A basic tool to determine exercise capacity in COPD: 4-meter gait speed.

Introduction: Determination of exercise capacity is crucial for chronic obstructive pulmonary disease (COPD) management since it is an indicator of life quality and mortality. Various previously defined tests, including the cardiopulmonary exercise test (CPET), the 6-minute walking test (6MWT), and the incremental shuttle walk test, are used to determine COPD patients' exercise capacity. However, they all have some disadvantages, such as time, personnel, and equipment requirements, limiting their daily practice use. Here, it was aimed to investigate the role of 4-meter gait speed (4mGS) in evaluating exercise capacity in COPD. Materials and Methods: We included 40-to-70-year-old COPD patients with no contraindications for exercise testing. We performed the tests at standard intervals without affecting each other's results. We also performed spirometry. We used the modified Medical Research Council Scale, COPD Assessment Test, and BODE index to determine the current status of individuals. Result: Twenty-three (female/male= 2/21) subjects aged 58.1 ± 7.3 were included in the study. A statistically significant correlation was observed between 4mGS and peak VO2 values. There was also a statistically significant relationship between 4mGS and 6MWT distance. 4mGS correlated with CAT and BODE scores to represent the general medical status of patients. Conclusions: Considering its easy applicability and reproducibility, 4mGS seems to be a strong candidate for daily clinical use in monitoring the exercise capacity of COPD patients. Further studies in larger patient groups are needed to support these results.

Pulmonary manifestations of antiphospholipid syndrome: a retrospective analysis of 67 patients.

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by arterial and/ or venous thrombosis accompanied by persistently elevated levels of antiphospholipid antibodies (aPLs). The aim of this study is to evaluate the pulmonary manifestations of APS and compare the levels of aPLs in patients with and without pulmonary involvement. We retrospectively reviewed the files of patients with the diagnosis of APS between October 2010 and May 2017. Demographic data, clinical, radiological and laboratory findings were recorded. The study included 67 patients (56 female/11 male) with a mean age of 39 ± 13 years. Pulmonary manifestations such as parenchymal and/or vascular involvement were seen in 12 (17.9%) patients. The patients with and without pulmonary manifestations were not significantly different in terms of age (p = 0.46), comorbidities (p = 0.48) and APS duration (p = 0.66). Acute pulmonary thromboembolism (PE) was determined in 11 (16.4%), alveolar hemorrhage in 2 (3%) patients. Four patients with acute PE (36%) developed chronic thromboembolic pulmonary hypertension (CTEPH). One patient developed both CTEPH and diffuse alveolar hemorrhage after acute PE during follow up. Antiphosholipid antibody IgM was highly positive in patients with PE compared to patients without PE (p = 0.005). Other antibodies and lupus anticoagulant were not significantly different in patients with and without PE. None of the patients were deceased due to pulmonary manifestations of APS. PE was the most common pulmonary manifestation of APS. The development of CTEPH was high among APS patients. Patients with APS should be closely followed for the onset of PE and CTEPH.

Is there any contribution of bronchial washing to biopsy in the diagnosis of patients with endobronchial pathology in the era of personalized medicine?

INTRODUCTION: Bronchoscopic biopsies and bronchial washings (BW) are commonly used together for the diagnosis of centrally located tumors. This study aimed to investigate the clinical relevance of routinely collecting BWs in patients who simultaneously had biopsies for visible endobronchial lesions in the current molecular analysis-driven personalized medicine era. MATERIALS AND METHODS: We retrospectively reviewed the patients who underwent fiberoptic bronchoscopy (FOB) between October 2011 and December 2016. Patients who had both BW and biopsy specimens (EBB: endobronchial forceps biopsy and/or EBNA: endobronchial needle aspiration biopsy) for visible endobronchial lesions were included in this study. Demographic and clinical data, macroscopic findings during FOB, pathology results, and final diagnoses were collected from the hospital database. RESULT: The study included 269 patients (220 males/49 females) with a mean age of 61.6 ± 10.6 years. While the overall diagnostic yield of FOB was 71.4%, the diagnostic yields of bronchoscopic procedures were 68.2% for EBB, 83.3% for EBNA, and 19.7% for BW. Only three patients (1.1%) with undiagnostic biopsies had positive BW cytology revealing merely malignant epithelial cells. CONCLUSIONS: BW provided a negligible diagnostic contribution in 1.1% (n= 3) of the patients. These three patients had undergone further diagnostic procedures for making a proper therapeutic management plan. In the era of personalized therapy, it is logical to obtain more biopsy in the time spent for BWs.

Diagnostic value of BRCA1-associated protein-1, glucose transporter-1 and desmin expression in the discrimination between reactive mesothelial proliferation and malignant mesothelioma in tissues and effusions.

OBJECTIVE: The aim of this study was to investigate the utility of BRCA1-associated protein-1 (BAP1), glucose transporter (GLUT)-1 and desmin expression by immunohistochemistry in the discrimination between reactive and malignant mesothelial proliferations. METHODS: A total of 88 biopsies and 30 effusions from mesothelioma cases were studied. Control groups were composed of 35 tissues and 30 cell blocks. The 88 mesothelioma cases were from 43 males and 45 females (mean age 56 years). Tumours were mostly localised to pleura (66/88, 75%) and of epithelioid histology (75/88, 85%). Cytology samples were from 17 males and 13 females (mean age 58 years), and 16 pleural and 14 peritoneal effusions. Twenty cytology cases had corresponding tissue biopsies. RESULTS: BAP1 loss was detected in 61/88 (69%) tissues and in 20/30 (67%) cytology samples from mesothelioma with a specificity of 100% for both sampling methods. BAP1 loss was observed more frequently in pleural and biphasic tumours. GLUT-1 immunoreactivity was identified in 54/81 (67%) and 23/25 (92%) malignant tissues and effusions, and in 6/33 (18%) and 6/30 (20%) benign tissues and effusions, respectively. Desmin loss was observed in 74/80 (92%) malignant biopsy samples, 16/21 (76%) malignant effusions and 10/34 (29%) of benign tissues, but in none of the reactive effusions. Concordance rate of results between biopsy and cytology was as follows: BAP1 20/20 (100%); GLUT-1 13/18 (72%); and desmin 10/14 (71%). CONCLUSIONS: BAP1, GLUT-1 and desmin are useful markers in the discrimination between reactive and malignant mesothelial proliferations. BAP1 loss seems to be diagnostic for mesotheliomas both in biopsy and cytology samples.

Humidification therapy; long-term effects in COPD and OSAS patients.

Humidification therapy is widely used in patients during invasive ventilation and the importance of heating and humidifying the inhaled air is well defined in both the acute and long term setting. On the other hand the continuous usage of humidification in noninvasive ventilation is controversial and the long term effects are still not well defined. The usage of noninvasive ventilation is especially important in hypercapnic Chronic obstructive pulmonary disease (COPD) and also the obstructive sleep apnea syndrome (OSAS) patients and compliance to this treatment is essential in long term. Limited number of studies have shown that heated humidification is preferred by COPD patients and might help in mucus clearance, reduce mucus viscosity and help in expectoration, but there was shown no priority as far as concerns the lung function or blood gas parameters. Humidification might also be important in long term oxygen treatment since the inhalation of dry air can lead to ciliary dysfunction, alterations in mucus properties and mucociliary clearance impairment. Studies concerning OSAS patients showed that humidification helps to reduce the nasal symptoms but plays no role in increasing the compliance of patients in long term. Multi-center studies with large number of patients are needed to identify patients' groups who are likely to benefit from the addition of humidification to noninvasive therapy.

Arterial stiffness in obstructive sleep apnoea: Is there a difference between daytime and night-time?

BACKGROUND AND OBJECTIVE: Obstructive sleep apnoea syndrome (OSAS) is a common chronic systemic disease in the general population, with known associated cardiovascular outcomes. We aimed to investigate arterial stiffness in OSAS patients and compare daytime and night-time values with control subjects. METHODS: A total of 104 patients undergoing investigation for OSAS with polysomnography also underwent pulse wave velocity (PWV) and augmentation index (AIx) measurements with Mobil-O-Graph for 24 h. Eighty-two patients were found to have OSAS and 22 did not have OSAS and acted as controls. RESULTS: PWV values of the 82 OSAS patients during the 24-h period, both daytime and night-time, were significantly higher than that of the control subjects. Moreover, night-time levels of AIx were significantly higher in OSAS patients than control subjects (P = 0.025). PWV during night-time was higher than daytime measurements in OSAS patients (P = 0.012). Apnoea hypopnoea index (AHI) was significantly correlated with PWV and AIx over 24 h (P = 0.0001, r = 0.412; P = 0.002, r = 0.333, respectively). Positive correlations were also found between oxygen desaturation index (ODI) with PWV and AIx during the night (P = 0.0001, r = 0.480; P = 0.002, r = 0.325, respectively). However, daytime AIx was not significantly correlated with ODI (P = 0.052, r = 0.205). CONCLUSION: OSAS patients, without known cardiovascular disease, have increased PWV, indicating an increased arterial stiffness, compared with control subjects and correlations between AHI and arterial stiffness indices suggest increased arterial stiffness with increased disease severity. Therefore, arterial stiffness should be considered as a possible cause for cardiovascular complications in OSAS patients.

Endobronchial ultrasound: an unusual diagnostic tool for pulmonary embolism.

Pulmonary thromboembolism (PTE) is an emergent and common pulmonary vascular disease. The most common diagnostic method for PTE is computer-aided tomography angiography. Endobronchial ultrasonography (EBUS) is used in diagnosis and staging of lung cancer via transbronchial needle aspiration from mediastinal lymphadenopathies and central masses. Diagnosis of PTE with EBUS is not common, although this technique helps to monitor pulmonary vasculature. The present case, a 60-year-old female patient to whom EBUS was applied because of mediastinal lymphadenopathy, was diagnosed as incidental PTE.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use at home for chronic respiratory failure.

INTRODUCTION: To define approach of pulmonologists in Turkey to noninvasive mechanical ventilation (NIV) use for chronic respiratory failure (CRF), the most currently applied technique for home mechanical ventilation. PATIENTS AND METHODS: A 38-question survey, developed and tested by the authors, was distributed throughout Turkey to 2205 pulmonologists by e-mail. RESULT: Twenty-seven percent of the pulmonologists responded (n=596). Domiciliary NIV was reported to be prescribed by 340 physicians [57.1% of all responders and 81% of pulmonologists practicing NIV at clinical practice (n= 420)]. NIV prescription was associated with physician's title, type of hospital, duration of medical license, total number of patients treated with NIV during residency and current number of patients treated with NIV per week (p< 0.05). Main estimated indications were listed as chronic obstructive pulmonary disease (median, 25-75 percentile of the prescriptions: 75%, 60-85), obesity hypoventilation syndrome (10%, 2-15), overlap syndrome (10%, 0-20) and restrictive lung disease (5%, 2-10). For utilization of NIV at home, Bilevel positive airway pressure-spontaneous mode (40%, 0-80) and oronasal mask (90%, 60-100) were stated as the most frequently recommended mode and interface, respectively. Pressure settings were most often titrated based on arterial blood gas findings (79.2%). Humidifier was stated not to be prescribed by approximately half of the physicians recommending domicilliary NIV, and the main reason for this (59.2%) was being un-refundable by social security foundation. CONCLUSION: There is a wide variation in Turkey for prescription of NIV, which is supposed to improve clinical course of patients with CRF. Further studies are required to determine the possible causes of these differences, frequency of use and patient outcomes in this setting.

Effects of nondipping pattern on systemic inflammation in obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a highly prevalent chronic systemic disease in the general population with high morbidity and mortality. Nondipping pattern-failure to drop blood pressure levels in nighttime-is also seen in OSAS patients. We aim to investigate dipping and nondipping patterns of OSAS patients and to compare inflammatory markers. MATERIALS AND METHODS: Patients with the confirmed diagnosis of OSAS with polysomnography underwent ambulatory blood pressure monitoring. During monitoring, patients with decreased nighttime mean systolic blood pressures 10 % or more were defined as dippers, and the patients without this amount of decrease were defined as nondippers. Peripheral venous blood samples were collected for the analysis of IL-2, IL-6, IL-8, IL-10, IL-12, and TNF-α. Results were compared with convenient statistical tests. RESULTS: According to monitoring results, 34 of 62 OSAS patients were dipper and 28 of 62 patients were nondipper. Demographic characteristics, OSAS severity, and Apnea Hypopnea Index were similar in both groups. When inflammatory markers were compared between two groups, IL-2 levels were found to be significantly different (p = 0.014). CONCLUSION: In conclusion, nondipping pattern appears to be associated with increased serum IL-2 levels indicating the increased inflammatory response independently from OSAS severity, and this pattern should be evaluated carefully for possible cardiovascular complications.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure.

INTRODUCTION: Noninvasive mechanical ventilation (NIV) has been increasingly used worldwide for acute respiratory failure (ARF), especially in patients with chronic lung disorders. We aimed to define the approach of pulmonologists in Turkey to NIV use for ARF management. MATERIALS AND METHODS: A 38-question survey, developed and tested by authors, was distributed by e-mail to a total of 2.205 pulmonologists in Turkey. RESULT: Response rate was 27% (n= 596). Seventy-one percent of responders were practicing NIV in clinic. NIV use was found to be associated with responder's academic title, age, duration of medical license, type of physician's hospital and its region, patient load, NIV experience during residency, and duration of NIV and intensive care unit (ICU) experience (p< 0.001). Based on sub-group analysis of responders using NIV, median number of NIV patients followed-up per week was 4 [interquartile range (IQR): 2-6]. Most of the NIV users reported employment of wards (90%) and/or ICUs (86%) to follow-up patients, while 8.4% of the responders were applying NIV only in ICU's. Chronic obstructive lung disease (COPD) (99.5%), obesity hypoventilation syndrome (93.7%) and restrictive lung disease (89.4%) were the most common indications. Majority of NIV users (87%) were applying NIV to > 60% of patients with COPD, and success rate in COPD was reported as over 60% by 93% of users. Oronasal mask (median and IQR 90, 80-100%, respectively) and home care NIV ventilators (median and IQR 50, 10-85%, respectively) were the most commonly utilized equipment. CONCLUSIONS: NIV use in ARF varies based on hospital type, region and, especially, experience of the physician. Although consistent with guidelines and general practice, NIV use can still be improved and increased.

[Associations between TGF-ß1 G/A and TNF-α 308 G/A gene polymorphisms with airway resistance in chronic obstructive pulmonary disease]. / Kronik obstrüktif akciger hastaliginda TGF-ß1 G/A ve TNF-α 308 G/A gen polimorfizmleri ile hava yolu direncinin degerlendirilmesi.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is an important morbidity and mortality cause all over the world. Although specific gene region has not been defined in the pathogenesis of COPD, cytokine gene polymorphisms like tumor necrosis factor-alfa (TNF-α) and transforming growth factor-beta1 (TGF-ß1) may contribute to the development of COPD. The aim of the present study was to evaluate the associations between airway resistance with TGF-ß1 G/A and TNF-α 308 G/A gene polymorphisms in COPD patients. PATIENTS AND METHODS: 264 subjects were included to the study (Group 1; 75 COPD patients, Group 2; 139 subjects with at least 10 packet year smoking history without airflow obstruction, Group 3; 50 healthy subjects). Pulmonary function tests and body plethysmography to measure airway resistance were performed to the subjects. TGF-ß1 800 G/A and TNF-α 308 G/A gene polymorphisms were evaluated. Chi-square, Anova and correlation analysis were used for statistical analysis. RESULTS: There were significant difference among COPD stages in terms of TNF-α 308 G/A polymorphism (p< 0.05). Thirteen (23.6%) stage 1 COPD patients had TNF-α 308 G/A polymorphism and the other did not have. We did not find statistically significant difference among COPD stages in terms of TGF-ß1 800 G/A polymorphism (p> 0.05). TNF-α and TGF-ß1 genotypes and TNF-a 308 G/A and TGF-ß1 800 G/A polymorphisms were not different among study groups. Moreover, no significant differences betweeen subjects with and without increased airway resistance in terms of TNF-α 308 G/A and TGF-ß1 800 G/A polymorphisms were present. CONCLUSION: These results can suggest the lack of association between TNF-α 308 G/A and TGF-ß1 800 G/A gene polymorphisms with COPD development and airway resistance in Turkish population.

[Effects of COPD on cognitive functions: a case control study]. / KOAH'in kognitif fonksiyonlar üzerine etkisi: Bir olgu kontrol çalismasi

INTRODUCTION: Assessment of disease severity, effects of disease on health status and future events should be considered to direct treatment strategies in chronic obstructive pulmonary disease (COPD) management. Although extrapulmonary effects of COPD are well known, effects of COPD on cognitive functions have not been evaluated sufficiently. therefore we aimed to determine cognitive functions of copd patients in the present study. MATERIALS AND METHODS: 112 COPD patients with moderate, severe and very severe irreversible airway obstruction and 44 age matched healthy subjects without COPD and systemic diseases as control group were enrolled to the study. Mini mental state examination (MMSE) was performed to evaluate cognitive functions. MMSE results were compared between patient and control groups. Moreover relationship between exacerbation frequency and cognitive functions was evaluated. RESULTS: Total 156 subjects as 112 COPD patients and 44 healthy subjects were included to the study. Mean age of COPD patients was 65.03 ± 7.63 years, and mean age of control group was 63.63 ± 8.96 years (p= 0.364). Mean score of MMSE in COPD patients was 23.8 ± 4.39, and mean score of MMSE in control group was 26.7 ± 2.88. We determined a significant difference in terms of MMSE scores betweeen patient and control group (p< 0.0001). MMSE scores and FEV1 values were significantly different among patients with moderate, sevre and very severe airflow obstruction (p= 0.001; p< 0.0001 respectively). We found a significant negative correlation between MMSE results and exacerbation frequency during last year (p= 0.003; r= -0.239). CONCLUSION: Lower MMSE scores of COPD patients than subjects in control group indicates the impairment of cognitive functions in COPD patients. Moreover a negative relationship between MMSE scores with exacerbation frequency during last year suggests that prevention from exacerbation can decrease cognitive impairment in COPD patients. We believe that assessment of cognitive functions and preventive strategies should be considered in COPD management.

The contribution of bronchoalveolar lavage in the diagnosis of welder's lung in a patient with pulmonary fibrosis.

Interstitial pulmonary fibrosis is rare clinical entity related to welding usually associated with long term and heavy exposure to welding fumes. A 56-year-old asymptomatic male patient was referred to our clinic due to abnormal chest X-ray findings that was requested for regular controls. He has been working as a welder both indoor and outdoor settings for the last 25 years. The radiological findings were compatible with usual interstitial pneumonia on computed tomography of thorax. Pulmonary function tests, exercise capacity and laboratory results were within normal limits. Collagen tissue markers were negative. In order to confirm the relation of welding with pulmonary fibrosis, bronchoalveolar lavage was performed and stained with Prussian blue. The demonstration of hemosiderin-laden macrophages (25%) confirmed this association and allowed differential diagnosis. Besides it helped the patient decide to leave his job.

[Assessment of relation among emotional status, pulmonary function test, exercise performance, and quality of life in patients with COPD]. / KOAH'li olgularda depresyon durumu, solunum fonksiyon testi, egzersiz performansi ve yasam kalitesi arasindaki iliskinin degerlendirilmesi.

Impaired pulmonary function tests, reduced exercise capacity and impaired quality of life are common problems in patients with chronic obstructive pulmonary diseases (COPD). Furthermore chronic respiratory disease is associated with increased risk for anxiety and depression. In the light of these data further studies investigating the effects of emotional status on quality of life and exercise performance in patients with COPD are needed in order to improve treatment modalities. This study was peformed to reveal emotional status on pulmonary function, quality of life, and exercise performance in patients with COPD. 52 (F/M = 13/39, mean age= 67 +/- 12 years) irreversible for bronchodilator test COPD patients (FEV(1)= 1.5 +/- 0.6 L) included to our study. Short form- 36, Beck's Depression Inventory (BDI), pulmonary function tests and 6-minute walking test (6-MWT) were performed to all patients. There was no significant difference between 17 patients with severe to very severe airway obstruction according to GOLD classification (mean FEV(1)= 0.95 +/- 0.2 L) and 35 patients with moderate airway obstruction (mean FEV(1)= 1.75 +/- 0.56 L) in terms of emotional status, exercise performance, and quality of life. Significant corelation was found between BDI and; FEV(1)(p= 0.02, r= -0.323), general health perception (p= 0.001, r= -0.451), vitality (p= 0.000, r= -0.619), general mental health (p= 0.000, r= -0.643), and physical function (p= 0.002, r= -0.426). No correlation was found between 6 MWT and emotional status, and quality of life. In this study it was demonstrated that airway obstruction has an important role for exercise limitation and emotional status related to impaired PFT and quality of life in patients with COPD. We conclude that respiratory intervention together with psychocologic interventions should be performed on patients with COPD by clinicians to achieve improved quality of life.

The publication rates of abstracts presented at the Turkish Respiratory Society (TUSAD) annual congress: adequate or not?

OBJECTIVE: In this study, we aimed to determine the publication status of the abstracts presented at the Turkish Respiratory Society Congress between 2011 and 2014. METHODS: The abstracts were classified according to presentation type (oral presentations, poster discussion, etc.), study type, study design, topic, publication status, time interval between the presentation and the publication date, and the journal in which the article was published. The conversion rate of presentations into full-text articles in peer-reviewed journals were surveyed through Elsevier's Scopus. RESULTS: The total number of abstracts submitted in the congress was 2 009. In terms of study type, the majority of abstracts were case reports (56.4%) and the remainder was original research. Totally, 179 abstracts were published in an indexed journal with an overall publication rate of 8.9%. 18.3% of oral presentations were converted into full-text article. Publication rates according to study types were 14.8% for original researches and 4.4% for case reports. The first three subspecialties with the highest publication rates were "sleep related breathing disorders" (16.9%), "interventional pulmonology" (16.7%) and "pleural diseases" (15.2%). Median publication/acceptance time was 8.0 months (0-38). CONCLUSION: This is the first study evaluating the publication rates of abstracts presented in a respiratory congress. Although the number of presented abstracts in the congress increased year by year, prominently in the case reports, over all conversion rates were decreased. We put forward that encouraging the authors to conduct higher-quality investigations would raise the publication rate as well as improve the scientific quality of congress.

Diagnostic utility of conventional transbronchial needle aspiration in older patients.

BACKGROUND: In older patients, diagnosis and initial treatment should be considered as soon as possible because of high disease burden and complications. Conventional transbronchial needle aspiration (C-TBNA) is an important and safe method for the diagnosis of mediastinal lesions and staging lung cancer in the general population. We aimed to evaluate the diagnostic utility and complications of C-TBNA procedure in older patients aged ≥ 65 years. METHOD: We retrospectively evaluated C-TBNA results consecutively. Demographic data, clinical, radiological and flexible bronchoscopy (FB) findings, complications during C-TBNA and incidence of diagnostic C-TBNA with the presence of abundant lymphoid cells of polymorphous appearance both in patients aged ≥ 65 years and in younger patients were determined. RESULTS: C-TBNA was performed to a total of 317 patients, including 109 older and 208 younger patients attended to our clinic between 2012 and 2016. The mean ages of older and younger patients were 70.3 ± 4.6 and 52.5 ± 10 years, respectively (p < 0.001). Overall, 75.2% of older and 80.3% of younger patients had diagnostic C-TBNA. The diagnostic utility of C-TBNA did not differ significantly between older and younger patients (p = 0.297). During C-TBNA, one older patient had a complication of bronchospasm, and four younger patients had complications such as bleeding (n = 1) and bronchospasm (n = 3). There was no statistically significant difference between older and younger patients in terms of complications during C-TBNA procedure (p = 0.49). CONCLUSION: C-TBNA is a safe procedure with similar diagnostic yield in older patients.

Efficacy of neuromuscular electrical stimulation in patients with COPD followed in intensive care unit.

INTRODUCTION: Serious problems on muscle strength and functional status can be seen in bedridden-patients with chronic obstructive pulmonary diseases (COPD) receiving mechanical ventilation. We aimed to investigate the impact of active extremity mobilization and neuromuscular electrical stimulation (NMES) on weaning processes, discharge from hospital and inflammatory mediators in COPD patients receiving mechanical ventilation. METHODS: Thirty conscious COPD patients (F/M:15/15) hospitalized in the intensive care unit (ICU) with diagnosis of respiratory failure were enrolled to this study. Patients were randomized into three groups, including 10 patients for each. Active extremity-exercise training and NMES were applied to Group-1, only NMES was applied to Group-2 and active extremity exercise training was applied to Group-3. Muscle strengths, mobilization duration and weaning situation were evaluated. Serum cytokine levels were evaluated. RESULTS: Lower extremity muscle-strength was significantly improved in Group-1 (from 3.00 to 5.00, P = 0.014) and 2 (from 4.00 to 5.00, P = 0.046). Upper extremity muscle strength was also significantly improved in all three groups (from 4.00 to 5.00 for all groups, P = 0.038, P = 0.046 and P = 0.034, respectively). Duration of mobilization and discharge from the ICU were similar among groups. There was a significant decrease in serum interleukin (IL)-6 level in Group-1 and in serum IL-8 level in Group-1 and Group-2 after rehabilitation. CONCLUSION: This study indicates that pulmonary rehabilitation can prevent loss of muscle strength in ICU. Nevertheless, we consider that further studies with larger populations are needed to examine the impact of NMES and/or active and passive muscle training in bedridden ICU patients who are mechanically ventilated.