SARCOPENIA IN CHRONIC

OBSTRUCTIVE PULMONARY
DISEASE
Marcella Jesslyn
01073180139

Perceptor:
dr. Samuel Sunarso, Sp.P, FPCP
SARCOPENIA IN COPD
DEFINITION : COPD
Common, preventable and treatable disease
characterized by persistent respiratory symptoms
and airflow limitation that is due to airway and/or
alveolar abnormalities usually caused by significant
exposure to noxious particles or gases
DEFINITION : SARCOPENIA
A condition characterized by loss of skeletal muscle
mass and function. Syndrome characterized by
progressive and generalized loss of skeletal
muscle mass and strength and strictly correlated
with physical disability, poor quality of life and death
SARCOPENIA
• Probable sarcopenia : ↓ muscle strength
• Sarcopenia : ↓ muscle strength, ↓ muscle
quantity/quality
• Severe sarcopenia : ↓ muscle strength, ↓ muscle
quantity/quality, ↓ physical performance
SARCOPENIA
Skeletal muscle mass index (SMI)
• Dual energy X-Ray Absorptiometry (DXA)
• Bioelectrical impedance analysis (BIA)
• Computed Tomography Scan (CT-Scan)
• Magnetic Resonance Imaging (MRI)
Measure extremities’ function
• Short physical performance battery (SPPB)
EPIDEMIOLOGY
• COPD 4th leading cause of death in the
world  3rd in 2020
• >3 million people died because of
COPD in 2012
EPIDEMIOLOGY
Prevalence of sarcopenia :
• 14.5% patients with COPD, increased with age and
GOLD severity (Jones, 2014)
• 24% patients with COPD (Asian Working Group for
Sarcopenia)
After pulmonary rehabilitation : 12/45 patients no longer
classified as sarcopenic
• 92.6% men, age >65 years
• History of smoking, moderate COPD
ETIOLOGY
Endogenous
• ↓ hormonal stimulation (GH, IGF-1, testosterone, estrogen)
• Loss motornuerones, denervation muscle fibres
• ↑ non-contractile tissue in muscle
↓ Anabolism
Exogenous
• ↓ physical activity
• Bed rest, immobilization
• malnutrition
Endogenous
• ↑ basal inflammatory profile (IL-6, TNF-𝝰)
↑ Catabolism
Exogenous
• Stress-induced inflammation : life events, depression
Cited by : E. Charbek, J.R. Espiritu, R. Nayak, J.E. Morley. 2018
RISK FACTORS
• Lack of physical activity
• Age ≥ 75 years
• Other :
1. Alteration immunity (↑ IL-6, TNF-𝝰)  chronic inflammation
2. Alteration connective tissue  ↑ fibrosblast and lipid  ↑
rigidity & ↓ elasticity
3. Nutrition
4. Corticosteroid use
o High dose 5 – 7 days (hydroc
o Low dose longterm  steroid induced myopathy
 FACTORS ASSOCIATED
No Low
Low SMI Sarcopenia
sarcopenia function
Age (years) 66 69 73 73
Sex (M:F) 147 : 73 14 : 13 136:149 57:33
MRC 3 3 4 4
FEV1 (%predicted) 46.3 37.9 45.6 40.5
Long term oxygen therapy
(%) 15 4 7 9
Use of walking aid (%) 2 0 19 17
 FACTORS ASSOCIATED
No Low
Low SMI Sarcopenia
sarcopenia function
BMI (kg/m) 28.8 21.1 29.2 21.4
Skeletal muscle mass (kg) 26.6 18.8 22.9 18.9
Skeletal Muscle Index (kg/m2) 9.2 6.8 8.6 6.9
Handgrip (kg) 33.9 29.6 22.6 21.5
4 meter gait speed (m/s) (4MGS) 1.07 1.00 0.77 0.77
5 repetition sit-to-stand test (s) 12.4 14.1 16.1 19.6
Short physical performance
battery (SPPB) 11 11 8 8

Incremental shuttle walk test /

ISWT (m) 309 257 152 157
 FACTORS ASSOCIATED
No Low
Low SMI Sarcopenia
sarcopenia Function
CAT (COPD Assesment Test) 19 22 23 24
Smoking status
(current/former/never)
Current 43 6 49 16
Former 170 19 216 67
Never 7 2 20 7
Number of exacerbations previous
2 2 2 2
12 months
 DIAGNOSIS
Physical
Muscle Mass Muscle Strength
Performance
ASM/ht Grip strength SPPB ≤8
<7.0 kg/m2 in men Gait speed ≤0.8
<27kg in men
EWGSOP2 <6.0 kg/m2 in women
<16kg in women
m/sec
TUG ≥20 sec 400 m
European Working Group on
walk test
Sarcopenia in Older People
≥6 min for completion
or non-completion

Muscle Mass Muscle Strength Physical

DXA, ASM/ht2 Performance
≤7.0 kg/m2 in men Grip strength
Gait speed
≤5.4 kg/m2 in women <26kg in men
AWGS BIA, SMI/ht2 <18kg in women
≤0.8 m/sec
Asian Working Group for DXA, ASM/ht2
Sarcopenia ≤7.0 kg/m2 in men
≤5.4 kg/m2 in women
 DIAGNOSTIC ALGORITHM
SARC Muscle
F/ Quantity
clinical / Quality

FIND CASES ASSESS CONFIRM SEVERITY

Physical
Muscle Performa
strength nce
SARC-F  4 sarcopenia predicted & poor prognosis
Component Question Scoring

FIND CASES
Strength How much difficulty do you have in None = 0
lifting carrying 5kg? Some = 1
A lot / unable = 2
Assistance in How much difficulty do you have None = 0
walking across a room? Some = 1
walking A lot, use aids / unable = 2
Rise from a How much difficulty do you have None = 0
transferring from a chair or bed? Some = 1
chair A lot / unable without help = 2

Climb stairs How much difficulty do you have None = 0

climbing a flight of 10 stairs? Some = 1
A lot / unable = 2
Falls How many times have you fallen in None = 0
the past year? 1 – 3 falls = 1
>4 falls = 2
GRIP STRENGTH TEST
Cut-off men Cut-off women
60 – 65 years 20 kg 8 kg

ASSESS
66 – 70 years 15 kg 6 kg
>70 years 15 kg 6 kg
THIRTY SECONDS CHAIR STAND TEST
Cut-off men Cut-off women
60 – 65 years 10 8
66 – 70 years 9 8
>70 years 8 7
• Skeletal muscle mass (SMM)

CONFIRM
• Appendicular skeletal muscle mass (ASM)
• Low Muscle quality
• DXA (absolute) SMM/ASM
• BIA  total estimated ASM
• CT Scan
• MRI
1. GAIT SPEED
Ask the patient to walk at a comfortable pace, 3 repetition and calculate the
average time

SEVERITY
Sarcopenia  walking 5 meter ≤ 0.8m/second

Interpretation
< 0.4 m/s Household ambulatory
0.4 – 0.8 m/s Limited community ambulatory
0.8 – 1.2 m/s Community ambulator
>1/2m/s Able to safely cross streets
2. SHORT PHYSICAL PERFORMANCE BATTERY (SPPB)
Calculating the balance tests, gait speed test and chair stand test.
The maximum score is 12 points

SEVERITY
and a score of ≤ 8 points indicates poor physical performance

BALANCE TEST
Participant must be able to stand unassisted without the use of cane or walker

Side-by-side Semi-tandem stand Tandem stand

Held 10 sec = 2 points

Held 10 sec = 1 point Held 10 sec = 1 point Held for 3 – 9.99 sec = 1 point
Not held for 10 sec = 0 point Not held for 10 sec = 0 point Held for < 3 sec = 0 point
Not attempted = 0 point Not attempted = 0 point Not attempted = 0 point
2. SHORT PHYSICAL PERFORMANCE BATTERY (SPPB)

GAIT SPEED TEST

SEVERITY
Normal walk, may use cane or walker aid

4 meter walk 3 meter walk

<4.82 seconds 4 points <3.62 seconds 4 points

4.82 – 6.20 seconds 3 points 3.62 – 4.65 seconds 3 points

6.21 – 8.70 seconds 2 points 4.66 – 6.52 seconds 2 points

 8.70 seconds 1 point  6.52 seconds 1 point

2. SHORT PHYSICAL PERFORMANCE BATTERY (SPPB)
CHAIR STAND TEST
Patient stand from the chair without using arms to measure the strength of

SEVERITY
the legs.
0 points if the patient unable to stand
Continue 5 repetitions without using arms
If chair stand time is 11.19 sec or less: 4 points

If chair stand time is 11.20 to 13.69 sec: 3 points

If chair stand time is 13.70 to 16.69 sec or more: 2 points

If chair stand time is 16.70 sec or more: 1 point

Unable to complete 5 chair stands or completes stands 0 point

in >60 sec:
3. TIMED UP AND GO TEST (TUG)

To evaluates physical function

SEVERITY
Rise from a standard chair
walk to a marker 3 m away, turn around
walk back and sit down again
≤ 10 seconds  normal mobility
11 – 20 seconds  normal for frail elderly & disabled
>20 seconds  needs assistance outside
4. WALKING 400 METERS

SEVERITY
To assess walking ability and endurance
Predict mortality
Complete 20 laps of 20 meter as fast as possible with 2
rest during test
Sarcopenia indicated : ≥6 min for completion or non
completion
CLASSIFICATION (GOLD)

In patients with FEV1/FVC <0.70

GOLD 1 : Mild FEV1 ≥ 80% predicted
GOLD 2 : Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 : Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 : Sangat b FEV1 <30% predicted
Modified British Medical Research Counci (MMRC)
COPD Assessment Test
Never cough 0 1 2 3 4 5 Cough all times
No phlegm (mucus) at all 0 1 2 3 4 5 Chest completely full of phlegm (mucus)

Does not feel tight at all 0 1 2 3 4 5 Chest feels very tight

When walk up a hill or one flight When walk up a hill/ one flight of
0 1 2 3 4 5
of stairs, not breathless stairs, very breathless
Not limited doing any activities at
0 1 2 3 4 5 Verly limited doing activities at home
home
Confident leaving my home Not at all confident leaving home
0 1 2 3 4 5
despite my lung condition because of lung condition
Sleep soundly 0 1 2 3 4 5 Don’t sleep soundly
Lost of energy 0 1 2 3 4 5 Have no energy at all
CLASSIFICATION (GOLD)

In patients with FEV1/FVC <0.70

GOLD 1 : Mild FEV1 ≥ 80% predicted
GOLD 2 : Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 : Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 : Sangat b FEV1 <30% predicted
TREATMENT
TREATMENT
1. Exercise
Determined exercise intensity with 6 minute walking
test, rating of perceived exertion (using borg scale 0 =
no breathless at all; 10 maximal) and heart rate.
Aerobic 3 times/week 20-60 minutes
Patient with FEV1 <50%, if SpO2 <90%  terminate
exercise
 Exercise

Pulmonary
Rehabilitation Aerobic exercise Progressive Sarcopenia
Strength training resistance exercise
Stretching (strength training)
Ventilatory muscle Aerobic exercise
training Stretching
Breath retraining Balance training
TREATMENT
2. Nutrition
Protein supply 1.0 – 1.2 g/kg for healthy elderly; 1.2 –
1.5 g/kg for elderly with chronic/acute disease
Improvement in mid-arm muscle strength
circumference, 6 minute walking test, respiratory
muscle strength and overall health-related quality of life

3. Medication
Vitamin D (muscle metabolism)
PREVENTION
• Nutritional supplement
• Angiotensin Converting Enzyme Inhibitor  primary and
secondary prevention of cardiovascular event, stroke
• Screening for anorexia (Council of Nutrition appetite
questionnaire)
Thank You