Effect of Vitamin D3 on Lung Function and Exercise Tolerance in D3 Deficient COPD Patients
Phase: PHASE1
Conditions: Stable COPD Patients
Sponsor: Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Effect of Vitamin D3 on Lung Function and Exercise 
Tolerance in D3 Deficient COPD Patients 
 
ClinicalTrials.gov ID: NCT03781895 
 
Document Date: December 23, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 

PROJECT SUMMARY 
Background: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and 
mortality throughout the world which is a preventable as well as treatable disease. It has some 
important extra pulmonary effects which may contribute to the magnitude of the severity of this 
disease. Standard therapeutic treatment alone does not optimize its remedy. Vitamin D3 has been 
found to improve the physical efficiency of patients with various morbid disorders, including 
respiratory ailments. Objectives: To evaluate the effects of Vitamin D3 on lung functions and 
exercise tolerance in patients with stable moderate COPD. Methods: For this, a prospective 
interventional randomized  double blinded  study will be carried out on 46 (eighty) vitamin D3 
deficient (serum 25 dihidroxycholecalceferol less than 30 ng/ml), male, stable (diagnosed patient, 
who has not experienced any acute exacerbation , hospitalizations , urgent care visits, or changes 
in routine medication within 4 weeks prior to study), moderate (post bronchodilator 
FEV1/FVC<0.70 of predicted value and FEV1=50 to 79% of predicted value) COPD patients (age 
≥40 years), who will be selected from the Out Patient Department (OPD) of the National Institute 
of Diseases of Chest and Hospital (NIDCH)  and will be grouped as A (control) and B (study) 
groups, respectively. All the patients will be again designated as A0, A90 (with  placebo) and B0, 
B90 (with D3) for before and after 90 days of follow up. All the participants will be matched in 
terms of duration of COPD, history of smoking, occupation and socioeconomic status. Along with 
the standard pharmacological treatment of COPD, the patients of the ‘Study group’ will be 
prescribed for 80000 IU of oral vitamin D3 per week for consecutive 3 months. Along with this, 
all patients both the groups will be advised to continue ad lib (according to their own choice) diet. 
At the very 1st day of the study, the lung functions will be assessed by measuring Forced vital 
capacity (FVC), Forced expiratory volume in one  second (FEV1), Forced expiratory  ratio 
(FEV1/FVC%), Peak expiratory flow rate (PEFR) and Forced mid expiratory flow of FVC(FEF25-
75%), with a portable digital spirometer.  In addition, exercise tolerance will be assessed by change 
in 6 Minute Walk Distance (6MWD) in 6 Minute Walk Test (6MWT). Changes in peripheral 
capillary oxygen saturation (SpO2) by Pulse Oximeter and degree of dyspnoea by Modified Borg 
Scale (MBS) will also be measured both before and after 6MWT to evaluate their change in both 
the groups. All these variables will be measured again after 90 days standard pharmacological 
treatment of COPD with D3 intervention (B group) and also without D3 intervention (A group). 
For statistical analysis, Chi-square test, independent sample ‘t’ test between two groups, paired 

Student’s ‘t’ test within two specific measurements of different durations of each group ,will be 
done. In the interpretation of results, ≤0.05 level of probability (p) will be accepted as significant. 
 
Expected outcome: 
Supplementation of vitamin D3 may cause statistically significant improvement in lung function 
test along with exercise tolerance in moderate stable COPD patient. 
 
Keywords: 
COPD, VitaminD3, FVC, FEV1, FEV1/FVC%, FEF25-75%, PEFR, SpO2, 6 Minute Walk 
Distance, Modified BORG scale 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1.Introduction: 
 
Chronic Obstructive Pulmonary Disease (COPD) is one of the major causes of chronic morbidity 
and mortality throughout the world (GOLD 2015). Many people suffer from the disease for years 
and die too early from its complications. COPD is the fourth leading cause of death in adults of 
United States and also projected to be the third by 2020 (Sabit et al 2007; Eickhoff et al 2008; 
Finkelstein and Scharf 2009). Though it is a preventable and treatable disease, once developed the 
disease along with its comorbidities cannot be cured. But its progression and morbidity can be 
reduced.  
In European countries, on the basis of different variables, the prevalence of COPD was ranged 
from 2.1% to 26.1% (Atsou et al 2011). Additionally it was 8.9% in India (from 6.2% to 13.5%) 
(Afonso 2011), 17.4% in Copenhagen (aged≥ 35 years) (Fabricious et al 2011) and 3.7% in Abu 
Dhabi (age 40 to 80 years) (Al Zaabi et al 2011). In Bangladesh among >40 years population it is 
21.24%, which suggests an overall prevalence of 4.32% in the total population of all age group 
(Habib et al 2010). Furthermore 90% of COPD deaths occur in low and middle income countries 
(Murray and Lopez 1997).  
COPD is a multicomponent disease, comprising emphysema in the lung parenchyma, large central 
airway inflammation and mucociliary dysfunction, bronchiolitis and small airway structural 
changes (Agusti 2005). Together, these separate factors contribute to the chronic airflow limitation 
that characterizes the condition (Agusti 2005; Lapperre et al 2004). In addition, there is evidence 
that systemic inflammation and extra pulmonary effects are also common in COPD, although the 
association between systemic inflammation and systemic manifestations of COPD is still not 
entirely clear. 
The airflow obstruction in this disease is generally persistent as well as progressive (Lapperre et 
al 2004). It has two clinical phases (stable phase and exacerbation phase), both of which are 
associated with inflammation (Barbu et al 2011). Independent risk factors for COPD are male 
gender, advanced age, low socioeconomic status, occupational exposure and cigarette smoking 

(both active and passive) (Caballero 2008), reactivity of airways, occupational factors and air 
pollution (Reilly  et al 2004).  
Vitamin D is a steroid important in bone mineralization and calcium homeostasis. The prevalence 
of vitamin D deﬁciency has been increasing in the general population in recent decades. The 
majority of circulating 25-hydroxyvitamin D [25(OH)D] is derived from sun exposure with a 
limited dietary contribution. The increased prevalence of vitamin D deﬁciency is attributed to sun 
avoidance, indoor lifestyle, use of sunscreen, and decreased intake of vitamin D-containing foods 
(Reilly et al 2004). Because vitamin D is sequestered in adipose tissue, the increasing prevalence 
of obesity also increases the prevalence of vitamin D deﬁciency (Holick  2007). 
Recently, research has found that vitamin D may play a role in multiple chronic diseases such as 
cancer, autoimmune diseases, infections, and cardiovascular disorders (Holick 2007; Holick and 
Chen 2008). Vitamin D may also have a role in several diseases involving the respiratory system. 
Recently Heideri et al (2015) reported that a significant proportion of young COPD patients may 
have insufficient (20 to 29 ng/ml) serum 25-OHD (Heideri et al 2015). They also found a 
statistically significant positive relationship between serum 25-OHD and FEV1 in this group of 
patients. Furthermore, it has been suggested that, lower vitamin D status in COPD may be due to 
diminished production of pre-vitamin D3 associated with skin aging caused by smoking and limited 
Ultra Violet B radiation exposure (Holick  2007; Janssens et al 2009). Moreover, higher serum 
vitamin D concentrations, assessed by [25(OH)D], have been associated with better lung function 
as measured by FEV1 in a large cross-sectional study of the U.S. population (Black and Scragg 
2005). Although the precise connection between vitamin D status and lung function is not clear at 
this point, it is postulated that vitamin D may improve lung function through its action on 
regulating inflammation (Mahon et al 2003; Xystrakis  et al 2006; Searing and Leung 2010), 
inducing antimicrobial peptides (De Smet and Contreas 2005), and/or its action on muscles 
(Hopkinson et al 2008; Forli et al 2009).  
It has also been suggested that, patients with COPD have a high prevalence of vitamin D 
deficiency, ranging from approximately 30% in mild COPD to over 75% in severe COPD (Black 
and Scragg 2005; Janssens et al 2010; Ferrari et al 2010; Kunisaki et al 2011). Particularly for 
COPD, vitamin D deficiency may enhance chronic airway and systemic inflammation, reduce 

bacterial clearance, and increase the risk for infectious exacerbations at the same time (Kunisaki 
et al 2011). In addition, Ferrari et al (2010) also demonstrated that the maximal exercise capacity 
and carbon monoxide transfer in the single breath method were both positively correlated with 
serum [25(OH)D] (Ferrari et al 2010). It has also been suggested that the impairment of exercise 
capacity in COPD may be related to a reduction in muscle strength (Forli et al 2009).  
To provide a quick, acceptable as well as repeatable and reproducible lung function data 
spirometry is a safe and practical procedure (Johns et al. 2014). The ventilatory functions of the 
lung such as, forced vital capacity (FVC), forced expiratory volume in 1st second (FEV1), 
FEV1/FVC ratio  (FEV1/FVC %),  forced mid expiratory flow rate between 25% and 75%  of  FVC 
(FEF25-75%) and peak expiratory flow rate (PEFR), can be assessed by spirometry (Wildhaber et al. 
2007; Mehrparvar, Mirmohammadi and Sohrabi 2010). The indices derived from this forced 
exhaled maneuver have become the most accurate and reliable way of supporting a diagnosis of 
COPD (Bangladesh Lung Health Manual 2010). This test should be undertaken in all patients who 
may have COPD. It is needed to make a confident diagnosis as well as to exclude other diagnoses 
that may present with similar symptoms. Although spirometry does not fully capture the impact of 
COPD on a patient’s health, it remains the gold standard for diagnosing the disease and monitoring 
its progression. It is the best standardized most reproducible and most objective measurement of 
airflow limitation available (GOLD 2015).  
In addition, oxygen saturation is an indicator of the percentage of hemoglobin saturated with 
oxygen at the time of the measurement. Peripheral capillary oxygen saturation values obtained 
from pulse oximetry (SpO2) is one part of a complete assessment of the patient’s oxygenation 
status. Normal oxygen saturation values are 97% to 99% in the healthy individual and of 95% is 
clinically accepted in a patient with a normal hemoglobin level (Schutz 2001). This value may 
vary with the amount of oxygen utilization by the tissues. For example, in some patients, there is 
a difference in SpO2 values at rest compared with those during activity, such as ambulation or 
positioning. However it does not reflect the patient’s ability to ventilate (Schutz 2001). 
Moreover, dyspnea is one of the most significant symptoms occurring during the progression of 
COPD and results from pulmonary hyperinflation, weakness of inspiratory muscles, increased 
ventilation, voluntary hyperventilation, increased respiratory work load and impaired function of 

the inspiratory muscles (Schutz  2001). The evaluation of dyspnea is very important in any chronic 
respiratory ailment. The effort dyspnea determined at the end of exercise is accepted as the best 
indicator of dyspnea (Kendrick et al 2010). There are several scales are available to evaluate 
dyspnea. Though the interpretation of dyspnea scales depends solely on the statements of the 
patients, but Modified Borg Scale (MBS) is known to be simple and partially objective, have 
usually been used to evaluate effort dyspnea in clinical practice (Kendrick et al 2010). 
Respiratory disease often presents with limited activity level and exercise capacity and reduced 
exercise tolerance is a hallmark of patients with COPD (Balke 1963). In 1963, Balke developed a 
simple test to evaluate the functional capacity by measuring the distance walked during a period 
of time.  Walk test are typically administered as a means of evaluating functional status, monitoring 
treatment effectiveness and establishing prognosis. The 6 minutes walk test (6 MWT) is a practical 
simple test that requires a 30 meter hallway but no exercise equipment or advance training for the 
observer. The test measures the distance that a person can quickly walk on a flat, hard surface in a 
period of 6 minutes. The self paced 6 MWT assesses the submaximal level of functional capacity. 
However, because most activities of daily living are performed at submaximal levels of exertion, 
the 6 minutes walk distance (6 MWD) may better reflect the functional exercise level for daily 
physical activities (ATS statement 2002). 
 
 
 
 
 
 
 
 
 
 
 
 
 

2. Rationale: 
 
Standard therapeutic treatment schedule has a limited role in improving the physical capacity in 
COPD patients (Singh et al 2003). Various supplementations and extra-therapeutic measures have 
been tried to improve the functional capacity of the COPD patients (Bool2012; Biswas et al 2013; 
Ismail  et al 2015). Vitamin D3 supplementation is one of them. The principal goals of adding 
vitamin D3 in the treatment schedule of these patients are to reduce symptoms and exacerbations, 
to improve quality of life and to increase physical and emotional participation in everyday 
activities which may not be adequately addressed by standard pharmacological regime alone for 
COPD (GOLD 2015). Recently, a number of studies have shown an association between vitamin 
D deﬁciency and severity of COPD (Janssens et al 2010; Ferrari et al 2010). In addition in a 
prospective study, FEV1 was measured in patients with severe and very severe COPD both before 
and after vitamin D3 supplementation and significant improvement was found (Zendedel et al 
2015). On the other hand, one recent study reported no significant improvement in FVC, FEV1 
and FEV1/FVC% in Vitamin D3 deficient COPD patients after vitamin D3 administration as 
compared to that of the control group (Jabbari et al 2013). 
However the volume of information regarding the effect of vitamin D3 administration in COPD 
patients is not enough for reaching any final conclusion. Moreover, with the best of our knowledge 
no study have been conducted to observe the effects of  this fat soluble vitamin on the spirometric 
lung function status, oxygen saturation and exercise tolerance in vitamin D3 insufficient, stable 
patients with moderate COPD.  
Therefore, on the basis of this background the present study has been designed to evaluate the 
effects of Vitamin D3 on the spirometric lung function status, peripheral capillary oxygen 
saturation and exercise tolerance in D3 deficient, male patients with stable moderate COPD. This 
study will draw attention of the physicians about the beneficial effects of the vitamin D3 on both 
pulmonary and extrapulmonary complications in COPD patients.  
 
 
 

Research Question: 
Does vitamin D3 has any effect on lung function and exercise tolerance in Vitamin D3 deficient 
stable COPD patients? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Hypothesis: 
Null: Vitamin D3 administration does not improve lung function and  exercise tolerance in vitamin 
D3 deficient  stable COPD patients.  
Alternate: Vitamin D3 administration improves lung function and exercise tolerance  in vitamin 
D3 deficient stable COPD patients. 
 
 
 
 
 
 
 

Objectives: 
 
General Objective 
To evaluate the effects of vitamin D3 administration on lung functions and exercise tolerance in 
vitamin D3 deficient male patients with stable  COPD. 
 
Specific Objectives 
 To measure the FVC, FEV1, FEV1/FVC%, PEFR and FEF25-75% of vitamin D3 insufficient  
male patients with stable moderate COPD, in order to assess their lung function status. 
 To measure the SpO2 at rest, in order to assess the basal oxygenation status in this group of 
patients. 
 To determine level of dyspnea at rest, in order to assess the basal breathlessness level in the 
same group of patients  
 To measure the 6MWD of all the patients, in order to assess their functional exercise capacity. 
 To measure both the SpO2 and level of dyspnea again after 6MWT, for the assessment of their 
exercise tolerance. 
 To measure all these variables after 90 days standard pharmacological treatment with vitamin 
D3 and also without vitamin D3 in stable COPD patients. 
 To compare the results of baseline and endline.  
 
       
  
 
 
 
 
 
 
 
 

 
Methodology: 
 
Consolidated Standard of Reporting Trials:                                 (Moher et al 2010)        
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TYPE OF STUDY 
: 
Prospective interventional   randomized  double blinded 
study 
PLACE OF STUDY 
: 
Department of Physiology, Bangabandhu Sheikh Mujib 
Medical University (BSMMU), Shahbagh, Dhaka 
STUDY PERIOD 
: 
March 2017 to February 2018 
STUDY POPULATION 
: 
Stable, moderate COPD patients with vitamin D3 
deficiency. 
SAMPLE SIZE 
: 
46 
SAMPLING 
: 
Simple random sampling .  
GROUPING 
OF 
THE 
SUBJECTS 
: 
 
Group A 
(Control group) 
: 
23 D3 deficient COPD patients without D3 administration 
                A0            
: 
On day 0 
                A90 
: 
On day 90 
Group B 
(Study group) 
: 
23  D3 deficient COPD patients with D3 administration 
                B0 
: 
On day 0 
                           B90 
: 
On day 90    

Sample size calculation: 
Using the following statistical formula 
n =    [(Zα+Zβ)2 X (σ12+σ22)] / (μ1-μ2)2     
                                                                   (Kirkwood and Sterne 2003) 
                                                                                                
Therefore, 
n  
=    
[(Zα+Zβ)2 X 
(σ12+σ22)] / 
(μ1-μ2)2 
=    
[(1.96+1.64)2 
X 
(26.92 
+27.52) 
/ 
(47.1-67.4)2 
=    [12.96 X (756.25+723.61)] / (20.3) 2 
=    19178.98 / 412.09 
=    46.54 
=    47 
 
Mean of control,  
μ1 
= 
47.1 
Mean of study group,  
μ2 
= 
67.4 
SD of control,  
σ1 
= 
26.9 
SD of study group,  
σ2 
= 
27.5 
 
 
 
            (Martineau et al. 2015) 
Type I Error,                
Zα 
= 
1.96 
Type II Error,              
Zβ   
= 
1.64 
 
 
 
(Kirkwood and Sterne 2003) 

Subject Selection:  
 
Inclusion Criteria  
 Age: >40 years  
  
          
 
(Heideri 2015) 
 Socioeconomic condition: Middle class 
 
           (Martineau et al 2015) 
 Smoking status: 
  
 
 
 (Janssens et al 2010) 
 
Current smoker 
= with history of active smoking 
 
 
Ex-smoker         
= with history of 0 – 8 quit year 
 
Duration 
= for >30 pack years 
 BMI: 25 – 29.9 kg/meter-sq  
  
 
 
  (Janssens et al 2010) 
 COPD patients at moderate stage according to GOLD criteria with > 4 years duration 
 
  
 
        (Rees et al 2013) 
 Stable COPD patients  
  
 
         (Mehrparver et al 2010) 
 Vitamin D3 deficient: 30 ng/ml 
  
    (Vitamin D Council 2017) 
 
 
Exclusion Criteria   
 
 
 
          (Said  and Abd-Einaeem 2015) 
With history of – 
 Chronic pulmonary diseases, like – 
bronchial asthma 
respiratory tract infection 
bronchiectasis       
pneumothorax 
pleural effusion  

tuberculosis           
pulmonary fibrosis  
pneumonectomy or pulmonary lobectomy 
 Chronic liver disease 
 Malignancy  
 Systemic hypertension  
 Thyrotoxicosis  
 Chronic cardiac diseases, like –  
angina 
congestive heart failure       
myocardial infarction 
cardiac arrhythmia 
cardiomegaly 
 Use of drugs known to affect vitamin D metabolism within 1 month prior to study, 
as, 
Anticonvulsants 
Glucocorticoids  
Calcium 
With biochemical evidence of – 
 Diabetes mellitus 
 Renal insufficiency 
 
All the criteria mentioned above will be scrutinized by taking history and clinical examination, 
except vitamin D3 deficiency, diabetes mellitus and renal insufficiency, which will be diagnosed 
biochemically. 

Principles Of Bangladesh Good Clinical Practice:  
 (Directoriate general of drug administration 2011) 
                
Before conducting the study the researcher will follow all the principals of  Bangladesh GCP 
,written below: 
1.Clinical trials should be conducted in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, and that are consistent with GCP and the applicable 
regulatory requirement(s).   
  
2. Before a trial is initiated, foreseeable risks and inconveniences should be weighed against the 
anticipated benefit for the individual trial participant and society. A trial should be initiated and 
continued only if the anticipated benefits justify the risks.   
  
3.  The rights, safety, and well-being of the trial participants are the most important 
considerations and should prevail over interests of science and society.   
  
4.  The available nonclinical and clinical information on an investigational product should be 
adequate to support the proposed clinical trial.   
  
5.  Clinical trials should be scientifically sound, and described in a clear, detailed protocol.   
  
6 . A trial should be conducted in compliance with the protocol that has received prior 
institutional review board (IRB)/independent ethics committee (IEC) approval/favorable opinion.  
 
7.  The medical care given to, and medical decisions made on behalf of, participants should 
always be the responsibility of a qualified physician or, when appropriate, of a qualified dentist.  
  
8.  Each individual involved in conducting a trial should be qualified by education, training, and 
experience to perform his or her respective task(s).   

  
9.  Freely given informed consent should be obtained from every participant prior to clinical trial 
participation.   
 10.  All clinical trial information should be recorded, handled, and stored in a way that allows its 
accurate reporting, interpretation and verification.   
  
11.  The confidentiality of records that could identify participants should be protected, respecting    
the    privacy and confidentiality rules in accordance with the applicable regulatory 
requirement(s).   
  
12.  Investigational products should be manufactured, handled, and stored in accordance with 
applicable good manufacturing practice (GMP). They should be used in accordance with the 
approved protocol.   
  
13.  Systems with procedures that assure the quality of every aspect of the trial should be 
implemented.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Ethical Implications: 
 Before conducting the study the researcher will take approval from International Review Board 
of BSMMU. In addition ,the institutional permission will also be taken for data collection. 
While conducting this study the researcher will focus special attention to protect the life, health, dignity, 
integrity, privacy and confidentiality of the personal information of the study subjects. 
After selection of subject the researcher will sit for an interview with the subject. The researcher will at 
first introduce himself mentioning his institutional affiliation, conflict of interest and will supply address, 
contact telephone number and information about sponsorship. After that the subject will be thoroughly 
informed about the objectives and outcome of the study. Brief explanation of the procedure will be given 
to them. The subject will also be assured if any problem arises during the test; it will be taken care of. 
The result of the test will be sent to him free of charge and if any abnormality is detected, then appropriate 
management will be given to him, if possible or will be referred to specific treatment facility as 
appropriate. He will be encouraged for voluntary participation in a cordial and friendly attitude and will 
be allowed freedom to withdraw from the study whenever he likes even after participation. They will be 
informed about the method of confidentiality of their identification. Their identity will be recorded 
only in questionnaire which will be kept in safe custody with the researcher. It will not enter in the 
computer and will not go in any publication. No personal identification will be used in data 
analysis, report writing or publication. They will also be assured that interview time will minimum 
for maintaining their comfort, some questions will be asked about the personal, family and medical 
history without any private enquiry.  The conflict of interest will be told to him if there is any. After he 
has understood these entire procedure, if he agrees to participate, then a willingly given informed written 
consent will be taken from him.  
There is no possibility of any physical, social or mental risk of the respondent. A pretested 
questionnaire will be filled up by the research assistant. 
 
All gathered information will be kept secret and only will be used for medical research and 
analysis. 
 
 

SITE OF SAMPLE COLLECTION: 
All the patients will be collected from the Out Patient Department (OPD) of National Institute of 
Diseases of Chest and Hospital (Annexure - I). 
 
STUDY PROCEDURE:   
 
 Investigator has applied for formal Clinical trials through www.Clinicaltrials.gov and was granted 
permission to go on with the trial (Annexure II) .On the first day of enrollment, the objectives, 
nature, purpose and potential risk of all the procedures used for the study will be explained in detail 
to each subject, with a cordial attitude giving emphasis on the benefits he might obtain from this 
study. He will be encouraged for voluntary participation and will be allowed to withdraw himself 
from the study even after participation, whenever he felt uneasy. If he agreed to be enrolled in the 
study, an informed written consent will be taken in a prescribed form (Annexure - IV). Detailed 
family history, medical history and thorough physical examination of each patient will be done 
and all the information will be recorded in a standard data sheet (Annexure - V). Then all the 
patients will be requested to attend the Department of Physiology at 9 am (about 1 and 1/2 hours 
after his breakfast) on the day of biochemical and spirometric examination. 
On the examination day, 5 ml of venous blood will be collected and taken to the Hematology 
laboratory as soon as possible for the estimation of serum 25-hydroxycholecalceferol, serum 
glucose 2 hours after breakfast and serum creatinine. After that his height and weight will be 
measured and the spirometric lung function test will be done by using a portable spirometer. After 
getting all the biochemical and spirometric reports the final selection will be done, according to 
the inclusion and exclusion criteria.  
Subsequently, all the eligible patients will be randomly assigned to either ‘Control’ or ‘Study’ 
groups and will be thoroughly informed about the objectives and detailed study procedure, once 
again.   Then the patients will be examined for the baseline value of all the study variables in Day 
1. 
Again after 90 days the study variables will be collected from same 46 patients.  
 

CONFOUNDING VARIABLES: 
 Age: >40 years  
  
          
 
(Heideri 2015) 
 Socioeconomic condition: Middle class 
 
           (Martineau et al 2015) 
 Smoking status: 
  
 
 
 (Janssens et al 2010) 
 
Current smoker 
= with history of active smoking 
 
 
Ex-smoker         
= with history of 0 – 8 quit year 
 
Duration 
= for >30 pack years 
 BMI: 25 – 29.9 kg/meter-sq  
  
 
 
  (Janssens et al 2010) 
COPD patients at moderate stage according to GOLD criteria with > 4 years duration 
 
  
 
        (Rees et al 2013) 
 Stable COPD patients  
  
 
         (Mehrparver et al 2010) 
 Vitamin D3 deficient: 30 ng/ml 
 
 
    (Vitamin D council 2017) 
 
 
All the above mentioned variables will be similar ,statistically non significant in both the groups 
to ensure the minimization of their effects. 
 
 
 
 
 
 
 
 

VITAMIN ADMINISTRATION : 
 
Collection: 
Vitamin D3 
Ingredient 
• Cholecalciferol (40,000IU) 
• Microcrystalline Cellulose (58.1 gm) 
• Butylated Hydroxy Toluene ( 0.2mg) 
• Magnesium Stearate (3mg) 
 
Gelatin Capsule Shell (1mg) 
Dose : 80,000 IU/wk 
Route : Oral 
Placebo : Courtesy of Beximco Pharmaceuticals LimitedBangladesh  
Ingredient : • Microcrystalline Cellulose (303.8gm) • Butylated Hydroxy Toluene (0.2mg) 
o Magnesium Stearate (3mg) 
o Gelatin Capsule Shell (1mg) 
 
 
 
 
 
 

STUDY VARIABLES: 
 
(1) Spirometric variables 
  FVC         (L)                         : 
Forced Vital Capacity 
  FEV1        (L) 
: 
Forced Expiratory Volume in 1st second 
  FEV1/FVC Ratio   (%)           : 
Forced Expiratory Ratio 
  PEFR       (L/min) 
: 
Peak Expiratory Flow Rate 
  FEF 25-75   (L/S)                      : 
Forced Expiratory Flow in the middle of FVC 
 
(2) Oxygenation variables 
  Resting SpO2       (%)             : 
Resting Peripheral Capillary Oxygen saturation 
(3) Exercise tolerance variables 
  6MWD         (meter)               : 
Six Minute Walk Distance 
  Level of Dyspnea 
: 
Modified Borg Scale 
(4) Hematological variables 
  25(OH)D    (ng/ml)                 : 
25-hydroxycholecalceferol 
  PTH           (pmol/l) 
: 
Parathyroid hormone 
  Ca2+           (mg/ml) 
: 
Ionic calcium 
  PO43-         (mg/ml) 
: 
Ionic phosphate 
  AP              (U/L) 
: 
Alkaline Phosphatase 
Subsequently a standard therapeutic treatment (according to GOLD guideline) (Annexure - VI) 
will be prescribed to all the selected stable moderate COPD patients. In addition, the patients of 

the ‘Study group’ will be prescribed for 80000 IU of oral vitamin D3 per week for consecutive 90 
days .  Along with this, all the patients of both the groups will be advised to continue ad lib 
(according to their own choice) diet. 
Proper education will be given about drug , method of taking medication and  medication  
plan.Afterwards,a good rapport will be built up to take time to time follow up  over telephone and 
visiting patient’s place .Schedule appointment ,hotline and follow up will be maintained properly. 
They will be requested to attend the Department of Physiology again on the 90th day, to have the 
assessment of all the above-mentioned study variables   
Any patient, who failed to follow the study procedure exactly during study period, will be dropped 
and a new one will be included to fulfill the desired total sample number.Thats why extended 
sample should be taken to fulfill the total sample number.   
Collection of blood sample (Afroza 2015):    
With all aseptic precaution, 5 ml of venous blood will be drawn from the antecubital vein by a 
disposable plastic syringe and was transferred immediately into a dry, clean test tube with a gentle 
push after removing needle, to avoid hemolysis. The test tube will be kept in slanting position till 
formation of clot. After centrifuging the clotted blood (at 3000 rpm for 10 minutes), the serum will 
be separated and taken into an Eppendorf tube and will be preserved in the refrigerator at -4˚C in 
the laboratory. The serum level of all the intended variables will be done by an auto analyzer in 
the hematology lab of Department of Physiology, BSMMU. 
 
Test procedure for spirometry (Afroza 2015): 
 At first, the subject will be asked to take rest sitting on a chair and remain calm and quiet for 
5 minutes. 
 The detailed procedure will be explained to him to ensure his maximum cooperation. 
 The switch of Spirometer will be on and windows will be open. 
 Patients’ information will be filled up and saved. 

 The patient will be asked to hold a disposable paper mouthpiece (connected to spirometer) 
in his hand horizontally and to place it in between his two lips. 
 To make good seal, he will also be asked to put the lips tightly around the outside of the 
mouthpiece. 
 Then he will be asked to inhale first as deeply and as rapidly, as possible, which will be 
followed by a forceful expiration for the possible longest period into the mouthpiece. 
 The readings of different variables will be recorded from the Spirometer monitor. 
 Three (3) consecutive readings at 5 minutes interval for each parameter will be taken and the 
best value will be noted.  
 
 
Test procedure for Pulse Oximetry (Afroza 2015): 
 The patient will be asked to take rest and remain calm and quiet for 10 minutes (MacAllister 
et al 2007).  
 The detailed procedure will be explained to him to ensure his maximum cooperation. 
 Then his right index finger will be washed with alcohol and pulse oximeter sensor will be 
applied.  
 The switch button will be on. 
 The reading will be recorded from the display screen. 
 Three (3) consecutive readings at 5 minutes interval will be taken and the best value will be 
noted. 
 
 
 
Procedure for Six Minute Walk Test (6MWT) (Ahmed, Begum and Ali 2014): 
The 6MWT will be performed at indoors, along a long, flat, straight, enclosed corridor with a hard 
surface that is seldom traveled. The walking course will be 30 meter in length which will be marked 
every 3 meter. The turnaround points will be marked with a cone. A starting line, which marked 

the beginning and end of each 60 meter lap, will be marked on the floor using brightly colored 
tape. 
The subject will be asked to walk at his own maximal pace along the corridor from the end, 
covering as much ground as he can, during the allotted time, without running. He will be also 
advised to take rest if he will be too exhausted to continue the test. Standard phrases at regular 
intervals (every 60 seconds) will be used, like: “you are doing well,” “keep up the good work”. At 
the same time he will be also informed about the past time and how much has left before the test 
was completed.  
If any of the subjects developed chest pain, intolerable dyspnoea, leg cramps, staggering, 
diaphoresis or pale appearance the test will be immediately stopped and the subject will be 
dropped. Again, when any subject will complete the total study procedure (according to the exact 
study design), he will be congratulated for good effort.  
 
STATISTICAL ANALYSIS: 
The results will be expressed as mean with standard deviation (mean±SD). 
The data will be statistically analyzed by a computer with SPSS (Version 16.0) using Chi-square 
test,(to know the qualitative difference between the observed  and expected result).Spirometric 
variables, oxygenation variables, exercise tolerance variables and hematological variables will be 
found between two groups of  patients. If the variables are normally distributed , statistical analysis 
will be done by parametic  statistical test. But if it is not normally distributed then it will be 
transformed into natural logarithm and again into   anti logarithm, to make it normally distributed, 
then parametric statistical test will be done.   Independent sample ‘t’ test between two groups, 
paired Student’s ‘t’ test within two specific measurements of different durations of each group will 
be done. 
In the interpretation of results, ≤0.05 level of probability (p) will be accepted as significant. 
 

PUBLICATION POLICY 
 
 Scientific article to be published in a scientific journal. 
 Presentation in scientific seminar or conference orally or through poster presentation. 
 Website dissemination through internet version of JBSP. 
 The supervisor of the study will take initiative for publication. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

INFORMED CONSENT STATEMENT    
Title of the study: Effect of vitamin D3 on lung function and exercise tolerance in 
D3 deficient COPD patients. 
                             
 
You are being asked to take part in a research study. Your participation is voluntary. 
Before agreeing to participate in this study, it is important that you read the following 
explanation of the study, if you do not understand what you are reading, do not sign 
it. Please ask the researcher to explain anything, you do not understand. If you decide 
to participate, you will be asked to sign this form and a copy will be given to you.  
Purpose of the study: The present study will be conducted to assess lung function 
status in male patients with stable COPD by spirometric lung function variables 
before and after supplementation therapy for a period of 3 months. 
This study may find out the benefit of vitamin D3 on lung function in COPD patients. 
Explanation of procedures: The researcher will take an interview and will do 
general examination of the body. Then the spirometric variable will be measured  
and exercise tolerance, oxygen saturation, the level of dyspnea and fatigue (Borg 
scale)  will be measured before and after six minute walk test . Then 5 ml venous 
blood will be collected under all aseptic precaution. The same procedure will be 
done on his follow up.  
Risks and discomfort: This study involves almost no physical risk. The researcher 
will be cautious in using the measurement tools so that the procedure does not harm 
you physically. However, while drawing the blood sample, the subject may 
experience slight discomfort, but it will be negligible. Adequate precautions will be 
taken to avoid any error.  

Withdrawal without prejudice: Each participant is free to withdraw the consent 
and discontinue participation in this study at any time. 
Confidentiality: Your identity in this study will be treated as confidential. Your 
name or identity will not be linked in any way to the research study.  
Costs and payments to subjects for participation in research: There is no 
financial support (compensation) for your participation in this research.  
Available medical treatment for research related injuries: If you are injured as a 
direct result of taking part in this research study, emergency medical care will be 
provided by transporting to your personal doctor or medical centre. 
Questions: Any question concerning the research, study participants can call Dr. 
Samia Hassan at 0191174400. 
Authorization: I have read and understood this consent form and I volunteer to 
participate in this research study, but I understand that my consent does not take 
away any legal rights in the case of negligence or other legal fault of anyone who is 
involved in this study.  
 
Participant’s 
Signature:........................................ 
Date:............................................. 
 
 
 

 
 
DATA SCHEDULE 
Title: Effects of Vitamin D3 on lung functions & exercise tolerance in male COPD patients  
ID No:  
 
SL No:                                 Date:……………. 
 
 
 
 
 
 
 
Name:  
 
 
 
         Age (years): 
 
 
 
Contact address:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
_____ 
 
Permanent Address: ________________________________________________ 
 
 
E-mail  ID : __________________ 
 
Subject information 

Contact No:    Tel: 
 
 
 
 
Cell: 
 
 
 
Occupation:  Dependent-1; Student-2; Unemployed-3; Business-4;, Service-5; Day labour-6; 
 
Education: Illiterate-0; primary-1; High School-2; SSC-3; HSC-4; Graduate-5; Masters-6;   
 
Marital status:  Married-1; Unmarried-2; Widower-3; Seperated-4; Divorced-5; Live together-6; 
 
Socioeconomic status: 
                     Monthly income (Taka): 
 
 
 
                     Number of family members: 
                     Residence: 
Urban/Rural 
Personal History  
 1. Smoking habit:  
Current smoker/Past smoker 
                                 Packs- year:         
 
 
                                 Duration of smoking: 
                                 Stopped for (in years, in case of past smoker): 
2. Marital status:  Married/Unmarried. 

3. Past medical history: 
 History of hypertension: 
 
           Yes/No                   
 History of Cardiac disease: 
 
 
Yes/No 
 History of Liver disease:                                               Yes/No 
      History of Psychic and neurological disorder:   
Yes/No.  
 History of diabetes mellitus:                                         Yes/No 
 Others:  
Yes/No 
      (If yes) 
      Duration of disease: 
 4.      Drug History: 
5.    Anthropometrical data: 
       Height: 
 
cm. 
 
 
       Weight:             Kg. 
       BMI:          kg/m2 
 6.    General examination :    ( present = +, absent = -)  
 
 
 
                   Anemia:       - / + / ++ / +++ 
                   Jaundice:      - /+ / ++ / +++ 
                   Pulse rate:   .............beat/min. 
                   Cyanosis:      -/+ / ++ / +++ 
                   Clubbing:     - /+ 
                   Edema    :      - /+ 

                   Ascites   : -/+ 
 
                    BP:             Systolic : ................ mm of Hg. 
         Diastolic: ................ mm of Hg 
 
7.     Systemic examination: 
 
 
   P/A examination: 
      Kidney- 
 
 
          Palpable/Not 
                        Spleen- 
 
 
          Palpable/Not 
       Liver- 
 
 
 
Palpable/Not 
       Heart-                                 Normal/Abnormal. 
      
 
 Respiratory System:   
                      Shape of the chest -        Normal/ Abnormal 
Movement of chest-        Abdominothoracic/ 
Thoracoabdominal  
Tracheal position -         Central/Shifted to right /Shifted 
to left                                                                           
Use of accessory respiratory muscles - Yes/No 
                     Percussion note -                                  Dull/Resonance 

Auscultation -                              
 
Clear/Creaps/Ronchi  
Breath sound -                                         Vesicular/Bronchial 
Added sound-                                           Yes/No. 
Study variables: 
Lung Function variables 
PV 
MV  
(day 0) 
% of PV  
(day 0) 
MV  
(day 90) 
% of PV
(day 90)
FVC:                       (L) 
 
 
 
 
 
FEV1:                      (L) 
 
 
 
 
 
FEV1/FVC              (%) 
 
 
 
 
 
PEFR:                     (L/S) 
 
 
 
 
 
FEF 25-75                 (L/S) 
 
 
 
 
 
MEF75 
(L/S) 
 
 
 
 
 
MEF50                    (L/S) 
 
 
 
 
 
MEF25                    (L/S) 
 
 
 
 
 
                   (PV=Predicted Value, MV=Measured Value)  
 
Variables 
 Before 
 (day 0) 
After 
(day 0) 
Before 
(day 90) 
After  
(day 90
Oxygen Saturation % (SpO2) 
 
 
 
 
Level of dyspnea (Borg Score) 
 
 
 
 

Level of fatigue (Borg Score) 
 
 
 
 
 
 Total Distance (in meter) Walked In 6 Minute      : 
The Modified Borg Scale: 
SCALE 
SEVERITY 
0 
No Breathlessness At All 
0.5 
Very Very Slight (Just Noticeable) 
1 
Very Slight 
2 
Slight Breathlessness 
3 
Moderate 
4 
Somewhat severe 
5 
Severe Breathlessness 
6 
 
7 
Very Severe Breathlessness 
8 
 
9 
Very Very Severe (Almost Maximum) 
10 
Maximum 
 
Hematological variables: 
 
 

Serum 25(OH)D 
ng/ml 
 
Serum PTH 
pg/ml 
 
Serum Ca2+ 
mg/dl 
 
Serum 
Alkaline 
phosphat
ase 
IU/L 
 
Serum 
SGPT 
IU/L 
 
Serum 
Creatini
ne  
mg/dl 
 
Fasting 
blood 
glucose 
mg/dl 
 
Serum 
HbA1c 
% 
 
Serum 
Choleste
rol  
(mg/dl) 
 

Serum 
TG  
(mg/dl) 
 
Serum 
HDL  
(mg/dl) 
 
Serum 
LDL  
(mg/dl) 
 
Serum 
PO43- 
mg/dl)