 ± 15.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.047 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF25-75% (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.6 ± 33.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.3 ± 20.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.030 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TLC (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104.1 ± 10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102.5 ± 10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.531 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">108.6 ± 18.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110.2 ± 23.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.892 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rtot (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 ± 35.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">162.2 ± 52.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2157876.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General initial characteristics of the patients." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Legend: SD = standard deviation; VC = vital capacity; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; FEF75% = forced expiratory flow when 75% of FVC has been exhaled; FEF25–75% = forced expiratory flow at 25–75% of FVC; TLC = total lung capacity; RV = residual volume; Rtot = total lung resistance." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obese with no pulmonary disease \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Baseline Mean ± SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After 6 to 9 months Mean ± SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3705 ± 821 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3904 ± 853 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEV1/FVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.7 ± 7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.1 ± 8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.133 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FVC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3577 ± 793 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3826 ± 877 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEV1 (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2963 ± 715 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3191 ± 688 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF75% (mL/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1299 ± 690 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1615 ± 784 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF25–75% (mL/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3123 ± 1381 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3481 ± 1340 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TLC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5522 ± 996 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5659 ± 1069 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.199 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1826 ± 389 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1776 ± 454 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.879 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rtot (kPa*s/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.33 ± 0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.24 ± 0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obese asthmatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3223 ± 552 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3491 ± 797 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.107 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEV1/FVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.7 ± 7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77.6 ± 8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.208 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FVC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3116 ± 558 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3419 ± 817 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.040 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pre-bronchodilator FEV1 (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2363 ± 490 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2658 ± 643 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.017 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchodilation in FEV1 (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">186 ± 181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">157 ± 130 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF75% (mL/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">654 ± 350 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">945 ± 466 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.018 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEF25-75% (mL/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1855 ± 806 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2283 ± 835 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.012 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TLC (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5200 ± 1075 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5859 ± 1162 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.036 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV (mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1938 ± 670 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2354 ± 593 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rtot (kPa*s/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49 ± 0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.32 ± 0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.035 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2157877.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Effect of weight loss on lung function after 6–9 months." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of obesity and associated comorbidities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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Original article

The impact of weight loss beyond lung function: benefit with respect to asthma outcomes

Lília Maia Santosa,

Corresponding author

lilasantos87@hotmail.com

Corresponding author at: Serviço de Pneumologia A, Centro Hospitalar e Universitário de Coimbra Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal.

, Bárbara Ramosa, João Almeidab, Cláudia Chaves Loureiroa,c, Carlos Robalo Cordeiroa,c

a Pulmonology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

b General Surgery Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

c Clinical Academic Center of Coimbra, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately 30&#37; of the population worldwide is overweight or obese&#44; due to physical inactivity and increased intake of energy-dense foods that are high in fat&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The percentage of overweight and obese individuals is estimated to double by the year 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The prevalence of morbid obesity is also estimated to increase to 11&#37; by the year 2030&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These factors make obesity&#44; defined by the WHO as a body mass index &#40;BMI&#41; &#8805;30&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#44; the third largest social burden created by human beings&#44; only surpassed by smoking and armed violence&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> According to the WHO&#44; obesity is subdivided into three classes&#58; class I &#40;BMI&#8239;&#61;&#8239;30&#8211;34&#46;9&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; class II &#40;BMI&#8239;&#61;&#8239;35&#8211;39&#46;9&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; and class III &#40;BMI&#8239;&#8805;&#8239;40&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Being overweight promotes metabolic and structural changes in the body&#59; therefore&#44; obese individuals present with several co-morbidities&#44; such as cardiovascular disease&#44; hypertension&#44; type 2 diabetes mellitus&#44; musculoskeletal disorders&#44; and some forms of cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a> A higher BMI is also associated with a higher risk of developing obesity-related diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Respiratory disorders are one of the co-morbidities associated with obesity&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a> The mechanism of such diseases is primarily mechanical&#44; pertaining to the excess adipose tissue that covers the thorax and abdomen&#46; The adipose tissue encumbers normal ventilation through limitation of two primary inspiratory movements&#58; contraction of the diaphragm&#44; which results in projection of the abdominal content in a downward and forward direction&#44; and an increase in chest diameter due to the movement of the ribs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;6&#8211;8</span></a> This results in stiffening of the total respiratory system and an increase in the mechanical work required to breathe&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Additionally&#44; adipose tissue has endocrine and paracrine functions&#44; producing a large number of cytokines and bioactive mediators that generate a pro-inflammatory state in obese individuals associated with atopy&#44; bronchial hyperactivity&#44; and increased risk and severity of asthma&#44; as well as endotypic modifications of asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#8211;8&#44;10&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Asthma is a common heterogeneous respiratory disease&#44; characterized by chronic airway inflammation&#44; with a substantially increasing prevalence in the later part of the 20th century&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Recent data suggest that &#8805;15&#37; of the general population in multiple countries suffer from asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The association between obesity and asthma is not well understood&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14</span></a> Obese asthmatic &#40;OA&#41; patients have more symptoms&#44; difficulty in controlling disease&#44; more frequent and severe exacerbations&#44; decreased response to both reliever and control medications&#44; and worse quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;10&#8211;12&#44;14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The obesity-related phenotype of asthma shows distinct characteristics and there is growing evidence that weight loss &#40;WL&#41; leads to an improvement in the control of asthma&#44; quality of life&#44; and lung function &#40;LF&#41;&#44; as well as a reduction in the use of medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;10&#44;12&#44;14</span></a> Asthma control is evaluated on the basis of the combination of the frequency and severity of day- and night-time symptoms&#44; future risk of adverse outcomes such as exacerbations&#44; use of rescue medication&#44; and limitation of day-time activities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> As the above-mentioned aspects constitute the aim of asthma management&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> a combination of both pharmacological and non-pharmacological therapies&#44; such as WL&#44; in the obesity-related phenotype&#44; may be advantageous&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment of obesity requires a multidisciplinary approach that includes behavioral modifications&#44; a calorie-restricted diet&#44; and physical exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> However&#44; bariatric surgery is the most effective intervention for producing sustained and significant WL&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;15</span></a> All studies describing the effect of bariatric surgery reported highly significant improvements in LF&#44; control and exacerbations of asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a> Most of them include data from one year&#44; but few demonstrate the effect of the significant improvement of all these outcomes associated with a significant reduction in controller medication&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; the aim of the present study was to evaluate the impact of WL on LF in obese individuals who had undergone bariatric surgery&#44; and on control of asthma&#44; quality of life&#44; LF&#44; and controller medication requirements in a sub-group of OA patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">The current work was a prospective&#44; longitudinal study performed on obese patients undergoing bariatric surgery at the Surgical Obesity Treatment Unit of the General Surgery Department of Centro Hospitalar e Universit&#225;rio de Coimbra &#40;CHUC&#41;&#44; Portugal&#44; between July 2015 and July 2017&#46; The CHUC Research Ethics Committee &#40;CHUC-088-15&#41; approved the study protocol&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients over 18 years of age who were scheduled to undergo bariatric surgery were invited to participate in the present study&#46; Patients who consented to participate were questioned about their smoking habits&#44; presence of respiratory disease&#44; and medication use&#46; This study included patients with no history of any respiratory disease rather than asthma or obstructive sleep apnea &#40;OSA&#41;&#44; who consented to participate&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">All included patients signed an informed consent form&#46; Classification of obesity was done according to the WHO criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Patients were divided into two groups based on the presence or absence of asthma&#58; OA and obese non-asthmatics &#40;O-NA&#41;&#46; OA patients had a previous diagnosis of asthma according to Global Initiative of Asthma &#40;GINA&#41; diagnostic criteria in adults&#44; confirmed retrospectively from their clinical charts&#44; or showed a clinically significant response to bronchodilator medications&#44; defined by an increase of &#62;12&#37; and &#62;200&#8239;ml in forced expiratory volume in first second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; and&#47;or forced vital capacity &#40;FVC&#41; from baseline&#44; during assessment of LF before surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> O-NA patients had no previous diagnosis of asthma by any physician and did not respond in a clinically significant manner to bronchodilator&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">LF of all included patients was assessed the day before bariatric surgery &#40;first day inward&#41;&#46; In OA patients&#44; control of asthma&#44; quality of life and level of treatment were also evaluated on the same day&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">LF &#40;plethysmography and bronchodilation test&#41; was evaluated in the Pulmonology Department of CHUC using plethysmograph MasterScreen&#8482; Body&#44; Vyaire&#44; Germany&#44; and the follow parameters were taken into account&#58; FVC&#44; FEV<span class="elsevierStyleInf">1</span>&#44; vital capacity &#40;VC&#41;&#44; total lung capacity &#40;TLC&#41;&#44; total lung resistance &#40;R<span class="elsevierStyleInf">tot</span>&#41;&#44; forced expiratory flow at 25&#8211;75&#37; of FVC &#40;FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span>&#41;&#44; flow when 75&#37; of FVC had been exhaled &#40;FEF<span class="elsevierStyleInf">75&#37;</span>&#41;&#46; Control of asthma was evaluated using the Control of Allergic Rhinitis and Asthma Test &#40;CARAT&#41;&#44; and quality of life using Asthma Life Quality &#40;ALQ&#41; questionnaire&#46; Level of treatment was assessed according to GINA treatment steps&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16&#44;17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">CARAT is a brief self-administered Portuguese questionnaire divided into two sections&#58; the first evaluates the symptoms of allergic rhinitis through four questions&#44; in which a total &#62;8 means good control&#59; and the second section evaluates the symptoms of asthma in six questions&#44; with good control defined as values &#62;16&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> ALQ is a questionnaire comprised of 20 items with a Yes&#47;No response&#44; wherein all questions are equally weighted and the total score is the sum of all positive answers&#44; ranging from 0 to 20&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients underwent gastric bypass or vertical gastrectomy by laparoscopy&#46; Before discharge&#44; a new LF assessment was scheduled for all patients included after six to nine months&#44; when patients returned to the hospital for follow-up &#40;Surgical Obesity Treatment Unit protocol follow-up schedule&#41;&#46; Control of asthma&#44; quality of life&#44; and GINA treatment step were re-evaluated in OA patients at the same time as the second LF assessment&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patients who did not consent to continue to participate&#44; those who did not undergo bariatric surgery&#44; those who did not undergo LF assessment in the second follow-up&#44; or those who died were excluded from the study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Clinical &#40;gender&#44; age&#44; weight&#44; BMI&#44; smoking habits&#44; asthma control&#44; quality of life&#44; asthma treatment step&#41; and functional parameters obtained were registered on a database&#46; Statistical analyses were carried out using SPSS&#174;&#44; version 24&#46;0 &#40;IBM SPSS Statistics for Windows&#44; Armonk&#44; NY&#58; IBM Corp&#41;&#46; The data of the patients are presented using descriptive statistics&#58; categorical data as frequencies &#40;percentages&#41; and continuous variables as mean and standard deviation &#40;SD&#41;&#46; Comparisons between the two groups&#44; OA and O-NA&#44; were performed using the Mann&#8211;Whitney U test&#44; while comparisons between BMI&#44; functional parameters&#44; asthma control&#44; quality of life&#44; and asthma treatment step before and after bariatric surgery were performed using the Wilcoxon test&#46; The normality of the distribution of variables was analyzed using the Kolmogorov-Smirnov test&#46; P&#8239;&#60;&#8239;0&#46;05 was considered significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">Results from 26 patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; with a median age of 44 years &#40;SD&#8239;&#61;&#8239;&#177;9&#46;7&#41;&#44; and who were predominantly female &#40;n&#8239;&#61;&#8239;19&#44; 73&#46;1&#37;&#41; and non-smokers &#40;n&#8239;&#61;&#8239;18&#44; 69&#46;2&#37;&#41; were analyzed&#46; Before surgery&#44; all patients were obese&#44; with class III obesity &#40;n&#8239;&#61;&#8239;22&#44; 84&#46;6&#37;&#41; in the majority of cases&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">With respect to bariatric surgery&#44; 65&#46;4&#37; of the patients underwent gastric bypass and 34&#46;6&#37; vertical gastrectomy surgeries&#46; The initial mean value for BMI was 44&#46;7&#8239;kg&#47;m<span class="elsevierStyleSup">2</span> &#40;SD&#8239;&#61;&#8239;&#177;5&#46;9&#41;&#44; with a significant mean decrease of 11&#46;3&#8239;kg&#47;m<span class="elsevierStyleSup">2</span> &#40;SD&#8239;&#61;&#8239;&#177;3&#46;8&#41;&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#60;&#8239;0&#46;001&#44; after 6&#8211;9 months of WL&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No significant differences were observed between genders &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;935&#41;&#44; age &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;196&#41;&#44; smoking habits &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;849&#41;&#44; or initial mean value &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;531&#41; and subsequent decrease &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;892&#41; of BMI between OA and O-NA patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Regarding the initial LF&#44; only FEV<span class="elsevierStyleInf">1</span>&#47;FVC &#40;p&#8239;&#61;&#8239;0&#46;022&#41;&#44; R<span class="elsevierStyleInf">tot</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;019&#41;&#44; FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;030&#41;&#44; and FEF<span class="elsevierStyleInf">75&#37;</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;047&#41; were significantly worse in OA patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">O-NA patients showed an increase in TLC &#40;137&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;199&#41;&#44; as well as a significant increase in VC &#40;199&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;005&#41;&#44; FVC &#40;249&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;011&#41; and FEV<span class="elsevierStyleInf">1</span> &#40;228&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;002&#41; following WL&#46; A significant improvement in R<span class="elsevierStyleInf">tot</span> &#40;&#8722;0&#46;090 kPa&#42;s&#47;L&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;003&#41; and increase of FEF<span class="elsevierStyleInf">75&#37;</span> and FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> of 316&#8239;mL &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;002&#41; and 358&#8239;mL &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;014&#41;&#44; respectively&#44; were observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Before surgery&#44; OA patients showed a mean CARAT score of 6&#46;1 &#40;SD&#8239;&#61;&#8239;&#177;3&#46;1&#41; in the upper airways and 13&#46;4 &#40;SD&#8239;&#61;&#8239;&#177;4&#46;1&#41; in the lower airways&#44; with mean of total CARAT score of 19&#46;6&#8239;&#177;&#8239;6&#46;7&#46; 25&#37; of the patients were on Step 3 and 75&#37; on Step 4 of the GINA treatment&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">After WL&#44; OA patients showed an increase in VC &#40;268&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;107&#41;&#44; as well as a significant increase FVC &#40;303&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;040&#41;&#44; FEV<span class="elsevierStyleInf">1</span> &#40;295&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41;&#44; and TLC &#40;659&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;036&#41;&#46; Significant improvement was also observed in FEF<span class="elsevierStyleInf">75&#37;</span> &#40;291&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;018&#41;&#44; FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> &#40;428&#8239;mL&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;012&#41;&#44; and R<span class="elsevierStyleInf">tot</span> &#40;&#8722;0&#46;17 kPa&#42;s&#47;L&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;035&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Improvement in LF was accompanied by a significant increase in CARAT score of the upper airways by 3&#46;9 &#40;SD&#8239;&#61;&#8239;&#177;1&#46;9&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41; and of the lower airways by 4&#46;2 &#40;SD&#8239;&#61;&#8239;&#177;4&#46;4&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;027&#41;&#44; as well as a significant mean decrease of 1&#46;8 &#40;SD&#8239;&#61;&#8239;&#177;1&#46;0&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41; in the GINA treatment step&#46; After surgery&#44; all OA decrease the step of treatment&#58; 37&#46;5&#37; were on Step 3&#44; 12&#46;5&#37; were on Step 2&#44; and 50&#37; were on Step 1 of the GINA treatment&#44; with a mean of total CARAT score was 27&#46;6&#8239;&#177;&#8239;1&#46;5&#46; The initial mean value for ALQ was 9&#46;6 &#40;SD&#8239;&#61;&#8239;&#177;5&#46;3&#41;&#44; which improved significantly with WL to 4&#46;1 &#40;SD&#8239;&#61;&#8239;&#177;2&#46;6&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The results showed no significant difference in improvement of LF between OA and O-NA patients with respect to VC &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;1&#46;000&#41;&#44; FVC &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;849&#41;&#44; FEV<span class="elsevierStyleInf">1</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;495&#41;&#44; TLC &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;54&#41;&#44; FEF<span class="elsevierStyleInf">75&#37;</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;849&#41;&#44; FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;567&#41;&#44; or R<span class="elsevierStyleInf">tot</span> &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;397&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">The present study demonstrates an early significant improvement in LF&#44; control of asthma&#44; and quality of life together with a significant reduction in controller medication&#44; in OA after WL&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Before surgery&#44; symptoms of allergic rhinitis and asthma were not controlled in OA patients despite step 4 or 5 of the GINA treatment&#46; Data published by Esteban-Gorgojo et al&#46; showed that obesity-related asthma is predominantly non-eosinophilic and&#44; although obesity can be either a cause or consequence&#44; it seems more plausible that it is caused by increased asthma severity&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In addition to the mechanical effect of excessive fat accumulation in the thoracic and abdominal cavities&#44; obesity induces a state of low-grade inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;11&#44;15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> In OA patients&#44; overproduction of leptin in the adipose tissue stimulates the production of pro-inflammatory mediators&#44; such as TNF-&#945;&#44; IL-6&#44; and IFN-&#947;&#44; which can all cause bronchial hyperactivity&#44; pulmonary inflammation&#44; and a poor response to inhaled corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8&#44;15&#44;18&#44;20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> IL-6 has also been associated with smooth muscle proliferation and epithelial damage in the airways&#44; leading to its remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Abnormalities in surfactant function leading to increased alveolar instability and collapse&#44; as well as increased oxidative stress with reduced bioavailability of the endogenous bronchodilator NO&#44; also have a negative effect on asthma outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;21</span></a> In the obesity-related phenotype of asthma a worse response to standard controller and reliever medications may also be due to associated comorbidities&#44; such as OSA and gastroesophageal reflux disease &#40;GERD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;12&#44;14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> Obesity is a well-established risk factor for the development of GERD that&#44; in turn&#44; hinders the control of asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;8&#44;12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Some studies have reported that the asthma medication required before bariatric surgery is strongly influenced by BMI and GERD&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">After surgery&#44; a significant decrease was observed in the mean value of BMI along with a significant improvement in the control of asthma and quality of life&#44; which was accompanied by a significant decrease in the step of GINA treatment&#46; Previous studies have also reported an improvement in asthma outcomes and a decrease in the use of medications with WL&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;24</span></a> Guerron et al&#46; reported that this reduction was observed as early as 30 days post-bariatric surgery and progressed over time&#44; regardless of the type of procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> However&#44; as far as we know&#44; very few studies assessed all these outcomes together with these significant results within a short period of time&#46; It must be noted that after 6&#8211;9 months of follow-up&#44; despite the fact that half of them were on Step 1 of GINA treatment and none needed controller medication on Step 4&#44; they achieved a good control&#46; The primary goal of asthma treatment is to control symptoms with minimal side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It must be understood that all pharmacological therapies may be associated with side effects&#44; which in the case of asthma&#44; are higher when a high dose of inhalational corticosteroids are used&#44; as observed in more severe asthmatic individuals&#44; such as OA&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It may be speculated that WL could lead to a reduction in bronchial inflammation and consequently&#44; better control of asthma and quality of life&#44; even with a reduction in the step of GINA treatment&#46; However&#44; better control of comorbidities&#44; such as GERD and OSA&#44; may also play an important role&#46; Regarding the quality of life&#44; the worst values before surgery may also be related to the greater limitations in the activities of daily living with more symptoms following mild efforts&#44; as a consequence of being overweight&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The mechanism by which obesity causes disorders of LF has not been completely established&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> A review conducted by Melo et al&#46; demonstrated a reduction in FEV<span class="elsevierStyleInf">1</span>&#44; FVC&#44; VC&#44; and TLC in obese individuals and some studies reported such changes even in cases with a minimal degree of obesity&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a> However&#44; it must be noted that extremely obese individuals may have normal LF&#44; as observed in O-NA patients prior to surgery in the present study&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a> A review conducted by Cheryl et al&#46; reported that despite many studies describing an association between an increase in BMI and decreased TLC&#44; the effects of obesity on TLC are modest and this LF parameter is usually maintained within a normal range even in patients with severe obesity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a> Similarly&#44; the authors have reported that although FEV<span class="elsevierStyleInf">1</span> and FVC tend to decrease with an increase in BMI&#44; the effects of obesity are minimal and the LF parameters mentioned are usually within the normal range in healthy obese adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Preliminary studies suggested a reduction in the diameter of small airways&#59; however&#44; the results are not consistent&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;25</span></a> In the present study&#44; O-NA patients showed no impairment in the baseline dynamic volumes of small airways&#46; Similarly&#44; Cheryl et al&#46; reported an increase in lung resistance in obese individuals&#44; indicating that the caliber of the airway is reduced throughout the tidal breathing cycle&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; the authors also stated that specific airway resistance&#44; adjusted for the lung volume at which the measurement was made&#44; was within the normal range&#44; which could explain the reason for the normal baseline R<span class="elsevierStyleInf">tot</span> value in O-NA patients in the present study&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Although obesity has a tendency to induce restrictive disorders&#44; obese patients breathe at low lung volumes and the tidal volume is typically approximately the same as the closing volume&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The consequent repeated opening and closing of peripheral airways may lead to rupture of alveolar attachments to bronchioles&#44; uncoupling the airways from the retractile forces of the parenchyma and worsening the limitation of airflow&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> FEF<span class="elsevierStyleInf">75&#37;</span> and FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> were described as being more reproducible and sensitive to detecting limitations in the small airways than FEV<span class="elsevierStyleInf">1</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> However&#44; when FVC and TLC are affected by disease&#44; forced expiratory flows are measured in different lung volumes than in healthy subjects&#44; making the use of predicted values calculated from healthy subjects problematic&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Thus&#44; the reduction&#44; in the absence of airway obstruction&#44; may result from reduced lung volume rather than from airway disease&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> This may explain the reduced FEF<span class="elsevierStyleInf">75&#37;</span> and FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span> in OA patients in the present study and the significant improvement with WL&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Despite the fact that obesity chiefly affects lung volume&#44; with the preservation of dynamic volumes&#44; improvement was observed in all capacities and dynamic volumes in the population included in the present study&#44; with significant changes in FEV<span class="elsevierStyleInf">1</span>&#44; FVC&#44; FEF<span class="elsevierStyleInf">75&#37;</span>&#44; and FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span>&#44; as well as R<span class="elsevierStyleInf">tot</span>&#44; in both groups after WL&#46;<span class="elsevierStyleSup">1</span> The improvement was higher in OA patients&#59; however&#44; the difference between the groups was not significant&#46; The improvement in TLC with WL supports the hypothesis concerning the mechanical effect of adipose tissue on LF in obese individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Additionally&#44; a significant increase in TLC was observed only in OA patients&#44; refuting the hypothesis that the parenchyma of these patients were more compliant than in O-NA&#8212;&#44; causing them to collapse more easily due to lung compression&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Improvement in FEV<span class="elsevierStyleInf">1</span>&#44; FVC&#44; FEF<span class="elsevierStyleInf">75&#37;</span>&#44; and FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span>&#44; even in O-NA patients&#44; suggested the relative effect of WL on the diameter of airways&#46; Similarly&#44; a significant decrease in R<span class="elsevierStyleInf">tot</span> was probably due to a reduction in the stiffness of the chest wall with WL and recruitment of airways that were previously closed due to compression by excess adipose tissue&#46; In O-NA patients&#44; the decrease in R<span class="elsevierStyleInf">tot</span> supports the hypothesis that the increase in the value with obesity could be attributed to a reduction in lung volume rather than airway obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The sample in the present study is comprised of patients who underwent bariatric surgery&#59; however&#44; in general&#44; not all OA patients meet the criteria for surgical intervention&#46; Previous studies have evaluated the effect of nonsurgical WL in patients with asthma and reported a significant improvement in LF&#44; use of rescue medications&#44; and frequency and severity of symptoms&#44; as well as the number of exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;15</span></a> A study by Scott et al&#46; suggested that WL of 5&#8211;10&#37; may be associated with significant improvements in asthma outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The superiority of surgical WL lies in the higher rate of success&#44; larger reduction in BMI &#40;&#177;15&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; and lasting results&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The present study has some limitations&#46; First&#44; the sample size was small reducing the ability to analyze certain effects&#44; such as the differences in the effect of WL on pre-existing asthma complicated by the subsequent development of obesity and symptoms of asthma that developed as a consequence of obesity&#46; On the other hand&#44; BMI was considered a measure of obesity&#44; which has some limitations&#44; such as the inability to describe the distribution of fat&#46; Fat distribution has distinct implications concerning normal physiological changes in the respiratory system&#44; as well as on metabolic inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;25</span></a> Control of comorbidities such as OSA and GERD were not assessed at baseline and after WL despite the fact that control of these factors may contribute to better control of asthma and improved quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;22&#44;28</span></a> Additionally&#44; levels of serum eosinophils&#44; exhaled NO&#44; or airway responsiveness to methacholine were not assessed prior to and 6&#8211;9 months after surgery&#46; Therefore&#44; conclusive information cannot be provided pertaining to changes in inflammatory status that may contribute to symptoms of asthma&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Weight loss proved to be effective in the improvement of LF in both OA and O-NA patients&#46; Additionally&#44; significant improvement in the control of asthma and quality of life was recorded in OA patients&#44; which was accompanied by a significant decrease in the GINA treatment step&#46; Thus&#44; it is important to implement healthcare programs for the obese population&#44; in order to improve LF and&#44; consequently&#44; quality of life&#46; Regarding OA patients&#44; the therapeutic approach should combine pharmacological therapies with WL&#44; rather than primarily focusing on disease control by stepping up asthma therapy&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Declarations of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "identificador" => "xres1261478"
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          "titulo" => "Keywords"
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          "titulo" => "Abbreviations"
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        3 => array:2 [
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          "titulo" => "Introduction"
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          "titulo" => "Methods"
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          "titulo" => "Results"
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          "titulo" => "Discussion"
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          "titulo" => "Conclusions"
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          "titulo" => "Funding"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2019-06-10"
    "fechaAceptado" => "2019-07-31"
    "PalabrasClave" => array:1 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1168227"
          "palabras" => array:7 [
            0 => "Obesity"
            1 => "Weight loss"
            2 => "Lung function"
            3 => "Asthma control"
            4 => "Asthma quality of life"
            5 => "Treatment step"
            6 => "Bariatric surgery"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1168228"
          "palabras" => array:19 [
            0 => "BMI"
            1 => "OA"
            2 => "WL"
            3 => "LF"
            4 => "CHUC"
            5 => "OSA"
            6 => "O-NA"
            7 => "GINA"
            8 => "FEV<span class="elsevierStyleInf">1</span>"
            9 => "FVC"
            10 => "VC"
            11 => "TLC"
            12 => "R<span class="elsevierStyleInf">tot</span>"
            13 => "FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span>"
            14 => "FEF<span class="elsevierStyleInf">75&#37;</span>"
            15 => "CARAT"
            16 => "ALQ"
            17 => "SD"
            18 => "GERD"
          ]
        ]
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    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We evaluated the effect of weight loss &#40;WL&#41; on lung function &#40;LF&#41; in obese individuals who underwent bariatric surgery&#44; and on asthma control&#44; quality of life&#44; LF&#44; and controller medication in a sub-group of obese asthma &#40;OA&#41; patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Obese individuals who underwent bariatric surgery between July 2015 and July 2017 were included in this prospective longitudinal study&#46; They were classified as OA or obese non-asthmatics &#40;O-NA&#41;&#46; LF was assessed preoperatively and 6&#8211;9 months postoperatively&#46; In OA patients&#44; asthma control&#44; quality of life&#44; and treatment step were evaluated&#46; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;05 was considered significant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Twenty-six patients &#40;OA&#58; n&#8239;&#61;&#8239;8&#59; O-NA&#58; n&#8239;&#61;&#8239;18&#41;&#44; 84&#46;6&#37; with class III obesity were enrolled&#46; Preoperatively&#44; OA patients showed worse values of LF parameters&#44; with upper and lower airway CARAT scores of 6&#46;1&#8239;&#177;&#8239;3&#46;1 and 13&#46;4&#8239;&#177;&#8239;4&#46;1&#44; respectively&#44; and 75&#37; were in step 4 of treatment&#46; After WL&#44; improvements in dynamic volumes&#44; lung capacities&#44; and total resistance were observed in both groups&#46; Despite greater increases in OA patients&#44; no significant differences were observed between groups&#46; In OA patients&#44; improvements in CARAT score of upper &#40;3&#46;9&#8239;&#177;&#8239;1&#46;9&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41; and lower &#40;4&#46;2&#8239;&#177;&#8239;4&#46;4&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;027&#41; airways&#44; and in Asthma Life Quality scores &#40;8&#46;1&#8239;&#177;&#8239;5&#46;6&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41; were observed along with a decrease &#40;&#8722;1&#46;8&#8239;&#177;&#8239;1&#46;0&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;017&#41; in treatment step&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">All LF parameters improved after WL&#46; Although the improvement was greater in OA patients&#44; the difference between groups was not significant&#46; Significant improvement from baseline in uncontrolled symptoms of OA patients and quality of life was observed after WL&#44; along with a significant decrease in treatment step&#46;</p></span>"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "titulo" => "Conclusions"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart of patients who underwent bariatric surgery&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Legend&#58; SD&#8239;&#61;&#8239;standard deviation&#59; BMI&#8239;&#61;&#8239;body mass index&#59; FEV<span class="elsevierStyleInf">1</span>&#8239;&#61;&#8239;forced expiratory volume in first second&#59; FVC&#8239;&#61;&#8239;forced vital capacity&#59; VC&#8239;&#61;&#8239;vital capacity&#59; FEF<span class="elsevierStyleInf">75&#37;</span>&#8239;&#61;&#8239; forced expiratory flow when 75&#37; of FVC has been exhaled&#59; FEF<span class="elsevierStyleInf">25&#8211;75&#37;</span>&#8239;&#61;&#8239;forced expiratory flow at 25&#8211;75&#37; of FVC&#59; TLC&#8239;&#61;&#8239;total lung capacity&#59; RV&#8239;&#61;&#8239;residual volume&#59; R<span class="elsevierStyleInf">tot</span>&#8239;&#61;&#8239;total lung resistance&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obese with no pulmonary disease <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41; or mean&#8239;&#177;&#8239;SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Male&#47;Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;27&#46;8&#41; &#47; 13 &#40;72&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;25&#41; &#47; 6 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;935&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#8239;&#177;&#8239;8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#8239;&#177;&#8239;11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;196&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122&#46;7&#8239;&#177;&#8239;23&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112&#8239;&#177;&#8239;23&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;261&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;5&#8239;&#177;&#8239;6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#8239;&#177;&#8239;5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;531&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI decrease &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3&#8239;&#177;&#8239;3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3&#8239;&#177;&#8239;4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;892&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoking habits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;72&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;62&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Current smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;849&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Former smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial lung function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEV1 &#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;7&#8239;&#177;&#8239;7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;7&#8239;&#177;&#8239;7&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&#46;6&#8239;&#177;&#8239;13&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;1&#8239;&#177;&#8239;12&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;807&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FVC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;7&#8239;&#177;&#8239;13&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;7&#8239;&#177;&#8239;10&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;724&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pre-bronchodilator FEV1 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;5&#8239;&#177;&#8239;17&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;6&#8239;&#177;&#8239;12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Post-bronchodilator FEV1 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104&#46;7&#8239;&#177;&#8239;16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;8&#8239;&#177;&#8239;16&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;311&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEF<span class="elsevierStyleInf">75&#37;</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;5&#8239;&#177;&#8239;36&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;5&#8239;&#177;&#8239;15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FEF<span class="elsevierStyleInf">25-75&#37;</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;6&#8239;&#177;&#8239;33&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;3&#8239;&#177;&#8239;20&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TLC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104&#46;1&#8239;&#177;&#8239;10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;5&#8239;&#177;&#8239;10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obese with no pulmonary disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">TLC &#40;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">RV &#40;mL&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Effect of weight loss on lung function after 6&#8211;9 months&#46;</p>"
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Article information

ISSN: 25310437
Original language: English

DOI:10.1016/j.pulmoe.2019.07.007

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2020 May	78	38	116
2020 April	64	25	89
2020 March	72	41	113
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