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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; exercise training is a core component of pulmonary rehabilitation&#44; supported by high-level evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The 6-min walk test &#40;6MWT&#41; has been adopted as standard procedure for exercise capacity assessment in patients with pulmonary diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is a simple&#44; widely used and reliable test&#44; useful for evaluating the functional status and prognosis of patients with a wide variety of diseases and the effects of several interventions&#44; such as rehabilitation&#44; pharmacological therapy and oxygen supplementation&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with COPD tend to stop exercising because of dyspnea rather than leg fatigue&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Their physical performance may be reduced by a significant ventilatory limitation to exercise&#44; particularly if peripheral muscle strength is not impaired&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> Consequently&#44; adjunctive strategies to improve exercise tolerance have been proposed&#44; such as non-invasive ventilation<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the application of positive expiratory pressure &#40;PEP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PEP is applied at the mouth in order to counterbalance the dynamic compression of the airways that leads to exercise-induced pulmonary hyperinflation&#46; In some patients with COPD&#44; reduced elastic recoil and the presence of expiratory flow limitation lead to pulmonary hyperinflation&#46; Patients may present increased residual volume at rest &#40;static hyperinflation&#41; and&#47;or may develop hyperinflation under strain &#40;dynamic hyperinflation&#41;&#44; as the increase of the respiratory rate shortens the expiratory time&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; airway dynamic compression may occur during expiration&#44; especially at high flow rates&#46; The equal pressure point &#40;EPP&#41; is shifted peripherally&#44; resulting in an earlier closure of the peripheral airways with consequent air trapping&#46; This phenomenon causes a gradual shift of the tidal volume &#40;<span class="elsevierStyleItalic">V</span><span class="elsevierStyleInf">t</span>&#41; to higher levels of functional residual capacity &#40;FRC&#41; and a progressive decrease in inspiratory capacity &#40;IC&#41;&#46; Dynamic pulmonary hyperinflation can be quantified by measuring that decrease in IC&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The application of PEP increases intraluminal airways pressure and moves the EPP back to the upper airways&#44; reducing dynamic compression and subsequently limiting pulmonary hyperinflation&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14</span></a> A similar effect is obtained by pursed lip breathing &#40;PLB&#41;&#44; which can be considered spontaneous PEP&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In COPD patients&#44; some studies investigated the effects of PEP on strength&#44; endurance&#44; lung volumes or walking exercise&#46; Padkao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> showed that the use of a flow-dependent conical-PEP lengthens isotonic quadriceps strength exercise periods&#46; It also produces an increase in slow vital capacity &#40;SVC&#41; and in IC &#40;&#43;200<span class="elsevierStyleHsp" style=""></span>ml&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;05&#41;&#44; with decreased pulmonary hyperinflation&#46; Monteiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> applied PEP using an oronasal mask after a submaximal treadmill exercise in moderate-to-severe COPD patients&#44; reporting an increase in IC after exercise&#46; Furthermore&#44; Martin and Davenport<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> demonstrated that extrinsic 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP reduced post-exercise dyspnea in COPD patients&#46; More recently&#44; in severe COPD patients&#44; Nicolini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that an adjunctive 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP&#44; administered via mouthpiece during the execution of a 6MWT&#44; significantly improved the distance covered&#44; oxygen saturation&#44; and heart rate&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">However&#44; contrasting results were reported by Wibmer et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> who applied flow-dependent PEP ranging from 10 to 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during the 6MWT in patients with stable mild-to-severe COPD&#46; They showed that PEP reduced FRC and the residual volume &#40;RV&#41; after exercise&#44; but the PEP group walked 30<span class="elsevierStyleHsp" style=""></span>m less than controls&#46; Despite these reports&#44; no studies have described the optimal level of PEP that could improve exercise tolerance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this context&#44; the main aim of our study was to investigate the effect of two different levels of PEP valve &#40;1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O vs 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; on the distance covered during a 6MWT &#40;6MWD&#41;&#44; compared to the basal 6MWT performed without PEP&#44; in patients with severe COPD &#40;FEV<span class="elsevierStyleInf">1</span>&#60;50&#37;&#41;&#46; Secondary outcomes were the evaluation of PEP effects on pulmonary function&#44; symptoms and vital parameters immediately after the 6MWT&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">This prospective&#44; single-blind&#44; randomized crossover study was performed at the Respiratory Rehabilitation Unit of Sestri Levante Hospital&#44; Italy and the Pulmonary Rehabilitation Unit of Fondazione S&#46; Maugeri IRCCS&#44; Lumezzane&#44; Brescia Italy&#44; from January 2013 to October 2013&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0045" class="elsevierStylePara elsevierViewall">We recruited 72 consecutive severe COPD subjects &#40;FEV<span class="elsevierStyleInf">1</span>&#60;50&#37;&#41; referred to our hospitals as in- and outpatients&#46; The inclusion criteria were&#58; age older than 18 years&#44; clinical stability with no changes in medication within two weeks prior the test&#44; and no exacerbations for at least three weeks&#46; Exclusion criteria were&#58; history of bronchial asthma&#44; severe bullous emphysema with history of spontaneous pneumothorax&#44; absence of written consent&#44; and orthopedic and neurological diseases limiting the ability to perform a 6MWT&#46; Fifty patients were included in the study and 22 were excluded &#40;15 were unable to perform 6MWT and 7 did not provide written informed consent&#41;&#46; The protocol received approval from the Institutional Ethics Committee of ASL 4 Chiavarese&#44; Italy and was carried out according to the Declaration of Helsinki&#46; The study was registered as ChiCTR-TTRCC-12002761 <a id="intr0010" class="elsevierStyleInterRef" href="http://www.chi.ctr.org/">www&#46;chi&#46;ctr&#46;org</a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study Protocol</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent two baseline 6MWTs&#44; a baseline spirometry and a whole-body plethysmography on the first day of admission to the rehabilitation facility&#46; On the second day&#44; we started the protocol and the subjects were randomized to two groups&#58; Group 1 performed the 6MWT with an adjunctive PEP of 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O &#40;PEP10&#41; and Group 2 with an adjunctive PEP of 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O &#40;PEP1&#41;&#46; Each group then changed the test sequence in a crossover design&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Instruments</span><p id="par0055" class="elsevierStylePara elsevierViewall">PEP was used during the development of the 6MWT&#46; It was administered by a PEP-valve &#40;PEEP Valve&#44; Ambu&#44; Denmark&#41;&#44; which consists of an adjustable threshold-load expiratory pressure valve in the range 0&#8211;20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; applied on expiration in a 2-way circuit&#44; with a valve that opens during inspiration&#46; The 2-way circuit is connected to an oronasal mask via a 20-mm inner diameter and 100-mm length tube&#46; As the 100<span class="elsevierStyleHsp" style=""></span>mm tube adds some degree of further resistance to patient exhalation&#44; we calculated the total PEP applied at the mouth by including a manual manometer in the circuit&#46; At rest&#44; the expiratory resistance in the PEP10 group was set at 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; while in the PEP1 group&#44; resistance was set at 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">All 6MWTs were performed according to the American Thoracic Society guidelines in a flat&#44; straight&#44; indoor corridor &#40;30<span class="elsevierStyleHsp" style=""></span>m marked by colored tape at each end to indicate turnaround points&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> Oxygen saturation and heart rate were recorded continuously with a lightweight Bluetooth wireless oxymeter &#40;Avant 9600&#44; Nonin Medical Inc&#46;&#44; US&#41;&#46; Respiratory rate&#44; dyspnea &#40;assessed on a Borg scale&#41; and distance walked in meters were recorded at the beginning and at the end of each test&#46; The patients rested at least 1<span class="elsevierStyleHsp" style=""></span>h between each test&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">All patients performed a baseline spirometry and whole-body plethysmography &#40;VMax 20 PFT Sensor Medics Yorba Linda&#44; CA&#44; US&#41;&#44; according to American and European &#40;ATS&#47;ERS&#41; guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Furthermore&#44; functional lung tests &#40;slow and forced spirometries&#41; were conducted using a portable spirometer &#40;Spirolab III&#44; Medical International Research&#44; Italy&#41;&#46; Measurements were obtained immediately at the beginning and within 1<span class="elsevierStyleHsp" style=""></span>min of the end of each 6MWT with PEP1 and PEP10&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical Analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Data analysis was performed with statistical software &#40;Stata Statistical Software&#58; Release 12&#46; StataCorp LP&#46; College Station&#44; TX&#44; US&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Primary outcome was 6MWD with different PEP levels &#40;PEP1&#44; PEP10&#41;&#46; Secondary outcomes were changes in respiratory functional measurements &#91;dyspnea assessed by Borg scale&#44; respiratory rate &#40;RR&#41;&#44; pulse-oxymetry&#93; and spirometry measurements &#91;slow vital capacity &#40;SVC&#41;&#44; inspiratory capacity &#40;IC&#41;&#44; forced vital capacity &#40;FVC&#41;&#44; expiratory reserve volume &#40;ERV&#41;&#93;&#46; A statistician not involved in the study generated the randomization schedule&#44; using a randomization table from a computer software program&#46; The randomization assignments were provided to the recruiting physician in sealed envelopes&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Descriptive analyses are presented as mean&#177;standard deviation&#46; Spirometry parameters obtained in PEP1 and PEP10 tests were compared using by paired <span class="elsevierStyleItalic">t</span>-tests&#46; Differences between the three conditions &#40;baseline&#44; PEP1&#44; PEP10&#41; were studied by ANOVA for repeated measures &#40;Fisher&#39;s test&#41;&#46; When significant differences were found&#44; post-hoc analysis with paired <span class="elsevierStyleItalic">t</span>-test and Bonferroni correction was done&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The investigators who performed the study data analysis were blinded to patient assignments&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">Seventy-two patients were initially recruited&#46; Fifteen subjects were excluded because they were unable to perform the 6MWT and 7 subjects refused to participate&#44; so the final sample comprised 50 subjects&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a> describes the clinical and anthropometrical characteristics of the study patients&#46; The patients were relatively elderly&#44; predominantly male&#44; and had severe COPD&#46; A quarter of them were receiving long-term oxygen therapy due to associated respiratory failure&#46; All patients had also severe static pulmonary hyperinflation&#46; All 50 patients completed the study&#46; Patient disposition is described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">F</span>-test for primary outcome &#40;6MWD&#41; shows a significant difference in results among different PEP levels and baseline &#40;<span class="elsevierStyleItalic">F</span>-test 0&#46;02&#41;&#46; Post-hoc analysis shows that the use of PEP1 and PEP10 produced an increase in walking distance &#40;PEP1 <span class="elsevierStyleItalic">P</span>&#60;&#46;002 and PEP10 <span class="elsevierStyleItalic">P</span>&#60;&#46;018&#41;&#44; compared to baseline&#46; There was no significant difference between PEP1 and PEP10&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the box plots of 6MWD&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">All changes &#40;end of 6MWT<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>baseline&#41; in secondary outcomes are reported in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#46; We observed a tendency to decreased HR and increased RR in both PEP1 and PEP10 condition&#44; compared to baseline&#44; which did not reach statistical significance&#46; No significant difference was found between PEP1 and PEP10 in changes in pulmonary function&#44; symptoms and physiological variables&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">A reduction in IC of 10&#37; and&#47;or &#62;150<span class="elsevierStyleHsp" style=""></span>ml&#44; compared to baseline was defined as dynamic hyperinflation&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> Ten subjects showed dynamic hyperinflation and 40 did not&#46; In the 40 subjects without dynamic hyperinflation&#44; we observed a significant change in the distance covered &#40;&#916; meters&#41; if 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP was applied&#46; No significant change was found if 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O was applied&#46; These results appear in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">In this randomized crossover trial&#44; conducted in patients with severe COPD&#44; we found that the application of 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP during the execution of 6MWT can improve the distance walked to the same extent as the application of 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP&#44; without affecting the cardiovascular response to exercise&#46; We did not find any effect of PEP on dyspnea at the end of exercise and post-exertion lung dynamic volumes&#44; particularly IC&#44; SVC&#44; FVC and ERV&#46; Moreover&#44; we found that the improvement of 6MWD is greater in patients with no or low dynamic hyperinflation when a low PEP is applied&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">So far&#44; only two other crossover randomized trials have investigated the effects of a PEP device on 6MWD&#44; with contrasting results&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 2013&#44; Nicolini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that a threshold PEP of 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O improved the distance walked during the 6MWT in patients with moderate-to-severe COPD&#46; They also demonstrated a significant improvement in post-exercise oxygen saturation and a decrease in peak heart rate during the 6MWT with PEP&#44; compared to controls without devices&#46; However&#44; in the same year&#44; Wibmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> investigated the same kind of patients and found that&#44; with a flow-dependent PEP in the range of 10&#8211;20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; patients walked 30&#46;8<span class="elsevierStyleHsp" style=""></span>m less than the controls without devices &#40;352&#177;92<span class="elsevierStyleHsp" style=""></span>m with no PEP&#44; 321&#177;93<span class="elsevierStyleHsp" style=""></span>m with PEP&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46; In their study&#44; they demonstrated the efficacy of flow-dependent PEP on lung dynamic volumes&#44; as total lung capacity&#44; FRC and RV were significantly reduced after the 6MWT with PEP&#44; compared to control group&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the three studies used different kinds of PEP&#44; it seems that the application of lower pressures produces better results in terms of distance covered during the 6MWT&#46; However&#44; the &#8220;right&#8221; level of PEP during exercise is still largely understudied&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In this context&#44; Martin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> applied two levels of threshold PEP &#40;13&#46;8 and 2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; and demonstrated a significant decrease in dyspnea with the use of the higher level of PEP after a treadmill constant load test&#46; However&#44; these results cannot be compared with ours&#44; because the authors applied PEP only after the conclusion of the exercise test&#44; rather than during effort&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Recently&#44; Bhatt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> reported good results regarding exercise tolerance improvement in patients with severe COPD&#46; They conducted a crossover trial investigating the effects of PLB on 6MWD and found that patients walked 34&#46;9<span class="elsevierStyleHsp" style=""></span>m more if they breathed with volitional PLB&#44; compared to breathing normally &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#44; with a concomitant reduction in RR after the test&#46; Furthermore&#44; they investigated the diaphragm excursion with ultrasonography and found a correlation between the improvements in 6MWD and the increase of diaphragm excursion with PLB&#46; The authors explain their findings by suggesting that the PLB imposes a control and slows the RR&#44; breaking the vicious circle of air trapping and dynamic pulmonary hyperinflation&#46; This might translate into less neuro-ventilatory dissociation and a reduced perception of dyspnea&#46; Low pressure PEP can be expected to act in a similar way&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As regards pulmonary function&#44; low PEP has also been proposed for airway clearance in patients with COPD and hypersecretion&#46; Venturelli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> studied a mechanical device which applies 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP at the mouth&#46; They reported a significant improvement of IC at rest when patients breathe into the PEP device&#44; compared to controls &#40;&#43;19&#46;5&#37; and &#43;2&#46;2&#37;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;044&#41;&#46; However&#44; no data are available during exercise&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Monteiro<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and Padkao<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> reported improvements in dynamic and static lung volumes&#44; we cannot confirm the effect of PEP devices on post-exercise lung volumes&#46; As we did not perform the spirometry immediately after the basal 6MWT&#44; we do not have data on the behavior of the IC and the other lung volumes during the 6MWT without PEP&#46; At present&#44; we do not know if PEP produces any improvements in lung volumes compared to no PEP&#46; We did not find any significant difference in the behavior of IC&#44; SVC&#44; ERV or FVC between PEP1 and PEP10&#46; The application of low and high levels of PEP during the 6MWT proved to have the same effect on lung volumes&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nevertheless&#44; in our &#8220;ad hoc&#8221; analysis&#44; we found that the application of low level PEP produces a greater improvement in the distance covered in the group of patients with no dynamic hyperinflation&#44; compared to the group of patients who presented dynamic hyperinflation&#46; This was in line with the findings of Callens et al&#46;&#44; who observed that change in IC after walking does not correlate with 6MWD&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion&#44; it is difficult to compare the effects of PEP on exercise tolerance in patients with COPD&#44; because the published studies are too heterogeneous&#44; and use a variety of exercise protocols&#44; types and levels of PEP and outcome measures&#46; In order to clarify the effects of PEP on lung mechanics&#44; it would be useful to evaluate the effect of PEP during a standardized exercise capacity test&#44; such as the cardiopulmonary exercise test&#46; As already discussed by Wibmer et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> a better standardized evaluation of dynamic lung volumes&#44; including at least some subsequent IC measures during the exercise&#44; should also be carried out&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Future studies should lead to a more practical utilization of PEP devices&#46; The effects of low level PEP during aerobic and strength training protocols&#44; in the mid to long term&#44; merit investigation&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitations of the Study</span><p id="par0170" class="elsevierStylePara elsevierViewall">Some limitations in the study were detected&#46; Firstly&#44; pulmonary function was not assessed directly during the test&#59; instead there was an average delay of 1<span class="elsevierStyleHsp" style=""></span>min between the end of 6MWT and the execution of the spirometry&#46; This could have led to an underestimation of the effects of PEP on lung function&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Furthermore&#44; two kinds of PEP devices were proposed&#58; flow-dependent or threshold-load&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> We used a threshold-load PEP valve&#44; but studies comparing both devices have not yet been published&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In 2012&#44; Monteiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> demonstrated in a controlled non-randomized trial that breathing in a PEP mask at 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during a treadmill test lasting 20<span class="elsevierStyleHsp" style=""></span>min produces less dynamic pulmonary hyperinflation&#44; compared to controls without PEP&#44; in severe COPD patients&#46; They demonstrated a significant increase in IC and less IC decrease after exercise with PEP&#44; compared to the control group&#46; In their protocol&#44; they started the exercise with 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP and&#44; if this was not tolerated by the patient&#44; they reduced resistance gradually to as low as 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; They found that the mean tolerated PEP value was 8&#177;1&#46;5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; We did not define the highest PEP value tolerated by the patients&#44; since PEP values higher than tolerated could limit the ability to exhale&#44; worsening dynamic pulmonary hyperinflation&#44; causing dyspnea and leading to poor results&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Another limitation may be related to the type of test employed&#46; During the 6MWT&#44; patients are allowed to slow down or stop if needed&#44; for example in case of severe dyspnea&#46; Moreover&#44; the patients choose the walking speed themselves&#46; For these reasons&#44; it is possible that dynamic hyperinflation is not addressed during the 6MWT&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">We also defined severe COPD as an inclusion criterion&#46; If we had included patients who only had reduced IC during exercise&#44; we may have found higher levels of significance&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; the minimum clinically important difference of the 6MWD has been previously established as 25<span class="elsevierStyleHsp" style=""></span>m<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> and this threshold was not reached in our study&#46; This could be due to the wide variability of the distance covered by the patients&#46; However&#44; even a small improvement obtained by having the patient breathe into a simple device&#44; while not clinically relevant&#44; may still indicate a correct strategy which merits further investigation&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Furthermore&#44; a sample size analysis was not carried out and it is possible that the number of patients may have been too small to obtain more significant results&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">In patients with severe COPD&#44; the application of 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O PEP seems to improve the exercise tolerance to the same extent as 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; with similar reported dyspnea&#46; No effects were found on lung volumes after exercise&#46; As previously reported protocols and levels and types of PEP vary widely&#44; further studies are recommended to confirm our results and to clarify the mechanism of action on lung mechanics&#46; Future studies should also investigate the effects of low levels of PEP on aerobic and strength training programs&#46;</p></span></span>"
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              "titulo" => "Background"
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          "titulo" => "Resumen"
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              "titulo" => "Introducci&#243;n"
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          "titulo" => "Palabras clave"
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              "titulo" => "Study Protocol"
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              "titulo" => "Limitations of the Study"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2015-06-10"
    "fechaAceptado" => "2015-11-19"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
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            0 => "6-Min walk test"
            1 => "Chronic obstructive pulmonary disease"
            2 => "Positive expiratory pressure"
            3 => "Exercise capacity"
            4 => "Distance covered"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Prueba de marcha de 6<span class="elsevierStyleHsp" style=""></span>min"
            1 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            2 => "Presi&#243;n espiratoria positiva"
            3 => "Capacidad de ejercicio"
            4 => "Distancia recorrida"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The application of positive expiratory pressure &#40;PEP&#41; devices during exercise had been proposed in order to counteract the pulmonary hyperinflation&#44; reduce the dyspnea and thus increase the exercise tolerance in patients with severe chronic obstructive pulmonary disease &#40;COPD&#41;&#46; This randomized controlled crossover trial investigated the effect of two different levels of PEP &#40;1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O and 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; on distance covered at 6<span class="elsevierStyleHsp" style=""></span>min walk test &#40;6MWT&#41; in patients with severe COPD&#46; Secondary outcomes were the evaluation of PEP effects on physiological and pulmonary function variables&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Seventy-two severe COPD patients&#44; referred to our hospitals as in and out patients&#44; were recruited&#46; A basal 6MWT without devices was performed on the first day&#44; and then repeated with PEP 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O &#40;PEP1&#41; and 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O &#40;PEP10&#41;&#44; with a randomized crossover design&#46; Slow and forced spirometries&#44; including the inspiratory capacity measure&#44; were repeated before and after each 6MWT&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">50 patients &#40;average age 69&#46;92 year&#44; mean FEV<span class="elsevierStyleInf">1</span> 41&#46;42&#37; of predicted&#41; concluded the trial&#46; The 6MWT improved significantly among both PEP levels and baseline &#40;323&#46;8<span class="elsevierStyleHsp" style=""></span>mt at baseline vs 337&#46;8 PEP1 and 341&#46;8 PEP10&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;002 and <span class="elsevierStyleItalic">P</span>&#60;&#46;018&#44; respectively&#41;&#46; The difference between PEP10 and PEP1 did not reach the significance&#46; No improvements were found in pulmonary function&#44; symptoms and physiological variables after the 6MWT&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In patients with severe COPD&#44; the application of 1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O of PEP seems to improve the exercise tolerance as 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; with similar dyspnea&#46; Further studies should investigate the effects of low levels of PEP on aerobic training programs&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Background"
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            "titulo" => "Methods"
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            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La aplicaci&#243;n de dispositivos de presi&#243;n espiratoria positiva &#40;PEP&#41; durante el ejercicio se hab&#237;a propuesto con el objetivo de contrarrestar la hiperinflaci&#243;n pulmonar&#44; reducir la disnea y mejorar as&#237; la tolerancia al ejercicio de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; grave&#46; En este ensayo controlado&#44; aleatorizado y cruzado se investig&#243; el efecto de dos niveles de PEP &#40;1<span class="elsevierStyleHsp" style=""></span>cm de H<span class="elsevierStyleInf">2</span>O y 10<span class="elsevierStyleHsp" style=""></span>cm de H<span class="elsevierStyleInf">2</span>O&#41; sobre la distancia recorrida por pacientes con EPOC grave durante la prueba de marcha de 6<span class="elsevierStyleHsp" style=""></span>min &#40;PM6<span class="elsevierStyleHsp" style=""></span>M&#41;&#46; Los criterios de valoraci&#243;n secundarios fueron los efectos de la PEP sobre variables fisiol&#243;gicas y de la funci&#243;n pulmonar&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se reclutaron setenta y dos pacientes con EPOC grave&#44; hospitalizados o ambulatorios&#44; derivados a nuestros hospitales&#46; El primer d&#237;a de este estudio aleatorizado y cruzado se efectu&#243; la PM6<span class="elsevierStyleHsp" style=""></span>M sin ning&#250;n dispositivo&#44; y posteriormente se repiti&#243; con una PEP de 1<span class="elsevierStyleHsp" style=""></span>cm de H<span class="elsevierStyleInf">2</span>O &#40;PEP1&#41; y de 10<span class="elsevierStyleHsp" style=""></span>cm de H<span class="elsevierStyleInf">2</span>O &#40;PEP10&#41;&#46; Antes y despu&#233;s de cada PM6<span class="elsevierStyleHsp" style=""></span>M se practicaron espirometr&#237;as lentas y forzadas&#44; que incluyeron la medici&#243;n de la capacidad inspiratoria&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cincuenta pacientes &#40;edad media 69&#44;92 a&#241;os&#44; FEV<span class="elsevierStyleInf">1</span> medio 41&#44;42&#37; del previsto&#41; finalizaron el ensayo&#46; La PM6<span class="elsevierStyleHsp" style=""></span>M mejor&#243; significativamente con los dos niveles de PEP&#44; en comparaci&#243;n con la situaci&#243;n inicial &#40;323&#44;8<span class="elsevierStyleHsp" style=""></span>m al inicio vs 337&#44;8 con la PEP1 y 341&#44;8 con la PEP10&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;002 y <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#44; respectivamente&#41;&#46; La diferencia entre la PEP10 y la PEP1 no fue significativa&#46; No se observaron mejor&#237;as en la funci&#243;n pulmonar&#44; los s&#237;ntomas ni las variables fisiol&#243;gicas posteriores a la prueba PM6<span class="elsevierStyleHsp" style=""></span>M&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En pacientes con EPOC grave&#44; la aplicaci&#243;n de una PEP de 1<span class="elsevierStyleHsp" style=""></span>cm de H<span class="elsevierStyleInf">2</span>O parece mejorar la tolerancia al ejercicio&#44; al igual que lo hace la aplicaci&#243;n de 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O y con un grado similar de disnea&#46; Deben realizarse otros estudios para investigar los efectos de los niveles bajos de PEP en los programas de entrenamiento aer&#243;bico&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0025"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Russo D&#44; Simonelli C&#44; Paneroni M&#44; Saleri M&#44; Piroddi IMG&#44; Cardinale F&#44; et al&#46; &#191;Cu&#225;l es el nivel &#243;ptimo de presi&#243;n espiratoria positiva &#40;PEP&#41; capaz de mejorar la tolerancia a la deambulaci&#243;n de los pacientes con EPOC grave&#63; Arch Bronconeumol&#46; 2016&#59;52&#58;354&#8211;360&#46;</p>"
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            "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "Available studies investigating the effects of PEP on exercise tolerance in patients with COPD"
            "identificador" => "sec0060"
          ]
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient disposition&#46;</p>"
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        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Box plot of 6MWD without PEP &#40;baseline&#41;&#44; and using PEP1 and PEP10 cmH<span class="elsevierStyleInf">2</span>O&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; FVC&#58; forced vital capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume at the 1st second&#59; TLC&#58; total lung capacity&#59; IC&#58; inspiratory capacity&#59; ERV&#58; expiratory reserve volume&#59; RV&#58; residual volume&#59; SpO<span class="elsevierStyleInf">2</span>&#58; peripheral oxygen saturation&#59; DL<span class="elsevierStyleSup">CO</span>&#58; carbon monoxide diffusion capacity&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients &#40;<span class="elsevierStyleItalic">n</span>&#61;50&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;male&#41;&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">GOLD level&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Long term oxygen therapy&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FVC&#44; &#37;pred</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FVC&#44; L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SVC&#44; L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#44; &#37;pred</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#44; L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#47;FVC</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">TLC&#44; &#37;pred</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">114&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IC&#44; L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ERV&#44; L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">RV&#44; &#37;pred</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SpO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">DL</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">CO</span></span><span class="elsevierStyleItalic">&#40;&#37; pred&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Basal dyspnea&#44; Borg score</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Anthropometrics and Baseline Characteristics of Patients Studied&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">RR&#58; respiratory rate&#59; HR&#58; heart rate&#59; IC&#58; inspiratory capacity&#59; SVC&#58; slow vital capacity&#59; ERV&#58; expiratory residual volume&#59; FVC&#58; forced vital capacity&#46; The percentage of change has been calculated as &#916;&#42;100&#47;basal value &#40;at rest before starting the 6MWT&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No PEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PEP1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PEP10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Final dyspnea&#44; BORG scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;37 &#40;2&#46;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;18 &#40;2&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;65 &#40;2&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;dyspnea&#44; BORG scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;91 &#40;2&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;86 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;47 &#40;2&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;dyspnea&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">176 &#40;172&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">244 &#40;228&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">161 &#40;157&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Final leg fatigue&#44; BORG scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;43 &#40;1&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;90 &#40;1&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;62 &#40;1&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;leg fatigue&#44; BORG scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;05 &#40;1&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;79 &#40;0&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;95 &#40;0&#46;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;leg fatigue&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172 &#40;145&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">188 &#40;163&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">205 &#40;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Final RR&#44; acts&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;75 &#40;4&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;53 &#40;5&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;88 &#40;7&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;RR&#44; acts&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;46 &#40;3&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;37 &#40;3&#46;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;86 &#40;3&#46;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RR&#44; &#37; of change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;7 &#40;19&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5 &#40;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;3 &#40;18&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Final HR&#44; beat&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;53 &#40;13&#46;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;10 &#40;16&#46;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;06 &#40;16&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;HR&#44; beat&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;61 &#40;12&#46;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;76 &#40;9&#46;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;30 &#40;12&#46;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;4 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;6 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;2 &#40;16&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Final SpO<span class="elsevierStyleInf">2</span>&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;55 &#40;5&#46;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;82 &#40;4&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;78 &#40;6&#46;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;SpO<span class="elsevierStyleInf">2</span>&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;33 &#40;6&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;45 &#40;4&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;49 &#40;3&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SpO<span class="elsevierStyleInf">2</span>&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;53 &#40;6&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;67 &#40;5&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;62 &#40;4&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;IC&#44; L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03 &#40;0&#46;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IC&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;27 &#40;15&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;42 &#40;19&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;SVC&#44; L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08 &#40;0&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10 &#40;0&#46;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SVC&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;87 &#40;12&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;08 &#40;37&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;ERV&#44; L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;02 &#40;0&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;06 &#40;0&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ERV&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;15&#46;91 &#40;85&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;30&#46;04 &#40;159&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#916;FVC&#44; L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08 &#40;0&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15 &#40;0&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FVC&#44; &#37; change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;47 &#40;10&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;02 &#40;44&#46;94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Changes in Secondary Outcomes Among Different PEP Settings&#44; Mean &#40;SD&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">6MWD&#58; 6-min walk distance&#59; PEP&#58; positive expiratory pressure&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PEP1</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PEP10</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Meters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#916; Meters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Meters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#916; Meters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with dynamic hyperinflation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">290 &#40;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;22 &#40;21&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;16&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">304 &#40;132&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;42 &#40;31&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with no dynamic hyperinflation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">342 &#40;124&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;83 &#40;26&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;84&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">345 &#40;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;39 &#40;31&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">P</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Results in Covered Distance &#40;6MWD&#41; for Patients With or Without Dynamic Hyperinflation&#46;</p>"
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      ]
      5 => array:5 [
        "identificador" => "tbl0005"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume 1st second&#59; RV&#58; residual volume&#59; 6MWD&#58; distance covered in 6-min walking test&#59; TLC&#58; total lung capacity&#59; FRC&#58; functional residual capacity&#59; 1RM&#58; 1 repetition maximum&#59; IC&#58; inspiratory capacity&#59; VC&#58; vital capacity&#59; PLB&#58; pursed lip breathing&#59; MIP&#58; maximal inspiratory pressure&#59; MEP&#58; maximal expiratory pressure&#59; US&#58; ultrasounds&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Primary outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PEP type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nicolini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP utilization improves 6MWD&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prospective&#44; randomized controlled&#44; single blind&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 &#40;50 controls&#41; in-outpatients with moderate- to-severe COPD &#40;&#37;FEV1 51&#8211;49&#37;&#44; &#37;RV 148&#8211;140&#37;&#44; mean basal 6MWD 232&#8211;262<span class="elsevierStyleHsp" style=""></span>mt&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWT at assessment&#44; repeated after 30<span class="elsevierStyleHsp" style=""></span>min of rest with PEP in the intervention group&#44; without devices in the control group&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O threshold-PEP connected to mouthpiece with a tube &#40;20<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; 100<span class="elsevierStyleHsp" style=""></span>mm length&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP improves 6MWD &#40;&#43;61 vs &#43;3<span class="elsevierStyleHsp" style=""></span>mt&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; During 6MWT&#44; PEP improves SpO<span class="elsevierStyleInf">2</span> and decreases FC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#59; NS reduction of Borg Dyspnea and Respiratory Rate&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wibmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Feasibility of a nasal PEP application during exercise&#44; effects on dynamic hyperinflation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized&#44; crossover&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 mild-moderate COPD &#40;FEV<span class="elsevierStyleInf">1</span>&#62;50&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWT repeated twice &#40;2&#8211;24<span class="elsevierStyleHsp" style=""></span>h of rest&#41;&#44; with and without nasal PEP &#40;crossover design&#41;&#44; with subsequent spirometry and Borg dyspnea assessment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWD&#44; spirometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nasal mask with headgear&#44; flow-dependent PEP 10&#8211;20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP decreases TLC&#44; FRC and RV &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41;&#44; but produces also a significant reduction of 6MWD &#40;&#8722;30&#46;8<span class="elsevierStyleHsp" style=""></span>mt&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Martin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP utilization reduces post-exercise dyspnea&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Double blind&#44; crossover&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 outpatients &#40;4 controls&#41; with COPD &#40;FEV<span class="elsevierStyleInf">1</span>&#60;50&#37;&#41; and habitual use of pursed lip breathing&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treadmill test repeated twice &#40;crossover design&#41;&#46; At the end of the test&#44; the intervention group performed 6 breaths in threshold PEP&#44; the control group in a sham-PEP&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Borg dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O threshold PEP &#40;13&#46;8<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O if measured at the mouth&#41; vs 2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O sham-PEP&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP reduces dyspnea 10<span class="elsevierStyleHsp" style=""></span>min after the exercise &#40;post-exercise Borg dyspnea&#58; 2&#46;6 and 1&#46;8 point&#44; control and intervention group respectively&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Padkao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conical-PEP reduces hyperinflation and increases exercise duration&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized&#44; crossover&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 COPD moderate-to-severe &#40;FEV<span class="elsevierStyleInf">1</span> 61&#37;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leg extension at 30&#37; 1RM with ankle weights&#44; 15 repetitions per min per leg&#44; with and without PEP &#40;crossover design&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spirometry &#40;TLC&#44; IC&#44; slow VC&#41; dyspnea&#44; legs effort&#44; exercise duration&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flow-dependent conical-PEP 4&#8211;20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O vs normal breathe&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP produces an increase of IC and slow VC &#40;&#43;200<span class="elsevierStyleHsp" style=""></span>ml&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;05&#41;&#44; of the exercise duration &#40;&#43;107<span class="elsevierStyleHsp" style=""></span>s&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;05&#41;&#44; and a reduction of RR during exercise &#40;&#8722;6&#46;1<span class="elsevierStyleHsp" style=""></span>breath&#47;min&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;05&#41;&#44; no adverse effects&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Monteiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Effect of PEP on inspiratory capacity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-randomized&#44; controlled&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 COPD &#40;FEV<span class="elsevierStyleInf">1</span> 38&#37;&#41; with dynamic hyperinflation&#44; defined as at least 15&#37; decrease of IC after treadmill exercise&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treadmill test lasting 20<span class="elsevierStyleHsp" style=""></span>min&#44; with subsequent IC measure&#46; If decreased at least of 15&#37;&#44; the test was repeated with PEP administration &#40;timing not specified&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Oronasal mask with headgear and unidirectional valve&#44; spring loaded PEP 5&#8211;10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEP produces an increase of IC &#40;1&#46;45<span class="elsevierStyleHsp" style=""></span>L and 1&#46;13<span class="elsevierStyleHsp" style=""></span>L with and without PEP respectively&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41; and less IC decrease after exercise &#40;&#8722;0&#46;18<span class="elsevierStyleHsp" style=""></span>L and &#8722;0&#46;57<span class="elsevierStyleHsp" style=""></span>L with and without PEP respectively&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bhatt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Effect of pursed lip breathing on exercise capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized&#44; crossover&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 COPD &#40;FEV<span class="elsevierStyleInf">1</span> 38&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWT at assessment&#44; repeated with PLB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6MWT&#44; spirometry&#44; MIP&#44; MEP&#44; diaphragmatic excursion with US&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Volitional pursed lip breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLB increases 6MWD &#40;&#43;34&#46;9<span class="elsevierStyleHsp" style=""></span>mt&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#44; reduces RR after 6MWT &#40;&#8722;4&#46;4<span class="elsevierStyleHsp" style=""></span>bpm&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;003&#41;&#46; Correlation between improvement in 6MWD and increase in diaphragmatic excursion with PLB&#46; Greater improvement in patients with poorer baseline 6MWD&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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