Original Article

Reference values for the incremental shuttle walk

test in healthy subjects: from the walk
distance to physiological responses*,**
Valores de referência para o teste de caminhada com carga progressiva
em indivíduos saudáveis: da distância percorrida às respostas fisiológicas

Victor Zuniga Dourado, Ricardo Luís Fernandes Guerra, Suzana Erico Tanni,
Letícia Cláudia de Oliveira Antunes, Irma Godoy

Abstract
Objective: To determine reference values for incremental shuttle walk distance (ISWD) and peak physiological
responses during the incremental shuttle walk test (ISWT), as well as to develop a series of predictive equations
for those variables in healthy adults. Methods: We evaluated 103 healthy participants ≥ 40 years of age (54
women and 49 men). We fitted each participant with a gas analysis system for use during the ISWT. Oxygen
consumption (VO2), carbon dioxide production, minute ventilation, heart rate (HR), ISWD, and maximal walking
velocity (MWV) were obtained as primary outcomes. We also assessed hand grip strength (HGS) and lean body
mass (LBM). Results: The regression analysis models, including physiological variables, ISWD, and MWV (adjusted
for age, body mass, height, and sex), produced R2 values ranging from 0.40 to 0.65 (for HR and peak VO2,
respectively). Using the models including LBM or HGS, we obtained no significant increase in the R2 values
for predicting peak VO2, although the use of those models did result in slight increases in the R2 values for
ISWD and MWV (of 8% and 12%, respectively). The variables ISWD, MWV, and ISWD × body mass, respectively,
explained 76.7%, 73.3%, and 81.2% of peak VO2 variability. Conclusions: Our results provide reference values
for ISWD and physiological responses to the ISWT, which can be properly estimated by determining simple
demographic and anthropometric characteristics in healthy adults ≥ 40 years of age. The ISWT could be used
in assessing physical fitness in the general adult population and in designing individualized walking programs.
Keywords: Reference values; Pulmonary gas exchange; Walking; Exercise test.

Resumo
Objetivo: Determinar valores de referência para a distância caminhada (DC) e para respostas fisiológicas durante
o teste de caminhada com carga progressiva (TCCP) e desenvolver equações preditivas para essas variáveis em
adultos saudáveis. Métodos: Foram avaliados 103 participantes saudáveis com idade ≥ 40 anos (54 mulheres
e 49 homens). Os participantes usaram um sistema de análise de gases durante o TCCP. Consumo de oxigênio
(VO2), liberação de gás carbônico, ventilação minuto, frequência cardíaca (FC), DC e velocidade máxima da
caminhada (VMC) foram obtidos como desfechos primários. Avaliamos também a força de preensão manual (FPM)
e a massa magra corporal (MMC). Resultados: Os modelos de regressão utilizando variáveis fisiológicas, DC e
VMC ajustados por idade, massa corporal, estatura e sexo apresentaram valores de R2 entre 0,40 e 0,65 (para
FC e pico de VO2, respectivamente). Os modelos incluindo MMC e FPM não aumentaram consideravelmente os
valores de R2 na previsão do pico de VO2, embora esses modelos tenham aumentado discretamente os valores do
R2 para DC e VMC (8% e 12%, respectivamente). As variáveis DC, VMC e DC × massa corporal, respectivamente,
explicaram 76,7%, 73,3% e 81,2% da variabilidade do pico de VO2. Conclusões: Nossos resultados originaram
valores de referência para a DC e respostas fisiológicas ao TCCP, que podem ser estimados adequadamente por
características demográficas e antropométricas simples em adultos saudáveis com idade ≥ 40 anos. O TCCP
poderia ser utilizado na avaliação da capacidade física na população geral de adultos e no desenvolvimento de
programas de caminhada individualizados.
Descritores: Valores de referência; Troca gasosa pulmonar; Caminhada; Teste de esforço.

*Study carried out at the Universidade Federal de São Paulo – UNIFESP, Federal University of São Paulo – Baixada Santista
Campus, Santos, Brazil.
Financial support: This study received financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP, São Paulo Research Foundation).
Correspondence to: Victor Z. Dourado. Avenida Ana Costa, 95, CEP 11060-001, Santos, SP, Brasil.
Tel./Fax: 55 13 3261-3324. E-mail: [email protected] or [email protected]
Submitted: 13 September 2012. Accepted, after review: 15 January 2013.
**A versão completa em português deste artigo está disponível em www.jornaldepneumologia.com.br

J Bras Pneumol. 2013;39(2):190-197

Reference values for the incremental shuttle walk test in healthy subjects: 191
from the walk distance to physiological responses

Introduction in CPET performed on a treadmill or on a cycle

ergometer. (10,11) Therefore, the ISWT appears to
The incremental shuttle walk test (ISWT) induce a maximum exercise response that is
was developed in order to assess the functional appropriate for assessing functional capacity.(12)
exercise capacity of patients with COPD.(1) The Elucidation of such physiological responses might
test subject walks back and forth along a 10-m be useful for assessing exercise capacity and for
flat course, with progressive increases in pace designing walking programs for middle-aged
imposed by audio signals, until no longer able and older adults. In addition, reference values,
to maintain the pace. The incremental character especially for VO2 and ISWD, might provide an
of the ISWT yields physiological responses closer easy way to assess the functional exercise capacity
to those observed in cardiopulmonary exercise in patients with chronic diseases.
testing (CPET).(2) Some authors argue that, as In this study, our primary objective was to
an externally paced walk test, the ISWT is more determine reference values for ISWD and peak
reproducible and yields greater physiological physiological responses during the ISWT, developing
responses in comparison with self-paced walk a series of simple predictive equations for those
tests.(3) One of the greatest advantages of the variables in healthy middle-aged adults and in
ISWT is its simplicity. The incremental shuttle healthy older adults. We also assessed the influence
walk distance (ISWD) is generally used as an that body composition and muscle strength have
index of cardiorespiratory fitness and has been on the main physiological variables obtained
suggested as a prognostic indicator in patients during the ISWT.
with chronic disease.(4)
Because of its simplicity and low cost, walking Methods
is the most popular exercise for middle-aged and
older adults. In healthy subjects, the heart rate We conducted a cross-sectional study to
variability threshold was reported to be a valid evaluate the physiological responses to the ISWT
tool for estimating the ventilatory threshold in 103 healthy adults aged 40 years and older.
during the ISWT.(5) The ISWT has also proven The Research Ethics Committee of the Federal
useful for quantifying the benefits of a walking University of São Paulo, located in the city of
program designed for healthy individuals.(6) Studies São Paulo, Brazil, approved the study, and all
evaluating the ISWT in healthy subjects have participants provided written informed consent.
shown that the ISWT is valid and responsive. We recruited a convenience sample from among
Despite the widespread use of the ISWT in clinical employees of the institution and residents of the
settings, few studies have assessed reference surrounding community. The following individuals
values and physiological responses to the test. were ineligible for inclusion in the study: those
Recently, the ISWD has been investigated in with a body mass index > 35 kg/m2; those who
healthy subjects, and regression equations have used a walking aid; those who exhibited abnormal
been developed, allowing a better interpretation post-bronchodilator spirometric results(13); those
of walking performance.(7-9) Two such studies who reported having cardiorespiratory, metabolic,
enrolled participants with comorbidities,(7,9) neuromuscular, or musculoskeletal disease; and
whereas another included only healthy individuals. those who were current smokers.
(8)
However, to our knowledge, there have been Eligible participants underwent a series of
no studies evaluating physiological responses evaluations over the course of two mornings,
to the ISWT in healthy subjects in other than a with a 7-day interval between the two. On day
superficial manner. 1, the participants completed a physical activity
Although the operational simplicity of walk readiness questionnaire, a face-to-face interview
tests is recognized as their most important quality, based on the main cardiovascular risk factors, and
the ISWT has been evaluated with the aid of a physical activity questionnaire in accordance
sophisticated telemetric gas analysis systems with the American College of Sports Medicine
in order to evaluate physiological responses, recommendations(14) so that we could exclude
especially in patients with cardiorespiratory those involved in high-intensity exercise and
diseases.(2,10) In such patients, the peak oxygen sports. They also underwent spirometry, hand grip
consumption (VO2) achieved on the ISWT strength (HGS) assessment, and anthropometric
exhibits a strong correlation with that achieved and body composition measurements. Those

J Bras Pneumol. 2013;39(2):190-197

192 Dourado VZ, Guerra RLF, Tanni SE, Antunes LCO, Godoy I

who met the eligibility criteria returned on day was not inferior to that obtained in the second
2 and underwent three ISWTs, 20 min apart. test, conducted without the equipment, we
Body mass (in kg) and height (in m) were evaluated the intraclass correlation coefficient
measured, and the body mass index (in kg/m2) was (ICC) with its 95% CI between those measures
calculated. Body composition was assessed using and compared their mean values using paired
a portable scale with a tetrapolar bioelectrical Student’s t-test.
impedance system (TBF-310GS; Tanita, Arlington We calculated the sample size considering a
Heights, IL, USA).(15) Total body fat (TBF), total minimum acceptable coefficient of correlation
body water, and lean body mass (LBM) were of 0.70 or a coefficient of determination (R2)
assessed using regression equations.(16) The LBM of 0.49. Assuming an alpha error of 0.05 and a
was also expressed as a percentage of the predicted beta error of 0.20, a minimum of 12 observations
value.(17) Spirometry was performed using a hand- for each variable included in the model would
held spirometer (Spiropalm; Cosmed, Pavona be sufficient. Therefore, 80 participants were
di Albano, Italy) in accordance with the criteria necessary, and we were able to include up to
established by the Brazilian Thoracic Association. 8 variables in each model. A series of multiple
(13)
We measured FEV1, FVC, and FEV1/FVC ratio. linear regression equations was developed using
The HGS of the dominant side was assessed the main physiological responses as dependent
using a hydraulic dynamometer (HS5001; Carci, variables. The models were first adjusted for
São Paulo, Brazil).(18) Three measurements were age, body mass, height, and sex. This procedure
performed at least 30 s apart. The highest value was applied because these variables are easily
was selected for further analysis. obtained. For VO2, MWV, and ISWD (the most
We conducted the ISWTs in a 10-m corridor, important variables related to aerobic exercise
increasing the pace by 0.17 m/s every minute.(1) capacity), the models were also adjusted for body
Dyspnea and leg fatigue were quantified before composition variables and HGS. Regarding body
and after each test with the Borg scale. Three composition, we chose LBM and TBF, which
ISWTs were performed 20 min apart. The ISWD presented the strongest correlations in the previous
(in m) and maximum walking velocity (MWV, in bivariate analysis. In addition, we used linear
m/s) obtained on the third test were selected for regressions in alternative prediction models to
further analysis. Because the ISWT was developed to determine whether peak VO2 correlated with
assess the functional exercise capacity of patients ISWD, with ISWD × body mass, and with MWV.
with lung disease, the original protocol consisted Multicollinearity was assessed before starting
of 12 levels (total distance, 1,020 m).(1) However, the regression procedures. The probability of
because we applied the test to healthy subjects, an alpha error was set at 0.05 for all analyses.
we extended it to 15 levels (1,500 m) in order We performed the statistical analysis with the
to minimize the ceiling effect. Statistical Package for the Social Sciences, version
15.0 (SPSS Inc., Chicago, IL, USA) and SigmaStat,
During the third ISWT, expired gases were
version 3.1 (Systat Software Inc., San Jose, CA,
collected and assessed by a portable telemetric
USA).
gas analysis system (K4b2; Cosmed; Pavona di
Albano, Italy). The physiological responses were
Results
analyzed breath-by-breath, and the data were
filtered every 15 s. The following variables were The sample comprised 103 participants (54
focused at the peak of the ISWT: VO2, carbon women and 49 men), and the mean age was
dioxide production, HR, and minute ventilation. 60 ± 10 years (Table 1). The participants were
The data were evaluated descriptively and distributed within the following age brackets:
are presented as mean ± standard deviation. 40-49 years (13 women and 12 men); 50-59 years
Sex-related differences in the main physiological (12 women and 11 men); 60-69 years (14 women
variables and the rate of perceived exertion were and 14 men); and ≥ 70 years (15 women and
evaluated using Student’s t-test or the Mann- 12 men). There were no significant differences
Whitney test. Pearson’s or Spearman’s coefficients among the four age groups studied in terms of
were used in order to assess bivariate correlations. the proportions of women and men. Between the
To ensure that the ISWD obtained in the third second and third ISWT, the ISWD reliability was
test, carried out using the gas analysis system, excellent (ICC = 0.973; 95% CI: 0.960-0.982)

J Bras Pneumol. 2013;39(2):190-197

Reference values for the incremental shuttle walk test in healthy subjects: 193
from the walk distance to physiological responses

and there was no significant difference between including LBM and that including HGS did not
the mean values (510 ± 148 m vs. 519 ± 161 m). result in a significant increase in the R2 values
The regression analysis models, using for predicting peak VO2 (Table 2), although the
physiological variables, ISWD, and MWV as use of those models did result in slight increases
dependent variables and adjusted for age, in the R2 values for ISWD and MWV (of 8% and
body mass, height, and sex, showed R2 values 12%, respectively). We selected ISWD, MWV,
ranging from 0.40 to 0.65 (for HR and peak and ISWD × body mass as the sole determinants
VO2, respectively; Table 2). Applying the model of peak VO2. In three different models, those
variables determined 76.7%, 73.3%, and 81.2%
Table 1 - General characteristics of the study sample. of the peak VO2, respectively (Figure 1).
Sex
Female Male Discussion
Variable
(n = 54) (n = 49)
Mean SD Mean SD This study investigated the major physiological
Age, year 59 11 59 9
responses to ISWT in healthy subjects. We derived
BM, kg* 68 14 80 12
a series of equations that can predict ISWD, as
Height, m* 1.57 0.07 1.71 0.07
well as cardiovascular, ventilatory, and metabolic
BMI, kg/m2 27 5 27 3
responses during the ISWT. Age and sex had
TBF, kg* 31 10 20 7
significant influences on those variables. However,
TBF, % of total BM* 35 6 25 5
after adjusting for sex and age, we found that
LBM, kg* 39 5 58 7
MWV and ISWD were the main determinants of
LBM, % of total BM* 64 6 74 5
peak VO2, regardless of body composition and
LBM, % of predicted 102 7 103 5
peripheral muscle strength.
LBMI, kg/m2* 17 1 20 1
The main finding of this study was the
HGS, kgf* 26 5 43 8
considerable influence that MWV and ISWD had
BM: body mass; BMI: body mass index; TBF: total body
on the peak VO2 obtained on the ISWT. The
fat; LBM: lean body mass; LBMI: lean body mass index; correlations between peak VO2 and ISWD, between
and HGS: handgrip strength. *p < 0.05 (females vs. males). peak VO2 and MWV, and between peak VO2 and

Table 2 - Linear prediction equations, adjusted for age, body mass, height, sex, body composition, and
muscle function, for peak physiological responses, total distance walked, and maximum walking velocity
related to the incremental shuttle-walk test.
Constant Body
Age, Height, HGS, LBM, TBF,
Variable Modela mass, Sexc R2 Sy.x
Mean LLNb years m kgf kg %
kg
VE, L/min A −43.7 −67.2 −0.5* 0.1 69.2* 13.0* - - - 0.54 14.3
HR, bpm A 146.2 117.9 −1.1* −0.4* 55.5* −2.1 - - - 0.40 17.2
VCO2, mL/min A 137.6 −493.2 −22.5* 5.4* 1,317.9* 554.5* - - - 0.63 383.5
Peak VO2, mL/ A 268.6 −337.9 −21.1* 9.2* 1,101.1* 535.6* - - - 0.65 368.1
min
B −134.1 −750.6 −16.2* 8.8 938.7* 297.5 14.8* - - 0.65 374.9
C −1,206.3 −1,731.7 −12.6* −21.0 883.3 207.8 - 56.0* 27.8 0.65 319.2
ISWD, m A 347.7 186.8 −7.2* −3.0* 472.3* 137.2* - - - 0.65 97.8
B 223.7 86.1 −5.8* −3.2* 421.3 67.1 4.8* - - 0.73 83.6
C −54.6 −198.4 −5.8* −4.3 666.0* 75.3 - 2.1 0.64 0.68 87.4
MWV, m/s A 1.59 1.32 −0.01* −0.004* 0.70* 0.22* - - - 0.60 0.17
B 0.89 0.66 −0.008* −0.005* 0.92* 0.06 0.008* - - 0.72 0.14
C 0.55 0.32 −0.009* −0.007 1.23* 0.11 - 0.003 0.002 0.67 0.14
LLN: lower limit of normal (calculated as 1.646 × Sy.x); HGS: handgrip strength; LBM: lean body mass; TBF: total body
fat; Sy.x: standard error about linear regression; VE: minute ventilation; VCO2: carbon dioxide production; VO2: oxygen
uptake; ISWD: incremental shuttle walk distance; and MWV: maximum walking velocity. aModel A included age, body
mass, height and sex; model B included age, body mass, height, sex, and HGS; and model C included age, body mass,
height, sex, LBM, and TBF. bUse “mean” column for prediction of the expected values and “LLN” column for lower
limit of normal. cSex: males = 1; females = 0. *Significant predictors (p < 0.05).

J Bras Pneumol. 2013;39(2):190-197

194 Dourado VZ, Guerra RLF, Tanni SE, Antunes LCO, Godoy I

5000 60
r = 0.78; R2=0.61; p < 0.0001 r = 0.86; R2=0.76; p < 0.0001
4000 50

Peak Vo2 (mL/mim/Kg)

Peak Vo2 (mL/mim)

40
3000
30
2000
20

1000 10

0 0
0 200 400 600 800 1000 1200 0 200 400 600 800 1000 1200
ISWD (m) ISWD (m)
Equation: Peak VO2 = 238.3 - (2.9 x ISWD) Equation: Peak VO2 = 3.1 + (0.038 x ISWD)

5000 r = 0.74; R2=0.56; p < 0.0001 60 r = 0.85; R2=0.73; p < 0.0001

4000 50
Peak Vo2 (mL/mim/Kg)
Peak Vo2 (mL/mim)

40
3000
30
2000
20

1000 10

0 0
1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2
MWV ((m/s) MWV ((m/s)
Equation: Peak VO2 = -1142 + (1644 x MWV) Equation: Peak VO2 = -16.1 - (22.4 x MWV)

5000
r = 0.90; R2=0.81; p < 0.0001

4000
Peak Vo2 (mL/mim)

3000

2000

1000

0
0 2000 4000 6000 8000 10000
ISWD x body massa (m x kg)
Equation: Peak VO2 = 257 + (0.038 x ISWD x body mass)

Figure 1 - Significant correlations between peak VO2 and incremental shuttle walk distance (ISWD), as
well as between peak VO2 and maximal walking velocity (MWV), during the incremental shuttle walk test.

ISWD × body mass ranged from 0.75 to 0.90. between peak VO2 and ISWD × body mass obtained
These values are similar to those described in the in CPET have been described in COPD patients
literature for the correlation between ISWD and (range, 0.73-0.88).(2,10,19,20) Correlations of this
peak VO2 obtained under laboratory conditions in magnitude have also been described during CPET
patients with cardiopulmonary disease. Consistent in patients with idiopathic pulmonary fibrosis(21)
correlations between peak VO2 and ISWD or and in patients with heart disease.(22-24) These

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Reference values for the incremental shuttle walk test in healthy subjects: 195
from the walk distance to physiological responses

results support the assertion that the ISWT is a obtain, such as body composition and muscle
suitable tool to assess the functional capacity function (Table 2).
of such patients. Our results indicate that the Various cardiovascular and ventilatory
peak VO2 obtained during the ISWT might be variables were determined in the present study
adequately estimated by using ISWD, MWV, or by a combination of age, sex, height, and body
body mass. In fact, Léger & Lambert(25) reported mass (R2 ranging from 0.54 to 0.65). Our results
similar results in the study in which they developed are similar to those described by Neder et al.,(29)
the precursor to the ISWT (the incremental shuttle who reported that several cardiovascular and
run test). In that study, the peak VO2 of young ventilatory variables might be determined by
adults was adequately predicted by the running the combination of age, sex, height, and body
speed, with a correlation of r = 0.84. In a study mass, with an R2 ranging from 0.102 to 0.691.
conducted by Cooper, who used the 12-min run The use of a gas analysis system did not result
test,(26) the 12-min run distance was also the in worse performance during the third ISWT in
most important determinant of cardiorespiratory the present study, given that the results of the
fitness in healthy young adults, a finding similar second and third ISWTs were not significantly
to those of the present study. Even in CPET, the different and exhibited excellent reliability. Our
work rate, or power, has been identified as the results differ from those described by Singh et al.,(10)
main determinant of peak VO2.(27) Because the who reported a shorter ISWD with the use of a
ISWT is performed on a flat surface, the MWV telemetric gas analysis system. This discrepancy
ultimately represents the workload of the test. might be explained primarily by the total weight of
Sex and age influenced the main variables the equipment we used, which was lower than the
4.1 kg of that used by Singh et al.(10) In addition,
obtained on the ISWT (peak VO2, ISWD, and
those authors(10) evaluated COPD patients, whereas
MWV). Several studies have reported that peak
our study involved only healthy participants. Our
VO2 suffers a decline with advancing age and
results show that, despite some minor discomfort
is lower in women,(28,29) even when allometric
related to the use of a face mask, the use of the
correction is used.(30) In the present study, R2
equipment had no impact on the ISWD.
values for ISWD, adjusted for age, body mass,
Our study has limitations that should be
height, and sex, ranged from 15% to 22%,
considered. The main limitation was that we
which are higher than those reported in the
did not perform CPET. However, comparing our
study conducted by Jürgensen et al.,(7) in which
results with those expected for CPET on a cycle
those attributes explained 50% of the ISWD ergometer derived from a randomized study,(29)
variability. This difference might be attributable the measured peak VO2 during the ISWT was
to the characteristics of the sample evaluated significantly higher than the expected values
in that study, which included individuals with for CPET on a cycle ergometer (1,760 ± 608
mild hypertension and smokers, whereas only mL/min vs. 1,568 ± 438 mL/min, p = 0.017).
healthy participants were included in the present Regarding CPET on a treadmill, when we compare
study. We found that body composition and our results with those found in another study
HGS, although presenting consistent correlations conducted in Brazil,(28) albeit qualitatively, the
with peak VO2, did not sufficiently increase the peak VO2 achieved during the ISWT corresponded
predictive power of the equations adjusted only to 80.6-108.2% of the peak VO2 expected in that
for demographic and anthropometric attributes. study. Another limitation was the convenience
Neder et al.(29) reported similar results in a study sampling technique that we used, which might
involving CPET on a cycle ergometer. In that have resulted in overestimation of the normal
study, the residuals of the equations involving physiological responses. However, we took care
muscle strength and body composition were to include only healthy individuals who were not
narrowed, although the R2 was not sufficiently involved in sports or vigorous physical activity.
increased.(29) Our results suggest that equations We believe that this minimized the bias of the
including age, sex, body mass, and height are sampling technique used.
useful because those variables are very simple to Our results provide reference values for ISWD
obtain and provide R2 values similar to those of and physiological responses to the ISWT, which
models with variables that are more difficult to can be properly estimated by determining simple

J Bras Pneumol. 2013;39(2):190-197

196 Dourado VZ, Guerra RLF, Tanni SE, Antunes LCO, Godoy I

demographic and anthropometric characteristics treadmill test and the shuttle walking test in chronic
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Sobre os autores
Victor Zuniga Dourado
Adjunct Professor. Universidade Federal de São Paulo – UNIFESP, Federal University of São Paulo – Baixada Santista Campus,
Santos, Brazil.

Ricardo Luís Fernandes Guerra

Adjunct Professor. Universidade Federal de São Paulo – UNIFESP, Federal University of São Paulo – Baixada Santista Campus,
Santos, Brazil.

Suzana Erico Tanni

Pulmonologist. Universidade Estadual Paulista – UNESP, São Paulo State University – Botucatu School of Medicine, Botucatu, Brazil.

Letícia Cláudia de Oliveira Antunes

Professor. Marechal Rondon College, São Manuel, Brazil. Physical Therapist. Universidade Estadual Paulista – UNESP, São Paulo
State University – Botucatu School of Medicine Hospital das Clínicas, Botucatu, Brazil.

Irma Godoy
Full Professor. Universidade Estadual Paulista – UNESP, São Paulo State University – Botucatu School of Medicine, Botucatu, Brazil.

J Bras Pneumol. 2013;39(2):190-197