Objective: To assess and compare the prevalence of comorbidities and risk factors for cardiovascular disease (CVD) in COPD patients according to disease severity. Methods: The study included 25 patients with mild-to-moderate COPD (68% male; mean age, 65 ± 8 years; mean FEV1, 73 ± 15% of predicted) and 25 with severe-to-very severe COPD (males, 56%; mean age, 69 ± 9 years; mean FEV1, 40 ± 18% of predicted). Comorbidities were recorded on the basis of data obtained from medical charts and clinical evaluations. Comorbidities were registered on the basis of data obtained from medical charts and clinical evaluations. The Charlson comorbidity index was calculated, and the Hospital Anxiety and Depression Scale (HADS) score was determined. Results: Of the 50 patients evaluated, 38 (76%) had been diagnosed with at least one comorbidity, 21 (42%) having been diagnosed with at least one CVD. Twenty-four patients (48%) had more than one CVD. Eighteen (36%) of the patients were current smokers, 10 (20%) had depression, 7 (14%) had dyslipidemia, and 7 (14%) had diabetes mellitus. Current smoking, depression, and dyslipidemia were more prevalent among the patients with mild-to-moderate COPD than among those with severe-to-very severe COPD (p < 0.001, p = 0.008, and p = 0.02, respectively). The prevalence of high blood pressure, diabetes mellitus, alcoholism, ischemic heart disease, and chronic heart failure was comparable between the two groups. The Charlson comorbidity index and HADS scores did not differ between the groups. Conclusions: Comorbidities are highly prevalent in COPD, regardless of its severity. Certain risk factors for CVD, themselves classified as diseases (including smoking, dyslipidemia, and depression), appear to be more prevalent in patients with mild-to-moderate COPD.

Keywords: Pulmonary disease, chronic obstructive; Spirometry; Cardiovascular diseases; Risk factors.

Objective: The identification of persistent airway obstruction is key to making a diagnosis of COPD. The GOLD guidelines suggest a fixed criterion-a post-bronchodilator FEV1/FVC ratio < 70%-to define obstruction, although other guidelines suggest that a post-bronchodilator FEV1/FVC ratio < the lower limit of normal (LLN) is the most accurate criterion. Methods: This was an observational study of individuals = 40 years of age with risk factors for COPD who were referred to our pulmonary function laboratory for spirometry. Respiratory symptoms were also recorded. We calculated the prevalence of airway obstruction and of no airway obstruction, according to the GOLD criterion (GOLD+ and GOLD-, respectively) and according to the LLN criterion (LLN+ and LLN-, respectively). We also evaluated the level of agreement between the two criteria. Results: A total of 241 individuals were included. Airway obstruction was identified according to the GOLD criterion in 42 individuals (17.4%) and according to the LLN criterion in 23 (9.5%). The overall level of agreement between the two criteria was good (? = 0.67; 95% CI: 0.52-0.81), although it was lower among the individuals = 70 years of age (? = 0.42; 95% CI: 0.12-0.72). The proportion of obese individuals was lower in the GOLD+/LLN+ category than in the GOLD+/LLN- category (p = 0.03), as was the median DLCO (p = 0.04). Conclusions: The use of the GOLD criterion appears to be associated with a higher prevalence of COPD. The agreement between the GOLD and LLN criteria also appears to be good, albeit weaker in older individuals. The use of different criteria to define airway obstruction seems to identify individuals with different characteristics. It is essential to understand the clinical meaning of discordance between such criteria. Until more data are available, we recommend a holistic, individualized approach to, as well as close follow-up of, patients with discordant results for airway obstruction.

Keywords: Pulmonary disease, chronic obstructive; Airway obstruction; Spirometry.

Objective: To identify risk factors for death among patients with severe asthma. Methods: This was a nested case-control study. Among the patients with severe asthma treated between December of 2002 and December of 2010 at the Central Referral Outpatient Clinic of the Bahia State Asthma Control Program, in the city of Salvador, Brazil, we selected all those who died, as well as selecting other patients with severe asthma to be used as controls (at a ratio of 1:4). Data were collected from the medical charts of the patients, home visit reports, and death certificates. Results: We selected 58 cases of deaths and 232 control cases. Most of the deaths were attributed to respiratory causes and occurred within a health care facility. Advanced age, unemployment, rhinitis, symptoms of gastroesophageal reflux disease, long-standing asthma, and persistent airflow obstruction were common features in both groups. Multivariate analysis showed that male gender, FEV1 pre-bronchodilator < 60% of predicted, and the lack of control of asthma symptoms were significantly and independently associated with mortality in this sample of patients with severe asthma. Conclusions: In this cohort of outpatients with severe asthma, the deaths occurred predominantly due to respiratory causes and within a health care facility. Lack of asthma control and male gender were risk factors for mortality.

Keywords: Asthma/mortality; Asthma/therapy; Risk factors.

Objective: To characterize the presence, extent, and patterns of dynamic hyperinflation (DH) during treadmill exercise testing in patients with moderate to severe COPD. Methods: This was a cross-sectional study involving 30 non-hypoxemic patients (FEV1= 43 ± 14% of predicted) who were submitted to a cardiopulmonary exercise test on a treadmill at a constant speed (70-80% of maximum speed) to the tolerance limit (Tlim). Serial inspiratory capacity (IC) maneuvers were used in order to assess DH. Results: Of the 30 patients studied, 19 (63.3%) presented with DH (DH+ group), having greater pulmonary function impairment at rest than did those without DH (DH− group). None of the variables studied correlated with exercise tolerance in the DH− group, whereas Tlim, IC, and perception of dyspnea during exercise did so correlate in the DH+ group (p < 0.05). In the DH+ group, 7 and 12 patients, respectively, presented with a progressive and a stable pattern of DH (ΔICTlim,2min = −0.28 ± 0.11 L vs. 0.04 ± 0.10 L; p < 0.01). Patients with a progressive pattern of DH presented with higher perception of dyspnea/Tlim rate and lower exercise tolerance than did those with a stable pattern (354 ± 118 s and 465 ± 178 s, respectively; p < 0.05). Conclusions: The presence of DH is not a universal phenomenon during walking in COPD patients, even in those with moderate to severe airflow limitation. In the patients who presented DH, a progressive pattern of DH had a greater impact on exercise tolerance than did a stable pattern of DH.

Keywords: Pulmonary disease, chronic obstructive; Exercise; Exercise test; Inspiratory capacity.

Objective: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. Methods: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. Results: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. Conclusions: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

Keywords: Pulmonary disease, chronic obstructive/mortality; Symptom flare up; Early warning score; Length of stay; Patient readmission.

Objective: To compare a once-daily long-acting β2 agonist (indacaterol 150 µg) with a once-daily long-acting anticholinergic (tiotropium 5 µg) in terms of their effects on exercise endurance (limit of tolerance, Tlim) in patients with moderate COPD. Secondary endpoints were their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Methods: This was a randomized, single-blind, crossover pilot study involving 20 patients (mean age, 60.9 ± 10.0 years; mean FEV1, 69 ± 7% of predicted). Spirometric parameters, Transition Dyspnea Index scores, Tlim, and exertional dyspnea were compared after three weeks of each treatment (with a one-week washout period between treatments). Results: Nineteen patients completed the study (one having been excluded because of COPD exacerbation). Improvement in Tlim from baseline tended to be greater after treatment with tiotropium than after treatment with indacaterol (96 ± 163 s vs. 8 ± 82 s; p = 0.06). Tlim significantly improved from baseline after treatment with tiotropium (having increased from 396 ± 319 s to 493 ± 347 s; p = 0.010) but not after treatment with indacaterol (having increased from 393 ± 246 to 401 ± 254 s; p = 0.678). There were no differences between the two treatments regarding improvements in Borg dyspnea scores and lung hyperinflation at "isotime" and peak exercise. There were also no significant differences between treatments regarding Transition Dyspnea Index scores (1.5 ± 2.1 vs. 0.9 ± 2.3; p = 0.39). Conclusions: In patients with moderate COPD, tiotropium tends to improve Tlim in comparison with indacaterol. No significant differences were observed between the two treatments regarding their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Future studies, including a larger number of patients, are required in order to confirm our findings and explore mechanistic explanations. (ClinicalTrials.gov identifier: NCT01693003 [http://www.clinicaltrials.gov/])

Keywords: Pulmonary disease, chronic obstructive; Exercise; Bronchodilator agents.

Objective: To establish clinical and functional baseline characteristics related to aerobic improvement (AI) after supervised training, in COPD patients submitted to a comprehensive pulmonary rehabilitation program (PR). Material and methods: Before and after PR was performed in 36 male COPD patients (25 with mild to moderate disease): clinical and anthropometric evaluation, 6-minute walking test, spirometry, arterial blood gas analysis, maximum inspiratory and expiratory pressure measurement, and a symptom-limited incremental cardiopulmonary exercise testing (MGC-CPX System). Supervised training intensity was targeted at the heart rate (HR) corresponding to anaerobic threshold (AT) or at 90% of the maximum HR attained. Results: Initial maximum oxygen consumption (VO2max) was negatively correlated with age and positively with the body mass index (BMI), the maximum inspiratory pressure (MIP) and the forced expiratory volume in one second (FEV1 ) - p < 0.05. After PR, an increment on submaximal exercise tolerance was found in 29 patients (80.5%); however, AI was only found in 15 individuals (41.6%). AI was associated to the following baseline variables: age < 65 years, AT < 40% of VO2max pred, BMI > 18.5, FEV1 > 60% pre and MIP > 60% pred (p < 0.05). Improvement in MIP and BMI and decrease in the maximum dyspnea score were found only in patients with AI (p < 0.05). Conclusion: Supervised pulmonary rehabilitation in a group of COPD patients was able to increase the submaximal exercise tolerance in most of them. Aerobic improvement was more prevalent in the younger, eutrophic, detrained and least obstructed patient; it was associated with an increment in BMI and MIP and decrease in the maximal dyspnea score after training.

Keywords: COPD. Pulmonary rehabilitation. Exercise training. COPD. Pulmonary rehabilitation. Exercise training.

Objective: To identify symptoms of dysphagia in individuals with COPD, based on their responses on a self-perception questionnaire. Methods: The study comprised 35 individuals with COPD and 35 healthy individuals, matched for age and gender. The study group was assessed regarding COPD severity; sensation of dyspnea; body mass index (BMI); and symptoms of dysphagia. The control group was assessed regarding BMI and symptoms of dysphagia. Results: The most common symptoms of dysphagia in the study group were pharyngeal symptoms/airway protection (p < 0.001); esophageal symptoms/history of pneumonia (p < 0.001); and nutritional symptoms (p < 0.001). Positive correlations were found between the following pairs of variables: FEV1 and BMI (r = 0.567; p < 0.001); pharyngeal symptoms/airway protection and dyspnea (r = 0.408; p = 0.015); and esophageal symptoms/history of pneumonia and pharyngeal symptoms/airway protection (r = 0.531; p = 0.001). There was a negative correlation between nutritional symptoms and BMI (r = −0.046; p < 0.008). Conclusions: Our results show that the individuals with COPD presented with symptoms of dysphagia that were associated with the pharyngeal and esophageal phases of swallowing, as well as with the mechanism of airway protection, a history of pneumonia, and nutritional symptoms.

Keywords: Deglutition disorders; Pulmonary disease, chronic obstructive; Pathological conditions, signs and symptoms.

Objective: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. Methods: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. Results: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. Conclusions: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood.

Keywords: Pulmonary disease, chronic obstructive; Allergy and immunology; Nasal lavage fluid; Asthma; Rhinitis, allergic, perennial.

Objective: To evaluate clinical predictors of poor sleep quality in COPD patients with and without obstructive sleep apnea (OSA). Methods: Consecutive stable patients with COPD were evaluated for OSA by means of overnight polysomnography; for sleep quality by means of the Pittsburgh Sleep Quality Index (PSQI); and for disease impact by means of the COPD Assessment Test. COPD severity was graded in accordance with the 2020 GOLD guidelines. Predictors of poor sleep quality were evaluated by multivariate logistic regression analysis. Results: We studied 51 patients with COPD alone and 51 patients with COPD and OSA. Both groups had similar age (66.2 ± 9.2 years vs. 69.6 ± 10.7, p = 0.09) and airflow limitation (p = 0.37). Poor sleep quality was present in 74.8% of the study participants, with no significant difference between COPD patients with and without OSA regarding PSQI scores (p = 0.73). Polysomnography showed increased stage 1 non-rapid eye movement sleep and arousal index, as well as reduced sleep efficiency and stage 3 non-rapid eye movement sleep, in the group of patients with COPD and OSA (p < 0.05). Independent predictors of poor sleep quality were GOLD grade C/D COPD (OR = 6.4; 95% CI, 1.79-23.3; p < 0.01), a COPD Assessment Test score = 10 (OR = 12.3; 95% CI, 4.1-36.5; p < 0.01), and lowest SaO2 < 80% (p < 0.0001). Conclusions: Poor sleep quality is quite common in patients with COPD and is associated with severe COPD and poor health status, having a negative impact on overall quality of life. Despite changes in polysomnography, OSA appears to have no impact on subjective sleep quality in COPD patients.

Keywords: Pulmonary disease, chronic obstructive; Sleep Quality; Sleep apnea, obstructive; Health status.

Objective: To identify factors associated with the minimal clinically important difference (MCID) for health-related quality of life (HRQoL) after physical conditioning in patients with COPD. Methods: Thirty-five patients were submitted to a 12-week program of physical conditioning (strength training plus low-intensity aerobic exercise). Body composition, incremental treadmill test results, endurance treadmill test results, six-minute walk test results, peripheral muscle strength, MIP, baseline dyspnea index (BDI) and Saint George's Respiratory Questionnaire (SGRQ) scores were assessed at baseline and after the program, thus allowing the variations (Δ) to be calculated. The MCID for HRQoL was defined as a reduction of ≥ 4% in the SGRQ total score. Subjects who responded to the program, achieving the MCID for HRQoL, were allocated to the responders (R) group (n = 24), and the remainder were allocated to the non-responders (NR) group (n = 11). Results: The values obtained for the following variables were significantly higher in group R than in group NR (p < 0.05): FEV1 (1.48 ± 0.54 L vs. 1.04 ± 0.34 L); VEF1/FVC (47.9 ± 11.7% vs. 35.5 ± 10.7%); PaO2 (74.1 ± 9.7 mmHg vs. 65.0 ± 8.9 mmHg); and ΔBDI, expressed as median and interquartile range (2.0 [0.0-3.5] vs. 0.0 [0.0-1.0]). The ΔBDI correlated significantly with the ΔSGRQ symptoms domain score, activity domain score and total score (r = 0.44, 0.60 and 0.62, respectively, p < 0.01 for all). After logistic regression, only ΔBDI remained as a predictor of MCID for HRQoL. Conclusions: Achieving the MCID for HRQoL after physical conditioning is associated with dyspnea reduction in COPD patients. Therefore, there is a need to develop treatment strategies designed to interrupt the dyspnea-inactivity-dyspnea cycle in such patients.

Keywords: Pulmonary disease, chronic obstructive; Quality of life; Dyspnea; Exercise; Rehabilitation.

Objective: Wood smoke exposure is a risk factor for COPD. For a given degree of airway obstruction, the reduction in DLCO is smaller in individuals with wood smoke-related COPD than in those with smoking-related COPD, suggesting that there is less emphysema in the former. The objective of this study was to compare HRCT findings between women with wood smoke-related COPD and women with smoking-related COPD. Methods:áTwenty-two women with severe COPD (FEV1/FVC ratio < 70% and FEV1 < 50%) were divided into two groups: those with wood smoke-related COPD (n = 12) and those with smoking-related COPD (n = 10). The two groups were compared regarding emphysema scores and airway involvement (as determined by HRCT); and functional abnormalities-spirometry results, DLCO, alveolar volume (VA), the DLCO/VA ratio, lung volumes, and specific airway resistance (sRaw). Results: There were no significant differences between the two groups in terms of FEV1, sRaw, or lung hyperinflation. Decreases in DLCO and in the DLCO/VA ratio were greater in the smoking-related COPD group subjects, who also had higher emphysema scores, in comparison with the wood smoke-related COPD group subjects. In the wood smoke-related COPD group, HRCT scans showed no significant emphysema, the main findings being peribronchial thickening, bronchial dilation, and subsegmental atelectasis. Conclusions: Female patients with severe wood smoke-related COPD do not appear to develop emphysema, although they do show severe airway involvement. The reduction in DLCO and VA, with a normal DLCO/VA ratio, is probably due to severe bronchial obstruction and incomplete mixing of inspired gas during the determination of single-breath DLCO.

O prejuízo funcional parece diferir entre membros superiores e membros inferiores de pacientes com DPOC. Dois possíveis mecanismos explicam os sintomas importantes de dispneia e fadiga relatados pelos pacientes ao executar tarefas com membros superiores não sustentados: a disfunção neuromecânica dos músculos respiratórios e a alteração dos volumes pulmonares durante as atividades realizadas com membros superiores. A disfunção neuromecânica está relacionada à alteração do padrão respiratório e à simultaneidade de estímulos aferentes e eferentes musculares, o que causaria a dissincronia na ação dos músculos respiratórios em pacientes com DPOC durante esse tipo de exercício. Adicionalmente, o aumento da ventilação durante os exercícios com membros superiores em pacientes com DPOC induz à hiperinsuflação dinâmica em diferentes cargas de trabalho. Nos membros inferiores, há redução da força e da endurance muscular do quadríceps femoral nos pacientes com DPOC comparados a indivíduos saudáveis. Uma explicação para essas reduções é a anormalidade no metabolismo muscular (diminuição da capacidade aeróbia), a dependência do metabolismo glicolítico e o acúmulo rápido de lactato durante o exercício. Quando contrastadas as atividades de membros superiores e membros inferiores, os exercícios com membros superiores resultam em maior demanda metabólica e ventilatória com mais intensa sensação de dispneia e fadiga. Devido às diferenças nas adaptações morfofuncionais dos músculos dos membros superiores e membros inferiores em pacientes com DPOC, protocolos específicos de treinamento de força e/ou endurance devem ser desenvolvidos e testados para os grupos musculares desses segmentos corporais.

Keywords: Pulmonary disease, chronic obstructive; Muscle fatigue; Upper extremity; Lower extremity.

Introduction: A great emphasis has been placed on health-related quality of life of COPD patients and specific questionnaires have been developed in order to measure it. Interventions directed to improve symptoms and decrease morbi-mortality may be evaluated by such questionnaires. Objective: This study describes the language and cultural adaptation of a new (and short) disease-specific health status questionnaire developed for chronic obstructive pulmonary diseases: the Airways Questionnaire 20 (AQ20). This questionnaire has only 20 simple items, and is one of the shortest ones ever described in the literature. Methods: In order to validate this questionnaire in Brazil, an initial translation from English to Portuguese has been made. The cultural adaptation was taken into consideration and then a back translation to English was undertaken, in order to obtain a final Portuguese version. Correlations were made with FEV1, SpO2, BMI and another disease specific health status questionnaire, the Saint George Respiratory Questionnaire (SGRQ), previously validated in Brazil. To test the reproducibility of AQ20, the interclass correlation ratio was done. Results: The interclass correlation ratio for the total score was a = 0.90 (intraobserver variability) and a = 0.93 (interobserver variability). The correlation with total SGRQ score was 0.76, with p < 0.001. Conclusion: It can be concluded that the Brazilian Portuguese version of AQ20 is reproducible, with good correlation with SGRQ total score, which makes it a valid questionnaire to measure health status in obstructive patients in Brazil.

Objective: To determine whether COPD patients with diaphragmatic dysfunction present higher risk of mortality than do those without such dysfunction. Methods: We evaluated pulmonary function, diaphragm mobility and quality of life, as well as determining the Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) index, in 42 COPD patients. The patients were allocated to two groups according to the degree to which diaphragm mobility was impaired: low mobility (LM; mobility ≤ 33.99 mm); and high mobility (HM; mobility ≥ 34.00 mm). The BODE index and the quality of life were quantified in both groups. All patients were followed up prospectively for up to 48 months in order to determine the number of deaths resulting from respiratory complications due to COPD. Results: Of the 42 patients evaluated, 20 were allocated to the LM group, and 22 were allocated to the HM group. There were no significant differences between the groups regarding age, lung hyperinflation or quality of life. However, BODE index values were higher in the LM group than in the HM group (p = 0.01). During the 48-month follow-up period, there were four deaths within the population studied, and all of those deaths occurred in the LM group (15.79%; p = 0.02). Conclusions: These findings suggest that COPD patients with diaphragmatic dysfunction, characterized by low diaphragm mobility, have a higher risk of death than do those without such dysfunction.

Keywords: Pulmonary disease, chronic obstructive/mortality; Diaphragm; Exercise tolerance; Quality of life.

Objective: To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score. Methods: In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT. Results: We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5  25.8 min/day vs. 105.2  49.4 min/day; p < 0.001), as was the distance walked (3.9  1.9 km/day vs. 6.4  3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results. Conclusions: Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures.

Keywords: Pulmonary disease, chronic obstructive; Activities of daily living; Exercise tolerance.

Objective: To verify if there are differences in Chronic Obstructive Pulmonary Disease (COPD) patient exacerbator and non-exacerbator phenotypes undergoing a Pulmonary Rehabilitation Program (PRP). Methods: A real life retrospective study included outpatients with COPD from public primary care who completed a 12-weeks PRP, three times a week. All were assessed before and after PRP using the six minute walk test (6MWT), the modified Medical Research Council (mMRC) dyspnea index, quality of life and Body mass Index, airflow Obstruction, Dyspnea and Exercise (BODE index). Results: A total of 151 patients were analyzed and mean age was 65.0 ± 8.1 years and mean Forced Expiratory Volume (FEV) 1% of predicted was 39.8 ± 15.9. The predominant gender was male (66.9%). Of these patients 31 (20.5%) were exacerbator phenotype There was a significant improvement in the mean distance in the 6MWT in both groups, with the largest change observed in the exacerbator group [mΔ (95% CI): 84.9 (57.1 112.6) vs. 48.6 (37-60.2) p= 0.018]. Significant reduction in dyspnea on the mMRC scale occurred in both groups, with the highest intensity in the exacerbator group [mΔ (95% CI): - 0.8 (-1.11 to 0.51) vs. -1.6 (-2.20 to -1.13) p = 0.006]. Improvement in the BODE index occurred in both groups, but the mean variation was also significantly greater in the exacerbator group [mΔ (95% CI): -1.44 (-2.17 to -0.70) p= 0.045]. Conclusion: Patients with COPD exacerbator phenotype had a greater magnitude of response to PRP (36 meters) when compared to non-exacerbator phenotype regardless the severity of airflow obstruction, also showing improvement in prognosis measured by the BODE index.

Keywords: Chronic obstructive pulmonary disease; Phenotype; Rehabilitation.