*1.3.2 Skeletal muscle index (SMI)*

One of the most important indicators of sarcopenia in chronic respiratory patients is the skeletal muscle index (SMI), which is measured by factors such as age, height, weight, ethnicity, gender, and BMI in a valid and reliable formula, and its rate in an evaluation table according to gender and age is measurable. This index is the most important factor in the diagnosis of sarcopenia in chronic patients, especially in patients with respiratory disease. SMI is calculated as a function of weight and height as follows: (height [m]\_0.244\_body mass) + (7.8\_height) + (6.6\_gender) – (0.098\_age) + (ethnicity – 3.3). The SMI index is then calculated by dividing an individual's SMI (kg) by his or her height squared (m<sup>2</sup> ). This indicator can be used as the main factor in the diagnosis of a respiratory patient with sarcopenia [21]**.**

The gold standard of research for evaluating sarcopenia relies on complete techniques, cross-sectional imaging, a non-functional, and more structured approach to routine care. A more practical alternative indicator of lumbar muscle density in L3 using a normalized computed tomography (CT) is called skeletal muscle index (SMI). While evidence suggests that decreased lumbar SMI is associated with adverse clinical outcomes, such as deaths in the lung or colorectal cancers, little research has investigated how this measure of sarcopenia relates to dyspnea or decreased exercise tolerance. Although lung cancer patients and respiratory patients often use chest CT scans as part of their care, fewer respiratory patients receive lumbar scans. This limits the ability to evaluate sarcopenia using the lumbar SMI and therefore requires the discovery of the quadriceps SMI instrument as a more accurate sarcopenia measure. Besides, the measurement of thoracic skeletal muscle, which is involved in breathing work, may be associated with better breathing and better functional capacity [22, 23]**.**

The sessions consisted of 1:15 h of training, with 25.6% of participants in the pulmonary rehabilitation program being a weakness (according to the Freud phenotype model), while only 10% of the participants did not meet any of the weakness criteria. Significant improvements have been reported in a variety of areas including the Dyspnea MRC scale, manual dynamometer, chronic fatigue and anxiety, emotional scores, hospital stress, and depression shuttle score and walking test. All of these parameters are related to sarcopenia indices in respiratory patients. Sarcopenia has increased with age and the World Initiative Index for Obstructive Pulmonary Disease. It can be clearly stated that disorders of the skeletal muscle are more important in evaluating sarcopenia in chronic respiratory patients [32, 33]**.** In the event of any disruption to the structure and function of the large musculoskeletal system of the body, especially the lower limbs and the foot, which are the main cause of movements, there will be widespread changes in weight loss, overweight, body composition, body diameter, water, fat, muscle percentage. Ultimately, the amount of physical activity a patient has directly related to their muscles [34, 35]**.**

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

The main objective of this study was to evaluate the relationship between rectus

femoris phenotype and femoral bone mineral density as the main indicators of sarcopenia in chronic respiratory patients following a pulmonary rehabilitation protocol with a cardiopulmonary exercise test approach (ERS/ATS instructions). The effect of this relationship on lung function and muscle structure in these

This study has been approved by the Ethic Committee and the Research Committee Parc Sanitari Sant Joan de Deu, in the research group: "Clinical and epidemiologic research on high-prevalence disorders" (Faculty of Medicine at the University of Barcelona). All patients who volunteered before signing an informed consent form had all information about the goals, techniques, possible outcomes, and therapeutic processes in the pulmonology, rehabilitation, and radio diagnostics departments. Also, all patient information without personal access is completely

**Figure 2** shows the general design of the study as a work plan of the study. The patients had asthma, COPD, bronchiectasis and obesity (randomly, 38 men and women selected from the chronic respiratory community at the hospital) with a dyspnea score ≥ 2 in MRC index. We evaluated the general characteristics of the patients including: gender, age, weight, height, BMI and clinical history, spirometry of lung function, at the pulmonology and rehabilitation departments. Then, they were referred to the Radio diagnostic department to perform a DEXA scan test to evaluate the femoral bone mineral density (T-score and Z-score) and ultrasonography on the rectus femoris quadriceps muscle (cross-sectional area, distance and circumference). They performed a 4-month long term a pulmonary rehabilitation protocol (**Table 1**), which included: exercise tests—incremental and constant,

confidential and is for the sole purpose of this research (**Figure 1**).

**2. Main objective**

**3.2 Study design**

**35**

patients has also been investigated.

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

**3. Methodology and materials**

**3.1 Ethics and Research Committees**

Spencer [24] and Soicher et al. [25] did not report a significant relationship between SMI and breath intensity. There was also no significant relationship between SMI, respiratory rate, and 6MWT interval. Similarly, the Cox proportional hazards model [25] did not show a significant relationship between SMI and manual weakness. Finally, using this technique, 50 patients with eligible Lumbar Scan diagnoses were identified and found similar results. Over time, the SMI has gradually declined unacceptably. There was a significant relationship between Pearson correlation coefficients in lumbar and thoracic scans in this issue. Their findings suggest that the definition of SMI-based sarcopenia is not associated with severe breathing, exercise capacity, or survival in a small sample of patients with advanced lung cancer. The strengths of the present study include a population with complementary sarcopenia features, severe breathing and exercise tolerance, and robust exploratory analysis. Despite the negative results, they demonstrated the feasibility of measuring sarcopenia using SMI. They were limited by the small sample size and missing data. Whereas a larger sample provides more power to detect significant index correlations. They used CT scans performed in the usual stages of care, which may not meet the exact criteria of future research. Changes in the quality of CT scans may result in indeterminacy. Besides, it cannot illuminate the severity of respiratory illnesses and other complications present in diagnostic models to potentially improve the accuracy of treatment models in respiratory patients [26, 27]**.**

#### *1.3.3 Anthropometric indexes*

For a more accurate diagnosis of sarcopenia, according to scientific reports, anthropometry and measurement of body sections such as arms, trunk, pelvis, and legs are important parameters for measuring anthropometry in the diagnosis of sarcopenia. A chronic respiratory patient must be normal, since muscle atrophy will be directly related to muscle weakness and general weakness of the body, and ultimately lead to a decrease in the physical activity of the patients. In these conditions, the quality of life of the patients is compromised and they are not able to continue their normal life and eventually the mortality rate increases [28]**.**

#### **1.4 Pulmonary rehabilitation in CRDs**

The results of scientific predictions show that pulmonary rehabilitation (PR) reduces frailty but there is little evidence of this intervention in this area. PR has been shown to significantly improve patients'symptoms and quality of life in patients with respiratory disease. Public daily activities can relieve shortness of breath and fatigue, as well as increase exercise tolerance, and affect patients' self-control and feel it. Recently, studies have shown that the lack of association between fat mass and the 6-minute walk test (6MWT) is one of the general considerations in assessing COPD patient status longitudinally to identify alternatives in predicting the future of these patients. In addition to improving respiratory and functional symptoms, pulmonary rehabilitation programs also target elements such as weakness, depression, inactivity, and fatigue [29, 30]**.**

Jones et al. [31] investigated the interaction of sarcopenia index in patients with COPD and response to pulmonary rehabilitation. In this study, 622 elderlies and middle-aged COPD patients were included in the study. An immediate cohort study was followed over four years of pulmonary rehabilitation in patients with weakness and COPD. The pulmonary rehabilitation program consisted of an 8-week outpatient and 2-time weekly and home-based one-time training program.

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

The sessions consisted of 1:15 h of training, with 25.6% of participants in the pulmonary rehabilitation program being a weakness (according to the Freud phenotype model), while only 10% of the participants did not meet any of the weakness criteria. Significant improvements have been reported in a variety of areas including the Dyspnea MRC scale, manual dynamometer, chronic fatigue and anxiety, emotional scores, hospital stress, and depression shuttle score and walking test. All of these parameters are related to sarcopenia indices in respiratory patients. Sarcopenia has increased with age and the World Initiative Index for Obstructive Pulmonary Disease. It can be clearly stated that disorders of the skeletal muscle are more important in evaluating sarcopenia in chronic respiratory patients [32, 33]**.** In the event of any disruption to the structure and function of the large musculoskeletal system of the body, especially the lower limbs and the foot, which are the main cause of movements, there will be widespread changes in weight loss, overweight, body composition, body diameter, water, fat, muscle percentage. Ultimately, the amount of physical activity a patient has directly related to their muscles [34, 35]**.**

### **2. Main objective**

The main objective of this study was to evaluate the relationship between rectus femoris phenotype and femoral bone mineral density as the main indicators of sarcopenia in chronic respiratory patients following a pulmonary rehabilitation protocol with a cardiopulmonary exercise test approach (ERS/ATS instructions). The effect of this relationship on lung function and muscle structure in these patients has also been investigated.

### **3. Methodology and materials**

#### **3.1 Ethics and Research Committees**

This study has been approved by the Ethic Committee and the Research Committee Parc Sanitari Sant Joan de Deu, in the research group: "Clinical and epidemiologic research on high-prevalence disorders" (Faculty of Medicine at the University of Barcelona). All patients who volunteered before signing an informed consent form had all information about the goals, techniques, possible outcomes, and therapeutic processes in the pulmonology, rehabilitation, and radio diagnostics departments. Also, all patient information without personal access is completely confidential and is for the sole purpose of this research (**Figure 1**).

#### **3.2 Study design**

**Figure 2** shows the general design of the study as a work plan of the study. The patients had asthma, COPD, bronchiectasis and obesity (randomly, 38 men and women selected from the chronic respiratory community at the hospital) with a dyspnea score ≥ 2 in MRC index. We evaluated the general characteristics of the patients including: gender, age, weight, height, BMI and clinical history, spirometry of lung function, at the pulmonology and rehabilitation departments. Then, they were referred to the Radio diagnostic department to perform a DEXA scan test to evaluate the femoral bone mineral density (T-score and Z-score) and ultrasonography on the rectus femoris quadriceps muscle (cross-sectional area, distance and circumference). They performed a 4-month long term a pulmonary rehabilitation protocol (**Table 1**), which included: exercise tests—incremental and constant,

#### **Figure 1.**

*Group sessions of chronic respiratory patients in Department of Rehabilitation at Parc Sanitari Sant Joan de Deu.*

preliminary characteristics (age, gender, height, weight, BMI, patients, smoking,

6 Cold down Light walking, deep breathing, stretching of muscles that more used in

*Cardio-pulmonary exercise protocol (study protocol) in chronic respiratory patients.*

**No Exercise Instructions Time**

and stretching of trunk in low back, chest, neck and shoulders and quadriceps

The test began with a 1-min warm-up period at minimal cycle ergometer load (15 W), with 5- to 10-W increases every 2 min that were individually selected to maintain the period of load increase in the 8-to-12-min range. 1-min active recovery using minimal cycle ergometer load followed the peak load interruption and was followed by a 6-min passive recovery. Treadmill test is special for patients that they have knee osteoarthritis and must be attention to standards indexes in exercise program and initially, the walking speed is very slow for warm up, but each minute the required walking speed progressively increases. Total, time for treadmill test 6 min

endurance muscle in major muscles, e.g., shoulders, back, low back, pectoral muscles, trunk sides, quadriceps, leg muscles that more used in exercise program and influence on breathing

RMT may consist of inspiratory muscle training (IMT) or expiratory muscle training (EMT) or a combination of both includes: (1) diaphragmatic reeducation, (2) profound inspiration, (3) inspiratory hiccups, (4) resistive inspiration with linear pressure load

(1) Pursed-lips breathing, (2) diaphragmatic (abdominal/belly) breathing, (3) better breathing tip: stop, reset, continue

exercise program, e.g., breathing muscle, major muscles, peripheral muscles that employed during exercise and fresh mind 1 min

1 Warm up Walking, rotation of joints in upper limbs and lower limbs, rotation

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

3 Light dumbbell Repetition of light dumbbell (50% resistance) for improvement of

**(min)**

15

25

10

10

5

10

Differences between pre- and post-rehabilitation protocol in assessments of spirometry, skeletal muscle index (SMI), femur bone mineral density and ultrasound rectus femoris muscle in quadriceps, were analysed using t-Student of one sample T-test, independent sample T-test and paired sample T-test. Evaluation of correlation between rectus femoris phenotype parameters and femur bone mineral density indexes was done using Pearson correlation in bivariate method of SPSS. In this study we received report analyzed from department of electrodiagnostic on rectus femoris muscle by ultrasound report and femur bone mineral density by DEXA scan that we used of these figures in assessments of rectus femoris phenotype

We evaluated all of the variables analysis by SPSS version 21.0 software (SPSS Inc., 2012, Chicago, IL, USA) and Excel 2016 (office 2016) to be used for database.

**Table 2** shows that, most of the patients had COPD and the prevalence was higher in men. We found significant changes in chronic respiratory patient's BMI

**4.1 Measurement preliminary characteristics and clinical history**

diabetic, hypertension, depression and crisis).

Statistical significance was set at P < 0.05.

and FBMD parameters.

2 Cycling ergometer or treadmill

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

4 Respiratory muscle training

5 Breathing techniques

**Table 1.**

**4. Results**

**37**

#### **Figure 2.** *Work plan concept (pulmonary rehabilitation protocol).*

12 weeks, 3 times a week, duration of each session was 1 h 15 min. Breathing techniques, respiratory muscle training and self-management, (ATS-ERS guidelines, 2013–2015) were conducted with the supervision of specialists. Following the pulmonary rehabilitation protocol, all patients performed assessments as postrehabilitation like pre-rehabilitation, according to the protocol study. *Main intervention*: cardiopulmonary exercise tests (CPET) was developed by American Thoracic Society in 2003 [36] as the gold standard with validity and reliability to study a patient with limited level of exercise and to evaluate improvement of respiratory patients before and after pulmonary rehabilitation protocol.
