ORIGINAL ARTICLE

COPD

Effects of inspiratory muscle training on

dyspnoea in severe COPD patients during
pulmonary rehabilitation: controlled
randomised trial
Marc Beaumont1, Philippe Mialon2, Catherine Le Ber1, Patricia Le Mevel1,
Loïc Péran1, Olivier Meurisse1, Capucine Morelot-Panzini3, Angelina Dion4 and
Francis Couturaud5
Affiliations: 1Pulmonary Rehabilitation Unit, Morlaix Hospital Centre, EA3878, European University of
Occidental Brittany, Morlaix, France. 2Pulmonary Physiology Unit, EA2438, European University of Occidental
Brittany, University Brest Centre, Brest, France. 3Pulmonary and Reanimation Unit, Pitié Salpétrière Hospital,
Paris, France. 4INSERM CIC 1412, University Hospital of Brest, Brest, France. 5Dept of Internal Medicine and
Chest Diseases, EA3878 (GETBO), CIC INSERM 1412, University Hospital of Brest, European University of
Occidental Brittany, Brest, France.
Correspondence: Marc Beaumont, GETBO, EA 3878, Pulmonary Rehabilitation Unit, Morlaix Hospital Centre,
European University of Occidental Brittany, 29672 Morlaix CEDEX, France.
E-mail: [email protected]

@ERSpublications
Inspiratory muscle training during pulmonary rehabilitation has no additional effect on dyspnoea
http://ow.ly/950d30ggYdd

Cite this article as: Beaumont M, Mialon P, Le Ber C, et al. Effects of inspiratory muscle training on
dyspnoea in severe COPD patients during pulmonary rehabilitation: controlled randomised trial. Eur
Respir J 2018; 51: 1701107 [https://doi.org/10.1183/13993003.01107-2017].

ABSTRACT The benefit of inspiratory muscle training (IMT) combined with a pulmonary rehabilitation
programme (PRP) is uncertain. We aimed to demonstrate that, in severe and very severe chronic
obstructive pulmonary disease (COPD) patients, IMT performed during a PRP is associated with an
improvement of dyspnoea.
In a single-blind randomised controlled trial, 150 severe or very severe COPD patients were allocated to
follow PRP+IMT versus PRP alone. The evaluations were performed at inclusion and after 4 weeks. The
primary outcome was the change in dyspnoea using the Multidimensional Dyspnoea Profile questionnaire
at the end of a 6-min walk test (6MWT) at 4 weeks. Secondary outcomes were changes in dyspnoea using
the Borg (end of the 6MWT) and modified Medical Research Council scales and in functional parameters
(maximal inspiratory pressure (PImax), inspiratory capacity, 6MWT and quality of life). All analyses were
performed on an intention-to-treat basis.
Dyspnoea decreased significantly in both groups; however, the improvement of dyspnoea was not
statistically different between the two groups. We only found a statistically significant greater increase of
PImax after IMT+PRP than after PRP alone.
In this trial including severe or very severe COPD patients, we did not find a significant benefit of IMT
during PRP+IMT as compared to PRP alone on dyspnoea, despite a significantly higher improvement of
PImax in the IMT group.

This article has supplementary material available from erj.ersjournals.com

Received: June 06 2017 | Accepted after revision: Oct 29 2017
This study is registered at www.ClinicalTrials.gov with identifier number NCT02074813
Support statement: This study was supported by the French Ministry of Health. Funding information for this article has
been deposited with the Crossref Funder Registry.
Conflict of interest: None declared.
Copyright ©ERS 2018

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 COPD | M. BEAUMONT ET AL.

Introduction
Pulmonary rehabilitation is an important component of chronic obstructive pulmonary disease (COPD)
management [1, 2]. During the past decade, several prospective trials have shown that pulmonary
rehabilitation in COPD patients was associated with a decrease in COPD-related handicap and an
improvement of quality of life. In addition, a reduction of mortality was suggested in one of these studies
when pulmonary rehabilitation was performed early after an acute COPD exacerbation [3].
In most of these trials, the pulmonary rehabilitation programme included individualised exercise training,
therapeutic education, respiratory physiotherapy, help with smoking cessation and nutritional and
psychosocial coverage. Exercise training included both endurance and force lower-limb training associated
with upper-limb training. In addition, the European Respiratory Society (ERS) consensus recommends
inspiratory muscle training (IMT) in association with a usual pulmonary rehabilitation programme in
patients with inspiratory muscle weakness. This recommendation is based on the results of several
meta-analyses [4–6], which suggested a beneficial effect of IMT on dyspnoea, strength and endurance of
inspiratory muscles and exercise capacity in the 6-min walk test (6MWT), particularly when the maximal
inspiratory pressure (PImax) was <60 cmH2O. However, the authors of the latest meta-analysis [6]
suggested that the benefit of IMT performed during pulmonary rehabilitation on dyspnoea has not yet
been demonstrated and the authors of the consensus about pulmonary rehabilitation specified that IMT
during pulmonary rehabilitation remains questionable [1].
In a recent randomised trial [7], we found that performing IMT during pulmonary rehabilitation in
COPD patients with a PImax >60 cmH2O did not result in a significant improvement of dyspnoea.
However, we also found a trend towards a benefit of IMT in more severe COPD patients; in these patients,
we hypothesised that strengthening the inspiratory muscles might produces a decrease in dynamic
hyperinflation, which is a major mechanism involved in dyspnoea. However, our sample size was too small
to be conclusive.
Thus, we conducted a randomised controlled trial comparing IMT with pulmonary rehabilitation versus
pulmonary rehabilitation only in severe or very severe COPD patients. The primary objective was to
demonstrate that IMT performed during pulmonary rehabilitation was associated with an improvement in
the sensory component of dyspnoea at end of the 6MWT. Secondary objectives were to evaluate the effect
of IMT on dyspnoea according to predefined strata (PImax) and on secondary end-points: quality of life
using the St George’s respiratory questionnaire (SGRQ), PImax, hyperinflation indices at rest, such as
inspiratory capacity, and at the end of the 6MWT.

Methods
Study population
Between March 5, 2014 and September 8, 2016, patients routinely admitted to the rehabilitation
programme unit of Centre Hospitalier des Pays de Morlaix (Morlaix, France) were eligible for the study if
they had severe or very severe COPD diagnosed according to American Thoracic Society (ATS)/ERS
criteria [8] at admission (forced expiratory volume in 1 s (FEV1) <50% predicted). Exclusion criteria were
previous pneumonectomy or lobectomy in the past 6 months, spontaneous risk of pneumothorax or rib
fracture, incapacity to follow a standard rehabilitation programme (locomotor deficits, acute cardiac failure
and acute exacerbation of COPD at the beginning of the programme) and the absence of written informed
consent. The study was approved by the ethics board (CPP Ouest 6, CPP803, n°2013-A01180-45) in
December 2013.

Intervention
At the time of inclusion, patients were randomised to follow a predefined standardised pulmonary
rehabilitation programme associated with IMT (IMT group) versus the same standardised pulmonary
rehabilitation programme without IMT (control group) for a duration of 4 weeks. Block randomisation
was performed by stratum (according to PImax ⩽60 cmH2O or >60 cmH2O) with variable block sizes.
Block sizes were randomly established by the statistician. Investigators were kept blinded to each block
size, to ensure that they could not become aware of patients’ allocation in advance.
The standardised pulmonary rehabilitation programme (IMT and control groups) was conducted over
4 weeks, 5 days per week and included aerobic exercise on a cycle ergometer and a treadmill (each for
30 min per day) [9, 10], strengthening of lower and upper limb muscle groups, a therapeutic educational
programme, aerobic gymnastics in groups, a smoking cessation programme and sociopsychological and
dietary advice.
In the IMT group, all subjects trained their inspiratory muscles daily during two sessions of 15 min each,
supervised by a physiotherapist, five times a week, over 4 weeks. The patients had to breathe slowly with

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 COPD | M. BEAUMONT ET AL.

an increased tidal volume; after 10 inspirations, they could have a break by breathing at rest for a short
time. The cycle of 10 inspirations was repeated 15 times. The inspiratory muscle training was performed
using a threshold inspiratory muscle trainer (PowerBreathe Medic; PowerBreathe, Southam, UK) at a
resistance generating a pressure corresponding to 50% of the initial PImax for each session. The intensity
was increased (+10%) after 10 days of training during the programme to reach 60% of the initial PImax.

Testing and end-points

The primary end-point was dyspnoea assessment using the Multidimensional Dyspnoea Profile (MDP)
questionnaire [11] after 4 weeks of the rehabilitation programme. The MDP questionnaire was
self-administered and performed at the end of the 6MWT.
The secondary end-points were the assessment of dyspnoea using the Borg scale performed at the end of
the 6MWT and the modified Medical Research Council (mMRC) scale, assessment of quality of life using
the SGRQ and the assessment of the functional changes in PImax measured using a Micro RPM (Micro
Medical, Rochester, UK) [12, 13] and inspiratory capacity at rest and inspiratory capacity at the end of the
6MWT using a portable spirometer (Spirobank II, MIR Medical International Research, Rome, Italy) [14].
All baseline functional measurements (i.e. FEV1, FEV1/forced vital capacity, total lung capacity (TLC),
residual volume, and inspiratory capacity) and two 6MWTs were performed in accordance with
international guidelines [15, 16].

Sample size
In order to verify our main objective, we assumed a reduction of at ⩾1 point by item of the sensory
component on the MDP questionnaire with a standard deviation at 2 points for the IMT group in
comparison with the control group. Such reduction was extrapolated from results obtained with the
commonly used Borg scale [17]. In addition, MEEK et al. [18] reported a standard deviation of ∼2 points
for the intensity of the sensory component to demonstrate the validity and reliability of the MDP
questionnaire, which is similar to that reported with the Borg scale [7, 17]. For an α-error of 5% and
β-error of 20%, the expected sample size would therefore be 126 patients. In order to anticipate loss to
follow-up, 150 patients needed to be included.

Statistical analyses
All the data were collected by a research nurse blinded to treatment allocation. Continuous variables were
expressed as mean±SD if distribution was normal; if not, results were presented as median (interquartile
range). The effect of IMT on dyspnoea and functional parameters was analysed using t-tests or Wilcoxon’s
test (in case of non-normal distribution) for within-group and between-group comparisons, respectively.
Correlations were analysed using Spearman’s rank correlation coefficient.
All data were analysed in an intention-to-treat analysis. For comparison, a p-value of <0.05 was considered
as statistically significant. All statistical tests were performed using SAS software (version 9.4; SAS Institute,
Cary, NC, USA).

Results
Between March 5, 2014 and September 8, 2016, 161 severe or very severe COPD patients attended our
pulmonary rehabilitation centre. After verification of eligibility criteria, 150 patients were included; one
patient who had one non-inclusion criterion was included, but was not randomised, and therefore was not
included in the analysis (figure 1). Finally, 149 patients were randomised to a standardised pulmonary
rehabilitation programme (PR; n=75) or a standardised pulmonary rehabilitation programme with IMT
(PR+IMT; n=74). Three patients had undergone pneumonectomy and three other patients had undergone
a lobectomy in the past years before the inclusion (>6 months prior to inclusion in the trial); all were in
the control group.
Demographic, clinical and initial spirometric data are reported in table 1. The two groups were
comparable except for mean age, which, unexpectedly, was lower in the IMT group. The characteristics of
dyspnoea sensation based on the MDP questionnaire are detailed in table 2.

Primary outcome
At the end of intervention, dyspnoea measured using the MDP questionnaire (sensory component)
showed a significant decrease in the PR+IMT (from 14.6±11.5 to 9.9±9.7; p<0.001) and the PR groups
(from 14.1±11.7 to 10.2±8.6; p=0.04); however, the decrease in dyspnoea was not statistically different
between the two groups (table 3).

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 COPD | M. BEAUMONT ET AL.

Secondary outcomes
At the end of intervention, dyspnoea measured using the Borg or the mMRC scale significantly decreased
in the PR+IMT (Borg 5.4±2.2 to 4.0±2.1, p<0.001; mMRC 2.3±1.1 to 1.4±1.2, p<0.001) and the PR groups
(Borg 5.2±2.0 to 4.2±1.8, p<0.001; mMRC 2.2±1.0 to 1.5±1.1, p<0.001); however, the decrease in dyspnoea
measured using both scales was not statistically different between the two groups (table 3).
At the end of intervention, PImax increased more in the IMT+PR group than in the PR group. In addition,
there was a trend towards a correlation between changes obtained after the programme in the PImax and in
the difference of inspiratory capacity (difference between effort and rest) or in MDP (table 4). However,
improvement of quality of life (SGRQ) was not different between the two groups (table 3). There was no
significant difference for any of the other functional parameters, such as 6MWT or hyperinflation
(table 3). Furthermore, there was no influence of confounding variables (age, body mass index (BMI),
arterial carbon dioxide tension (PaCO2), arterial oxygen tension (PaO2), BODE (BMI, airflow obstruction,
dyspnoea, exercise capacity) index, oxygen therapy, non-invasive ventilation, inhaled treatment and
chronic heart failure) on the primary end-point (data not shown).
Finally, no heterogeneity was observed between predefined strata; particularly, no added benefit of IMT
during pulmonary rehabilitation was observed in the subgroup of patients with PImax ⩽60 cmH2O (online
supplementary table S1).

Enrolment Assessed for eligibility (n=161)

Not included (n=11)

Did not meet inclusion criteria (n=7)
Declined to participate (n=2)
Other reasons (n=2)

1 patient wrongly included

was not randomised

Randomised (n=149)

149 analysed patients

Allocated to intervention: PR+IMT (n=74) Allocated to intervention: PR (control) (n=75)

Received allocated intervention (n=74) Received allocated intervention (n=75)
Did not receive allocated intervention (n=0) Did not receive allocated intervention (n=0)

Follow-up

Lost to follow-up (n=0) Lost to follow-up (n=0)

Discontinued intervention (exacerbation n=19; Discontinued intervention (exacerbation n=23;
urinary tract infection n=1) arthritis n=1; embolism n=1)

Analysis

Analysed (n=73) Analysed (n=74)

Excluded from analysis (no evaluation at day Excluded from analysis (no evaluation at day
21: incapacity to follow programme n=1) 21: exacerbation with ICU hospitalisation n=1)

FIGURE 1 CONSORT (Consolidated Standards of Reporting Trials) 2010 flow diagram. PR: pulmonary
rehabilitation; IMT: inspiratory muscle training; ICU: intensive care unit.

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 COPD | M. BEAUMONT ET AL.

In addition, post hoc stratification on hyperinflation indexes (i.e. inspiratory capacity <80% predicted or
⩾80% pred [19] and inspiratory capacity/TLC >25% or ⩽25% [20]) showed no significant difference
between the two groups in terms of improvement of dyspnoea (measured using the MDP questionnaire,
mMRC dyspnoea scale and Borg scale), quality of life (SGRQ) or 6-min walking distance (6MWD) (online
supplementary tables S2 and S3).

Discussion
In this randomised controlled trial investigating the effect of IMT during a pulmonary rehabilitation
programme with a pulmonary rehabilitation programme without IMT in severe or very severe COPD
patients, dyspnoea was improved in the two groups but change in dyspnoea was not found to be different
between the two groups, even in the subgroup of patients with an inspiratory muscle weakness (PImax
⩽60 cm H2O). The improvement of quality of life and 6MWD was not statistically different between
the two groups. We only observed a significantly higher improvement of PImax in the pulmonary
rehabilitation-associated IMT group as compared to the pulmonary rehabilitation group.
In the present study, we assessed the benefit of IMT on dyspnoea using the MDP questionnaire as a
primary outcome and other dyspnoea scales (mMRC and Borg scales) as secondary outcomes. The MDP
questionnaire was chosen because of its high sensitivity in detecting dyspnoea changes after intervention
[11, 18, 21, 22] and for its ability to explore multiple components of dyspnoea [23, 24]. We found a
decrease of dyspnoea in the two groups using the MDP questionnaire, Borg scale at the end of the 6MWT
or mMRC scale. However, we found no difference between the two groups in terms of improvement of
MDP questionnaire, Borg scale or mMRC scale in the overall study population or in the predefined
subgroups, despite a higher PImax improvement in the IMT group as compared to the non-IMT group.
These results are in accordance with other studies. 10 studies compared IMT (using a threshold device)
performed during pulmonary rehabilitation versus pulmonary rehabilitation alone; however, only four of
these studies used dyspnoea as the main outcome [7, 25–33]. If an improvement in dyspnoea was found
after pulmonary rehabilitation with or without IMT, the magnitude of dyspnoea improvement was not

TABLE 1 Baseline patient characteristics and values of the initial tests

IMT group Control group p-value

Subjects 74 75
Female/male 30/44 25/50 0.362
Age years 62.2±8.0 65.9±8.9 0.009#
BMI kg·m−2 26.2±5.9 24.7±5.9 0.128
Oxygen therapy 36 37 0.933
NIV 18 24 0.298
GOLD stage 3 37 32 0.369
GOLD stage 4 37 43
FEV1 % pred 36.4±9.5 34.2±8.4 0.139
FEV1/VC % 0.6±0.1 0.6±0.1 0.595
RV % pred 210.7±58.7 211.1±82.2 0.975
TLC % pred 123.5±21.2 123.0±32.5 0.923
PImax cmH2O 66.2±21.7 64.8±23.0 0.691
PImax % pred 76.5±24.4 77.1±24.8 0.891
mMRC dyspnoea score 2 (2–3) 2 (2–3) 0.741
SGRQ-T 53.5±13.8 56.4±14.9 0.235
SGRQ-S 58.9±21.5 58.3±21.8 0.860
SGRQ-A 71.1±17.2 74.9±16.4 0.172
SGRQ-I 41.6±14.9 45.2±18.9 0.197
6MWD m 386.6±111.7 373.1±96.0 0.430
6MWD % pred 59.7±15.6 58.0±13.0 0.459
PaO2 mmHg 67.9±9.1 68.1±9.5 0.906
PaCO2 mmHg 43.1±6.7 45.2±6.7 0.069

Data are presented as n, mean±SD or median (interquartile range), unless otherwise stated. IMT inspiratory
muscle training; BMI: body mass index; NIV: non-invasive ventilation; GOLD: Global Initiative for Chronic
Obstructive Lung Disease; FEV1: forced expiratory volume in 1 s; % pred: % predicted; VC: vital capacity;
RV: residual volume; TLC: total lung capacity; PImax: maximal inspiratory pressure; mMRC: modified
Medical Research Council; SGRQ: St George’s Respiratory Questionnaire; T: total; S: symptoms; A: activity;
I: impact; 6MWD: 6-min walking distance; PaO2: arterial oxygen tension; PaCO2: arterial carbon dioxide
tension. #: p<0.05.

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 COPD | M. BEAUMONT ET AL.

found to be statistically different between patients who had pulmonary rehabilitation with IMT and those
who had pulmonary rehabilitation only [7, 27, 28]. These observations are consistent with those of a
recent meta-analysis [6]. We found no heterogeneity in strata analysis, particularly according to whether
patients had PImax ⩽60 cmH2O or >60 cmH2O (online supplementary table S1). Finally, there was a
significant clinical improvement of quality of life in the two groups (SGRQ-total from 53.5±13.8 to
43.9±13.5, p<0.001 for the PR+IMT group and from 56.4±14.9 to 47.2±14.5 for the PR group alone), as
described in other studies [5, 6]. Moreover, there was no difference in improvement of quality of life
between the groups. Thus, our results support the general statement of the ATS/ERS consensus on key
concepts in pulmonary rehabilitation [1] that mention that the addition of IMT to pulmonary
rehabilitation was questionable. In addition, our results do not support the ATS/ERS [1] and Société de
Pneumologie de Langue Française [34] consensus that recommend adding IMT to a pulmonary
rehabiltation programme if patients present an objective weakness of inspiratory muscles (PImax
⩽60 cmH2O); this statement was based on one meta-analysis [4] and not on randomised controlled trials
evaluating IMT in COPD patients with or without inspiratory muscle weakness [4].
PImax increased in both groups, but change in PImax was greater in the PR+IMT group (+14.8 cmH2O)
than in the PR group (+9.9 cmH2O, p=0.04). The magnitude of PImax increase following IMT is consistent
with changes reported by GOSSELINK et al. [6] (+13 cmH2O). However, despite a statistically significant
difference between the two groups for PImax, dynamic hyperinflation was not different between groups.
This was confirmed by the low correlation between change in PImax and change in dynamic hyperinflation
at effort. The underlying hypothesis was that IMT could increase diaphragmatic velocity by increasing
type II fibres [35], allowing a shorter inspiratory time [36] and a greater expiratory time, which could
decrease hyperinflation (translated into changes in inspiratory capacity at effort) [37, 38]. Thus by
increasing PImax, IMT may decrease dynamic hyperinflation in severe COPD patients, and consequently
dyspnoea. In a prior study [7], we found a similar trend towards an improvement of dyspnoea with IMT
in the subgroup of severe COPD patients. In the present study, we found no significant improvement of
dynamic hyperinflation evaluated with difference of inspiratory capacity at rest and at effort between the
beginning and the end of the programme for PR and PR+IMT groups (0.3±0.6 to 0.4±0.5, p=0.087 and
0.5±0.5 to 0.6±0.5, p=0.35, respectively). These results do not confirm those obtained in our previous
study. We did not evaluate dynamic hyperinflation for a given level, because patients improved their
6MWD. This could have slightly decreased the sensitivity to detect improvement in dynamic
hyperinflation. Dynamic hyperinflation and deconditioning are major causes of dyspnoea [39, 40]. From
the available data, exercise training does not have a direct effect on dynamic hyperinflation [41], but
reduces ventilatory needs for a given level of exertion [41–43], and this is attributable to breathing pattern
modification [43]. Therefore, pulmonary rehabilitation can improve dyspnoea by increasing exercise

TABLE 2 Baseline characteristics of dyspnoea sensation, measured using the Borg scale,
multidimensional dyspnoea profile (MDP) questionnaire and the modified Medical Research
Council (mMRC) scale

IMT group Control group p-value

Subjects 74 75
mMRC 2 (2–3) 2 (2–3) 0.741
Borg (at end of the 6MWT) 5.4±2.2 5.2±2.0 0.522
MDP questionnaire (at end of the 6MWT)
Unpleasantness 4.1±2.5 4.1±2.5 0.873
Sensory intensity 14.6±11.5 14.1±11.7 0.814
Muscle work/effort 2.8±2.9 3.2±2.7 0.497
Not enough air/smothering/air hunger 3.1±3.1 2.8±3.1 0.674
Tight/constricted 1.9±2.7 1.9±2.5 0.904
Mental effort/concentration 3.0±3.2 2.6±2.9 0.453
Breathing a lot (rapid/deep/heavy) 3.8±3.0 3.7±3.1 0.813
Depression 0.6±1.7 0.6±1.5 0.893
Anxiety 1.1±2.1 1±1.8 0.737
Frustration 1.5±2.8 1.3±2.3 0.617
Anger 1.0±2.2 0.6±1.6 0.177
Fear 0.5±1.6 0.7±1.5 0.476

Data are presented as n, median (interquartile range), or mean±SD, unless otherwise stated. IMT:
inspiratory muscle training; 6MWT: 6-min walk test.

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TABLE 3 Change (after minus before intervention) in dyspnoea sensation and functional
parameters at the end of the 6-min walk test (6MWT) after intervention (Multidimensional
Dyspnoea Profile (MDP) and Borg scales)

IMT group Control group p-value

Subjects n 74 75
Dyspnoea scales
Borg scale −1.4±2.0 −1.0±1.9 0.160
mMRC −0.9±1.2 −0.8±1.3 0.508
MDP questionnaire
Unpleasantness −0.4±2.4 −0.8±2.4 0.382
Sensory intensity −4.6±10.5 −3.6±11.0 0.549
Muscle work/effort −0.7±2.9 −0.9±3.1 0.700
Not enough air/smother/air hunger −1.2±3.3 −1.0±2.6 0.637
Tight/constricted −0.6±2.8 −0.4±2.4 0.597
Mental effort/concentrate −1.0±2.9 −0.6±2.9 0.360
Breathing a lot (rapid/deep/heavy) −1.0±2.8 −0.7±3.4 0.473
Depression −0.3±1.9 −0.2±1.1 0.625
Anxiety −0.0±2.4 −0.2±1.6 0.659
Frustration −0.6±2.3 −0.6±2.2 0.982
Anger −0.2±2.7 −0.1±1.6 0.732
Fear 0.1±2.5 −0.2±1.4 0.292
SGRQ
Total −10.1±10.9 −9.0±12.5 0.580
Symptoms −4.8±15.1 −3.4±14.8 0.581
Activity −9.1±14.7 −10.3±17.6 0.653
Impact −12.1±13.7 −10.1±14.7 0.406
Functional parameters
PImax cmH2O 14.8±14.9 9.9±13.8 0.041#
IC at rest L 0.1±0.5 0.2±0.4 0.404
IC at end of 6MWT L 0.0±0.5 0.0±0.7 0.796
IC at end of 6MWT – at rest L −0.1±0.6 −0.2±0.7 0.525
6MWD m 23.4±51.2 36.2±44.9 0.111

Data are presented as mean±SD, unless otherwise stated. IMT: inspiratory muscle training; mMRC:
modified Medical Research Council; SGRQ: St George’s Respiratory Questionnaire; PImax: maximal
inspiratory pressure; IC: inspiratory capacity; 6MWD: 6-min walking distance. #: p<0.05.

capacity and decreasing deconditioning [44, 45]. Our results might therefore be interpreted in the same
way as those of SPRUIT et al. [1] specifying that “because whole-body exercise training confers substantial
improvements in health-related quality of life, it seems that detecting further improvement using IMT is
difficult”. Despite the increase in PImax, there was no difference for the items “muscle work/effort” and
“mental effort/concentration” of the MDP questionnaire.

TABLE 4 Correlation between inspiratory capacity (IC) and maximal inspiratory pressure (PImax)

ΔPImax Subjects n ΔMDP Subjects n

All patients
ΔIC at rest 0.152 146 −0.259 146
Δ(IC effort – IC at rest) −0.005 132
Control group
ΔIC at rest 0.152 74 −0.326 74
Δ(IC effort – IC at rest) 0.036 65
IMT group
ΔIC at rest 0.178 72 −0.207 72
Δ(IC effort – IC at rest) −0.058 67

Δ: difference between the beginning and the end of the programme; MDP: multidimensional dyspnoea
profile; IMT: inspiratory muscle training.

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 COPD | M. BEAUMONT ET AL.

Our study has some limitations. First, the method (threshold inspiratory training, 50–60% of PImax) is in
line with recommendations [5]; however, this programme only lasted 4 weeks, whereas studies included in
the meta-analysis by GOSSELINK et al. [5] lasted 1–4 months. Nevertheless, we observed a similar increase in
PImax [5]. Therefore, we do not think this factor could affect the results. Second, patients improved their
6MWD between the beginning and the end of the programme; therefore, dyspnoea is not evaluated at the
same level of effort. Although it is inherent to the 6MWT, this may be a limit of this study. Last, only six
patients with lobectomy or pneumonectomy, all in the control group, were included in our study. Thoracic
mechanics differ between patients with an obstructive disease and those with a mixed impairment (i.e.
obstructive and restrictive defects) and the effect of IMT on PImax change might be different; however, this
could not be determined in our study.
The strengths of our study are 1) the use of a randomised design; 2) a well predefined and standardised
rehabilitation programme that was administered for all entering patients; 3) a predefined and standardised
protocol for IMT rehabilitation and the use of predefined objective end-points that were performed and
measured according to international guidelines [1, 2, 12]; and 4) blinded data collection. Finally, to our
knowledge, our study is the largest randomised trial having evaluated the potential benefit of IMT during
pulmonary rehabilitation in severe and very severe COPD patients.
In conclusion, in severe or very severe COPD patients, pulmonary rehabilitation with IMT was not found
to be superior to pulmonary rehabilitation without IMT in terms of dyspnoea, quality of life or exercise
capacity (6MWD) improvement, despite a significantly higher improvement of PImax in the IMT group.
The level of the initial PImax (⩽60 cmH2O or >60 cmH2O) did not change these results.

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