Exercise capacity in sarcoidosis. Study of 29 patients

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Study of 29 patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "686" "paginaFinal" => "689" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Öznuc Akkoca, Gökhan Celik, Füsun Ulger, Peri Arbak, Sevgi Saryal, Gülseren Karabykoglu, Doganay Alper" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Öznuc" "apellidos" => "Akkoca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Gökhan" "apellidos" => "Celik" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Füsun" "apellidos" => "Ulger" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Peri" "apellidos" => "Arbak" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 4 => array:3 [ "nombre" => "Sevgi" "apellidos" => "Saryal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Gülseren" "apellidos" => "Karabykoglu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 6 => array:3 [ "nombre" => "Doganay" "apellidos" => "Alper" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Ankara University. Faculty of Medicine. Department of Chest Diseases. Cebeci Hospital. Ankara. Turkey." "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Abant Ízzet Baysal University. Düzce Faculty of Medicine. Department of Chest Diseases. Düzce. Turkey." "etiqueta" => "b" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Capacidad de ejercicio en la sarcoidosis. Estudio de 29 pacientes" ] ] "textoCompleto" => "Sarcoidosis, a systemic granulomatous disease of unknown etiology characterized by the formation of epithelioid cell granuloma without caseation, primarily affects the lungs and lymphatic system. The incidence rates are higher among young to middle-aged adults and women.The lungs are affected in more than 90% of patients with sarcodosis. Exertional dyspnea, dry cough and altered exercise tolerance occur in one-half of all patients1,2. Although symptomatic muscle involvement is rare (1-2%), asymptomatic muscle involvement is believed to occur in 50-80% of patients. Muscle involvement, systemic and metabolic factors, and decreased lung volume may contribute to diminished inspiratory and expiratory muscle strength1,3.The extent of pulmonary parenchymal disease and detection of progressive functional impairment during the course of the disease is important for the diagnosis and management of sarcoidosis patients; yet there is no true non-invasive 'gold standard' for measuring the extent of disease in patients with pulmonary sarcoidosis. Pulmonary function tests in sarcoidosis typically reveal a restrictive pattern with a reduction in carbon monoxide diffusion capacity (DLCO). In rare studies, it is reported that airflow limitation may be observed at the initial diagnosis4,5.On the other hand, cardiopulmonary exercise testing has been used more commonly in early diagnosis of interstitial lung diseases during the last decade; since it offers a sensitive mean to evaluate ventilatory, cardiovascular and metabolic functions. In early studies, it has been showed that the exercise intolerance in patients with sarcoidosis may be attributed to a 25-30% reduction in maximal aerobic capacity compared to healthy age-matched controls6,7.There is a limited number of studies concerning the exercise response of patients with sarcoidosis. The aims of the present study were 1) to evaluate the degree of impairment in pulmonary function tests, arterial blood gas analysis, respiratory muscle strength, exercise capacity and correlation of these parameters with radiological stages of sarcoidosis; 2) to further evaluate the use of cardiopulmonary exercise testing in assessing the of extent of pulmonary disease; and 3) to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis.Patients and methodSubjectsIn this prospective study, 29 patients with the diagnosis of biopsy specimen-proven sarcoidosis, according to the criteria of American Thoracic Society (ATS) were included1. All of the patients were newly-diagnosed, untreated and non-smokers.The diagnosis of sarcoidosis was based on clinical features, radiological findings and histological evidence of non-caseating granulomata1,8. Chest radiographs were examined by three pulmonologists: stage 0, no radiographic abnormalities; stage l, bilateral hilar adenopathy without parenchymal abnormalities; stage ll, bilateral hilar adenopathy with interstitial parenchymal infiltrates; stage lll, interstitial parenchymal infiltrates without hilar adenopathy; and stage lV, cicatricial changes1.All of the patients were diagnosed and studied at the Chest Diseases Department and Pulmonary Physiology Laboratory of the same department. Patients with accompanying disease; such as cardiac, other respiratory or neuromuscular disorders, were not enrolled in the study.Cases were grouped according to their radiological stages: (stage I, group 1; stage II, group 2; stage III, group 3). There were no stage 0 and stage IV patients included. Groups 1, 2 and 3 included 11, 13 and 5 patients, respectively.Physical examination of all patients was performed and past medical history was noted. Complete blood count and serum chemistry was done; and serum angiotensin-converting enzyme (SACE) levels were measured. Pulmonary function tests, cardiopulmonary exercise testing and arterial blood gas analysis were performed for each patient.Pulmonary function tests (PFT)PFT, including ventilatory tests, carbon monoxide diffusing capacity (DLCO), lung volumes, mouth inspiratory and expiratory pressures were measured at rest using Vmax 229 Pulmonary Function/Cardiopulmonary Exercise Testing Instruments (Sensor Medics, Bilthoven, The Netherlands). All of the tests were performed in sitting position and the best of three attempts was evaluated. The tests were compatible with the American Thoracic Society (ATS) criteria9. Predicted values were calculated using European Community for Steel and Coal (ECCS) reference values10.Respiratory muscle strengthInspiratory muscle strength (PImax) was measured near residual volume (RV) and expiratory muscle strength (PEmax) was measured near total lung capacity (TLC). Percentage PImax and PEmax were calculated according to Black and Hyatt's reference values11.Exercise testingProgressive cycle exercise tests to symptom limitation were conducted on an electronically braked cycle ergometer (Vmax 229 Pulmonary Function/Cardiopulmonary Exercise Testing Instruments, Sensor Medics, Bilthoven, The Netherlands)12. All of the patients were monitorized, throughout the testing, in terms of electrocardiography (ECG), arterial pressure and oxygen saturation. After the initial evaluation, subjects began cycling at a pedalling rate of 50-60 rpm/min for three minutes and afterwards the work was increased by 15-25 watts every minute. The patients were strongly encouraged to perform maximally. The test was terminated at the point of symptom limitation. Peak work rate (watt), peak oxygen consumption (VO2), peak oxygen consumption/kg (VO2/kg), peak carbon dioxide production (VCO2), gas exchange ratio (R, VCO2/VO2), minute ventilation (VE), respiratory rate (f), breathing reserve (BR), heart rate (HR), heart rate reserve (HRR), O2 pulse and oxygen uptake/work rate ratio (VO2/WR) were recorded. Metabolic parameters of the exercise test (VO2 and VCO2) were compared with predicted normal values of Jones et al13. Dead space to tidal volume ratio (Vd/Vt) was calculated (Vd/Vt = (PaCO2-PECO2)/PaCO2). Anaerobic threshold (AT) was determined by V-slope method and reported as the percentage of predicted VO2 peak.Arterial blood gas analysis (ABG)ABG was performed at rest and at peak performance with a Rapidlab 348 pH/Blood Gas Analyser (Chiron Diagnostics Ltd., Essex, UK); pH, PaO2, PaCO2, and SaO2 were measured. An alveolar-arterial oxygen pressure gradient (P[A-a]O2) was calculated for each arterial blood sample using measured respiratory quotients.The change in VO2 (VO2) was calculated as the difference in oxygen uptake between peak exercise and resting measurements of oxygen consumption. PaO2 was calculated as the difference in arterial oxygen tension between peak exercise and resting measurements. P(A-a)O2 was expressed as the difference between peak exercise and resting measurements. BR was calculated as difference between measured resting MVV and peak exercise ventilation. HRR was calculated as the difference between peak and resting heart rate.Statistical AnalysisStatistical analysis was performed through SPSS (SPSS, Inc., Chicago, IL, USA).For all variables, descriptive statistics were generated as mean ± standard deviation (SD). Data of groups were compared using Kruskal-Wallis one way analysis of variance. In case of unequal averages Mann-Whitney U test was used to assess the differences between groups. Due to the exploratory nature of this study, correction for p-values was not performed.Spearman's rank correlation test was performed to reveal relationships between measured physiological parameters and radiological stages. All significance tests were two tailed and p-values lower than 0.05 were considered to be significant.ResultsTwenty-nine (biopsy specimen-proven) untreated patients were included, 20 of them were females. Mean age was 42.50 ± 9.80 years. There were no differences between groups with regard to age and gender.Fatigue and generalized weakness were most common symptoms, expressed by 6 of 29 patients. They were radiological stage II and III, 2 and 4 patients, respectively. Dyspnea on exertion was the complaint of 5 patients, 4 of them were radiological stage III.Mean SACE level was 98.26 ± 114.16 IU. Although there was no significant difference between groups, higher serum levels of SACE were measured in advanced stages.Results of pulmonary function tests and respiratory muscle strength of the patients are seen in table 1.<img src="2v124n18-13075090tab01.gif"></img>Evaluation of all patients showed a mild decrease in DLCO, while PFT parameters were normal. According to radiological stages, a mild and moderate decrease in DLCO was found in stage II and III, respectively. Significant difference in DLCO was assessed between stages I and III. Although inspiratory and expiratory muscle strength was within normal limits, an insignificant decrease was observed in higher radiological stage (table 1).Progressive cycle exercise tests to symptom limitation were conducted for 6-10 min duration. Mean duration was 7.91 ± 1.07 min. Anaerobic threshold (AT) was not determined in 6 of the cases (20%). In the rest of the patients, AT, found by V-Slope method, was 44% of the predicted peak VO2. A significant decrement was observed in terms of VO2 and VO2/kg, with increasing radiological stage (p < 0.05). Peak metabolic and ventilatory parameters of patients during the cardiopulmonary exercise testing, and arterial blood gas parameters at rest and at peak exercise are shown in table 2. It was observed that VO2 in group 3 was lower than that of group 1 (p < 0.05). A decrease in PaO2 during exercise was only seen in stage III patients (1.20 mmHg). P(A-a)O2 was found to increase with exercise in groups 2 and 3; but differences between groups were insignificant. In addition, decrement in O2 pulse (64%) and oxygen uptake/work rate ratio (VO2/WR) (62%) was significant in stage III.<img src="2v124n18-13075090tab02.gif"></img>The correlation between peak VO2 and other parameters are seen in table 3. Significant correlations were found between peak VO2 and DLCO, VE, O2 pulse and VO2/WR (p < 0.01).<img src="2v124n18-13075090tab03.gif"></img>There was a significant correlation between radiological stages and physiological parameters (table 4). Exercise capacity was found to decrease with radiological extension of the disease (r = 0.43; p < 0.05). DLCO, PaO2 at rest and during exercise, SaO2 at rest and during exercise, changes in P(A-a) O2, O2 pulse and VO2/WR were also correlated with radiological stage.<img src="2v124n18-13075090tab04.gif"></img>DiscussionThe major finding from the present prospective study is a significant limitation in exercise capacity in patients with sarcoidosis, which showed a significant correlation with radiological stages of diseases, diffusing capacity and some functional parameters (FEV1, FEV1/FVC). Especially in patients with stage l disease exercise capacity was limited although they had completely normal spirometry.It has been previously postulated that maximal oxygen consumption decreases in sarcoidosis. Matthews and Hooper showed a limitation on progressive incremental exercise tests in 12 of 31 sarcoid patients, 11 of them had abnormal PFT14. Sietsema et al. also declared that eleven of 20 sarcoid patients had failed to reach the predicted percent of maximum VO215. These studies emphasize the partial effect of ventilatory limitation on decreased exercise capacity. In our study, slight decrease in DLCO with normal PFT (TLC, VC, FEV1) was found conflicting with the results mentioned above.In the study of Miller et al, 56% of the patients with normal spirometry and decreased diffusion capacity reached the predicted maximal VO2, while only 14% of the patients with normal spirometry and DLCO had limited exercise capacity. Patients with normal pulmonary function, in the study of Delobbe, exhibited a 30% lower maximal workload and/or VO2max than controls2. In our study, we did not determine any decrease in respiratory reserve despite decreased maximal minute ventilation. In addition, peak VO2 was significantly correlated with DLCO (r = 0.52, p < 0.01), while no correlation was found with breathing reserve (r = 0.28, p > 0.05). Considering all the patients, it was thought that ventilation limitation had little effect on exercise capacity.In patients with severe parenchymal disease, impaired exercise capacity may reflect a limitation by ventilatory mechanics15,16. Athos et al. have proven that chest radiograph is the best overall predictor of exercise performance and found evident ventilatory and gas exchange abnormalities in stage II and III patients16. We found a significant decrease in FEV1 together with a decrease in maximal minute ventilation, in stage III patients. An insignificant decrease in TLC and VC was also demonstrated. These results made us think that ventilatory performance has a clear effect on exercise capacity, especially in advanced radiological stages of disease.Pulmonary gas exchange impairment was postulated as another limiting factor that has an effect on exercise capacity4,14-17. Abnormal gas exchange can be documented by demonstrating the decrease in PaO2 and rise in P(A-a)O2 at maximal exercise, in sarcoidosis. Medinger has claimed that the change in alveolar-arterial oxygen pressure gradient at rest and exercise is the most important physiological parameter, especially in early radiological stages of disease, and P(A-a)O2/VO2 was emphasized to show disease severity and progression4. Besides, Medinger also has shown that Vd/Vt and P(a-et)CO2 are correlated across all radiographic stages of sarcoidosis18. Athos et al. have stated that changes in PaO2 and P(A-a)O2 are important factors in exercise limitation of advanced stages16. In our study, stage III patients had lower PaO2 and higher P(A-a)O2 than earlier stages, at rest. There was no significant change in PaO2 and P(A-a)O2 and no significant correlation between peak VO2% and arterial blood gas levels. Insignificant decrease in PaO2 and increase in P(A-a) O2 with exercise, together with the correlation between VO2 and Vd/Vt resulted in a limitation effect of gas exchange impairment on exercise capacity, especially in advanced radiological stages of disease.Although clinical evidence of myocardial involvement is only present in about 5% of patients with sarcoidosis, unsuspected cardiac involvement may be found in as many as 10-15% of patients1,14,15. Left heart failure may appear because of cardiac involvement; in addition, cor pulmonale may develop due to pulmonary vascular disease in sarcoidosis15. Moreover, the impaired heart rate response to exercise in sarcoidosis could be related to sinus and/or atrio-ventricular conduction dysfunction secondary to myocardial conducting system infiltration with sarcoid granulomas2,19. Ventricular dysfunction because of myocardial involvement and subclinical cardiac dysfunction due to granulomatous infiltration of sinus nodosum may also develop19.In the present study, patients could not reach the predicted maximum heart rate, in spite of reached maximal efforts shown by pH values and R values; and heart rate reserve was observed to increase (31.65 ± 11.72/min). No electrocardiographic change was seen. Decreased heart rate response to exercise in sarcoidosis may account at least in part for the observed maximal exercise limitation.Exercise intolerance due to circulatory impairment was thought to develop in our cases, since we have observed a decrease in O2 pulse and oxygen uptake / work rate ratio. In addition, a significant correlation was found between peak VO2 and two parameters mentioned above (p < 0.01). None of the patients had pulmonary thromboembolism, coronary heart disease and/or cardiac failure. Complete blood count and serum chemistry was within normal limits.Hansen and Wasserman17 have concluded that the pathophysiology of the pulmonary circulation is usually more important than ventilatory mechanics in limiting exercise in patients with interstitial pulmonary disease such as asbestosis, pulmonary alveolar proteinosis and sarcoidosis. Many investigators stressed on the importance of pulmonary vascular disease and pulmonary hypertension in interstitial pulmonary processes and emphasized their effects on morbidity .Respiratory muscle strength and respiratory muscle endurance are reduced in sarcoidosis due to involvement of respiratory muscles. Systemic or metabolic factors and decreased lung volumes may also contribute to the decrease in respiratory muscle strength3,20. Reduced respiratory muscle strength in the presence of sarcoidosis may aggravate the exercise intolerance independent of ventilatory function impairment20. In patients with cardiopulmonary disorders, respiratory muscle strength is a significant contributor to work capacity in addition to any contribution from ventilatory, circulatory and gas exchange impairment21. Decrease in respiratory muscle strength in our cases was not observed. This should be related with uninvolved respiratory muscles and normal lung volumes. Therefore respiratory muscle effect on exercise tolerance was not thought as one of the reasons of impairment.In the present study, a correlation between radiological stages and physiological parameters (DLCO, DLCO/VA, PaO2, P[A-a]O2 and exercise time) was revealed (p < 0.01). A negative correlation was found between radiological stage and peak VO2 (p < 0.05), suggesting that the radiographic stage is a good predictor of exercise performance as in the study of Athos16.Exercise capacity is impaired in early stages of sarcoidosis. Moreover, it was found to be the earliest impaired physiological parameter in patients with sarcoidosis. Exercise intolerance, having mutifactorial basis, is correlated with radiological stages. Circulatory impairment and impaired heart rate response to exercise have effects on decreased exercise capacity. Especially in advanced radiological stages of disease, ventilatory and gas exchange impairment also seems to be effective on limiting exercise capacity. Prospective clinical studies with larger series of all stages are needed to define mechanisms of exercise intolerance in sarcoidosis." "pdfFichero" => "2v124n18a13075090pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec223568" "palabras" => array:3 [ 0 => "Sarcoidosis" 1 => "Capacidad de ejercicio" 2 => "Pruebas de función respiratoria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec223567" "palabras" => array:3 [ 0 => "Sarcoidosis" 1 => "Exercise capacity" 2 => "Pulmonary function tests" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Background and objective: Sarcoidosis is a systemic granulomatous disease of unknown etiology. Aims of this prospective study are to evaluate degree of impairment in pulmonary function tests (PFT), arterial blood gas analysis (ABG), respiratory muscle strength, exercise capacity and correlation of these parameters with radiological stages; to further evaluate the use of cardiopulmonary exercise testing in assessment of extent of pulmonary disease; and to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis. Patients and method: 29 patients with sarcoidosis were grouped according to their radiological stages (stage I: group 1; stage II, group 2; stage III, group 3). Groups 1, 2 and 3 included 11, 13 and 5 patients, respectively. PFT, cardiopulmonary exercise testing and ABG were performed for each patient. Results: Evaluation of all patients showed a significant decrement in exercise capacity. Patients in stage III had decreased diffusing capacity and exercise capacity. There was limitation in exercise capacity in stage I patients who had completely normal spirometry and diffusing capacity. We also found a correlation between radiological stages of the disease and exercise capacity, diffusing capacity and ABG. Conclusions: Exercise capacity is impaired also in early stages of sarcoidosis and it was found to be the earliest impaired physiological parameter in sarcoid patients. Exercise intolerance, having mutifactorial basis, is correlated with radiological stages. Circulatory impairment and impaired heart rate response to exercise have effects on limitation in exercise capacity. Especially in advanced radiological stages of disease, ventilatory and gas exchange impairment also seems to be effective on limiting exercise in patients with sarcoidosis." ] "es" => array:1 [ "resumen" => "Fundamento y objetivo: La sarcoidosis es una enfermedad sistémica granulomatosa de etiología desconocida. Los objetivos de este estudio prospectivo fueron evaluar el grado de deterioro de las pruebas funcionales respiratorias, la gasometría arterial, la fuerza de la musculatura respiratoria y la capacidad de ejercicio, así como la correlación de estos parámetros con los estadios radiológicos. Además, se decidió evaluar la utilización de las pruebas de ejercicio cardiorrespiratorio en la valoración de la extensión de la enfermedad pulmonar y, por último, discutir los mecanismos fisiopatológicos de limitación de la capacidad de ejercicio en los pacientes con sarcoidosis. Pacientes y método: Se incluyó a 29 pacientes, que fueron agrupados según sus estadios radiológicos (estadio I, grupo 1; estadio II, grupo 2; estadio III, grupo 3). Los grupos 1, 2 y 3 incluyeron 11, 13 y 5 pacientes, respectivamente. En cada paciente se realizaron pruebas de funcionalismo respiratorio, pruebas de ejercicio cardiorrespiratorio y gasometría arterial. Resultados: Se observó una disminución significativa de la capacidad de ejercicio. Los pacientes del estadio III tenían una disminución de las capacidades de difusión y de ejercicio. Se observó una limitación de la capacidad de ejercicio en los pacientes del estadio I que, por otra parte, mostraron una capacidad de difusión y espirometría normales. También observamos una correlación entre los estadios radiológicos de la enfermedad y la capacidad de ejercicio, capacidad de difusión y gasometría arterial. Conclusiones: La capacidad de ejercicio está deteriorada en los estadios iniciales de la sarcoidosis y éste fue el parámetro fisiológico más precozmente deteriorado en estos pacientes. La intolerancia al ejercicio, con una base multifactorial, se correlaciona con los estadios radiológicos. La afección circulatoria y la respuesta alterada de la frecuencia cardíaca al ejercicio tienen efectos sobre la limitación de la capacidad de ejercicio. 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Capacidad de ejercicio en la sarcoidosis. Estudio de 29 pacientes

Öznuc Akkocaa, Gökhan Celika, Füsun Ulgera, Peri Arbakb, Sevgi Saryala, Gülseren Karabykoglua, Doganay Alpera

a Ankara University. Faculty of Medicine. Department of Chest Diseases. Cebeci Hospital. Ankara. Turkey.

b Abant Ízzet Baysal University. Düzce Faculty of Medicine. Department of Chest Diseases. Düzce. Turkey.

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    "textoCompleto" => "<p class="elsevierStylePara">Sarcoidosis&#44; a systemic granulomatous disease of unknown etiology characterized by the formation of epithelioid cell granuloma without caseation&#44; primarily affects the lungs and lymphatic system&#46; The incidence rates are higher among young to middle-aged adults and women&#46;</p><p class="elsevierStylePara">The lungs are affected in more than 90&#37; of patients with sarcodosis&#46; Exertional dyspnea&#44; dry cough and altered exercise tolerance occur in one-half of all patients<span class="elsevierStyleSup">1&#44;2</span>&#46; Although symptomatic muscle involvement is rare &#40;1-2&#37;&#41;&#44; asymptomatic muscle involvement is believed to occur in 50-80&#37; of patients&#46; Muscle involvement&#44; systemic and metabolic factors&#44; and decreased lung volume may contribute to diminished inspiratory and expiratory muscle strength<span class="elsevierStyleSup">1&#44;3</span>&#46;</p><p class="elsevierStylePara">The extent of pulmonary parenchymal disease and detection of progressive functional impairment during the course of the disease is important for the diagnosis and management of sarcoidosis patients&#59; yet there is no true non-invasive &#39;gold standard&#39; for measuring the extent of disease in patients with pulmonary sarcoidosis&#46; Pulmonary function tests in sarcoidosis typically reveal a restrictive pattern with a reduction in carbon monoxide diffusion capacity &#40;DLCO&#41;&#46; In rare studies&#44; it is reported that airflow limitation may be observed at the initial diagnosis<span class="elsevierStyleSup">4&#44;5</span>&#46;</p><p class="elsevierStylePara">On the other hand&#44; cardiopulmonary exercise testing has been used more commonly in early diagnosis of interstitial lung diseases during the last decade&#59; since it offers a sensitive mean to evaluate ventilatory&#44; cardiovascular and metabolic functions&#46; In early studies&#44; it has been showed that the exercise intolerance in patients with sarcoidosis may be attributed to a 25-30&#37; reduction in maximal aerobic capacity compared to healthy age-matched controls<span class="elsevierStyleSup">6&#44;7</span>&#46;</p><p class="elsevierStylePara">There is a limited number of studies concerning the exercise response of patients with sarcoidosis&#46; The aims of the present study were <span class="elsevierStyleItalic">1&#41;</span> to evaluate the degree of impairment in pulmonary function tests&#44; arterial blood gas analysis&#44; respiratory muscle strength&#44; exercise capacity and correlation of these parameters with radiological stages of sarcoidosis&#59; <span class="elsevierStyleItalic">2&#41;</span> to further evaluate the use of cardiopulmonary exercise testing in assessing the of extent of pulmonary disease&#59; and <span class="elsevierStyleItalic">3&#41;</span> to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis&#46;</p><p class="elsevierStylePara">Patients and method</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Subjects</span></p><p class="elsevierStylePara">In this prospective study&#44; 29 patients with the diagnosis of biopsy specimen-proven sarcoidosis&#44; according to the criteria of American Thoracic Society &#40;ATS&#41; were included<span class="elsevierStyleSup">1</span>&#46; All of the patients were newly-diagnosed&#44; untreated and non-smokers&#46;</p><p class="elsevierStylePara">The diagnosis of sarcoidosis was based on clinical features&#44; radiological findings and histological evidence of non-caseating granulomata<span class="elsevierStyleSup">1&#44;8</span>&#46; Chest radiographs were examined by three pulmonologists&#58; stage 0&#44; no radiographic abnormalities&#59; stage l&#44; bilateral hilar adenopathy without parenchymal abnormalities&#59; stage ll&#44; bilateral hilar adenopathy with interstitial parenchymal infiltrates&#59; stage lll&#44; interstitial parenchymal infiltrates without hilar adenopathy&#59; and stage lV&#44; cicatricial changes<span class="elsevierStyleSup">1</span>&#46;</p><p class="elsevierStylePara">All of the patients were diagnosed and studied at the Chest Diseases Department and Pulmonary Physiology Laboratory of the same department&#46; Patients with accompanying disease&#59; such as cardiac&#44; other respiratory or neuromuscular disorders&#44; were not enrolled in the study&#46;</p><p class="elsevierStylePara">Cases were grouped according to their radiological stages&#58; &#40;stage I&#44; group 1&#59; stage II&#44; group 2&#59; stage III&#44; group 3&#41;&#46; There were no stage 0 and stage IV patients included&#46; Groups 1&#44; 2 and 3 included 11&#44; 13 and 5 patients&#44; respectively&#46;</p><p class="elsevierStylePara">Physical examination of all patients was performed and past medical history was noted&#46; Complete blood count and serum chemistry was done&#59; and serum angiotensin-converting enzyme &#40;SACE&#41; levels were measured&#46; Pulmonary function tests&#44; cardiopulmonary exercise testing and arterial blood gas analysis were performed for each patient&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pulmonary function tests &#40;PFT&#41;</span></p><p class="elsevierStylePara">PFT&#44; including ventilatory tests&#44; carbon monoxide diffusing capacity &#40;DLCO&#41;&#44; lung volumes&#44; mouth inspiratory and expiratory pressures were measured at rest using V<span class="elsevierStyleInf">max</span> 229 Pulmonary Function&#47;Cardiopulmonary Exercise Testing Instruments &#40;Sensor Medics&#44; Bilthoven&#44; The Netherlands&#41;&#46; All of the tests were performed in sitting position and the best of three attempts was evaluated&#46; The tests were compatible with the American Thoracic Society &#40;ATS&#41; criteria<span class="elsevierStyleSup">9</span>&#46; Predicted values were calculated using European Community for Steel and Coal &#40;ECCS&#41; reference values<span class="elsevierStyleSup">10</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Respiratory muscle strength</span></p><p class="elsevierStylePara">Inspiratory muscle strength &#40;PI<span class="elsevierStyleInf">max</span>&#41; was measured near residual volume &#40;RV&#41; and expiratory muscle strength &#40;PE<span class="elsevierStyleInf">max</span>&#41; was measured near total lung capacity &#40;TLC&#41;&#46; Percentage PI<span class="elsevierStyleInf">max</span> and PE<span class="elsevierStyleInf">max</span> were calculated according to Black and Hyatt&#39;s reference values<span class="elsevierStyleSup">11</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Exercise testing</span></p><p class="elsevierStylePara">Progressive cycle exercise tests to symptom limitation were conducted on an electronically braked cycle ergometer &#40;V<span class="elsevierStyleInf">max</span> 229 Pulmonary Function&#47;Cardiopulmonary Exercise Testing Instruments&#44; Sensor Medics&#44; Bilthoven&#44; The Netherlands&#41;<span class="elsevierStyleSup">12</span>&#46; All of the patients were monitorized&#44; throughout the testing&#44; in terms of electrocardiography &#40;ECG&#41;&#44; arterial pressure and oxygen saturation&#46; After the initial evaluation&#44; subjects began cycling at a pedalling rate of 50-60 rpm&#47;min for three minutes and afterwards the work was increased by 15-25 watts every minute&#46; The patients were strongly encouraged to perform maximally&#46; The test was terminated at the point of symptom limitation&#46; Peak work rate &#40;watt&#41;&#44; peak oxygen consumption &#40;VO<span class="elsevierStyleInf">2</span>&#41;&#44; peak oxygen consumption&#47;kg &#40;VO<span class="elsevierStyleInf">2</span>&#47;kg&#41;&#44; peak carbon dioxide production &#40;VCO<span class="elsevierStyleInf">2</span>&#41;&#44; gas exchange ratio &#40;R&#44; VCO<span class="elsevierStyleInf">2</span>&#47;VO<span class="elsevierStyleInf">2</span>&#41;&#44; minute ventilation &#40;VE&#41;&#44; respiratory rate &#40;f&#41;&#44; breathing reserve &#40;BR&#41;&#44; heart rate &#40;HR&#41;&#44; heart rate reserve &#40;HRR&#41;&#44; O<span class="elsevierStyleInf">2</span> pulse and oxygen uptake&#47;work rate ratio &#40;VO<span class="elsevierStyleInf">2</span>&#47;WR&#41; were recorded&#46; Metabolic parameters of the exercise test &#40;VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span>&#41; were compared with predicted normal values of Jones et al<span class="elsevierStyleSup">13</span>&#46; Dead space to tidal volume ratio &#40;Vd&#47;Vt&#41; was calculated &#40;Vd&#47;Vt &#61; &#40;PaCO<span class="elsevierStyleInf">2</span>-PECO<span class="elsevierStyleInf">2</span>&#41;&#47;PaCO<span class="elsevierStyleInf">2</span>&#41;&#46; Anaerobic threshold &#40;AT&#41; was determined by V-slope method and reported as the percentage of predicted VO<span class="elsevierStyleInf">2</span> peak&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Arterial blood gas analysis &#40;ABG&#41;</span></p><p class="elsevierStylePara">ABG was performed at rest and at peak performance with a Rapidlab 348 pH&#47;Blood Gas Analyser &#40;Chiron Diagnostics Ltd&#46;&#44; Essex&#44; UK&#41;&#59; pH&#44; PaO<span class="elsevierStyleInf">2</span>&#44; PaCO<span class="elsevierStyleInf">2</span>&#44; and SaO<span class="elsevierStyleInf">2</span> were measured&#46; An alveolar-arterial oxygen pressure gradient &#40;P&#91;A-a&#93;O<span class="elsevierStyleInf">2</span>&#41; was calculated for each arterial blood sample using measured respiratory quotients&#46;</p><p class="elsevierStylePara">The change in VO<span class="elsevierStyleInf">2</span> &#40;VO<span class="elsevierStyleInf">2</span>&#41; was calculated as the difference in oxygen uptake between peak exercise and resting measurements of oxygen consumption&#46;  PaO<span class="elsevierStyleInf">2</span> was calculated as the difference in arterial oxygen tension between peak exercise and resting measurements&#46;   P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> was expressed as the difference between peak exercise and resting measurements&#46; BR was calculated as difference between measured resting MVV and peak exercise ventilation&#46; HRR was calculated as the difference between peak and resting heart rate&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical Analysis</span></p><p class="elsevierStylePara">Statistical analysis was performed through SPSS &#40;SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p><p class="elsevierStylePara">For all variables&#44; descriptive statistics were generated as mean &#177; standard deviation &#40;SD&#41;&#46; Data of groups were compared using Kruskal-Wallis one way analysis of variance&#46; In case of unequal averages Mann-Whitney U test was used to assess the differences between groups&#46; Due to the exploratory nature of this study&#44; correction for p-values was not performed&#46;</p><p class="elsevierStylePara">Spearman&#39;s rank correlation test was performed to reveal relationships between measured physiological parameters and radiological stages&#46; All significance tests were two tailed and p-values lower than 0&#46;05 were considered to be significant&#46;</p><p class="elsevierStylePara">Results</p><p class="elsevierStylePara">Twenty-nine &#40;biopsy specimen-proven&#41; untreated patients were included&#44; 20 of them were females&#46; Mean age was 42&#46;50 &#177; 9&#46;80 years&#46; There were no differences between groups with regard to age and gender&#46;</p><p class="elsevierStylePara">Fatigue and generalized weakness were most common symptoms&#44; expressed by 6 of 29 patients&#46; They were radiological stage II and III&#44; 2 and 4 patients&#44; respectively&#46; Dyspnea on exertion was the complaint of 5 patients&#44; 4 of them were radiological stage III&#46;</p><p class="elsevierStylePara">Mean SACE level was 98&#46;26 &#177; 114&#46;16 IU&#46; Although there was no significant difference between groups&#44; higher serum levels of SACE were measured in advanced stages&#46;</p><p class="elsevierStylePara">Results of pulmonary function tests and respiratory muscle strength of the patients are seen in table 1&#46;</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab01.gif"></img></p><p class="elsevierStylePara">Evaluation of all patients showed a mild decrease in DLCO&#44; while PFT parameters were normal&#46; According to radiological stages&#44; a mild and moderate decrease in DLCO was found in stage II and III&#44; respectively&#46; Significant difference in DLCO was assessed between stages I and III&#46; Although inspiratory and expiratory muscle strength was within normal limits&#44; an insignificant decrease was observed in higher radiological stage &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">Progressive cycle exercise tests to symptom limitation were conducted for 6-10 min duration&#46; Mean duration was 7&#46;91 &#177; 1&#46;07 min&#46; Anaerobic threshold &#40;AT&#41; was not determined in 6 of the cases &#40;20&#37;&#41;&#46; In the rest of the patients&#44; AT&#44; found by V-Slope method&#44; was 44&#37; of the predicted peak VO<span class="elsevierStyleInf">2</span>&#46; A significant decrement was observed in terms of VO<span class="elsevierStyleInf">2</span> and VO<span class="elsevierStyleInf">2</span>&#47;kg&#44; with increasing radiological stage &#40;p &#60; 0&#46;05&#41;&#46; Peak metabolic and ventilatory parameters of patients during the cardiopulmonary exercise testing&#44; and arterial blood gas parameters at rest and at peak exercise are shown in table 2&#46; It was observed that  VO<span class="elsevierStyleInf">2</span> in group 3 was lower than that of group 1 &#40;p &#60; 0&#46;05&#41;&#46; A decrease in PaO<span class="elsevierStyleInf">2</span> during exercise was only seen in stage III patients &#40;&#173;1&#46;20 mmHg&#41;&#46; P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> was found to increase with exercise in groups 2 and 3&#59; but differences between groups were insignificant&#46; In addition&#44; decrement in O<span class="elsevierStyleInf">2</span> pulse &#40;64&#37;&#41; and oxygen uptake&#47;work rate ratio &#40;VO<span class="elsevierStyleInf">2</span>&#47;WR&#41; &#40;62&#37;&#41; was significant in stage III&#46;</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab02.gif"></img></p><p class="elsevierStylePara">The correlation between peak VO<span class="elsevierStyleInf">2</span> and other parameters are seen in table 3&#46; Significant correlations were found between peak VO<span class="elsevierStyleInf">2</span> and DLCO&#44; VE&#44; O<span class="elsevierStyleInf">2</span> pulse and VO<span class="elsevierStyleInf">2</span>&#47;WR &#40;p &#60; 0&#46;01&#41;&#46;</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab03.gif"></img></p><p class="elsevierStylePara">There was a significant correlation between radiological stages and physiological parameters &#40;table 4&#41;&#46; Exercise capacity was found to decrease with radiological extension of the disease &#40;r &#61; &#173;0&#46;43&#59; p &#60; 0&#46;05&#41;&#46; DLCO&#44; PaO<span class="elsevierStyleInf">2</span> at rest and during exercise&#44; SaO<span class="elsevierStyleInf">2</span> at rest and during exercise&#44; changes in P&#40;A-a&#41; O<span class="elsevierStyleInf">2</span>&#44; O<span class="elsevierStyleInf">2</span> pulse and VO<span class="elsevierStyleInf">2</span>&#47;WR were also correlated with radiological stage&#46;</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab04.gif"></img></p><p class="elsevierStylePara">Discussion</p><p class="elsevierStylePara">The major finding from the present prospective study is a significant limitation in exercise capacity in patients with sarcoidosis&#44; which showed a significant correlation with radiological stages of diseases&#44; diffusing capacity and some functional parameters &#40;FEV<span class="elsevierStyleInf">1</span>&#44; FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#41;&#46; Especially in patients with stage l disease exercise capacity was limited although they had completely normal spirometry&#46;</p><p class="elsevierStylePara">It has been previously postulated that maximal oxygen consumption decreases in sarcoidosis&#46; Matthews and Hooper showed a limitation on progressive incremental exercise tests in 12 of 31 sarcoid patients&#44; 11 of them had abnormal PFT<span class="elsevierStyleSup">14</span>&#46; Sietsema et al&#46; also declared that eleven of 20 sarcoid patients had failed to reach the predicted percent of maximum VO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">15</span>&#46; These studies emphasize the partial effect of ventilatory limitation on decreased exercise capacity&#46; In our study&#44; slight decrease in DLCO with normal PFT &#40;TLC&#44; VC&#44; FEV<span class="elsevierStyleInf">1</span>&#41; was found conflicting with the results mentioned above&#46;</p><p class="elsevierStylePara">In the study of Miller et al&#44; 56&#37; of the patients with normal spirometry and decreased diffusion capacity reached the predicted maximal VO<span class="elsevierStyleInf">2</span>&#44; while only 14&#37; of the patients with normal spirometry and DLCO had limited exercise capacity&#46; Patients with normal pulmonary function&#44; in the study of Delobbe&#44; exhibited a 30&#37; lower maximal workload and&#47;or VO<span class="elsevierStyleInf">2max</span> than controls<span class="elsevierStyleSup">2</span>&#46; In our study&#44; we did not determine any decrease in respiratory reserve despite decreased maximal minute ventilation&#46; In addition&#44; peak VO<span class="elsevierStyleInf">2</span> was significantly correlated with DLCO &#40;r &#61; 0&#46;52&#44; p &#60; 0&#46;01&#41;&#44; while no correlation was found with breathing reserve &#40;r &#61; 0&#46;28&#44; p &#62; 0&#46;05&#41;&#46; Considering all the patients&#44; it was thought that ventilation limitation had little effect on exercise capacity&#46;</p><p class="elsevierStylePara">In patients with severe parenchymal disease&#44; impaired exercise capacity may reflect a limitation by ventilatory mechanics<span class="elsevierStyleSup">15&#44;16</span>&#46; Athos et al&#46; have proven that chest radiograph is the best overall predictor of exercise performance and found evident ventilatory and gas exchange abnormalities in stage II and III patients<span class="elsevierStyleSup">16</span>&#46; We found a significant decrease in FEV<span class="elsevierStyleInf">1</span> together with a decrease in maximal minute ventilation&#44; in stage III patients&#46; An insignificant decrease in TLC and VC was also demonstrated&#46; These results made us think that ventilatory performance has a clear effect on exercise capacity&#44; especially in advanced radiological stages of disease&#46;</p><p class="elsevierStylePara">Pulmonary gas exchange impairment was postulated as another limiting factor that has an effect on exercise capacity<span class="elsevierStyleSup">4&#44;14-17</span>&#46; Abnormal gas exchange can be documented by demonstrating the decrease in PaO<span class="elsevierStyleInf">2</span> and rise in P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> at maximal exercise&#44; in sarcoidosis&#46; Medinger has claimed that the change in alveolar-arterial oxygen pressure gradient at rest and exercise is the most important physiological parameter&#44; especially in early radiological stages of disease&#44; and P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span>&#47;VO<span class="elsevierStyleInf">2</span> was emphasized to show disease severity and progression<span class="elsevierStyleSup">4</span>&#46; Besides&#44; Medinger also has shown that Vd&#47;Vt and P&#40;a-et&#41;CO<span class="elsevierStyleInf">2</span> are correlated across all radiographic stages of sarcoidosis<span class="elsevierStyleSup">18</span>&#46; Athos et al&#46; have stated that changes in PaO<span class="elsevierStyleInf">2</span> and P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> are important factors in exercise limitation of advanced stages<span class="elsevierStyleSup">16</span>&#46; In our study&#44; stage III patients had lower PaO<span class="elsevierStyleInf">2</span> and higher P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> than earlier stages&#44; at rest&#46; There was no significant change in  PaO<span class="elsevierStyleInf">2</span> and P&#40;A-a&#41;O<span class="elsevierStyleInf">2</span> and no significant correlation between peak VO<span class="elsevierStyleInf">2</span>&#37; and arterial blood gas levels&#46; Insignificant decrease in PaO<span class="elsevierStyleInf">2</span> and increase in P&#40;A-a&#41; O<span class="elsevierStyleInf">2</span> with exercise&#44; together with the correlation between VO<span class="elsevierStyleInf">2</span> and Vd&#47;Vt resulted in a limitation effect of gas exchange impairment on exercise capacity&#44; especially in advanced radiological stages of disease&#46;</p><p class="elsevierStylePara">Although clinical evidence of myocardial involvement is only present in about 5&#37; of patients with sarcoidosis&#44; unsuspected cardiac involvement may be found in as many as 10-15&#37; of patients<span class="elsevierStyleSup">1&#44;14&#44;15</span>&#46; Left heart failure may appear because of cardiac involvement&#59; in addition&#44; cor pulmonale may develop due to pulmonary vascular disease in sarcoidosis<span class="elsevierStyleSup">15</span>&#46; Moreover&#44; the impaired heart rate response to exercise in sarcoidosis could be related to sinus and&#47;or atrio-ventricular conduction dysfunction secondary to myocardial conducting system infiltration with sarcoid granulomas<span class="elsevierStyleSup">2&#44;19</span>&#46; Ventricular dysfunction because of myocardial involvement and subclinical cardiac dysfunction due to granulomatous infiltration of sinus nodosum may also develop<span class="elsevierStyleSup">19</span>&#46;</p><p class="elsevierStylePara">In the present study&#44; patients could not reach the predicted maximum heart rate&#44; in spite of reached maximal efforts shown by pH values and R values&#59; and heart rate reserve was observed to increase &#40;31&#46;65 &#177; 11&#46;72&#47;min&#41;&#46; No electrocardiographic change was seen&#46; Decreased heart rate response to exercise in sarcoidosis may account at least in part for the observed maximal exercise limitation&#46;</p><p class="elsevierStylePara">Exercise intolerance due to circulatory impairment was thought to develop in our cases&#44; since we have observed a decrease in O<span class="elsevierStyleInf">2</span> pulse and oxygen uptake &#47; work rate ratio&#46; In addition&#44; a significant correlation was found between peak VO<span class="elsevierStyleInf">2</span> and two parameters mentioned above &#40;p &#60; 0&#46;01&#41;&#46; None of the patients had pulmonary thromboembolism&#44; coronary heart disease and&#47;or cardiac failure&#46; Complete blood count and serum chemistry was within normal limits&#46;</p><p class="elsevierStylePara">Hansen and Wasserman<span class="elsevierStyleSup">17</span> have concluded that the pathophysiology of the pulmonary circulation is usually more important than ventilatory mechanics in limiting exercise in patients with interstitial pulmonary disease such as asbestosis&#44; pulmonary alveolar proteinosis and sarcoidosis&#46; Many investigators stressed on the importance of pulmonary vascular disease and pulmonary hypertension in interstitial pulmonary processes and emphasized their effects on morbidity &#46;</p><p class="elsevierStylePara">Respiratory muscle strength and respiratory muscle endurance are reduced in sarcoidosis due to involvement of respiratory muscles&#46; Systemic or metabolic factors and decreased lung volumes may also contribute to the decrease in respiratory muscle strength<span class="elsevierStyleSup">3&#44;20</span>&#46; Reduced respiratory muscle strength in the presence of sarcoidosis may aggravate the exercise intolerance independent of ventilatory function impairment<span class="elsevierStyleSup">20</span>&#46; In patients with cardiopulmonary disorders&#44; respiratory muscle strength is a significant contributor to work capacity in addition to any contribution from ventilatory&#44; circulatory and gas exchange impairment<span class="elsevierStyleSup">21</span>&#46; Decrease in respiratory muscle strength in our cases was not observed&#46; This should be related with uninvolved respiratory muscles and normal lung volumes&#46; Therefore respiratory muscle effect on exercise tolerance was not thought as one of the reasons of impairment&#46;</p><p class="elsevierStylePara">In the present study&#44; a correlation between radiological stages and physiological parameters &#40;DLCO&#44; DLCO&#47;VA&#44; PaO<span class="elsevierStyleInf">2</span>&#44; P&#91;A-a&#93;O<span class="elsevierStyleInf">2</span> and exercise time&#41; was revealed &#40;p &#60; 0&#46;01&#41;&#46; A negative correlation was found between radiological stage and peak VO<span class="elsevierStyleInf">2</span> &#40;p &#60; 0&#46;05&#41;&#44; suggesting that the radiographic stage is a good predictor of exercise performance as in the study of Athos<span class="elsevierStyleSup">16</span>&#46;</p><p class="elsevierStylePara">Exercise capacity is impaired in early stages of sarcoidosis&#46; Moreover&#44; it was found to be the earliest impaired physiological parameter in patients with sarcoidosis&#46; Exercise intolerance&#44; having mutifactorial basis&#44; is correlated with radiological stages&#46; Circulatory impairment and impaired heart rate response to exercise have effects on decreased exercise capacity&#46; Especially in advanced radiological stages of disease&#44; ventilatory and gas exchange impairment also seems to be effective on limiting exercise capacity&#46; Prospective clinical studies with larger series of all stages are needed to define mechanisms of exercise intolerance in sarcoidosis&#46;</p>"
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          "palabras" => array:3 [
            0 => "Sarcoidosis"
            1 => "Capacidad de ejercicio"
            2 => "Pruebas de funci&#243;n respiratoria"
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            1 => "Exercise capacity"
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        "resumen" => "Background and objective&#58; Sarcoidosis is a systemic granulomatous disease of unknown etiology&#46; Aims of this prospective study are to evaluate degree of impairment in pulmonary function tests &#40;PFT&#41;&#44; arterial blood gas analysis &#40;ABG&#41;&#44; respiratory muscle strength&#44; exercise capacity and correlation of these parameters with radiological stages&#59; to further evaluate the use of cardiopulmonary exercise testing in assessment of extent of pulmonary disease&#59; and to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis&#46; Patients and method&#58; 29 patients with sarcoidosis were grouped according to their radiological stages &#40;stage I&#58; group 1&#59; stage II&#44; group 2&#59; stage III&#44; group 3&#41;&#46; Groups 1&#44; 2 and 3 included 11&#44; 13 and 5 patients&#44; respectively&#46; PFT&#44; cardiopulmonary exercise testing and ABG were performed for each patient&#46; Results&#58; Evaluation of all patients showed a significant decrement in exercise capacity&#46; Patients in stage III had decreased diffusing capacity and exercise capacity&#46; There was limitation in exercise capacity in stage I patients who had completely normal spirometry and diffusing capacity&#46; We also found a correlation between radiological stages of the disease and exercise capacity&#44; diffusing capacity and ABG&#46; Conclusions&#58; Exercise capacity is impaired also in early stages of sarcoidosis and it was found to be the earliest impaired physiological parameter in sarcoid patients&#46; Exercise intolerance&#44; having mutifactorial basis&#44; is correlated with radiological stages&#46; Circulatory impairment and impaired heart rate response to exercise have effects on limitation in exercise capacity&#46; Especially in advanced radiological stages of disease&#44; ventilatory and gas exchange impairment also seems to be effective on limiting exercise in patients with sarcoidosis&#46;"
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        "resumen" => "Fundamento y objetivo&#58; La sarcoidosis es una enfermedad sist&#233;mica granulomatosa de etiolog&#237;a desconocida&#46; Los objetivos de este estudio prospectivo fueron evaluar el grado de deterioro de las pruebas funcionales respiratorias&#44; la gasometr&#237;a arterial&#44; la fuerza de la musculatura respiratoria y la capacidad de ejercicio&#44; as&#237; como la correlaci&#243;n de estos par&#225;metros con los estadios radiol&#243;gicos&#46; Adem&#225;s&#44; se decidi&#243; evaluar la utilizaci&#243;n de las pruebas de ejercicio cardiorrespiratorio en la valoraci&#243;n de la extensi&#243;n de la enfermedad pulmonar y&#44; por &#250;ltimo&#44; discutir los mecanismos fisiopatol&#243;gicos de limitaci&#243;n de la capacidad de ejercicio en los pacientes con sarcoidosis&#46; Pacientes y m&#233;todo&#58; Se incluy&#243; a 29 pacientes&#44; que fueron agrupados seg&#250;n sus estadios radiol&#243;gicos &#40;estadio I&#44; grupo 1&#59; estadio II&#44; grupo 2&#59; estadio III&#44; grupo 3&#41;&#46; Los grupos 1&#44; 2 y 3 incluyeron 11&#44; 13 y 5 pacientes&#44; respectivamente&#46; En cada paciente se realizaron pruebas de funcionalismo respiratorio&#44; pruebas de ejercicio cardiorrespiratorio y gasometr&#237;a arterial&#46; Resultados&#58; Se observ&#243; una disminuci&#243;n significativa de la capacidad de ejercicio&#46; Los pacientes del estadio III ten&#237;an una disminuci&#243;n de las capacidades de difusi&#243;n y de ejercicio&#46; Se observ&#243; una limitaci&#243;n de la capacidad de ejercicio en los pacientes del estadio I que&#44; por otra parte&#44; mostraron una capacidad de difusi&#243;n y espirometr&#237;a normales&#46; Tambi&#233;n observamos una correlaci&#243;n entre los estadios radiol&#243;gicos de la enfermedad y la capacidad de ejercicio&#44; capacidad de difusi&#243;n y gasometr&#237;a arterial&#46; Conclusiones&#58; La capacidad de ejercicio est&#225; deteriorada en los estadios iniciales de la sarcoidosis y &#233;ste fue el par&#225;metro fisiol&#243;gico m&#225;s precozmente deteriorado en estos pacientes&#46; La intolerancia al ejercicio&#44; con una base multifactorial&#44; se correlaciona con los estadios radiol&#243;gicos&#46; La afecci&#243;n circulatoria y la respuesta alterada de la frecuencia card&#237;aca al ejercicio tienen efectos sobre la limitaci&#243;n de la capacidad de ejercicio&#46; Especialmente en los estadios radiol&#243;gicos avanzados de la enfermedad&#44; el deterioro ventilatorio y del intercambio gaseoso parecen tener asimismo influencia sobre la limitaci&#243;n del ejercicio en pacientes con sarcoidosis&#46;"
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Article information

ISSN: 00257753
Original language: English

DOI:10.1157/13075090

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Year/Month	Html	Pdf	Total

2023 March	4	1	5
2017 October	18	7	25
2017 September	15	2	17
2017 August	12	1	13
2017 July	17	1	18
2017 June	23	11	34
2017 May	35	9	44
2017 April	15	2	17
2017 March	18	38	56
2017 February	13	2	15
2017 January	17	3	20
2016 December	24	1	25
2016 November	20	1	21
2016 October	67	13	80
2016 September	58	5	63
2016 August	24	6	30
2016 July	16	3	19
2016 June	35	11	46
2016 May	20	14	34
2016 April	26	8	34
2016 March	23	22	45
2016 February	20	15	35
2016 January	22	18	40
2015 December	12	8	20
2015 November	21	14	35
2015 October	18	8	26
2015 September	20	9	29
2015 August	39	6	45
2015 July	29	3	32
2015 June	15	6	21
2015 May	25	7	32
2015 April	29	11	40
2015 March	20	12	32
2015 February	9	8	17
2015 January	15	2	17
2014 December	48	1	49
2014 November	35	3	38
2014 October	47	0	47
2014 September	37	1	38
2014 August	35	3	38
2014 July	35	2	37
2014 June	38	4	42
2014 May	26	2	28
2014 April	28	0	28
2014 March	21	1	22
2014 February	32	0	32
2014 January	33	2	35
2013 December	21	2	23
2013 November	17	2	19
2013 October	24	1	25
2013 September	23	1	24
2013 August	23	1	24
2013 July	19	1	20
2005 May	1134	0	1134

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