Does Telerehabilitation for Coronavirus Disease 2019 Patients Discharged with Oxygen Shorten the Time of Weaning from Oxygen?

OBJECTIVE: Early pulmonary rehabilitation (PR) and acute and post-acute mobilization with telemonitoring and telerehabilitation (TR) have been recommended for coronavirus disease 2019 (COVID-19) patients. We aimed to compare the duration of weaning from oxygen in patients with hypoxemic COVID-19 who received PR and those who did not. MATERIAL AND METHODS: This study was designed as a quasi-experimental study and was conducted on patients discharged with oxygen supplementation between December 2021 and May 2022. They were compared with patients who received PR and those who did not in terms of the duration of oxygen use. RESULTS: A total of 61 patients (9 women in each group) completed the study. The mean age was 65 ± 12. Thirty patients underwent PR (group 1) and the remaining 31 patients were classified as control group (group 2). When the groups were compared in terms of duration of oxygen use, patients who performed PR were statistically significant shorter duration than those who did not (P = .012). In addition, PR improved their quality of life compared to group 2. CONCLUSION: It was concluded that although PR has many indications, it is also effective, feasible, and safe in prolonged infections and it was thought that TR may also be effective as supervised PR.

Adding Non-Invasive Positive Pressure Ventilation to Supplemental Oxygen During Exercise Training in Severe Chronic Obstructive Pulmonary Disease: A Randomized Controlled Study.

OBJECTIVE: Chronic obstructive pulmonary disease is currently the fourth leading cause of death in the world. Pulmonary rehabilitation is recommended for chronic obstructive pulmonary disease. MATERIAL AND METHODS: This study aimed to evaluate the effects of non-invasive ventilation, supplemental oxygen, and exercise training and supplemental oxygen during exercise training during pulmonary rehabilitation practice in comparison with only exercise training on lung functions, blood gases, lactate levels, respiratory muscle pressures, dyspnea, walking distances, quality of life, and depression in patients with severe chronic obstructive pulmonary disease. The main outcome measure is exercise capacity (6-minute walk test), and the secondary end-point included quality of life. RESULTS: Thirty-five patients (mean ± SD age, 65.4 ± 6.5 years) with a mean bronchodilator forced expiratory volume in the first second of expiration of 39.4 ± 7%, undergoing an 8-week outpatient pulmonary rehabilitation, were randomized to either non-invasive ventilation, supplemental oxygen, and exercise training, supplemental oxygen during exercise training, or exercise training groups. The improvements in respiratory muscle strength were higher in non-invasive ventilation, supplemental oxygen, and exercise training patients than the moderate improvements in the exercise training group. Both non-invasive ventilation, supplemental oxygen, and exercise training and supplemental oxygen during exercise training groups showed significant increases in the 6-minute walk test and incremental shuttle walk test. However, the increase in walking distance was better in non-invasive ventilation, supplemental oxygen, and exercise training group (69.8 ± 53.2 m in 6-minute walk test and 66.6 ± 65.2 m in incremental shuttle walk test, P = .001 and P = .005, respectively) compared to supplemental oxygen during exercise training group (42.5+55.5 m in 6-minute walk test and 53.5+70.2 m in incremental shuttle walk test, P = .01 each, respectively). The total St. George's Respiratory Questionnaire score was similar in all study groups after the intervention. Symptoms of depression significantly improved only in non-invasive ventilation, supplemental oxygen, and exercise training group (-2.8+2.8, P = .006). CONCLUSION: Non-invasive positive-pressure ventilation (NIPPV) added to supplemental oxygen during exercise training was associated with better physiological adaptations than other modalities.

Efficacy of pulmonary rehabilitation on patients with non-cystic bronchiectasis according to disease severity.

INTRODUCTION: The European Respiratory Society guidelines support pulmonary rehabilitation (PR) in bronchiectasis through high-quality evidence. This study aimed to evaluate the efficacy of PR on bronchiectasis patients according to disease severity assessed by the Bronchiectasis Severity Index (BSI). MATERIALS AND METHODS: This prospective study included patients with stable bronchiectasis. Demographic data of all patients were questioned. All patients underwent an 8-week PR program. The patients were grouped into three according to disease severity (mild, moderate and severe) based on their BSI scores. The following parameters were evaluated at baseline (pre-PR) and after PR (post-PR): pulmonary function test results, carbon monoxide diffusion capacity, body mass index, exercise capacity (6-minute walking test), quality of life (QoL; St. George's Respiratory Questionnaire), and Hospital Anxiety and Depression scores. RESULT: The study included 69 patients (55 males; mean age, 62.6 ± 9 years). After PR, the patients were observed to have significantly improved QoL and exercise capacity (p< 0.05). According to BSI, 16 (23.2%), 29 (42.0%), and 24 (34.8%) patients had mild, moderate, and severe bronchiectasis, respectively. These patient groups significantly differed regarding age, exercise capacity, and QoL (p< 0.05). Comparing the change between post-PR and pre-PR values of the study parameters (∆ = post-PR value - pre-PR value), no significant differences were observed regarding the exercise capacity and QoL (p> 0.05) in the groups. CONCLUSIONS: PR increases exercise capacity and QoL in bronchiectasis patients, and its efficacy does not differ according to disease severity. Thus, appropriate bronchiectasis patients should be referred to PR program regardless of disease severity.

Effect of Rebound Thymic Hyperplasia on Survival in Chemotherapy-Treated Lung Cancer.

OBJECTIVES: Thymus is a lymphoepithelial system in which cells responsible for the immune system are produced and directed. The aim of this study is to determine the overall survival effect of rebound thymic hyperplasia (RTH) in patients with non-small cell lung cancer (NSCLC) treated with systemic chemotherapy (CT). MATERIALS AND METHODS: The study was designed as retrospective case series. One hundred and thirty patients who met the inclusion criteria were evaluated. Demographic data, type of tumor, and treatments administered were recorded. The frequency of RTH development and the relationship between RTH development and survival was investigated. RESULTS: The median age of the patients was 59, and nine of 13 patients (69.4%) with RTH were iden-tified as stable disease, two patients had a partial response (15.3%), and two were evaluated as progres-sive disease (15.3%). Of the remaining 117 patients, 78 (66.6%) had stable disease, 11 (9.4%) had com-plete response, 21 (17.9%) had partial response, and seven patients were evaluated as having progressive disease (5.9%). The patients were categorized into two groups: Group 1 - without RTH and group 2 - with RTH. Thirteen (10%) of 130 patients developed RTH (group 2), while the remaining 117 (90%) patients did not have RTH (group 1). There was no difference between the two groups (59.1 years) in terms of age (p = 0.933). The RTH developed after a median time of 4.5 months (2-7 months) after CT had been administered. Overall survival was longer in patients with RTH than in patients without RTH (20.04 months) (95% CI, 4.79-35.29) vs. 10.05 months (95% CI, 8.74-11.36; p=0.049). CONCLUSION: The developing of RTH during systemic CT may be a prognostic marker in stage 4 non-small cell lung cancer.

Metabolic activity of primary tumour on PET/CT has a relationship with survival in stages I-III small-cell lung carcinoma.

INTRODUCTION: There is limited evidence about the prognostic value of FDG-PET/CT metrics in small cell lung cancer (SCLC) patients staged with TNM staging system. OBJECTIVES: The aim of this study is to examine the prognostic value of pretreatment FDG-SUVmax in patients with SCLC staged with 8th TNM staging system. METHODS: A total of 344 (292 male) SCLC patients with pretreatment FDG- PET/CT were included. One hundred fifty-three of cases were stages I-III, 191 were stage IV. SUVmax values were obtained for primary tumour, lymph nodes and metastases. Univariate and multivariate analysis were performed to determine the effect of pretreatment SUVmax, with cut-off value of median, on progression-free and overall survival (PFS and OS). RESULTS: Median OS and PFS for patients with stages I-III were 16.50 and 11.00 months, respectively. Median OS and PFS for patients with stage IV were 10.00 and 7.00 months, respectively. SUVmax of the primary tumour (PT), lymph nodes or metastasis were not associated with OS and PFS on univariate analysis. On multivariate analysis, SUVmax -PT with cut-off value of 11.60 was found to be an independent prognostic factor for OS in patients with stages I-III (HR;1.88, 95% CI:1.15-3.08, P = .012). But the SUVmax -PT (HR; 1.60, 95% CI: 0.99-2.60; P = .057) for PFS was found to be a prognostic factor with marginal significance. SUVmax were not significantly associated with OS and PFS in patients with stage IV disease. CONCLUSION: Pretreatment SUVmax -PT (median cut-off 11.6) may have a prognostic value of OS and PFS in patients with TNM staged I-III SCLC.

Bone mineral density and vitamin D levels in patients with group a COPD.

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is a chronic, inflammatory airway disease associated with osteoporosis. Reduced bone mineral density (BMD) and impaired bone quality were shown to cause increased bone fragility and fractures in COPD patients. The aim of this study was to evaluate vitamin D levels and BMDs in Group A COPD patients. METHODS: This case-control study involved 33 males aged 50 or above diagnosed with Group A COPD and 44 age-matched healthy males. Participants' serum vitamin D and other indicators were evaluated as well as lumbar and hip BMD of COPD patients. RESULTS: Vitamin D levels were significantly lower in COPD patients (15.13 ± 6.02 ng/L) than controls (21.89 ± 4.49 ng/L). Two patients had a history of thoracic vertebral fracture. Lumbar (L1-L4) T scores were normal in 16 patients (48.5%) and indicated osteopenia in 15 (45.5%) and osteoporosis in 2 (6%). Hip femur total T scores were normal in 19 patients (57.6%) and indicated osteopenia in 14 (42.4%). CONCLUSION: Vitamin D deficiency/insufficiency is prevalent in COPD patients, and BMD decreases in the early period of the disease. Vitamin D and BMD should be evaluated in the early stages to prevent osteoporosis and its complications in COPD patients.

Carotid intima-media thickness in chronic obstructive pulmonary disease and survival: A multicenter prospective study.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality. Carotid intima-media thickness (CIMT) is a noninvasive method assessing atherosclerosis. OBJECTIVE: It was aimed to determine relationship and survival between COPD and CIMT. METHODS: CIMT was measured using Doppler ultrasound (USG) in 668 stable COPD patients at 24 centers. Patients were followed-up for 2 years. RESULTS: There were 610 patients who completed the study. There were 200 patients CIMT with <0.78 mm (group 1), and 410 with CIMT ≥ 0.78 mm (group 2). There was a significant difference at the parameters of age, gender, smoking load, biomass exposure, GOLD groups and degree of airway obstruction (FEV1) between groups 1 and 2. Our results revealed positive correlations between mean CIMT and age, smoking load (pack-years), biomass exposure (years), exacerbation rate (last year), duration of hypertension (years) and cholesterol level; negative correlations between CIMT and FEV1 (P < 0.05). According to logistic regression model, compared with group A, risk of CIMT increase was 2.2-fold in group B, 9.7-fold in group C and 4.4-fold in group D (P < 0.05). Risk of CIMT increase was also related with cholesterol level (P < 0.05). Compared with infrequent exacerbation, it was 2.8-fold in the patients with frequent exacerbation (P < 0.05). The mean survival time was slightly higher in group 1, but not significant (23.9 vs 21.8 months) (P > 0.05). CONCLUSION: This study is the first regarding CIMT with combined GOLD assessment groups. It has revealed important findings supporting the increase in atherosclerosis risk in COPD patients. We recommend Doppler USG of the carotid artery in COPD patients at severe stages.

In Which the Gain is more from Pulmonary Rehabilitation? Asthma or COPD?

OBJECTIVES: Pulmonary rehabilitation (PR) is useful for patients with chronic obstructive pulmonary disease (COPD) but not clear for patients with asthma. The aim of the present study was to evaluate the effectiveness of PR in patients with asthma by comparing patients with COPD. The study was designed as a retrospective case series. We recruited patients with COPD and asthma. MATERIALS AND METHODS: Demographics, respiratory symptoms, medications, smoking history, comorbidities, exercise capacity, respiratory function tests, and quality of life (QOL) were recorded. Exercise capacity was evaluated by the 6-minute walk test (6MWT), QOL with St. George's Respiratory Questionnaire (SGRQ), 36-item Short Form Health Survey (SF-36) Quality of Life Questionnaire, and Hospital Anxiety and Depression (HAD) Scale. RESULTS: Forty-two patients with asthma and 25 COPD who completed PR were included in the study. There was no difference in terms of age and sex between the groups (p=0.100 and p=0.365, respectively); however, body mass index was higher in the asthmatic group (p=0.007). Partial oxygen pressure (pO2) difference and arterial oxygen saturation (SpO2) difference were significantly higher in the COPD group than in the asthma group after PR (p<0.05). When the patients were compared before and after PR in both groups, a significant increase was detected in exercise capacity and QOL (6MWT, HADa, SGRQ, and SF-36 in all domains) (p<0.05). When two groups are contrasted according to the difference between pre- and post-PR of variables, there was no significant difference except pO2, SpO2, and Medical Research Council (p>0.05). CONCLUSION: Physicians refer patients with COPD to PR; however, patients with asthma are not generally referred to the same frequency. We would like to emphasize that PR may be as effective as COPD in asthma.

Factors affecting TST level in patients undergoing dialysis: a multicenter study.

INTRODUCTION: The risk of TB is increased in patients with chronic kidney disease (CKD) when compared with individuals with normal renal function. We aimed to determine tuberculin skin test (TST) response and the factors which might affect the response in patients with CKD undergoing dialysis in this study. METHODS: The purified protein derivative solution was administered to the patients and the diameter of induration was measured. Additionally, the age, gender and smoking status of the patients were interrogated. Comorbidities were recorded both by patients' self-reports and data from the hospital files. The number of Bacille Calmette-Guerin (BCG) scars was recorded by checking both shoulders. FINDINGS: The study was conducted with a total of 371 patients (194 men and 177 women). The mean age was 60.09 ± 15.88, TST was 6.99 ± 6.9, duration of dialysis was 4.44 ± 4.5 (3.8-0.1,24). A total of 229 patients have comorbodities (61.7%, the most frequent was hypertension). Logistic regression model was performed. Gender, vitamin D treatment and high parathormone (PTH) levels remained in the final stage of the analysis and vitamin D intake and PTH levels were detected to be statistically significant (P = 0.002, 0.007, respectively). DISCUSSION: This study is the first study which showed a correlation between TST negativity and increased PTH levels and receiving vitamin D treatment. Starting from this point, it was concluded that PTH may suppress the immune system and especially cellular immunity.

Are idiopathic pulmonary fibrosis patients more anxious and depressive than patient's with other interstitial lung disease?

BACKGROUND AND AIM: Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive interstitial lung disease (ILD) with unknown etiology that occurs primarily in older adults with a median survival time of 2.5±3.5 years. Since there is no curative treatment for IPF, patients with IPF may have symptoms of depression and anxiety more than those of other interstitial lung diseases. There is a few studies about comparison of anxiety depression with other interstitial lung disease and IPF. In this study, we investigated whether anxiety depression in IPF was more frequent than other ILDs and its effect on quality of life. METHODS: The study was designed as a prospective study. Age, sex, smoking status, respiratory symptoms, comorbidities, pulmonary function tests, diffusion capacity of the lungs for carbon monoxide (TLCO), SF-36, and depression/anxiety levels, radiological findings, erythrocyte sedimentation rate (ESR), CRP level, blood gas analysis, complete blood count parameters were recorded. RESULTS: The mean age of 50 IPF and 42 non-IPF interstitial lung disease patients were 67.4±7.1 and 64.9±7.2, respectively. Compared with the non-IPF group, SF-36 total, SF-36 physical function and SF-36 physical role severity were significantly lower in the IPF group, while the GAP score was significantly higher. There was no significant difference between the two groups in HAM-Anxiety and HAM-depression for total scores. But mild anxiety was present in most of non-IPF group. No severe anxiety was observed in this group. Forty-nine of 50 patients with IPF patients had moderate-severe anxiety and the difference was statistically significant compared to non-IPF patients. CONCLUSIONS: This is one of the first studies of anxiety and depression symptoms are also important in non IPF ILD like IPF. Patients with non-IPF ILD have similar anxiety depression with IPF patients in this study. This study led to the conclusion that anxiety depression should also be evaluated in non-IPF ILD patients.

Does the severity of interstitial lung disease affect the gains from pulmonary rehabilitation?

INTRODUCTION: Reduced exercise capacity is a main feature of Interstitial Lung Diseases (ILDs) and it is related to closely prognosis of these patients. Pulmonary Rehabilitation (PR) results to improve in peak exercise capacity, dyspnea and quality of life in ILDs. OBJECTIVES: We aimed to evaluate the benefits of PR in patients with ILDs and to determine whether there are similar gains in patients with severe ILD. METHODS: We recruited ILD stable patients. All patients were evaluated with pulmonary function test, exercise capacity [6-minute walking test (6MWD)], quality of life [Short Form-36 (SF-36), St. George's Respiratory Questionnare (SGRQ), Hospital anxiety and Depression (HAD)] before and after PR (8 week). RESULTS: Fifty-seven patients who completed PR program, 30 women and 27 men, included in this study. It was determined a significant difference in terms of quality of life and exercise capacity (P < .05) before and after PR. When these patients were divided into 2 groups (DLCO <40% predicted, severe: group-1, and group-2: other ≥40], there was no difference between 2 groups except for forced expiratory volume in 1 second, pulse oxygen saturation and partial oxygen pressure (pO2 ). When compared the differences between pre and post values of all variables, there was no difference significantly except 4 variables (SF-36; physical functioning, social functioning, role physical and pO2 ). CONCLUSION: PR led to improvement in quality of life and exercise capacity in ILDs. In addition, PR, irrespective of the severity of the disease, is particularly beneficial in patients with severe ILDs.

Effects of pulmonary rehabilitation in patients with mild-to-moderate chronic obstructive pulmonary disease: Bottom of an iceberg.

OBJECTIVES: This study aims to compare the effects of pulmonary rehabilitation (PR) in patients with mild-to-moderate and severe-to-very severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Between January 2005 and December 2010, a total of 76 patients with mild-to-moderate (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stages I+II, n=33, mean age 66.0±8.6 years) and severe-to-very severe (GOLD Stages III+IV, n=43, mean age 63.5±8.8 years) COPD completed an eight-week outpatient PR program. Incremental and endurance shuttle walk tests (ISWT, ESWT), St. George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Hospital Anxiety and Depression Scale were assessed before and after PR. Changes after the intervention were compared between two groups. RESULTS: There were significant improvements in the ISWT and median 60 m [(-150)-(400)] in mild-to-moderate group and 70 m [(0)-(270)] in severe-to-very severe group (both, p<0.001). The ESWT time improved in both groups, 122s [(-279)-(665)] (p=0.002) and 61s [(-180)- (878)] (p<0.001), respectively. Significant effects were observed in all domains of the SGRQ except the impact score in mild-to-moderate patients. There were significant improvements in all domains except the symptoms score in severe-to-very severe patients. Using the CRQ, a significant improvement was shown in all domains of CRQ except the dyspnea score of mild-to-moderate patients. Anxiety and depression scores decreased after PR in both groups (p<0.05). According to changes in outcomes, there was no difference in any parameters between two groups. CONCLUSION: This study demonstrates that patients with mild-to-moderate COPD benefit from PR comparably to patients with severe-to- very-severe COPD. Although patients with mild-to-moderate COPD are not usually symptomatic, our findings suggest that they should be included in PR.

Comparison of the Fractional Exhaled Nitric Oxide Levels in Adolescents at Three Schools Located Three Different Distances from a Large Steel Mill.

Objectives. Exposure to ambient metals and air pollutants in urban environments has been associated with impaired lung health and inflammation in the lungs. Fractional exhaled nitric oxide (FeNO) is a reliable marker of airway inflammation. In this study, we aimed to compare the FeNO levels of three schools that have different distances from iron and steel industry zone for assessing the effects of heavy metals and air pollution on their respiratory health. Methods. Pulmonary function test and FeNO measurements were evaluated in 387 adolescents in three schools which have different distance from plant. Results. FeNO levels were significantly higher in School I (n = 142; 18.89 ± 12.3 ppb) and School II (n = 131; 17.68 ± 7.7 ppb) than School III (n = 114; 4.28 ± 3.9 ppb). Increased FeNO concentration was related to the distance of iron and steel industry zone in young adults. Conclusion. The FeNO concentrations in school children were inversely proportional to the distance from the steel mill. There are needed some studies that can evaluate the safe distance and legislation must consider these findings.

Clinical factors and comorbidities affecting the cost of hospital-treated COPD.

PURPOSE: We aimed to assess the effects of comorbidities on COPD costs and to investigate the relationship between comorbidities and clinical variables. PATIENTS AND METHODS: All patients hospitalized with a diagnosis of COPD exacerbation between January 1, 2014, and December 31, 2014, at all state hospitals of Aydin province, a city located in the western part of Turkey, were included in this study. The costs examined in the study pertained to medications, laboratory tests, hospital stays, and other treatment-related factors, such as consumption of materials, doctor visits, and consultation fees. RESULTS: A total of 3,095 patients with 5,237 exacerbations (mean age, 71.9±10.5 years; 2,434 males and 661 females) were evaluated. For 880 of the patients (28.9%), or 3,852 of the exacerbations (73.1%), at least one comorbid disease was recorded. The mean cost of each exacerbation was $808.5±1,586, including $325.1±879.9 (40.7%) for hospital stays, $223.1±1,300.9 (27.6%) for medications, $46.3±49.6 (0.9%) for laboratory expenditures, and $214±1,068 (26.5%) for other treatment-related factors, such as consumption of materials, doctor visits, and consultation fees. The cost of each exacerbation was $1,014.9 in patients with at least one comorbidity, whereas it was $233.6 in patients without comorbidity (P<0.001). Age >65 years, female gender, hospitalization in an intensive care unit, invasive or noninvasive mechanical ventilation, and a long duration of hospitalization were all found to be significant factors in increasing total costs during the exacerbations requiring hospitalization (P<0.05 for all). CONCLUSION: Comorbidities have an important role in the total costs of acute exacerbations of COPD. Strategies for the prevention, diagnosis, and effective management of comorbidities would decrease the overall financial burden associated with acute exacerbations of COPD.

Adherence to Current COPD Guidelines in Turkey.

UNLABELLED: INTRODUCTION-OBJECTIVE: Despite the availability of national and international guidelines, chronic obstructive pulmonary diseases (COPD) treatment is not always prescribed according to these recommendations. We aimed to see if COPD patients in Turkey have been treated appropriately according to COPD guidelines. METHODS: This is a cross-sectional study carried out in six different chest diseases clinics. The COPD outpatients were categorized by spirometry classification (SC) and the combined classification (CC) of COPD. The treatment protocols were evaluated to check whether they were suitable for both classifications. RESULTS: Overall, 307 patients were included in the study. Of the treatment protocols, 40.4% were suitable for both classifications: 30.9% for CC and 20.8% for SC. A total of 51.8% of the patients were reported to be using an unsuitable therapy for SC and 38.4% for CC. Ninety-eight per cent of the unsuitable treatment was overtreatment. Fifty-eight per cent of the patients were using LABA + LAMA + ICS. Improper ICS usage was identified in 97.1% in CC, 93.1% in SC. The cost savings of all patients in one year would be 17,099$ with an appropriate treatment protocol following COPD guidelines. CONCLUSION: The most common type of inappropriate COPD treatments is overtreatment, generally with ICS. As treatment protocols following COPD guidelines change over time, there is still a low rate of adherence by clinicians in their clinical practice to guideline recommendations. Awareness of these guidelines by pulmonary specialists should be improved.

Effects of nutritional supplementation combined with conventional pulmonary rehabilitation in muscle-wasted chronic obstructive pulmonary disease: a prospective, randomized and controlled study.

BACKGROUND AND OBJECTIVE: Nutritional depletion in chronic obstructive pulmonary disease (COPD) adversely affects health status and mortality. We aimed to evaluate the effects of nutritional supplementation (NS) with pulmonary rehabilitation (PR) on body composition, mid-thigh cross-sectional area (CSA), dyspnoea, exercise capacity, health-related quality of life, anxiety and depression in advanced COPD patients. METHODS: Forty-six patients were randomized to PR and nutritional support (PRNS), PR or the control group. Dyspnoea was measured with Medical Research Council and BORG scales. Exercise capacity was measured through 6-min walk test and shuttle tests; health-related quality of life was assessed with St. George's Respiratory Questionnaire. Psychological status was measured with Hospital Anxiety and Depression Scale. Body weight and body mass indexes (BMI) were also evaluated. Fat-free mass was measured through bioelectrical impedance analyser. The CSA of quadriceps was calculated in mid-level of the thigh with magnetic resonance imaging. RESULTS: Dyspnoea and total scores of St. George's Respiratory Questionnaire improved in both groups (P < 0.05). Six-minute walk test and incremental shuttle walk test distances in PRNS and PR patients increased significantly as (62.6 ± 42.4 m, 43.3 ± 59.2 m, both P = 0.001; and 63.3 ± 70.1 m and 69.3 ± 69.7 m, both P = 0.001). Although anxiety improved in both groups (P < 0.05), there was no change in depression. Body weight, BMI and fat-free mass index (FFMI) (1.1 ± 0.9 kg, 0.2 ± 1.4 kg/m(2) and 0.6 ± 0.5 kg/m(2), P < 0.05) in PRNS, whereas body weight and FFMI (0.6 ± 0.7 kg, 0.1 ± 0.6 kg/m(2) P < 0.05) increased in PR after the intervention. There was a significant increase in mid-thigh CSA (2.5 ± 4.1 cm(2)) only in PRNS (P = 0.04). CONCLUSION: The combination of NS with PR resulted in improvements particularly in lean body mass and mid-thigh CSA. This study suggests combining NS with PR in reversing weight loss and muscle wasting in COPD.