rpcardioRational Pharmacotherapy in CardiologyРациональная Фармакотерапия в Кардиологии1819-64462225-3653«SILICEA-POLIGRAF» LLC10.20996/1819-6446-2022-08-04rpcardio-2788Research ArticleORIGINAL STUDIESОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯRespiratory Muscle Strength in Patients with Coronary Heart Disease and Different Musculoskeletal DisordersСила дыхательных мышц у пациентов с ишемической болезнью сердца и различными вариантами нарушения костно-мышечной функцииhttps://orcid.org/0000-0002-3023-6239БаздыревЕ. Д.BazdyrevE. D.

Баздырев Евгений Дмитриевич.

Кемерово.

eLibrary SPIN 4545-0791

Evgeny D. Bazdyrev.

Kemerovo.

eLibrary SPIN 4545-0791

edb624@mail.ruhttps://orcid.org/0000-0002-2314-9487ТерентьеваН. А.TerentyevaN. A.

Терентьева Наталья Александровна.

Кемерово.

eLibrary SPIN 1323-2050

Natalia A. Terentyeva.

Kemerovo.

eLibrary SPIN 1323-2050

https://orcid.org/0000-0003-4948-2429ГалимоваН. А.GalimovaN. A.

Галимова Наталья Александровна.

Кемерово.

eLibrary SPIN 9296-4964

Natalia A. Galimova.

Kemerovo.

eLibrary SPIN 9296-4964

https://orcid.org/0000-0003-2384-5682КривошаповаК. Е.KrivoshapovaK. E.

Кривошапова Кристина Евгеньевна.

Кемерово.

eLibrary SPIN 4272-7552

Kristina E. Krivoshapova.

Kemerovo.

eLibrary SPIN 4272-7552

https://orcid.org/0000-0002-4642-3610БарбарашО. Л.BarbarashO. L.

Барбараш Ольга Леонидовна.

Кемерово.

eLibrary SPIN 5373-7620

Olga L. Barbarash.

Kemerovo.

eLibrary SPIN 5373-7620

Научно-исследовательский институт комплексных проблем сердечно-сосудистых заболеванийРоссияResearch Institute for Complex Issues of Cardiovascular DiseasesRussian Federation202207092022184393401Copyright © Bazdyrev E.D., Terentyeva N.A., Galimova N.A., Krivoshapova K.E., Barbarash O.L., 20222022Баздырев Е.Д., Терентьева Н.А., Галимова Н.А., Кривошапова К.Е., Барбараш О.Л.Bazdyrev E.D., Terentyeva N.A., Galimova N.A., Krivoshapova K.E., Barbarash O.L.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.rpcardio.online/jour/article/view/2788Aim

Aim. To measure respiratory muscle strength (RMS) in patients with coronary heart disease (CHD) and different musculoskeletal disorders (MSD).

Material and methods

Material and methods. Patients were divided in four groups according to the MSD. Group I included 52 (13.4%) patients with sarcopenia, group II included 28 (7.2%) patients with osteopenia, group III included 25 (6.5%) patients with osteosarcopenia, group IV included 282 (72.9%) patients without MSD. All patients underwent the assessment of maximal expiratory (МЕР) and maximal inspiratory mouth pressures (MIP).

Results

Results. The mean RMS values were lower than the normative values, and the strength of the expiratory muscles was 1.25 times lower compared to the inspiratory muscles. Both of these parameters were within the normal range in 191 (49.3%) patients, and lower values were noted in 196 (50.7%). An isolated decrease in MIP was observed in 24.8% of patients, an isolated decrease in МЕР in 6.5%, a combined decrease in MIP and МЕР in 19.4% of patients. Comparative analysis of МЕР and MIP (depending on the MSD) did not demonstrate statistically significant differences. Lower МЕР (76.9%) and MIP (75%) values were noted mainly in the group of patients with sarcopenia. A similar pattern was notes in patients with osteosarcopenia and in patients without MSD. Normative values of RMS were observed in patients with osteopenia. Correlation analysis revealed a unidirectional relationship between RMS and the parameters of muscle function (hand grip strength, muscle area and musculoskeletal index) and a multidirectional relationship between МЕР and BMI (r -0.743, p=0.013), MIP and patient age (r -0.624, p=0.021).

Conclusion

Conclusion. Respiratory muscle weakness was diagnosed in half of the patients with coronary heart disease. There were no statistically significant differences in RMS between patients with MSD and isolated CHD, despite lower values in the group with MSD. Correlation analysis revealed an association between RMS and muscle function.

Цель

Цель. Оценить силу дыхательных мышц у больных с ишемической болезнью сердца (ИБС) с различными вариантами нарушения костномышечной функции.

Материалы и методы

Материалы и методы. С учетом нарушений костно-мышечного статуса (КМС) сформированы четыре группы. В I группу вошли 52 (13,4%) пациента с изолированной саркопенией, во II группу - 28 (7,2%) больных изолированной остеопенией, в III группу - 25 (6,5%) пациентов с остеосаркопенией, IV группу составили лица без нарушений КМС - 282 (72,9%). Всем участникам выполнено исследование силы дыхательных мышц с анализом максимальных экспираторного (MEP) и инспираторного (MIP) давлений в полости рта.

Результаты

Результаты. Медиана силы дыхательных мышц была ниже нормативных значений, причем, сила экспираторных мышц ниже в 1,25 раза в сравнении с инспираторными. В пределах нормы оба параметра отмечены у 191 (49,3%) больного, у 196 (50,7%) верифицированы различные варианты снижения. Изолированное снижение MIP наблюдалось у 24,8% пациентов, изолированное снижение МЕР - у 6,5%, сочетанное снижение MIP и МЕР - у 19,4%. Сравнительный анализ МЕР и MIP в зависимости от варианта нарушения КМС не продемонстрировал статистически значимых различий. Наибольшая доля лиц со сниженным MEP (76,9%) и MIP (75%) отмечена в группе с изолированной саркопенией. Аналогичная закономерность определена для пациентов с остеосаркопенией и лиц без нарушений костно-мышечного статуса. Нормативные значения силы дыхательных мышц зарегистрированы у больных остеопенией. По результатам корреляционного анализа выявлена однонаправленная связь силы дыхательных мышц с параметрами, характеризующими мышечную функцию (сила сжатия кисти, площадь мышц и скелетно-мышечный индекс) и разнонаправленную связь МЕР и индекса массы тела (г -0,743, р=0,013), MIP и возраста пациента (r -0,624, р=0,021).

Заключение

Заключение. У половины пациентов с ИБС диагностирована клинически значимая слабость дыхательных мышц. Не выявлено статистически значимых различий по силе дыхательных мышц между больными с нарушением КМС и изолированной ИБС, несмотря на более низкие параметры в группе с нарушениями КМС. Корреляционный анализ продемонстрировал закономерную связь силы дыхательных мышц с параметрами, характеризующими мышечную функцию.

саркопенияостеопенияостеопорозостеосаркопенияишемическая болезнь сердцакостно-мышечный статуссила дыхательных мышцsarcopeniaosteopeniaosteoporosisosteosarcopeniacoronary heart diseasemusculoskeletal disordersrespiratory muscle strengthИсследование выполнено в рамках гранта РНФ 22-15-00305 «Патофизиологические особенности формирования остеосаркопенического ожирения при мультифокальном атеросклерозе как маркера биологического старения».The study was funded by the Russian Science Foundation (grant number 22-15-00305 "Ра1Ьо-physiological features of osteosarcopenic obesity in patients with multifocal atherosclerosis as a marker of biological aging”).ReferencesFraser HC, Kuan V, Johnen R, et al. Biological mechanisms of aging predict age-related disease cooccurrence in patients. Aging Cell. 2022;21(4):e13524. DOI:10.1111/acel.13524.Fraser HC, Kuan V, Johnen R, et al. Biological mechanisms of aging predict age-related dis-ease cooccurrence in patients. Aging Cell. 2022;21(4):e13524. DOI:10.1111/acel.13524.Farr JN, Almeida M. The Spectrum of Fundamental Basic Science Discoveries Contributing to Organismal Aging. J Bone Miner Res. 2018;33(9):1568-84. DOI:10.1002/jbmr.3564.Farr JN, Almeida M. The Spectrum of Fundamental Basic Science Discoveries Contributing to Organismal Aging. J Bone Miner Res. 2018;33(9):1568-84. DOI:10.1002/jbmr.3564.Kirk B, Zanker J, Duque G. Osteosarcopenia: epidemiology, diagnosis, and treatment-facts and numbers. J Cachexia Sarcopenia Muscle. 2020;11(3):609-18. DOI:10.1002/jcsm.12567.Kirk B, Zanker J, Duque G. Osteosarcopenia: epidemiology, diagnosis, and treatment-facts and numbers. J Cachexia Sarcopenia Muscle. 2020;11(3):609-18. DOI:10.1002/jcsm.12567.Vilaro J, Ramirez-Sarmiento A, Juana MA, et al. Global muscle dysfunction as a risk factor of readmission to hospital due to COPD exacerbations. Respir Med. 2010;104(12):1896-902. DOI:10.1016/j.rmed.2010.05.001.Vilaro J, Ramirez-Sarmiento A, Juana MA, et al. Global muscle dysfunction as a risk factor of readmission to hospital due to COPD exacerbations. Respir Med. 2010;104(12):1896-902. DOI:10.1016/j.rmed.2010.05.001.Kera T, Kawai H, Hirano H, et al. Definition of Respiratory Sarcopenia With Peak Expiratory Flow Rate. J Am Med Dir Assoc. 2019;20(8):1021-5. DOI:10.1016/j.jamda.2018.12.013.Kera T, Kawai H, Hirano H, et al. Definition of Respiratory Sarcopenia With Peak Expiratory Flow Rate. J Am Med Dir Assoc. 2019;20(8):1021-5. DOI:10.1016/j.jamda.2018.12.013.Vang P, Vasdev A, Zhan WZ, et al. Diaphragm muscle sarcopenia into very old age in mice. Physiol Rep. 2020;8(1):e14305. DOI:10.14814/phy2.14305.Vang P, Vasdev A, Zhan WZ, et al. Diaphragm muscle sarcopenia into very old age in mice. Physiol Rep. 2020;8(1):e14305. DOI:10.14814/phy2.14305.Greising SM, Mantilla CB, Gorman BA, et al. Diaphragm muscle sarcopenia in aging mice. Exp Gerontol. 2013;48(9):881-7. DOI:10.1016/j.exger.2013.06.001.Greising SM, Mantilla CB, Gorman BA, et al. Diaphragm muscle sarcopenia in aging mice. Exp Gerontol. 2013;48(9):881-7. DOI:10.1016/j.exger.2013.06.001.Ohara DG, Pegorari MS, Oliveira Dos Santos NL, et al. Respiratory Muscle Strength as a Discriminator of Sarcopenia in Community-Dwelling Elderly: A Cross-Sectional Study. J Nutr Health Aging. 2018;22(8):952-8. DOI:10.1007/s12603-018-1079-4.Ohara DG, Pegorari MS, Oliveira Dos Santos NL, et al. Respiratory Muscle Strength as a Discriminator of Sarcopenia in Community-Dwelling Elderly: A Cross-Sectional Study. J Nutr Health Aging. 2018;22(8):952-8. DOI:10.1007/s12603-018-1079-4.Greising SM, Mantilla CB, Medina-Martmez JS, et al. Functional impact of diaphragm muscle sarcopenia in both male and female mice. Am J Physiol Lung Cell Mol Physiol. 2015;309(1):L46-52. DOI:10.1152/ajplung.00064.2015.Greising SM, Mantilla CB, Medina-Martmez JS, et al. Functional impact of diaphragm muscle sarcopenia in both male and female mice. Am J Physiol Lung Cell Mol Physiol. 2015;309(1):L46-52. DOI:10.1152/ajplung.00064.2015.Shakouri SK, Salekzamani Y, Taghizadieh A, et al. Effect of respiratory rehabilitation before open cardiac surgery on respiratory function: a randomized clinical trial. J Cardiovasc Thorac Res. 2015;7(1):13-7. DOI:10.15171/jcvtr.2015.03.Shakouri SK, Salekzamani Y, Taghizadieh A, et al. Effect of respiratory rehabilitation before open cardiac surgery on respiratory function: a randomized clinical trial. J Cardiovasc Thorac Res. 2015;7(1):13-7. DOI:10.15171/jcvtr.2015.03.Chen X, Hou L, Zhang Y, et al. The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial. Clin Rehabil. 2019;33(5):913-22. DOI:10.1177/0269215519828212.Chen X, Hou L, Zhang Y, et al. The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial. Clin Rehabil. 2019;33(5):913-22. DOI:10.1177/0269215519828212.Dsouza FV, Amaravadi SK, Samuel SR, et al. Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis. Ann Rehabil Med. 2021;45(4):264-73. DOI:10.5535/arm.21027.Dsouza FV, Amaravadi SK, Samuel SR, et al. Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis. Ann Rehabil Med. 2021;45(4):264-73. DOI:10.5535/arm.21027.Moreira JMA, Grilo EN. Quality of life after coronary artery bypass graft surgery - results of cardiac rehabilitation programme. J Exerc Rehabil. 2019;15(5):715-22. DOI:10.12965/jer.1938444.222.Moreira JMA, Grilo EN. Quality of life after coronary artery bypass graft surgery - results of cardiac rehabilitation programme. J Exerc Rehabil. 2019;15(5):715-22. DOI:10.12965/jer.1938444.222.Osailan A, Abdelbasset WK. Exercise-based cardiac rehabilitation for postcoronary artery by-pass grafting and its effect on hemodynamic responses and functional capacity evaluated using the Incremental Shuttle Walking Test: A retrospective pilot analysis. J Saudi Heart Assoc. 2020;32(1):25-33. DOI:10.37616/2212-5043.1005.Osailan A, Abdelbasset WK. Exercise-based cardiac rehabilitation for postcoronary artery by-pass grafting and its effect on hemodynamic responses and functional capacity evaluated using the Incremental Shuttle Walking Test: A retrospective pilot analysis. J Saudi Heart Assoc. 2020;32(1):25-33. DOI:10.37616/2212-5043.1005.Российские клинические рекомендации. Коронарное шунтирование больных ишемической болезнью сердца: реабилитация и вторичная профилактика. КардиоСоматика. 2016;7(3-4):5-71. DOI:10.26442/CS45210.Russian clinical guidelines. Coronary artery bypass grafting in patients with is-chemic heart disease: rehabilitation and secondary prevention. Cardiosomatics. 2016;7(3-4):5-71 (In Russ.) DOI:10.26442/CS45210.Иванов С.В., Сумин А.Н. Современные тенденции рутинной реваскуляризации миокарда. Комплексные Проблемы Сердечно-сосудистых Заболеваний. 2021;10(2):25-35. DOI:10.17802/2306-1278-2021-10-2-25-35.Ivanov SV, Sumin AN. Current trends in routine myocardial revascularization. Complex Is-sues of Cardiovascular Diseases. 2021;10(2):25-35 (In Russ.) DOI:10.17802/2306-1278-2021-10-2-25-35.Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31. DOI:10.1093/ageing/afy169.Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31. DOI:10.1093/ageing/afy169.Мельниченко Г.А., Белая Ж.Е., Рожинская Л.Я., и др. Федеральные клинические рекомендации по диагностике, лечению и профилактике остеопороза. Проблемы Эндокринологии. 2017;63(6):392-426. DOI:10.14341/probl2017636392-426.Mel'nichenko GA, Belaya ZE, Rozhinskaya LY, et al. Russian federal clinical guidelines on the diagnostics, treatment, and prevention of osteoporosis. Problems of Endocrinology. 2017;63(6):392-426 (In Russ.) DOI:10.14341/probl2017636392-426.Баздырев Е.Д., Терентьева Н.А., Кривошапова К.Е., и др. Распространенность вариантов нарушения костно-мышечного статуса у пациентов с ишемической болезнью сердца. Рациональная Фармакотерапия в Кардиологии. 2021;17(3):369-75. DOI:10.20996/1819-6446-2021-06-03.Bazdyrev ED, Terentyeva NA, Krivoshapova KE, et al. Prevalence of Musculoskeletal Disorders in Patients with Coronary Artery Disease. Rational Pharmacotherapy in Cardiology. 2021;17(3):369-75 (In Russ.) DOI:10.20996/1819-6446-2021-06-03.American Thoracic Society/European Respiratory Society. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002;166(4):518-624. DOI:10.1164/rccm.166.4.518.American Thoracic Society/European Respiratory Society. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002;166(4):518-624. DOI:10.1164/rccm.166.4.518.Mora Romero UJ, Gochicoa Rangel L, Guerrero Zúñiga S, et al. Maximal inspiratory and expiratory pressures: Recommendations and procedure. Neumol Cir Torax. 2019;78(Supl.2):S135-S141. (in Spanish) DOI:10.35366/NTS192F.Mora Romero UJ, Gochicoa Rangel L, Guerrero Zúñiga S, et al. Maximal inspiratory and expiratory pressures: Recommendations and procedure. Neumol Cir Torax. 2019;78(Supl.2):S135-S141. (in Spanish) DOI:10.35366/NTS192F.Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care. 2009;54(10):1348-59.Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care. 2009;54(10):1348-59.Laveneziana P, Albuquerque A, Aliverti A, et al. ERS Statement on Respiratory Muscle Testing at Rest and during Exercise. Eur Respir J. 2019;53(6):1-34. DOI:10.1183/13993003.01214-2018.Laveneziana P, Albuquerque A, Aliverti A, et al. ERS Statement on Respiratory Muscle Testing at Rest and during Exercise. Eur Respir J. 2019;53(6):1-34. DOI:10.1183/13993003.01214-2018.Nagano A, Wakabayashi H, Maeda K, et al. Respiratory Sarcopenia and Sarcopenic Respiratory Disability: Concepts, Diagnosis, and Treatment. J Nutr Health Aging. 2021;25(4):507-15. DOI:10.1007/s12603-021-1587-5.Nagano A, Wakabayashi H, Maeda K, et al. Respiratory Sarcopenia and Sarcopenic Respiratory Disability: Concepts, Diagnosis, and Treatment. J Nutr Health Aging. 2021;25(4):507-15. DOI:10.1007/s12603-021-1587-5.Bordoni B, Morabito B, Simonelli M. Ageing of the Diaphragm Muscle. Cureus. 2020;12(1):e6645. DOI:10.7759/cureus.6645.Bordoni B, Morabito B, Simonelli M. Ageing of the Diaphragm Muscle. Cureus. 2020;12(1):e6645. DOI:10.7759/cureus.6645.Nucci RAB, de Souza RR, Suemoto CK, et al. Diaphragm muscle structure in the elderly: Findings from an autopsy study. Acta Histochem. 2020;122(2):151487. DOI:10.1016/j.acthis.2019.151487.Nucci RAB, de Souza RR, Suemoto CK, et al. Diaphragm muscle structure in the elderly: Findings from an autopsy study. Acta Histochem. 2020;122(2):151487. DOI:10.1016/j.acthis.2019.151487.Lalley PM. The aging respiratory system--pulmonary structure, function and neural control. Respir Physiol Neurobiol. 2013;187(3):199-210. DOI:10.1016/j.resp.2013.03.012.Lalley PM. The aging respiratory system--pulmonary structure, function and neural control. Respir Physiol Neurobiol. 2013;187(3):199-210. DOI:10.1016/j.resp.2013.03.012.Kera T, Kawai H, Hirano H, et al. Relationships among peak expiratory flow rate, body composition, physical function, and sarcopenia in community-dwelling older adults. Aging Clin Exp Res. 2018;30(4):331-40. DOI:10.1007/s40520-017-0777-9.Kera T, Kawai H, Hirano H, et al. Relationships among peak expiratory flow rate, body composition, physical function, and sarcopenia in community-dwelling older adults. Aging Clin Exp Res. 2018;30(4):331-40. DOI:10.1007/s40520-017-0777-9.Verissimo P, Timenetsky KT, Casalaspo TJA, et al. High Prevalence of Respiratory Muscle Weakness in Hospitalized Acute Heart Failure Elderly Patients. PLoS One. 2015;10(2):e0118218. DOI:10.1371/journal.pone.0118218.Verissimo P, Timenetsky KT, Casalaspo TJA, et al. High Prevalence of Respiratory Muscle Weakness in Hospitalized Acute Heart Failure Elderly Patients. PLoS One. 2015;10(2):e0118218. DOI:10.1371/journal.pone.0118218.Fernández-Rubio H, Becerro-de-Bengoa-Vallejo R, Rodríguez-Sanz D, et al. Unraveling the Role of Respiratory Muscle Metaboloreceptors under Inspiratory Training in Patients with Heart Failure. Int J Environ Res Public Health. 2021;18(4):1697. DOI:10.3390/ijerph18041697.Fernández-Rubio H, Becerro-de-Bengoa-Vallejo R, Rodríguez-Sanz D, et al. Unraveling the Role of Respiratory Muscle Metaboloreceptors under Inspiratory Training in Patients with Heart Failure. Int J Environ Res Public Health. 2021;18(4):1697. DOI:10.3390/ijerph18041697.Riou M, Pizzimenti M, Enache I, et al. Skeletal and Respiratory Muscle Dysfunctions in Pulmonary Arterial Hypertension. J Clin Med. 2020;9(2):410. DOI:10.3390/jcm9020410.Riou M, Pizzimenti M, Enache I, et al. Skeletal and Respiratory Muscle Dysfunctions in Pulmonary Arterial Hypertension. J Clin Med. 2020;9(2):410. DOI:10.3390/jcm9020410.Shin HI, Kim DK, Seo KM, et al. Relation Between Respiratory Muscle Strength and Skeletal Muscle Mass and Hand Grip Strength in the Healthy Elderly. Ann Rehabil Med. 2017;41(4):686-92. DOI:10.5535/arm.2017.41.4.686.Shin HI, Kim DK, Seo KM, et al. Relation Between Respiratory Muscle Strength and Skeletal Muscle Mass and Hand Grip Strength in the Healthy Elderly. Ann Rehabil Med. 2017;41(4):686-92. DOI:10.5535/arm.2017.41.4.686.Bahat G, Tufan A, Ozkaya H, et al. Relation between hand grip strength, respiratory muscle strength and spirometric measures in male nursing home residents. Aging Male. 2014;17(3):136-40. DOI:10.3109/13685538.2014.936001.Bahat G, Tufan A, Ozkaya H, et al. Relation between hand grip strength, respiratory muscle strength and spirometric measures in male nursing home residents. Aging Male. 2014;17(3):136-40. DOI:10.3109/13685538.2014.936001.Giua R, Pedone C, Scarlata S, et al. Relationship between respiratory muscle strength and physical performance in elderly hospitalized patients. Rejuvenation Res. 2014;17(4):366-71. DOI:10.1089/rej.2014.1549.Giua R, Pedone C, Scarlata S, et al. Relationship between respiratory muscle strength and physical performance in elderly hospitalized patients. Rejuvenation Res. 2014;17(4):366-71. DOI:10.1089/rej.2014.1549.Ro HJ, Kim DK, Lee SY, et al. Relationship Between Respiratory Muscle Strength and Conventional Sarcopenic Indices in Young Adults: A Preliminary Study. Ann Rehabil Med. 2015;39(6):880-7. DOI:10.5535/arm.2015.39.6.880.Ro HJ, Kim DK, Lee SY, et al. Relationship Between Respiratory Muscle Strength and Conventional Sarcopenic Indices in Young Adults: A Preliminary Study. Ann Rehabil Med. 2015;39(6):880-7. DOI:10.5535/arm.2015.39.6.880.Beaumont M, Forget P, Couturaud F, Reychler G. Effects of inspiratory muscle training in COPD patients: A systematic review and meta-analysis. Clin Respir J. 2018;12(7):2178-88. DOI:10.1111/crj.12905.Beaumont M, Forget P, Couturaud F, Reychler G. Effects of inspiratory muscle training in COPD patients: A systematic review and meta-analysis. Clin Respir J. 2018;12(7):2178-88. DOI:10.1111/crj.12905.Templeman L, Roberts F. Effectiveness of expiratory muscle strength training on expiratory strength, pulmonary function and cough in the adult population: a systematic review. Physiotherapy. 2020;106:43-51. DOI:10.1016/j.physio.2019.06.002.Templeman L, Roberts F. Effectiveness of expiratory muscle strength training on expiratory strength, pulmonary function and cough in the adult population: a systematic review. Physiotherapy. 2020;106:43-51. DOI:10.1016/j.physio.2019.06.002.Cebria I Iranzo MA, Balasch-Bernat M, Tortosa-Chulia MA, Balasch-Parisi S. Effects of Resistance Training of Peripheral Muscles Versus Respiratory Muscles in Older Adults With Sarcopenia Who are Institutionalized: A Randomized Controlled Trial. J Aging Phys Act. 2018;26(4):637-46. DOI:10.1123/japa.2017-0268.Cebria I Iranzo MA, Balasch-Bernat M, Tortosa-Chulia MA, Balasch-Parisi S. Effects of Resistance Training of Peripheral Muscles Versus Respiratory Muscles in Older Adults With Sarcopenia Who are Institutionalized: A Randomized Controlled Trial. J Aging Phys Act. 2018;26(4):637-46. DOI:10.1123/japa.2017-0268.Liu K, Zhang W, Yang Y, et al. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. 2020;39:101166. DOI:10.1016/j.ctcp.2020.101166.Liu K, Zhang W, Yang Y, et al. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. 2020;39:101166. DOI:10.1016/j.ctcp.2020.101166.

The authors declare that there are no conflicts of interest present.