Ao considerar que os distúrbios respiratórios relacionados ao sono, apneia obstrutiva do sono (AOS) e dessaturação noturna de oxigênio (DNO), podem estar presentes em pacientes com doença pulmonar obstrutiva crônica (DPOC), este estudo teve como objetivos: (1) estimar a frequência de AOS e DNO na amostra e nos graus e categorias GOLD (Global Initiative for Chronic Obstructive Lung Disease); (2) avaliar a relação da presença de AOS e DNO no agravamento clínico de pacientes com DPOC. Estudo transversal em 56 pacientes com DPOC estável e pressão parcial arterial de oxigênio (PaO2) diurna > 60 mmHg, submetidos à coleta dos seguintes dados: demográficos, antropométricos e de hábito tabágico; relato de ronco e sonolência diurna; número de exacerbações e hospitalizações; escala de dispneia do Medical Reserch Council modificada; teste de avaliação da DPOC; escala de sonolência de Epworth; espirometria; gasometria arterial; hemograma; monitorização ambulatorial da pressão arterial e polissonografia. Os pacientes foram classificados em graus e categorias GOLD e divididos em 3 grupos de estudo: grupo DPOC pura, grupo síndrome de sobreposição (SS) e grupo dessaturador (D). Os resultados mostraram: 30 pacientes do sexo masculino (54%); idade: 63,7 (DP=7,3) anos; índice de massa corpórea (IMC): 25,2 (DP=4,3) Kg/m2; circunferência do pescoço: 38,4 (DP=3,2) cm; 46% tabagistas; carga tabágica: 50,0 (DP=20,7) anosmaço; volume expiratório forçado no primeiro segundo (VEF1): 56,4 (DP=19,8) % do previsto; PaO2: 78,3 (DP=8,0) mmHg; saturação arterial de oxigênio (SaO2): 95,5 (DP=1,4) %; 29 pacientes (52%) eram do grupo DPOC pura, 14 (25%) do grupo SS e 13 (23%) do grupo D; frequência de AOS e DNO na amostra: 25% e 23%, respectivamente; frequência de AOS nos GOLD 1234: 14%, 24%, 25%, 50% (p=0,34) e GOLD ABCD: 44%, 15%, 25%, 26% (p=0,31), respectivamente; frequência da DNO nos GOLD 1234: 29%, 24%, 19%, 25% (p=0,88) e GOLD ABCD: 11%, 20%, 25%, 30% (p=0,35), respectivamente. Evidências de diferença estatística entre os 3 grupos: sexo (DPOC pura: 48% de homens versus SS: 86% versus D: 31%; p<0,01); IMC (DPOC pura: 23,9 (DP=3,8) versus SS: 24,7 (DP=4,6) versus D: 28,6 (DP=3,5) Kg/m2; p<0,01); circunferência do pescoço (DPOC pura: 37,4 (DP=2,7) versus SS: 40,0 (DP=2,9) versus D: 38,9 (DP=3,9) cm; p=0,03); relato de sonolência diurna (DPOC pura: 17% versus SS: 0 versus D: 38%; p=0,03); SaO2 diurna (DPOC pura: 95,8 (DP=1,5) % versus SS: 95,8 (DP=1,1) % versus D: 94,7 (DP=1,3) %; p=0,04); descenso noturno diastólico (DPOC pura: 6,5 (DP=7,0) % versus SS: 2,3 (DP=7,3) % versus D: 5,6 (DP=7,0) %; p=0,04). Conclui-se que, em pacientes com DPOC, a frequência de AOS e DNO foi elevada na amostra e não sofreu influência dos graus ou categorias GOLD; encontrou-se associação entre a presença de AOS e o sexo masculino, maior circunferência do pescoço e menor descenso noturno diastólico; e a presença de DNO associou-se com o sexo feminino, maior IMC, maior relato de sonolência diurna e menor SaO2 diurna. Estas características podem contribuir para diferenciar clinicamente os grupos SS e D do grupo DPOC pura / While considering that the sleep-related breathing disorders, obstructive sleep apnea (OSA) and nocturnal oxygen desaturation (NOD) may be present in patients with chronic obstructive pulmonary disease (COPD), this study aimed to: (1) to estimate the frequency of OSA and NOD in the sample and in the GOLD degrees and categories (Global Initiative for Chronic Obstructive Lung Disease); (2) to assess the relationship of the presence of OSA and NOD in the clinical aggravation of patients with COPD. Transversal study in 56 patients suffering from stable COPD and daytime partial arterial oxygen tension (PaO2) > 60 mmHg, subjected to the collection of the following data: demographic and anthropometric data, and smoking habit; report of snoring and daytime sleepiness; number of exacerbations and hospitalizations; modified Medical Research Council dyspnea scale; COPD assessment test; Epworth Sleepiness Scale; spirometry; arterial gasometry; hemogram; ambulatory blood pressure monitoring and polysomnography. The patients were classified in GOLD degrees and categories and divided into 3 study groups: pure COPD group, overlap syndrome (OS) and desaturator group (D). The results showed: 30 male patients (54%); age 63,7 years old (DP=7,3); body mass index (BMI) 25,2 Kg/m2 (DP=4,3); neck circumference 38,4 cm (DP=3,2); 46% smokers; smoking load 50,0 pack years (DP=20,7); forced expiratory volume in the first second (FEV1) 56,4% of the expected (DP=19,8); PaO2 78,3 mmHg (DP=8,0); arterial oxygen saturation (SaO2) 95,5% (DP=1,4); 29 patients (52%) belonged to the pure COPD group, 14 (25%) to the OS group and 13 (23%) to the D group; frequency of OSA and NOD in the sample: 25% and 23%, respectively; frequency of OSA in the GOLD 1234: 14%, 24%, 25%, 50% (p=0,34) and GOLD ABCD: 44%, 15%, 25%, 26% (p=0,31), respectively; NOD frequency in the GOLD 1234: 29%, 24%, 19%, 25% (p=0,88) and GOLD ABCD: 11%, 20%, 25%, 30% (p=0,35), respectively. Evidences of statistical difference among the three groups: sex (pure COPD: 48% men versus OS: 86% versus D: 31%; p<0,01); BMI (pure COPD: 23,9 (DP=3,8) versus OS: 24,7 (DP=4,6) versus D: 28,6 (DP=3,5) Kg/m2; p<0,01); neck circumference (pure COPD: 37,4 (DP=2,7) versus OS: 40,0 (DP=2,9) versus D: 38,9 (DP=3,9) cm; p=0,03); report of daytime sleepiness (pure COPD: 17% versus OS: 0 versus D: 38%; p=0,03); daytime SaO2 (pure COPD: 95,8% (DP=1,5) versus OS: 95,8% (DP=1,1) versus D: 94,7% (DP=1,3); p=0,04); diastolic sleep dip (pure COPD: 6,5% (DP=7,0) versus OS: 2,3% (DP=7,3) versus D: 5,6% (DP=7,0); p=0,04). It was concluded that, in patients with COPD, the OSA and NOD frequency was high in the sample and was not influenced by GOLD grades or categories. An association between the presence of OSA and the male sex, a larger neck circumference and a smaller diastolic sleep dip was found; and the presence of the NOD was associated with the female sex, a larger BMI, a more significant report of daytime sleepiness and a smaller daytime SaO2. These characteristics may contribute to differentiate clinically the OS and D groups from the pure COPD group

Introdução: O uso de biomassa como combustível para aquecimento e preparação de alimentos vem sendo considerado como um importante fator associado à prevalência aumentada de sintomas respiratórios e à perda de função pulmonar. No presente estudo apresentamos os efeitos respiratórios da exposição crônica à combustão de biomassa (BM) dentro (BMD) ou fora (BMF) do domicílio em uma população do interior do Brasil e comparamos os resultados aos de indivíduos da mesma população que utilizam gás liquefeito de petróleo (GLP). Métodos: Foram incluídos 1402 indivíduos em 260 domicílios divididos em três grupos de acordo com a exposição (GLP, BMD, BMF). Os sintomas respiratórios foram avaliados utilizando questionários validados. O índice de refletância de filtros de papel foi utilizado para avaliar a exposição à biomassa. Em 48 domicílios a concentração de material particulado PM2,5 também foi quantificada. Provas de função pulmonar (PFP) foram realizadas em 120 indivíduos. Resultados: O índice de refletância correlacionou-se diretamente com a concentração de PM2,5 (r=0,92, p<0,001) e foi portanto utilizado para estimar a exposição (ePM2,5). Demonstramos aumento significativo do ePM2,5 no grupo BMD e BMF em comparação com o grupo GLP (p<0,001). Houve ainda aumento significativo da razão de chances (OR) para tosse produtiva, chiado e dispnéia nos adultos expostos à BMD (OR=2,93, 2,33, 2,59, respectivamente) e BMF (OR=1,78, 1,78, 1,80, respectivamente) em comparação com o grupo GLP. As PFP demonstraram que tanto o grupo BM-nãotabagista como GLP-tabagista apresentaram redução no % do VEF1 predito e na relação VEF1/CVF quando comparado com GLP-não-tabagista (p=0,002), o mesmo ocorrendo para o grupo BM-tabagista, em relação a todos os demais (p<0,05). A prevalência de obstrução de vias aéreas encontrada no grupo BM-não-tabagista e GLP-tabagista foi semelhante (20%) e menor do que a observada no grupo BM-tabagista (33%). A PFP correlacionou-se inversamente com o tempo de exposição e a concentração de ePM2,5 (p<0,001). Conclusões: A exposição crônica à combustão de biomassa está associada com o aumento da prevalência de sintomas respiratórios, redução da função pulmonar e desenvolvimento de doença pulmonar obstrutiva crônica. Esses efeitos estão associados com a duração e magnitude da exposição e são potencializadas pelo tabagismo. / Introduction: The use of biomass fuels for cooking and heating is considered an important factor associated with respiratory symptoms and loss of pulmonary function. We report the respiratory effects of chronic exposure to biomass (BM) combustion in a Brazilian population and compared the results with those of individuals from the same community using Liquefied Petroleum Gas (LPG). Methods: 1,402 individuals in 260 residences were divided into three groups according to exposure (LPG, indoor-BM, outside-BM). Respiratory symptoms were assessed using questionnaires. Reflectance of paper filters was used to assess BM. In 48 residences the amount of PM2.5 was also quantified. Pulmonary function tests (PFT) were performed in 120 individuals. Results: Reflectance-index correlated directly with PM2.5 (r=0.92, p<0.001) and was used to estimate exposure (ePM2.5). There was a significant increase in ePM2.5 in Indoor-BM and Outside-BM, compared to LPG (p<0.001). There was a significantly increased odds ratio (OR) for cough with sputum, sneezing and dyspnea in adults exposed to Indoor-BM (OR=2.93, 2.33, 2.59, respectively) and Outside-BM (OR=1.78, 1.78, 1.80, respectively) compared to LPG. PFTs revealed both non-smoker-BM and smoker-LPG individuals to have decreased %predicted-FEV1 and FEV1/FVC as compared to non-smoker-LPG (p=0.022). Reduction was also observed in both parameters between smoker-BM and other groups (p<0.05). The prevalence of chronic obstructive pulmonary disease was 20% for both non-smoker-BM and smoker-LPG and smaller than that observed for smoker-BM (33%). PFT data was inversely correlated with duration and ePM2.5 (p<0.001). The prevalence of airway obstruction was 20% in both non-smoker-BM and smoker-LPG subjects. Conclusions: Chronic exposure to BM is associated with increased prevalence of respiratory symptoms, reduced lung function and development of chronic obstructive pulmonary disease. These effects are associated with the duration and magnitude of exposure and are exacerbated by tobacco smoke.

INTRODUÇÃO: As exacerbações da doença pulmonar obstrutiva crônica (DPOC) afetam profundamente a força muscular periférica e a capacidade funcional destes pacientes, entretanto, intervenções para prevenir estas perdas funcionais e sistêmicas são pobremente compreendidas. OBJETIVOS: Avaliar os efeitos do treinamento resistido sobre a força muscular periférica, capacidade funcional e a qualidade de vida em pacientes com DPOC durante a hospitalização. Além disso, avaliar a resposta desta intervenção sobre a inflamação sistêmica e a atividade física de vida diária. MÉTODOS: Vinte e nove pacientes hospitalizados na enfermaria de um Hospital Universitário por exacerbação da DPOC foram randomizados em dois grupos: controle (GC) e treinamento (GT). Eles foram avaliados no 2° dia de internação, na alta hospitalar e após 30 dias. Nestas avaliações foram verificadas a força muscular periférica dos membros inferiores e superiores, a distância percorrida no teste de caminha de 6 minutos (TC6min), a inflamação sistêmica (TNF-, PCR, IL1, IL-12p70, IL-6, IL-8, IL10), a saúde relacionada a qualidade de vida e a atividade física de vida diária. RESULTADOS: Nossos resultados demonstram que durante a hospitalização todos os pacientes, independente do grupo, mantiveram-se a maior parte do tempo (87%) na posição deitada ou sentada. Os pacientes do GC demonstraram uma redução de força muscular dos membros inferiores (p<0,05), mas sem alteração na distância percorrida em 6 minutos (p>0,05) durante a hospitalização. Os pacientes do GT demonstraram uma melhora na força muscular dos membros inferiores e do TC6min (p<0,05) que permaneceram até 30 dias após a alta hospitalar. Diferentemente do GC, os pacientes do GT apresentaram uma melhora do domínio impacto no questionário de qualidade de vida após a alta hospitalar. Não houve diferença entre os grupos nos marcadores inflamatórios sistêmicos analisados durante a hospitalização e após 30 dias. Além disso, diversos pacientes de ambos os grupos permaneciam fisicamente inativos (70%) em casa. CONCLUSÃO: Nossos resultados sugerem que o treinamento resistido durante a hospitalização melhora a força muscular periférica e capacidade funcional. Entretanto, sem alterar a inflamação sistêmica e a atividade física de vida diária / BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) profoundly affects the peripheral muscle strength and functional capacity of patients, however, interventions to prevent these losses and systemic function are poorly understood. OBJECTIVE: Evaluate the effects of resistance training on peripheral muscle strength, functional capacity and quality of life in COPD patients during hospitalization. In addition, evaluate the response of this intervention on systemic inflammation and physical activity of daily living. METHODS: Twenty-nine patients hospitalized in the ward of a university hospital for exacerbation of COPD were randomized into two groups: control (CG) and training (GT). They were evaluated at day 2 after admission, hospital discharge and after 30 days. These assessments were verified to peripheral muscle strength of upper and lower limbs, the distance walked in 6 minutes, systemic inflammation (TNF-, CRP, IL1, IL-12p70, IL-6, IL-8 and IL10), health-related quality of life and physical activity of daily living. RESULTS: Our results show that during hospitalization all patients, regardless of group, remained most of the time (87%) in the lying or sitting position. The CG patients showed a reduction in muscle strength of lower limbs (p <0.05) but no change in distance walked in 6 minutes (p> 0.05) during hospitalization. TG patients demonstrated improvement in muscle strength of lower limbs and distance walked in 6 minutes (p <0.05) that remained until 30 days after hospital discharge. Differently from GC, the GT patients showed an improvement in the domain impact on health-related quality of life after discharge. There was no difference between groups in systemic inflammatory markers analyzed during hospitalization and after 30 days. In addition, several patients in both groups remained physically inactive (70%) at home. CONCLUSION: Our results suggest that resistance training during hospitalization improves peripheral muscle strength and functional capacity. However, without altering systemic inflammation and physical activity of daily living

This thesis investigated lifestyle characteristics including cigarette smoking, alcohol consumption, dietary supplements intake, physical activity, and urinary incontinence status for Japanese patients with chronic obstructive pulmonary disease (COPD). Field studies were conducted in the middle of Japan. The study was conducted using a cross-sectional survey and all patients were recruited from the outpatient departments of six hospitals in three districts/prefectures, namely, Aichi, Gifu, and Kyoto. Three hundred referred COPD patients diagnosed by respiratory physicians were recruited in 2006. Inclusion criteria were (i) aged between 50 and 75 years; and (ii) had COPD as the primary functionally limiting illness which was diagnosed within the past four years. Diagnosis of COPD was confirmed by spirometry with FEV1/FVC < 70%, where FEV1 = forced expiratory volume in one second and FVC = forced vital capacity. A structured questionnaire was administered to collect information on lifestyle characteristics. All interviews, averaging 40 minutes, took place in the hospital outpatient departments. Clinical characteristics, height, weight and presence of any co-morbidity (e.g. diabetes, hypertension, cardiovascular disease), were retrieved from medical records. / A total of 278 eligible participants (244 men and 34 women) were available for analysis. The majority were men (88%) with mean age 66.5 (SD 6.7) years and mean body mass index (BMI) 21.9 (SD 3.6). Most of them were married (84%), had high school or below education (80%) and retired (55%). In relation to cigarette smoking, 62 (53 male and 9 female) participants (22.5%) were current smokers of whom the great majority (89%) smoked daily. Only six (2.1%) participants were never smokers. The prevalence of smoking by time from diagnosis was: 24.5% (< 1 year), 20.6% (1-2 years), and 18.9% (2-4 years). Continuous smoking was inversely associated with age (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.90-0.98), BMI (OR = 0.88, 95% CI 0.80-0.97) and disease severity vii (OR = 0.29, 95% CI 0.12-0.74 for severe COPD and OR = 0.29, 95% CI 0.09-0.92 for very severe COPD). For alcohol consumption, 158 (150 male and 8 female) patients (56.8%) drank alcohol regularly on at least a monthly basis, the majority of them (73.4%) being daily drinkers. Beer was the most preferred alcoholic beverage drank (30.9%). Alcohol intake appeared to be positively associated with the habit of adding soy sauce to foods, whereas dyspnoea of patients posed significant limitations for them to drink alcoholic beverages. / Also, female patients tended to have lower alcohol consumption levels than male patients. Regarding dietary supplements, 117 (101 male and 16 female) participants (42.1%) were dietary supplement users, but the prevalence for female patients (47.1%) was higher than male patients (41.4%). Younger patients (≤ 60 years) and those with severe COPD had relatively low proportion of users (27.3% and 28.9%, respectively). Dietary supplementation was found to be affected by age (p = 0.04), COPD severity (p = 0.03) and presence of co-morbidity (p = 0.03). Older patients over 60 years were more likely to take dietary supplements (OR = 2.44, 95% CI 1.03-5.80), whereas severe COPD patients (OR = 0.41, 95% CI 0.18-0.95) and those with a co-morbidity (OR = 0.54, 95% CI 0.32-0.94) tended not to use. With respect to physical activity of COPD patients, 198 (175 male and 23 female) of them (77%) participated in physical activities on at least weekly basis, but only 22% and 4% engaged in moderate and vigorous activities, respectively. Over 2/3 of them walked at least weekly. Regression analysis showed that perceived life-long physical activity involvement appeared to be positively associated with total physical activity, whereas patients with very severe COPD tended to have significantly lower total physical activity levels. / Besides COPD severity, both age and smoking exhibited a negative impact on walking. It is evident that walking activities decreased among very severe patients, current smokers and those in advanced age. The prevalence of urinary incontinence was 12.6% (10% for men and 32% for women). The most common occurrence of urine loss was before reaching the toilet (54%) followed by coughing/sneezing (23%). While urge incontinence was reported viii by 63% of male incontinent patients, 82% of female incontinent patients experienced stress incontinence. Incontinence was more likely among female patients (OR = 8.7, 95% CI 3.2-23.4) and older patients over 70 years (OR = 2.3, 95% CI 1.0-5.2). COPD severity was also found to be a significant factor (p = 0.007), with very severe patients at slightly higher risk of urinary incontinence (OR = 1.1, 95% CI 0.3-3.5) than mild COPD patients, though the relationship appeared not to be linear across the severity classifications. It is alarming to find mild and moderate COPD patients continue to smoke. The implementation of a co-ordinated tobacco control program immediately post diagnosis is needed for the effective pulmonary rehabilitation of COPD patients. The high alcohol consumption by COPD patients is also alarming. Alcohol control programs targeting male patients should be promoted during pulmonary rehabilitation in order to minimise the harm due to excessive drinking. Dietary supplements are popular for patients with COPD especially among older patients. / The findings are important to clinical trials and experimental interventions advocating nutritional supplementation therapy for pulmonary rehabilitation. Patients with COPD had lower physical activity levels than the general elderly population. Older patients with very severe COPD and those who currently smoke should be targeted for intervention and encouraged to increase their participation in physical activity so as to maintain their health and well being. The high prevalence yet underreporting of urinary incontinence suggested that education and regular assessment are needed after COPD diagnosis. Appropriate exercise and treatment tailored for the specific type of incontinence incurred should be incorporated within the rehabilitation program of COPD patients. To maintain a healthy lifestyle and to achieve optimal outcomes during the pulmonary rehabilitation of COPD patients, the identified factors should be taken into consideration and health awareness programs should be promoted in conjunction with respiratory physicians and allied health professionals.

The primary aim of this thesis was to develop a better understanding of the physiology and perceptual responses associated with the performance of continuous (CE) and intermittent exercise (IE) in patients with moderate chronic obstructive pulmonary disease (COPD). A secondary aim was to examine factors that could potentially limit exercise tolerance in COPD patients, particularly in relation to the dynamics of the cardiovascular system and muscle metabolism. The results of the four studies conducted to achieve these aims are presented in this thesis. In Study 1, the physiological, metabolic and perceptual responses to an acute bout of IE and CE were examined in 10 individuals with moderate COPD. Each subject completed an incremental exercise test to exhaustion on a cycle ergometer. Subjects then performed IE (1 min exercise: 1 min rest ratio) and CE tests at 70% of peak power in random order on separate days. Gas exchange, heart rate, plasma lactate concentration, ratings of breathlessness, inspiratory capacity and the total amount of work completed were measured during each exercise test. Subjects were able to complete a significantly greater amount of work during IE (71 ± 32 kJ) compared with CE (31 ± 24 kJ). Intermittent exercise was associated with significantly lower values for oxygen uptake, expired ventilation and plasma lactate concentration when compared with CE. Subjects also reported a significantly lower rating of breathlessness during IE compared to CE. The degree of dynamic lung hyperinflation (change in end-expiratory lung volume) was lower during IE (0.23 ± 0.07 L) than during CE (0.52 ± 0.13 L). The results suggest that IE may be superior to CE as a mode of training for patients with COPD. The greater amount of total work performed and the lower measured physiological responses attained with intermittent exercise could potentially allow greater training adaptations to be achieved in individuals with more limited lung function. The purpose of Study 2 was to compare the adaptations to 8 wk of supervised intermittent and continuous cycle ergometry training, performed at the same relative intensity and matched for total work completed, in patients with COPD. Nineteen subjects with moderate COPD were stratified according to age, gender, and pulmonary function, and then randomly assigned to either an IE (1 min exercise: 1 min rest ratio) or CE training group. Subjects trained 3 d per week for 8 wk and completed 30 min of exercise. Initial training intensity, i.e., the power output applied during the CE bouts and during the exercise interval of the IE bouts, was determined as 50% of the peak power output achieved during incremental exercise and was increased by 5% each week after 2 wk of training. The total amount of work performed was not significantly different (P=0.74) between the CE (750 ± 90 kJ) and IE (707 ± 92 kJ) groups. The subjects who performed IE (N=9) experienced significantly lower levels of perceived breathlessness and lower limb fatigue during the exercise-training bouts than the group who performed CE (N=10). However, exercise capacity (peak oxygen uptake) and exercise tolerance (peak power output and 6-min walk distance) improved to a similar extent in both training groups. During submaximal constant-load exercise, the improved (faster) phase II oxygen uptake kinetic response with training was independent of exercise mode. Furthermore, training-induced reductions in submaximal exercise heart rate, carbon dioxide output, expired ventilation and blood lactate concentrations were not different between the two training modes. Exercise training also resulted in an equivalent reduction for both training modes in the degree of dynamic hyperinflation observed during incremental exercise. Thus, when total work performed and relative intensity were the same for both training modes, 8 wk of CE or IE training resulted in similar functional improvements and physiological adaptations in patients with moderate COPD. Study 3 examined the relationship between exercise capacity (peak oxygen uptake) and lower limb vasodilatory capacity in 9 patients with moderate COPD and 9 healthy age-matched control subjects. While peak oxygen uptake was significantly lower in the COPD patients (15.8 ± 3.5 mL·min-1·kg-1) compared to the control subjects (25.2 ± 3.5 mL·kg-1·min-1), there were no significant differences between groups in peak calf blood flow or peak calf conductance measured 7 s post-ischemia. Peak oxygen uptake was significantly correlated with peak calf blood flow and peak conductance in the control group, whereas there was no significant relationship found between these variables in the COPD group. However, the rate of decay in blood flow following ischemia was significantly slower (p less than 0.05) for the COPD group (-0.036 ± 0.005 mL·100 mL-1·min-1·s-1) when compared to the control group (-0.048 ± 0.015 mL·100 mL-1·min-1·s-1). The results of this study suggest that the lower peak exercise capacity in patients with moderate COPD is not related to a loss in leg vasodilatory capacity. Study 4 examined the dynamics of oxygen uptake kinetics during high-intensity constant-load cycling performed at 70% of the peak power attained during an incremental exercise test in 7 patients with moderate COPD and 7 healthy age-matched controls. The time constant of the primary component (phase II) of oxygen uptake was significantly slower in the COPD patients (82 ± 8 s) when compared to healthy control subjects (44 ± 4 s). Moreover, the oxygen cost per unit increment in power output for the primary component and the overall response were significantly higher in patients with COPD than in healthy control subjects. A slow component was observed in 5 of the 7 patients with COPD (49 ± 11 mL·min-1), whereas all of the control subjects demonstrated a slow component of oxygen uptake (213 ± 35 mL·min-1). The slow component comprised a significantly greater proportion of the total oxygen uptake response in the healthy control group (18 ± 2%) than in the COPD group (10 ± 2%). In the COPD patients, the slow component amplitude was significantly correlated with the decrease in inspiratory capacity (r = -0.88, P less than 0.05; N=5), indicating that the magnitude of the slow component was larger in individuals who experienced a greater degree of dynamic hyperinflation. This study demonstrated that most patients with moderate COPD are able to exercise at intensities high enough to elicit a slow component of oxygen uptake during constant-load exercise. The significant correlation observed between the slow component amplitude and the degree of dynamic hyperinflation suggests that the work of breathing may contribute to the slow component in patients with COPD.

<p>The overall aims of the studies were to investigate the effects of different training modalities on exercise capacity and health-related quality of life (HRQoL) in patients with moderate or severe COPD and, further, to explore two of the physical tests used in pulmonary rehabilitation.</p><p>In <b>study I</b>, the 12-minute walking distance (12MWD) did not increase on retesting in patients with exercise-induced hypoxemia (EIH) whereas 12MWD increased significantly on retesting in the non-EIH patients. In <b>study II</b>, we found that the incremental shuttle walking test was as good a predictor of peak exercise capacity (W peak) as peak oxygen uptake (VO₂ peak) is. In <b>study III</b>, we investigated the effects of two different combination training programmes when training twice a week for eight weeks. One programme was mainly based on endurance training (group A) and the other on resistance training and callisthenics (group B). W peak and 12MWD increased in group A but not in group B. HRQoL, anxiety and depression were unchanged in both groups. Ratings of perceived exertion at rest were significantly lower in group A than in group B after training and during 12 months of follow-up. Twelve months post-training, 12MWD was back to baseline in group A, but significantly shorter than at baseline in group B. Thus, a short endurance training intervention delayed decline in 12MWD for at least one year. Patients with moderate and severe COPD responded to training in the same way. In <b>study IV</b>, both interval and continuous endurance training increased W peak, VO₂ peak, peak exhaled carbon dioxide (VCO₂ peak) and 12MWD. Likewise, HRQoL, dyspnoea during activities of daily life, anxiety and depression improved similarly in both groups. At a fixed, submaximal workload (isotime), the interval training reduced oxygen cost and ventilatory demand significantly more than the continuous training did.</p>

Long-term oxygen therapy (LTOT) or home mechanical ventilation (HMV) can improve survival time in chronic respiratory failure. A national quality register could be an aid to identifying risk markers and optimizing therapy for respiratory failure. Aims: ▪To identify risk markers for chronic respiratory failure, especially when triggered by chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). ▪To predict sex-related differences in the future need of LTOT for COPD and to study sex related survival rate in COPD patients starting LTOT. ▪To investigate if HMV is more effective than LTOT alone in treating chronic respiratory failure caused by kyphoscoliosis. ▪To evaluate the use of quality indicators in LTOT. Methods: Swedish national registers for LTOT and HMV were established in 1987 and 1996 respectively. They were reconstructed in 2004 to form the web-based register Swedevox. Indications for LTOT were based on the guidelines from the Swedish Society for Respiratory Medicine. The incidence and prevalence of LTOT for COPD were measured annually from 1987 to 2000, and the future need for LTOT was estimated on the basis of the frequency of ever smoking in Sweden in 2001 in different age groups. A postal questionnaire on occupational exposures was completed by 181 patients with severe pulmonary fibrosis who started LTOT between 1997 and 2000, and by 757 controls. Odds ratios (ORs) were calculated. Time to death was evaluated in kyphoscoliotic patients starting HMV or LTOT alone in 1996-2004. Ten quality indicators were defined and evaluated based on data from patients starting LTOT in 1987-2005. Results: The incidence each year of LTOT in COPD patients increased more rapidly in women than in men (from 2.0 and 2.8/100,000 in 1987 to 7.6 and 7.1/100,000 in 2000 respectively, (p < 0.001)). Women ran a 1.9 times higher risk than men to develop chronic hypoxemia from COPD and had a higher survival rate during LTOT. In men, IPF was associated with exposure to birch dust with an OR 2.7, (95% confidence interval (CI) 1.30–5.65) and with hardwood dust, OR 2.7 (95% CI 1.14–6.52). Patients with kyphoscoliosis showed a better survival rate with HMV than with LTOT alone with a hazard ratio of 0.30 (95%CI 0.18-0.51), adjusted for age, sex, concomitant respiratory diseases, and blood gas levels. There were improvements in the following eight quality indicators for LTOT: access to LTOT, PaO2 ≤ 7.3 kPa without oxygen, no current smoking, low number of thoracic deformity patients without concomitant HMV, LTOT > 16 hours of oxygen/day, mobile oxygen equipment, reassessment of hypoxemia when LTOT was not started in a stable state COPD, and avoidance of continuous oral steroids in COPD. There was a decline in the indicator PaO2 > 8 kPa on oxygen. First-year survival rate in COPD was unchanged. Conclusions: The incidence and prevalence of LTOT increase more rapidly in women than in men. Survival rate during LTOT in COPD is better in women than in men. Exposure to birch and hardwood dust may contribute to the risk of IPF in men. Survival rate in patients with kyphoscoliosis was three times better with HMV than with LTOT alone. The national quality register for LTOT showed improvements in eight out of ten quality indicators. Levels for excellent quality in the indicators are suggested.

Chronic obstructive pulmonary disease, COPD, places a substantial burden of disability on the growing number of patients and causes large costs for the society. Tobacco smoke is the most important risk factor. Progressive exertional dyspnea is the major symptom which leads to diminished physical and social activities, reduced physical capacity and decreased health related quality of life, HRQoL. The aim of this thesis was to evaluate different physical training modalities in patients with COPD with regard to physical capacity and HRQoL. Patients with moderate to severe COPD were included in the studies. In the first intervention, 20 patients trained on a treadmill with or without supplemental oxygen, three times per week, during eight weeks. In the second intervention, 30 patients were randomised to high-intensity group training either in water or on land, and 13 patients were included in a control group. The patients in the water and land groups trained three times per week during three months and once a week during the following six months. Oxygen supplementation during physical training did not enlarge the positive effects of the same training with air in patients with exercise-induced hypoxaemia. Both groups improved the distance walked after training. High-intensity group training in water and on land was found to be effective with regard to walking distance and HRQoL compared to the control group. Training in water seemed to be of greater benefit compared to training on land concerning walking distance and experienced physical health when the training was accomplished three times per week. The thigh muscle strength increased after training in both the water and the land group. The muscle endurance in knee extension was low in the majority of the patients and was not improved after the training intervention. An evaluation of the long-term effects of physical group training and the effects of decreased training frequency showed that training with low frequency (once a week) during six months did not seem to be sufficient to maintain the level achieved after a three months period of higher frequency training (three times per week). However, the two periods combined seemed to prevent decline in physical capacity and HRQoL compared to baseline. The conclusion is that physical training is of benefit for patients with COPD with regard to physical capacity and HRQoL. Training can be performed individually or in groups, with high intensity, in water and on land. It is also concluded that the training can, under controlled conditions, be performed without supplemental oxygen even in patients with exercise-induced hypoxaemia.

The overall aim of this thesis was to describe subjects with chronic obstructive pulmonary disease (COPD) from different perspectives. Focus was on patients at the time of diagnosis, impact of the disease in comparison to other chronic diseases, factors associated with good health and quality of life (QoL), and diagnostic spirometry in clinical practice. Methods: Qualitative method, grounded theory, was used to analyse patients´ perspectives at the time of diagnosis in a primary care setting (n=10). Public health surveys in the general population were used to compare chronic diseases (n=10,755) and analyse factors associated with health outcomes in COPD (n=1,475). Medical records and spirometry reports, from primary and secondary care, were analysed to assess diagnosis of COPD in clinical practice (n=533). Results: In clinical practice, 70% of patients at the time of diagnosis of COPD lacked spirometry results confirming the diagnosis. Factors related to consequences of smoking, shame and restrictions in physical activity (PA) in particular, were described by patients at the time of diagnosis of COPD. In general subjects with COPD (84%), rheumatoid arthritis (74%) and diabetes mellitus (72%) had an activity level considered too low to maintain good health. In COPD, the most important factor associated with good health and quality of life was a high level of PA. Odds ratios (OR (95%CI)) varied from 1.90 (1.47-2.44) to 7.57 (4.57-12.55) depending on the degree of PA, where subjects with the highest PA level had the best health and QoL. Conclusions: Subjects with COPD need to be diagnosed at an early stage, and health professionals should be aware that feelings of shame could delay patients from seeking care and thus obtaining a diagnosis. The use of spirometry and the diagnostic quality should be emphasised. In patients with COPD greater attention should be directed on increasing the physical activity level, as patients with a low level of physical activity display worse health and quality of life.

The Obstructive Lung Disease in Northern Sweden (OLIN) Studies started in 1985 as an epidemiological project with the aim to detect preventable risk factors for obstructive lung diseases and allergy. In recent years there has been a focus also on obstructive sleep apnoea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) besides asthma and allergy. The aim of this thesis was to estimate the prevalence and incidence of COPD, risk factors for COPD, and decline in lung function in relation to COPD. The OLIN cohort I (cI) was recruited in 1985/86 and consisted of all 6610 subjects born 1919-20, 1934-35 and 1949-50 in eight geographical areas of Norrbotten. A postal questionnaire survey was performed in 1985/86, 1992 and in 1996. All subjects reporting respiratory symptoms at the questionnaire in 1985/86 were invited to examination in 1986, 1996 and 2002-03. A random sample of 1500 subjects from the participants at the 1996 postal questionnaire survey was invited to examination in 1996 and 2003. The participation rate has been high, ≥85%. The OLIN cohort III (cIII) was recruited in 1992, a postal questionnaire was sent to a random sample of 5681 subjects aged 20-69 years. In 1994/95 a random sample of 970 subjects were invited to examination of whom 666 participated. The prevalence of COPD in the general population sample (cIII) in ages &lt;45 was 4.1%, 11.6%, 9.1%, and 5.1% according to the criteria of BTS1 , ERS2 , GOLD3 , and ATS4 respectively. The corresponding figures in ages ≥45 were 9.7%, 15.4%, 17.1%, and 16.5% respectively. In the age-stratified general population sample (&gt;45 y, cI), the prevalence was 8.1% and 14.3% according to the BTS and GOLD criteria. The prevalence was strongly associated with higher age and smoking but not gender. The prevalence among smokers 76-77 years old was 45% and 50% (BTS and GOLD criteria). A majority of subjects with COPD had respiratory symptoms (in prevalent BTS 94%), most commonly cough and sputum production. Nearly a half of the subjects with COPD had contacted health care due to respiratory complaints other than common colds, but only a minority reported a physician diagnosis relevant for COPD (16% of prevalent COPD according to BTS in cIII, 31% in cI). The 10-year cumulative incidence of COPD (1986-1996) was estimated at 8.2% (BTS) and 13.5% (GOLD) in the symptomatics of cI, associated with higher age and smoking but not gender. Persistent smoking, male gender and reported chronic productive cough were associated with a faster decline in FEV1. Among incident cases of COPD a large proportion (23% of incident BTS) had a rapid decline in FEV1, &gt;90 ml/year, corresponding to a decrease of 28 percent-units of normal value during ten years.The 7-year cumulative incidence of COPD in the random sample of cI (1996-2003) was estimated at 4.9% and 11.0% (NICE guidelines5 and GOLD) and associated with smoking but not gender. The incidence according to GOLD, but not NICE, was associated with increasing age. In multi-variate analysis most respiratory symptoms were markers of increased risk for developing COPD. In conclusion, the prevalence and the incidence of COPD were associated with age and smoking and affected by the use of different spirometric criteria. Respiratory symptoms marked an increased risk for developing COPD. A high proportion of subjects developing COPD had a rapid decline in lung function. Further, there was a substantial underdiagnosis of COPD. 1 British Thoracic Society: FEV1/VC&lt;0.70 &amp; FEV1&lt;80%predicted (pred), 2 European Respiratory Society: FEV1/VC&lt;88%pred in men, &lt;89%pred in women, 3 Global initiative for Chronic Obstructive Lung Disease:FEV1/FVC&lt;0.70, 4 American Thoracic Society: FEV1/FVC&lt;0.75 + symptoms or physician diagnosis, 5 The British National Institute for Clinical Excellence: FEV1/FVC&lt;0.70 &amp; FEV1&lt;80%pred.