**4.2 Measurement of correlation between FBMD and RFMTCSA**

In the analysis of Pearson's correlation r = 0.607 between T-scores and Z-score in femur bone mineral density (FBMD) and Rectus femoris Mid-Tight Cross Sectional Area (RFMTCSA) in pre-rehabilitation, there is a significant correlation between the variables (P < 0.001). In the analysis of the Pearson's correlation r = 0.910 in post-rehabilitation between T-score and Z-scores in FBMD and RFMTCSA, there have a higher significant correlation between variables than pre-rehabilitation on P < 0.001 (**Table 3**). It can be said that there is a significant relationship between FBMD and RFMTCSA after pulmonary rehabilitation protocol, and in both T-score and Z-score of FBMD with rectus femoris phenotype in RFMTCSA significant

progress was observed. But in chronic respiratory patients this significant increase was shown in Z-score higher than T-score. Also we can see that in circumference of RFMTCSA between pre- and post-rehabilitation protocol did not have significant change or improvement in correlation with T-score and Z-score (**Figure 4**).

*Correlation between T-score and Z-score of the femur bone mineral density and rectus femoris cross sectional*

*The Main Clinical Indicators of Sarcopenia in Patients with Chronic Respiratory Disease…*

*DOI: http://dx.doi.org/10.5772/intechopen.91333*

There was a significant increase in musculoskeletal index before (prerehabilitation SMI, mean = 16 32) and (post-rehabilitation SMI, mean = 17 34) after the pulmonary rehabilitation protocol and they showed positive changes after

In the spirometry variables, we can see that most significant changes have occurred in FEV1/FVC % (mean SEM = 40.00 7.0 vs mean SEM = 35.00 7.0)

**4.3 Measurement of skeletal muscle index (SMI)**

*area in phenotype quadriceps, at P < 0.001.*

**Figure 4.**

**41**

the rehabilitation protocol P < 0.001 (**Table 3**).

**4.4 Measurement of spirometry lung function**

**Figure 3.** *Oxygen capsulate consumption monitored at home, h/per day, P < 0.05.*


#### **Table 3.**

*T-test skeletal muscle index on chronic respiratory airway patients on P < 0.05.*

*The Main Clinical Indicators of Sarcopenia in Patients with Chronic Respiratory Disease… DOI: http://dx.doi.org/10.5772/intechopen.91333*

#### **Figure 4.**

*Correlation between T-score and Z-score of the femur bone mineral density and rectus femoris cross sectional area in phenotype quadriceps, at P < 0.001.*

progress was observed. But in chronic respiratory patients this significant increase was shown in Z-score higher than T-score. Also we can see that in circumference of RFMTCSA between pre- and post-rehabilitation protocol did not have significant change or improvement in correlation with T-score and Z-score (**Figure 4**).

#### **4.3 Measurement of skeletal muscle index (SMI)**

There was a significant increase in musculoskeletal index before (prerehabilitation SMI, mean = 16 32) and (post-rehabilitation SMI, mean = 17 34) after the pulmonary rehabilitation protocol and they showed positive changes after the rehabilitation protocol P < 0.001 (**Table 3**).

#### **4.4 Measurement of spirometry lung function**

In the spirometry variables, we can see that most significant changes have occurred in FEV1/FVC % (mean SEM = 40.00 7.0 vs mean SEM = 35.00 7.0)

staging of the disease. Sarcopenia and obesity have direct effects on lung function values and we recommend that both elements should be evaluated in all respiratory patients. We found that respiratory patients with sarcopenia had lower T-score BMD, which means a higher prevalence of osteoporosis. Also, the presence of sarcopenia was significantly associated with an increased risk of osteoporosis and low BMD in both low- and high-weight patient groups. Therefore, in evaluating patients with CRDs, the presence of sarcopenia should be considered an indepen-

*The Main Clinical Indicators of Sarcopenia in Patients with Chronic Respiratory Disease…*

Lung function is a stronger independent predictor compared to body composition parameters. Taken together, these parameters are not only useful for assessing breathing and the treatment process, but are also a potential surrogate for patients' physical function. Some of the limitations of our study deserve attention. The relatively small size of our samples, which may be in line with the study hypothesis, may limit our findings. But our conclusion holds for a whole population, but may not be entirely true for a population with more prevalent respiratory disease. This does not mean that the conclusion is highly generalizable. We evaluated body composition by DEXA, a method widely accepted in scientific research, but not by the "gold standard" for patients. Besides, we define sarcopenia based on purely quantitative parameters of body composition, but we are also able to provide information on the qualitative dimension of sarcopenia. Finally, the cross-sectional design of the study allowed for the creation of a causal sequence among the relationships studied. Body composition may be an important determinant of physical function in elderly respiratory patients. This research is needed to confirm these observations on larger samples to improve our understanding of the factors influencing physical function in a more complex population such as chronic

In a study similar to our study, Xiong et al. [13] mentioned the intensity of echo (EI) was significantly increased by ultrasonography in rectus femoris at all stages of the GOLD standard following the pulmonary rehabilitation protocol for COPD patients. However, the cross-sectional area of rectus femoris (RFcsa) in GOLD standard decreased. This suggests that changes in EI Rectus femoris may occur earlier in muscle size in patients with COPD. EI was not associated with age, BMI, and airflow obstruction in our patients. These results show peripheral muscle function in patients with COPD, whose strength and size of the quadriceps are lower than in normal subjects. Some researchers have focused on the relationship between quadriceps strength and thickness with lung function in respiratory patients, which can be assessed using muscle ultrasound [37]**.** In another study, the effect of small and large muscular disorders was examined on admission, especially in quadriceps. Rongchang [9], reported expected gender differences in quadriceps muscle for COPD and control groups and similar data were also reported, indicating that in quantifying quadriceps performance compared to controls, sex and age, mean QMVC declined 47% and 45% in men and women; a more severe decrease than previously reported, indicating a significant impairment of quadriceps strength in COPD patients. In other studies, the effects of small and large muscular disorders,

especially in the quadriceps, was related to the time of hospitalization.

but also for the severity and duration of hospitalization.

In the study Greening et al. [4] measured the level of quadriceps (Qcsa) as a marker of muscle mass. This method has previously been confirmed in computed tomography, Qcsa as well as X-ray absorptiometry in people with COPD and is useful for patient evaluation in acute conditions and under the need of patient effort. Regarding the hospital admission, the mean daily proportion of patients with respiratory distress and disorder was different in the small and large muscle groups. This indicates that skeletal muscle function is crucial not only for hospital admission

dent risk factor for low BMD.

*DOI: http://dx.doi.org/10.5772/intechopen.91333*

respiratory patients.

**43**

#### **Figure 5.**

*Mean different between spirometry parameters (liter, %) in asthma, bronchiectasis, COPD and obesity patients in pre- and post-pulmonary rehabilitation protocol.*

and FEV1/FVC ltr (mean SEM = 27.00 5.0 vs mean SEM = 25.00 5.0). In variable of FEV1 % (mean SEM = 51.00 2.0 vs mean SEM = 52.00 2.0), we saw that there was a significant change in pre- and post-rehabilitation protocol that cannot be considered as acceptable positive changes but can be seen in the effectiveness of the pulmonary rehabilitation protocol on spirometry variables in chronic respiratory patients (P < 0.001) (**Table 3**). Also, we reported that in bronchitis patients we have had highest significant in FEV1/FVC % and obesity patients had more significant in FEV1 %. Asthma patients had increase significant in FVC perc in pre- and post-rehabilitation protocol (**Figure 5**).

## **5. Discussion**

In this study, we concluded that by comparing bone, muscles as the main indicators diagnosis of sarcopenia in chronic respiratory patients, we find that rectus femoris is the most effective quadriceps muscles in the diagnosis of sarcopenia. RFMTCSA, Distance, and Circumference muscle parameters, and DEXA scan at Z-score and T-score of femur bone density after patients' rehabilitation protocol were significantly different. In other words, in all the ultrasound indices of the rectus femoris muscle and the DEXA scan data of the femur, we found positive incremental data. With these considerations in mind, it can be said that although patients with normal daily activities can control the main indicators of sarcopenia, they can improve the quality of life and improve the outcomes of all major muscular and bone markers. Muscle function, lung function, and exercise capacity require a comprehensive pulmonary rehabilitation program that can help to prevent muscle weakness and degeneration, as well as reduce important bone mineral density such as the femur and ultimately their mortality rate. We conclude that not all factors are necessary to accurately determine the severity of sarcopenia in patients with chronic respiratory disease, and if specialists consider rectus femoris ultrasound and femur bone DEXA as the most important factors for maintaining body stability, they can monitor the latest status of respiratory patients with sarcopenia and more accurately diagnose the health status and mortality of the chronic respiratory patients.

We also examined whether spirometry indices are actual measurements and better predictors of whether CRDs patients develop sarcopenia than the GOLD

### *The Main Clinical Indicators of Sarcopenia in Patients with Chronic Respiratory Disease… DOI: http://dx.doi.org/10.5772/intechopen.91333*

staging of the disease. Sarcopenia and obesity have direct effects on lung function values and we recommend that both elements should be evaluated in all respiratory patients. We found that respiratory patients with sarcopenia had lower T-score BMD, which means a higher prevalence of osteoporosis. Also, the presence of sarcopenia was significantly associated with an increased risk of osteoporosis and low BMD in both low- and high-weight patient groups. Therefore, in evaluating patients with CRDs, the presence of sarcopenia should be considered an independent risk factor for low BMD.

Lung function is a stronger independent predictor compared to body composition parameters. Taken together, these parameters are not only useful for assessing breathing and the treatment process, but are also a potential surrogate for patients' physical function. Some of the limitations of our study deserve attention. The relatively small size of our samples, which may be in line with the study hypothesis, may limit our findings. But our conclusion holds for a whole population, but may not be entirely true for a population with more prevalent respiratory disease. This does not mean that the conclusion is highly generalizable. We evaluated body composition by DEXA, a method widely accepted in scientific research, but not by the "gold standard" for patients. Besides, we define sarcopenia based on purely quantitative parameters of body composition, but we are also able to provide information on the qualitative dimension of sarcopenia. Finally, the cross-sectional design of the study allowed for the creation of a causal sequence among the relationships studied. Body composition may be an important determinant of physical function in elderly respiratory patients. This research is needed to confirm these observations on larger samples to improve our understanding of the factors influencing physical function in a more complex population such as chronic respiratory patients.

In a study similar to our study, Xiong et al. [13] mentioned the intensity of echo (EI) was significantly increased by ultrasonography in rectus femoris at all stages of the GOLD standard following the pulmonary rehabilitation protocol for COPD patients. However, the cross-sectional area of rectus femoris (RFcsa) in GOLD standard decreased. This suggests that changes in EI Rectus femoris may occur earlier in muscle size in patients with COPD. EI was not associated with age, BMI, and airflow obstruction in our patients. These results show peripheral muscle function in patients with COPD, whose strength and size of the quadriceps are lower than in normal subjects. Some researchers have focused on the relationship between quadriceps strength and thickness with lung function in respiratory patients, which can be assessed using muscle ultrasound [37]**.** In another study, the effect of small and large muscular disorders was examined on admission, especially in quadriceps.

Rongchang [9], reported expected gender differences in quadriceps muscle for COPD and control groups and similar data were also reported, indicating that in quantifying quadriceps performance compared to controls, sex and age, mean QMVC declined 47% and 45% in men and women; a more severe decrease than previously reported, indicating a significant impairment of quadriceps strength in COPD patients. In other studies, the effects of small and large muscular disorders, especially in the quadriceps, was related to the time of hospitalization.

In the study Greening et al. [4] measured the level of quadriceps (Qcsa) as a marker of muscle mass. This method has previously been confirmed in computed tomography, Qcsa as well as X-ray absorptiometry in people with COPD and is useful for patient evaluation in acute conditions and under the need of patient effort. Regarding the hospital admission, the mean daily proportion of patients with respiratory distress and disorder was different in the small and large muscle groups. This indicates that skeletal muscle function is crucial not only for hospital admission but also for the severity and duration of hospitalization.
