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Andrianopoulos V, Wagers SS, Groenen MTJ, Vanfleteren LE, Franssen FME, Smeenk FWJM, Vogiatzis I, Wouters EFM, Spruit MA. Characteristics and determinants of endurance cycle ergometry and six-minute walk distance in patients with COPD. BMC Pulm Med 2014; 14:97. [PMID: 24885117 PMCID: PMC4229855 DOI: 10.1186/1471-2466-14-97] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/20/2014] [Indexed: 11/10/2022] Open
Abstract
Background Exercise tolerance can be assessed by the cycle endurance test (CET) and six-minute walk test (6MWT) in patients with Chronic Obstructive Pulmonary Disease (COPD). We sought to investigate the characteristics of functional exercise performance and determinants of the CET and 6MWT in a large clinical cohort of COPD patients. Methods A dataset of 2053 COPD patients (43% female, age: 66.9 ± 9.5 years, FEV1% predicted: 48.2 ± 23.2) was analyzed retrospectively. Patients underwent, amongst others, respiratory function evaluation; medical tests and questionnaires, one maximal incremental cycle test where peak work rate was determined and two functional exercise tests: a CET at 75% of peak work rate and 6MWT. A stepwise multiple linear regression was used to assess determinants. Results On average, patients had impaired exercise tolerance (peak work rate: 56 ± 27% predicted, 6MWT: 69 ± 17% predicted). A total of 2002 patients had CET time of duration (CET-Tend) less than 20 min while only 51 (2.5%) of the patients achieved 20 min of CET-Tend . In former patients, the percent of predicted peak work rate achieved differed significantly between men (48 ± 21% predicted) and women (67 ± 31% predicted). In contrast, CET-Tend was longer in men (286 ± 174 s vs 250 ± 153 s, p < 0.001). Also, six minute walking distance (6MWD) was higher in men compared to women, both in absolute terms as in percent of predicted (443 m, 67%predicted vs 431 m, 72%predicted, p < 0.05). Gender was associated with the CET-Tend but BMI, FEV1 and FRC were related to the 6MWD highlighting the different determinants of exercise performance between CET and 6MWT. Conclusions CET-Tend is a valuable outcome of CET as it is related to multiple clinical aspects of disease severity in COPD. Gender difference should temper the interpretation of CET.
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Affiliation(s)
- Vasileios Andrianopoulos
- Department of Research & Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Hornerheide 1, 6085 NM Horn, Eindhoven, Netherlands.
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Gagnon P, Guenette JA, Langer D, Laviolette L, Mainguy V, Maltais F, Ribeiro F, Saey D. Pathogenesis of hyperinflation in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014; 9:187-201. [PMID: 24600216 PMCID: PMC3933347 DOI: 10.2147/copd.s38934] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable lung disease characterized by airflow limitation that is not fully reversible. In a significant proportion of patients with COPD, reduced lung elastic recoil combined with expiratory flow limitation leads to lung hyperinflation during the course of the disease. Development of hyperinflation during the course of COPD is insidious. Dynamic hyperinflation is highly prevalent in the advanced stages of COPD, and new evidence suggests that it also occurs in many patients with mild disease, independently of the presence of resting hyperinflation. Hyperinflation is clinically relevant for patients with COPD mainly because it contributes to dyspnea, exercise intolerance, skeletal muscle limitations, morbidity, and reduced physical activity levels associated with the disease. Various pharmacological and nonpharmacological interventions have been shown to reduce hyperinflation and delay the onset of ventilatory limitation in patients with COPD. The aim of this review is to address the more recent literature regarding the pathogenesis, assessment, and management of both static and dynamic lung hyperinflation in patients with COPD. We also address the influence of biological sex and obesity and new developments in our understanding of hyperinflation in patients with mild COPD and its evolution during progression of the disease.
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Affiliation(s)
- Philippe Gagnon
- Faculté de Médecine, Université Laval, Québec, QC, Canada ; Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Jordan A Guenette
- Centre for Heart Lung Innovation, University of British Columbia, St Paul's Hospital, Vancouver, BC, Canada ; Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Langer
- Department of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Louis Laviolette
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | - François Maltais
- Faculté de Médecine, Université Laval, Québec, QC, Canada ; Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Fernanda Ribeiro
- Faculté de Médecine, Université Laval, Québec, QC, Canada ; Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Didier Saey
- Faculté de Médecine, Université Laval, Québec, QC, Canada ; Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Laveneziana P, Guenette JA, Webb KA, O’Donnell DE. New physiological insights into dyspnea and exercise intolerance in chronic obstructive pulmonary disease patients. Expert Rev Respir Med 2014; 6:651-62. [DOI: 10.1586/ers.12.70] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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O'Donnell DE, Laveneziana P, Webb K, Neder JA. Chronic obstructive pulmonary disease: clinical integrative physiology. Clin Chest Med 2013; 35:51-69. [PMID: 24507837 DOI: 10.1016/j.ccm.2013.09.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Peripheral airway dysfunction, inhomogeneous ventilation distribution, gas trapping, and impaired pulmonary gas exchange are variably present in all stages of chronic obstructive pulmonary disease (COPD). This article provides a cogent physiologic explanation for the relentless progression of activity-related dyspnea and exercise intolerance that all too commonly characterizes COPD. The spectrum of physiologic derangements that exist in smokers with mild airway obstruction and a history compatible with COPD is examined. Also explored are the perceptual and physiologic consequences of progressive erosion of the resting inspiratory capacity. Finally, emerging information on the role of cardiocirculatory impairment in contributing to exercise intolerance in patients with varying degrees of airway obstruction is reviewed.
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Affiliation(s)
- Denis E O'Donnell
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada.
| | - Pierantonio Laveneziana
- Service d'Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée Hôpital Universitaire Pitié-Salpêtrière (AP-HP), Laboratoire de Physio-Pathologie Respiratoire, Faculty of Medicine, Pierre et Marie Curie University (Paris VI), 47-83 Boulevard de l'Hôpital,75013 Paris, France
| | - Katherine Webb
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada
| | - J Alberto Neder
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada
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Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WDC, Pitta F, Sewell L, Raskin J, Bourbeau J, Crouch R, Franssen FME, Casaburi R, Vercoulen JH, Vogiatzis I, Gosselink R, Clini EM, Effing TW, Maltais F, van der Palen J, Troosters T, Janssen DJA, Collins E, Garcia-Aymerich J, Brooks D, Fahy BF, Puhan MA, Hoogendoorn M, Garrod R, Schols AMWJ, Carlin B, Benzo R, Meek P, Morgan M, Rutten-van Mölken MPMH, Ries AL, Make B, Goldstein RS, Dowson CA, Brozek JL, Donner CF, Wouters EFM. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188:e13-64. [PMID: 24127811 DOI: 10.1164/rccm.201309-1634st] [Citation(s) in RCA: 2154] [Impact Index Per Article: 195.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope. PURPOSE The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field. METHODS A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members. RESULTS An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed. CONCLUSIONS The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.
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van der Vaart H, Murgatroyd SR, Rossiter HB, Chen C, Casaburi R, Porszasz J. Selecting constant work rates for endurance testing in COPD: the role of the power-duration relationship. COPD 2013; 11:267-76. [PMID: 24182350 DOI: 10.3109/15412555.2013.840572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Constant work rate (CWR) exercise testing is highly responsive to therapeutic interventions and reveals physiological and functional benefits. No consensus exists, however, regarding optimal methods for selecting the pre-intervention work rate. We postulate that a CWR whose tolerated duration (tlim) is 6 minutes (WR6) may provide a useful interventional study baseline. WR6 can be extracted from the power-duration relationship, but requires 4 CWR tests. We sought to develop prediction algorithms for easier WR6 identification using backward stepwise linear regression, one in 69 COPD patients (FEV1 45 ± 15% pred) and another in 30 healthy subjects (HLTH), in whom cycle ergometer ramp incremental (RI) and CWR tests with tlim of ∼6 minutes had been performed. Demographics, pulmonary function, and RI responses were used as predictors. We validated these algorithms against power-duration measurements in 27 COPD and 30 HLTH (critical power 43 ± 18W and 231 ± 43W; curvature constant 5.1 ± 2.7 kJ and 18.5 ± 3.1 kJ, respectively). This analysis revealed that, on average, only corrected peak work rate ( = WRpeak-1 min × WRslope) in RI was required to predict WR6 (COPD SEE = 5.0W; HLTH SEE = 5.6W; R(2) > 0.96; p < 0.001). In the validation set, predicted and actual WR6 were strongly correlated (COPD R(2) = 0.937; HLTH 0.978; p < 0.001). However, in COPD, unlike in HLTH, there was a wide range of tlim values at predicted WR6: COPD 8.3 ± 4.1 min (range 3.6 to 22.2 min), and HLTH 5.5 ± 0.7 min (range 3.9 to 7.0 min). This analysis indicates that corrected WRpeak in an incremental test can yield an acceptable basis for calculating endurance testing work rate in HLTH, but not in COPD patients.
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Affiliation(s)
- Hester van der Vaart
- 1Department of Pulmonology, University Medical Center Groningen, Groningen, Netherlands
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Lahaije A, van Helvoort H, Dekhuijzen R, Heijdra Y. Can COPD patients who hyperinflate during daily life activities be identified by laboratory tests? ACTA ACUST UNITED AC 2013; 86:237-42. [PMID: 23989464 DOI: 10.1159/000351108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 03/28/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identification of patients with chronic obstructive pulmonary disease (COPD) who develop dynamic hyperinflation (DH) during activities in daily life (ADL) is important, because of the association between DH and dyspnea and exercise limitation. OBJECTIVE We aimed to answer the question whether measurements of DH during metronome-paced tachypnea (MPT) or cardiopulmonary exercise testing (CPET) can be used to identify patients who develop DH during ADL. METHODS DH was measured by tracking changes in inspiratory capacity during CPET, MPT and ADL. Bland-Altman plots were used to evaluate agreement in DH between methods. With a receiver operating characteristic (ROC) analysis, the overall accuracy of MPT and CPET to identify patients who hyperinflate during ADL was assessed. RESULTS There are broad limits of agreement in DH between methods. ROC curve analyses showed good overall accuracy of both CPET and MPT to identify patients who hyperinflate during ADL. For CPET, area under the curve (AUC) = 0.956 (95% CI 0.903-1.009). For MPT, AUC = 0.840 (95% CI 0.699-0.981). Sensitivity and specificity to identify patients who hyperinflate during ADL with CPET were 96 and 83%, respectively, and with MPT, they were 89 and 77%, respectively. CONCLUSION Both CPET and MPT can serve as screening tools to identify patients who are susceptible to developing DH during ADL. In practice, MPT is the most simple and inexpensive surrogate. However, the sensitivity of MPT is not optimal. When DH does not occur during CPET, it is unlikely to occur during ADL.
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Affiliation(s)
- A Lahaije
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, Nijmegen, The Netherlands
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Charususin N, Gosselink R, Decramer M, McConnell A, Saey D, Maltais F, Derom E, Vermeersch S, van Helvoort H, Heijdra Y, Klaassen M, Glöckl R, Kenn K, Langer D. Inspiratory muscle training protocol for patients with chronic obstructive pulmonary disease (IMTCO study): a multicentre randomised controlled trial. BMJ Open 2013; 3:e003101. [PMID: 23921069 PMCID: PMC3740252 DOI: 10.1136/bmjopen-2013-003101] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/05/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Inspiratory muscle training (IMT) has been applied during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, it remains unclear if the addition of IMT to a general exercise training programme leads to additional clinically relevant improvements in patients with COPD. In this study, we will investigate whether the addition of IMT to a general exercise training programme improves 6 min walking distance, health-related quality of life, daily physical activity and inspiratory muscle function in patients with COPD with inspiratory muscle weakness. METHODS AND ANALYSIS Patients with COPD (n=170) with inspiratory muscle weakness (Pi,max <60 cm H2O or <50%pred) will be recruited to a multicentre randomised placebo controlled trial of IMT and allocated into one of the two groups. Patients in both groups will follow a 3 month general exercise training programme, in combination with home-based IMT. IMT will be performed with a recently developed device (POWERbreathe KH1). This device applies an inspiratory load that is provided by an electronically controlled valve (variable flow resistive load). The intervention group (n=85) will undertake an IMT programme at a high intensity (≥50% of their Pi,max), whereas the placebo group (n=85) will undertake IMT at a low training intensity (≤10% of Pi,max). Total daily IMT time for both groups will be 21 min (6 cycles of 30 breaths). Improvement in the 6 min walking distance will be the primary outcome. Inspiratory muscle function, health-related quality of life and daily physical activity will be assessed as secondary outcomes. ETHICS AND DISSEMINATION Ethics approval has been obtained from relevant centre committees and the study has been registered in a publicly accessible clinical trial database. The results will be easily interpretable and should immediately be communicated to healthcare providers, patients and the general public. RESULTS This can be incorporated into evidence-based treatment recommendations for clinical practice. CLINICALTRIALSGOV NCT01397396.
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Affiliation(s)
- Noppawan Charususin
- Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
- Department of Physical Therapy, Thammasat University, Pathumthani, Thailand
| | - Rik Gosselink
- Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
- Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Leuven, Belgium
| | - Marc Decramer
- Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Leuven, Belgium
| | - Alison McConnell
- Centre for Sports Medicine and Human Performance, Brunel University, London, UK
| | - Didier Saey
- Centre de recherche, Institut Universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Francois Maltais
- Centre de recherche, Institut Universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Eric Derom
- Department of Pulmonology, University Hospital Ghent, Ghent, Belgium
| | | | - Hanneke van Helvoort
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Yvonne Heijdra
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Mariska Klaassen
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Rainer Glöckl
- Department of Respiratory Medicine & Sports Therapy, Schön Klinik Berchtesgaden, Schönau am Königssee, Germany
| | - Klaus Kenn
- Department of Respiratory Medicine & Sports Therapy, Schön Klinik Berchtesgaden, Schönau am Königssee, Germany
| | - Daniel Langer
- Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
- Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Leuven, Belgium
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Inspiratory Capacity during Exercise: Measurement, Analysis, and Interpretation. Pulm Med 2013; 2013:956081. [PMID: 23476765 PMCID: PMC3582111 DOI: 10.1155/2013/956081] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 12/21/2012] [Indexed: 12/24/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is an established method for evaluating dyspnea and ventilatory abnormalities. Ventilatory reserve is typically assessed as the ratio of peak exercise ventilation to maximal voluntary ventilation. Unfortunately, this crude assessment provides limited data on the factors that limit the normal ventilatory response to exercise. Additional measurements can provide a more comprehensive evaluation of respiratory mechanical constraints during CPET (e.g., expiratory flow limitation and operating lung volumes). These measurements are directly dependent on an accurate assessment of inspiratory capacity (IC) throughout rest and exercise. Despite the valuable insight that the IC provides, there are no established recommendations on how to perform the maneuver during exercise and how to analyze and interpret the data. Accordingly, the purpose of this manuscript is to comprehensively examine a number of methodological issues related to the measurement, analysis, and interpretation of the IC. We will also briefly discuss IC responses to exercise in health and disease and will consider how various therapeutic interventions influence the IC, particularly in patients with chronic obstructive pulmonary disease. Our main conclusion is that IC measurements are both reproducible and responsive to therapy and provide important information on the mechanisms of dyspnea and exercise limitation during CPET.
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Maltais F. Exercise and COPD: therapeutic responses, disease-related outcomes, and activity-promotion strategies. PHYSICIAN SPORTSMED 2013; 41:66-80. [PMID: 23445862 DOI: 10.3810/psm.2013.02.2001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) reduces patients' exercise capacities and their abilities to perform daily physical activities, thereby increasing morbidity and mortality rates. The cycle of dyspnea, deconditioning, and declining physical activity not only accelerates the progression of COPD but also increases the risk for developing or aggravating metabolic and cardiovascular diseases. Cardiovascular and metabolic comorbidities also limit physical function, and their disabling effects in combination with COPD may be greater than the effects of each disease alone. The impact of COPD and its treatment on the ability to exercise, and the degree of physical activity in daily life, can be measured by field-based tests (eg, the 6-minute walk test or incremental and endurance shuttle-walk test), laboratory-based tests (eg, incremental or constant work-rate treadmill and cycle-ergometer tests), and physical activity assessments (eg, questionnaires and accelerometers). Walking tests increase oxygen consumption and desaturation in patients with COPD more than cycling tests with similar work-rate profiles and may more closely resemble patients' normal activities. Despite the questionable relevance of exercise testing to patients' daily functionality, exercise parameters remain important predictors of survival in patients with COPD. Treatment of COPD (pharmacotherapy, pulmonary rehabilitation, or both) can increase exercise capacity and physical activity in daily life, which potentially slows the decline of lung function, reduces the frequencies of exacerbations and hospitalizations, decreases mortality, slows the progression of comorbidities, improves health-related quality of life, and increases the activity reserve for routine function. This article examines the interactions of reduced physical activity and decreased exercise capacity with the progression of COPD, comorbidities, and mortality. The article also describes the available exercise tests for patients with COPD and reviews the evidence indicating that treating COPD improves exercise capacity. Notably, it appears that even mild COPD reduces exercise capacity and daily physical activity, indicating the need for early intervention.
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Bruni GI, Gigliotti F, Binazzi B, Romagnoli I, Duranti R, Scano G. Dyspnea, chest wall hyperinflation, and rib cage distortion in exercising patients with chronic obstructive pulmonary disease. Med Sci Sports Exerc 2012; 44:1049-56. [PMID: 22595983 DOI: 10.1249/mss.0b013e318242987d] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Whether dyspnea, chest wall dynamic hyperinflation, and abnormalities of rib cage motion are interrelated phenomena has not been systematically evaluated in patients with chronic obstructive pulmonary disease (COPD). Our hypothesis that they are not interrelated was based on the following observations: (i) externally imposed expiratory flow limitation is associated with no rib cage distortion during strenuous incremental exercise, with indexes of hyperinflation not being correlated with dyspnea, and (ii) end-expiratory chest wall volume may either increase or decrease during exercise in patients with COPD, with those who hyperinflate being as breathless as those who do not. METHODS Sixteen patients breathed either room air or 50% supplemental O2 at 75% of peak exercise in randomized order. We evaluated the volume of chest wall (V(cw)) and its compartments: the upper rib cage (V(rcp)), lower rib cage (V(rca)), and abdomen (V(ab)) using optoelectronic plethysmography; rib cage distortion was assessed by measuring the phase angle shift between V(rcp) and V(rca). RESULTS Ten patients increased end-expiratory V(cw) (V(cw,ee)) on air. In seven hyperinflators and three non-hyperinflators, the lower rib cage paradoxed inward during inspiration with a phase angle of 63.4° ± 30.7° compared with a normal phase angle of 16.1° ± 2.3° recorded in patients without rib cage distortion. Dyspnea (by Borg scale) averaged 8.2 and 9 at the end of exercise on air in patients with and without rib cage distortion, respectively. At iso-time during exercise with oxygen, decreased dyspnea was associated with a decrease in ventilation regardless of whether patients distorted the rib cage, dynamically hyperinflated, or deflated the chest wall. CONCLUSIONS Dyspnea, chest wall dynamic hyperinflation, and rib cage distortion are not interrelated phenomena.
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Lahaije AJMC, Willems LM, van Hees HWH, Dekhuijzen PNR, van Helvoort HAC, Heijdra YF. Diagnostic accuracy of metronome-paced tachypnea to detect dynamic hyperinflation. Clin Physiol Funct Imaging 2012; 33:62-9. [DOI: 10.1111/j.1475-097x.2012.01164.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 07/17/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Anke J. M. C. Lahaije
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
| | - Laura M. Willems
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
| | | | | | | | - Yvonne F. Heijdra
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
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Baldi BG, Albuquerque ALP, Pimenta SP, Salge JM, Kairalla RA, Carvalho CRR. Exercise Performance and Dynamic Hyperinflation in Lymphangioleiomyomatosis. Am J Respir Crit Care Med 2012; 186:341-8. [DOI: 10.1164/rccm.201203-0372oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Effect of bisoprolol on respiratory function and exercise capacity in chronic obstructive pulmonary disease. Am J Cardiol 2012; 110:258-63. [PMID: 22497677 DOI: 10.1016/j.amjcard.2012.03.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/03/2012] [Accepted: 03/03/2012] [Indexed: 01/06/2023]
Abstract
Cardioselective β blockers are considered to have little impact on lung function at rest in patients with chronic obstructive pulmonary disease (COPD). However, their effects on dynamic hyperinflation, an important mechanism contributing to symptoms and exercise tolerance in patients with COPD, have not been evaluated. Twenty-seven patients with moderate to severe COPD (forced expiratory volume in 1 second 52 ± 13% predicted) completed pulmonary function tests, echocardiography, maximal exercise tests, and cycle endurance tests at baseline. Inspiratory capacity was measured at 2-minute intervals during the cycle endurance test to quantify dynamic hyperinflation. Pulmonary function and cycle endurance testing were repeated after 14 days of bisoprolol 10 mg/day and 14 days of placebo in a randomized, double-blind, placebo-controlled, crossover trial. The extent of dynamic hyperinflation at peak isotime exercise with bisoprolol and placebo was compared. Peak isotime was defined as the latest time point that was reached during the 2 cycle endurance tests. Changes in inspiratory capacity from rest to peak isotime were different with bisoprolol compared to placebo (-0.50 ± 0.35 vs -0.41 ± 0.33 L, p = 0.01). Exercise duration tended to be lower with bisoprolol compared to placebo (305 ± 125 vs 353 ± 172 seconds, p = 0.11). The magnitude of change in exercise duration between the bisoprolol and placebo conditions was correlated with the magnitude of change in inspiratory capacity (r = 0.57, p <0.01). In conclusion, bisoprolol was associated with modest worsening dynamic hyperinflation, whereas exercise duration remained unchanged in patients with moderate to severe COPD. The magnitude of these effects was small and should not contraindicate the use of bisoprolol in patients with COPD.
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Guenette JA, Raghavan N, Harris-McAllister V, Preston ME, Webb KA, O’Donnell DE. Effect of adjunct fluticasone propionate on airway physiology during rest and exercise in COPD. Respir Med 2011; 105:1836-45. [DOI: 10.1016/j.rmed.2011.08.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 08/22/2011] [Accepted: 08/24/2011] [Indexed: 10/17/2022]
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van Ranst D, Otten H, Meijer JW, van 't Hul AJ. Outcome of pulmonary rehabilitation in COPD patients with severely impaired health status. Int J Chron Obstruct Pulmon Dis 2011; 6:647-57. [PMID: 22162650 PMCID: PMC3232171 DOI: 10.2147/copd.s24579] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Effects of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients with severely impaired health status are poorly documented since these patients are usually excluded from clinical trials. This retrospective, observational study aims to study the impact of disease on health status and the effects of PR on COPD patients referred to a tertiary center for PR in The Netherlands. METHODS Between June 2006 and June 2010, 437 patients with COPD were allocated to our intensive, comprehensive PR program. Patients participated in this interdisciplinary program for 12 weeks for a weekly average of 20-25 hours. Before and directly after, several measures of physical performance and health-related quality of life were determined. RESULTS At baseline, most patients (75%) had a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage of III-IV. Peak exercise performance on a cycle ergometer was on average reduced to 43 ± 29 Watt, and health-related quality of life was significantly impaired, with a total score on the St George's Respiratory Questionnaire (SGRQ) of 66. Health-care utilization in the year preceding PR was very high. After rehabilitation, all outcome measures improved statistically significantly (P < 0.001). Exercise performance measured with the 6 minute walking distance test improved clinically significantly in 68% of the patients, whereas 75% of the patients showed a clinically meaningful improvement in quality of life as measured with the SGRQ. Multiple regression analysis revealed that 19% of the variation in responses on the 6 minute walking distance test and the SGRQ could be explained on the basis of baseline characteristics. CONCLUSION The present study provides data to indicate that COPD patients may substantially benefit from rehabilitation in a tertiary pulmonary rehabilitation center, despite a severely impaired health status and high level of health-care utilization, in which prior treatment in primary and secondary care have failed to improve health status. Individual rehabilitation responses can only partially be predicted on the basis of baseline characteristics. Consequently, no firm conclusions can be drawn from this study with respect to the selection of candidates that could be deemed eligible for this rehabilitation program when entering the program.
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Affiliation(s)
- Dirk van Ranst
- Revant, Pulmonary Rehabilitation Center Schoondonck, Breda, The Netherlands.
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Laveneziana P, Webb KA, Ora J, Wadell K, O'Donnell DE. Evolution of dyspnea during exercise in chronic obstructive pulmonary disease: impact of critical volume constraints. Am J Respir Crit Care Med 2011; 184:1367-73. [PMID: 21885624 DOI: 10.1164/rccm.201106-1128oc] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patients with chronic obstructive pulmonary disease (COPD) primarily describe their exertional dyspnea using descriptors alluding to increased effort or work of breathing and unsatisfied inspiration or inspiratory difficulty. OBJECTIVES The purpose of this study was to examine the impact of changes in dynamic respiratory mechanics during incremental (INCR) and high-intensity constant work-rate (CWR) cycle exercise on the evolution of dyspnea intensity and its major qualitative dimensions in patients with moderate-to-severe COPD. METHODS Sixteen subjects with COPD performed symptom-limited INCR and CWR cycle exercise tests. Measurements included dyspnea intensity and qualitative descriptors, breathing pattern, operating lung volumes, and esophageal pressure (Pes). MEASUREMENTS AND MAIN RESULTS During both exercise tests, there was an inflection in the relation between tidal volume (Vt) and ventilation. This inflection occurred significantly earlier in time during CWR versus INCR exercise but at a similar ventilation, Vt, and tidal Pes swing. Beyond this inflection, there was no further change in Vt despite a continued increase in ventilation and tidal Pes. During both tests, "work and effort" was the dominant dyspnea descriptor selected up to the inflection point, whereas after this point dyspnea intensity and the selection frequency of "unsatisfied inspiration" rose sharply. CONCLUSIONS Regardless of the exercise test protocol, the inflection (or plateau) in the Vt response marked the point where dyspnea intensity rose abruptly and there was a transition in the dominant qualitative descriptor choice from "work and effort" to "unsatisfied inspiration." Intensity and quality of dyspnea evolve separately and are strongly influenced by mechanical constraints on Vt expansion during exercise in COPD.
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Affiliation(s)
- Pierantonio Laveneziana
- Respiratory Investigation Unit, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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Effect of indacaterol on exercise endurance and lung hyperinflation in COPD. Respir Med 2011; 105:1030-6. [DOI: 10.1016/j.rmed.2011.03.014] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/18/2022]
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Worth H, Förster K, Eriksson G, Nihlén U, Peterson S, Magnussen H. Budesonide added to formoterol contributes to improved exercise tolerance in patients with COPD. Respir Med 2010; 104:1450-9. [DOI: 10.1016/j.rmed.2010.07.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 07/09/2010] [Accepted: 07/09/2010] [Indexed: 11/28/2022]
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:111-20. [DOI: 10.1097/spc.0b013e32833a1dfc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Exertional dyspnea in chronic obstructive pulmonary disease: mechanisms and treatment approaches. Curr Opin Pulm Med 2010; 16:144-9. [DOI: 10.1097/mcp.0b013e328334a728] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current World Literature. Curr Opin Pulm Med 2010; 16:162-7. [DOI: 10.1097/mcp.0b013e32833723f8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hannink J, Lahaije A, Verberkt C, Dekhuijzen R, van Helvoort H, Heijdra Y. Validity of Oxycon Mobile in measuring inspiratory capacity in healthy subjects. Clin Physiol Funct Imaging 2010; 30:206-9. [PMID: 20184624 DOI: 10.1111/j.1475-097x.2010.00924.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Inspiratory capacity (IC) assessments have been performed mainly in laboratory settings, because of fixed measurement devices. Oxycon Mobile (OM) is the mobile and wireless version of Oxycon Pro (OP), a commonly used fixed measurement device. The purpose of this study was to examine IC agreement between OM and OP at rest and during steady-state exercise. Also, the within- and between-days variability of IC's were determined. METHODS Thirty-five healthy subjects were recruited. Twenty-five subjects were included for determining validity of the OM and ten subjects for the variability study. For validation of OM, resting and exercise IC's (IC(rest) and IC(exercise) respectively) were measured consecutively by OM and OP, in random order. Exercise consisted of cycle ergometry at 50% of subject's predicted maximal exercise capacity. RESULTS The mean difference between OM and OP regarding IC(rest) was -0.05L, with limits of agreement of -0.47 to 0.37L (or -1.2% with limits of agreement of -11.6 to 9.3%) (P>0.05). The mean difference of IC(exercise) was -0.06L, and the limits of agreement were -0.48 to 0.35L (or -1.4% with limits of agreement of -11.8 to 9.0%) (P>0.05). No significant differences in IC's within- or between-days were found. DISCUSSION The limits of agreement of the IC measured by OM and OP were +/-10%, which is recommended for interdevice reproducibility. We conclude that OM and OP can be used interchangeably for measuring IC at rest and during steady-state exercise.
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Affiliation(s)
- Jorien Hannink
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Zhang X, Waterman LA, Ward J, Baird JC, Mahler DA. Advantages of endurance treadmill walking compared with cycling to assess bronchodilator therapy. Chest 2009; 137:1354-61. [PMID: 20040610 DOI: 10.1378/chest.09-2470] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Walking is a familiar daily activity that is generally limited by breathlessness, whereas cycling is an uncommon physical effort typically limited by leg discomfort. The hypothesis was that patients with COPD would exhibit greater improvements in exercise endurance and relief of breathlessness with bronchodilator therapy during treadmill walking compared with cycling. METHODS In this randomized, 2 x 2, double-blind, placebo-controlled, crossover trial, 20 patients with COPD (age, 64 +/- 7 years; FEV(1), 56 +/- 14% predicted) performed constant-load endurance exercise on the treadmill and cycle ergometer at 85% of capacity after inhaling normal saline (NS) or arformoterol (ARF) (15 microg). RESULTS Increases in endurance times and consistency of responses were greater with treadmill walking (Delta: 157 +/- 286 s; P = .024; 80% improved) than with cycle exercise (Delta: 110 +/- 219 s; P = .038; 65% improved) with ARF compared with NS. However, these changes were not significantly different. The slope of breathlessness-time (mean Delta = -29%; P = .007) and the magnitude of oxygen desaturation were significantly lower with ARF compared with NS during treadmill, but not cycle, exercise. Inspiratory capacity values were similar between modes of exercise when comparing the same study medication. CONCLUSIONS Improved endurance times support both constant-load treadmill and cycle exercise to assess the efficacy of bronchodilator therapy in patients with COPD. Unique differences in physiologic and perceptual responses with bronchodilation demonstrate advantages of treadmill walking as an exercise stimulus. TRIAL REGISTRATION clinicaltrials.gov; Identifier: NCT00754546.
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Affiliation(s)
- Xiaolei Zhang
- Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756-0001, USA
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