101
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When obesity and chronic obstructive pulmonary disease collide. Physiological and clinical consequences. Ann Am Thorac Soc 2015; 11:635-44. [PMID: 24625243 DOI: 10.1513/annalsats.201312-438fr] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In many parts of the world, the prevalence of both chronic obstructive pulmonary disease (COPD) and obesity is increasing at an alarming rate. Such patients tend to have greater respiratory symptoms, more severe restriction of daily activities, poorer health-related quality of life, and greater health care use than their nonobese counterparts. Physiologically, increasing weight gain is associated with lung volume reduction effects in both health and disease, and this should be considered when interpreting common pulmonary function tests where lung volume is the denominator, such as FEV1/FVC and the ratio of diffusing capacity of carbon monoxide to alveolar volume, or indeed when evaluating the physiological consequences of emphysema in obese individuals. Contrary to expectation, the presence of mild to moderate obesity in COPD appears to have little deleterious effect on respiratory mechanics and muscle function, exertional dyspnea, and peak symptom-limited oxygen uptake during cardiopulmonary exercise testing. Thus, in evaluating obese patients with COPD reporting activity restriction, additional nonpulmonary factors, such as increased metabolic loading, cardiocirculatory impairment, and musculoskeletal abnormalities, should be considered. Care should be taken to recognize the presence of obstructive sleep apnea in obese patients with COPD, as effective treatment of the former condition likely conveys an important survival advantage. Finally, morbid obesity in COPD presents significant challenges to effective management, given the combined effects of erosion of the ventilatory reserve and serious metabolic and cardiovascular comorbidities that collectively predispose to an increased risk of death from respiratory failure.
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102
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Scuarcialupi MEA, Berton DC, Cordoni PK, Squassoni SD, Fiss E, Neder JA. Can bronchodilators improve exercise tolerance in COPD patients without dynamic hyperinflation? J Bras Pneumol 2014; 40:111-8. [PMID: 24831394 PMCID: PMC4083636 DOI: 10.1590/s1806-37132014000200003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/02/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate the modulatory effects that dynamic hyperinflation (DH), defined as a reduction in inspiratory capacity (IC), has on exercise tolerance after bronchodilator in patients with COPD. METHODS An experimental, randomized study involving 30 COPD patients without severe hypoxemia. At baseline, the patients underwent clinical assessment, spirometry, and incremental cardiopulmonary exercise testing (CPET). On two subsequent visits, the patients were randomized to receive a combination of inhaled fenoterol/ipratropium or placebo. All patients then underwent spirometry and submaximal CPET at constant speed up to the limit of tolerance (Tlim). The patients who showed ΔIC(peak-rest) < 0 were considered to present with DH (DH+). RESULTS In this sample, 21 patients (70%) had DH. The DH+ patients had higher airflow obstruction and lower Tlim than did the patients without DH (DH-). Despite equivalent improvement in FEV1 after bronchodilator, the DH- group showed higher ΔIC(bronchodilator-placebo) at rest in relation to the DH+ group (p < 0.05). However, this was not found in relation to ΔIC at peak exercise between DH+ and DH- groups (0.19 ± 0.17 L vs. 0.17 ± 0.15 L, p > 0.05). In addition, both groups showed similar improvements in Tlim after bronchodilator (median [interquartile range]: 22% [3-60%] vs. 10% [3-53%]; p > 0.05). CONCLUSIONS Improvement in TLim was associated with an increase in IC at rest after bronchodilator in HD- patients with COPD. However, even without that improvement, COPD patients can present with greater exercise tolerance after bronchodilator provided that they develop DH during exercise.
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Affiliation(s)
| | | | | | | | - Elie Fiss
- Paraíba School of Medical Sciences, João Pessoa, Brazil
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103
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Physiological mechanisms of dyspnea relief following ivacaftor in cystic fibrosis: a case report. Respir Physiol Neurobiol 2014; 205:105-8. [PMID: 25447681 DOI: 10.1016/j.resp.2014.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 10/24/2014] [Accepted: 10/29/2014] [Indexed: 11/22/2022]
Abstract
Ivacaftor is a novel oral pharmacologic agent that specifically targets the genetic defect of cystic fibrosis (CF) by augmenting chloride conductance through the CF transmembrane regulator (CFTR) protein. For individuals with CF and at least one copy of the G551D gating mutation, improvements in sweat chloride, nutritional parameters, lung function, respiratory symptoms, and exercise tolerance (i.e., 6-min walk distance) are attained within 2 weeks of initiating ivacaftor. However, there are no reports detailing the physiological and sensory implications of these improvements and their underlying mechanisms. We performed detailed cardiopulmonary exercise testing pre- and post-initiation of ivacaftor in a 27-year old male with CF (CFTR genotype F508del/G551D) and chronic airflow obstruction (FEV1/FVC=0.44). An improvement of FEV1 (by 16%) following ivacaftor was accompanied by clinically significant improvements in exercise capacity (by 14%) and exertional dyspnea (by up to 5 Borg scale units). These improvements were attributable, at least in part, to favorable alterations in the ventilatory response to exercise, including improvements in breathing patterns (e.g., increased tidal volume and reduced breathing frequency) and dynamic operating lung volumes (e.g., increased inspiratory reserve volume and inspiratory capacity) and decreases in dynamic mechanical ventilatory constraints.
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104
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Neder JA, O'Donnell CDJ, Cory J, Langer D, Ciavaglia CE, Ling Y, Webb KA, O'Donnell DE. Ventilation Distribution Heterogeneity at Rest as a Marker of Exercise Impairment in Mild-to-Advanced COPD. COPD 2014; 12:249-56. [PMID: 25230258 DOI: 10.3109/15412555.2014.948997] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The difference between total lung capacity (TLC) by body plethysmography and alveolar volume (VA) from the single-breath lung diffusing capacity measurement provides an index of ventilation distribution inequalities in COPD. The relevance of these abnormalities to dyspnea and exercise intolerance across the continuum of disease severity remains unknown. Two-hundred and seventy-six COPD patients distributed across GOLD grades 1 to 4 and 67 healthy controls were evaluated. The "poorly communicating fraction" (PCF) of the TLC was estimated as the ratio (%) of TLC to VA. Healthy subjects showed significantly lower PCF values compared to GOLD grades 1 to 4 (10 ± 3% vs. 17 ± 8% vs. 27 ± 10% vs. 37 ± 10% vs. 56 ± 11%, respectively; p < 0.05). Pulmonary gas exchange impairment, mechanical ventilatory constraints and ventilation-corrected dyspnea scores worsened across PCF tertiles (p < 0.05). Of note, GOLD grades 1 and 2 patients with the highest PCF values had pronounced exercise ventilatory inefficiency and dyspnea as a limiting symptom. In fact, dyspnea was a significant contributor to exercise limitation only in those with "moderate" or "extensive" PCF (p < 0.05). A receiver operating characteristics curve analysis revealed that PCF was a better predictor of severely reduced maximal exercise capacity than traditional pulmonary function indexes including FEV1 (area under the curve (95% confidence interval) = 0.85 (0.81-0.89), best cutoff = 33.4%; p < 0.01). In conclusion, PCF is a readily available functional marker of gas exchange and mechanical abnormalities relevant to dyspnea and exercise intolerance across the COPD grades.
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Affiliation(s)
- J Alberto Neder
- 1 Respiratory Investigation Unit, Queen's University & Kingston General Hospital , Kingston, Ontario , Canada
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105
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Langer D, Ciavaglia CE, Neder JA, Webb KA, O'Donnell DE. Lung hyperinflation in chronic obstructive pulmonary disease: mechanisms, clinical implications and treatment. Expert Rev Respir Med 2014; 8:731-49. [PMID: 25159007 DOI: 10.1586/17476348.2014.949676] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lung hyperinflation is highly prevalent in patients with chronic obstructive pulmonary disease and occurs across the continuum of the disease. A growing body of evidence suggests that lung hyperinflation contributes to dyspnea and activity limitation in chronic obstructive pulmonary disease and is an important independent risk factor for mortality. In this review, we will summarize the recent literature on pathogenesis and clinical implications of lung hyperinflation. We will outline the contribution of lung hyperinflation to exercise limitation and discuss its impact on symptoms and physical activity. Finally, we will examine the physiological rationale and efficacy of selected pharmacological and non-pharmacological 'lung deflating' interventions aimed at improving symptoms and physical functioning.
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Affiliation(s)
- Daniel Langer
- Respiratory Investigation Unit, Queen's University & Kingston General Hospital, 102 Stuart Street, Kingston, ON K7L 2V6, Canada
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106
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Does expiratory muscle activity influence dynamic hyperinflation and exertional dyspnea in COPD? Respir Physiol Neurobiol 2014; 199:24-33. [DOI: 10.1016/j.resp.2014.04.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 04/15/2014] [Accepted: 04/18/2014] [Indexed: 11/24/2022]
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107
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Abstract
As parenchymal lung disease in chronic obstructive pulmonary disease becomes increasingly severe there is a diminishing prospect of drug therapies conferring clinically useful benefit. Lung volume reduction surgery is effective in patients with heterogenous upper zone emphysema and reduced exercise tolerance, and is probably underused. Rapid progress is being made in nonsurgical approaches to lung volume reduction, but use outside specialized centers cannot be recommended presently. Noninvasive ventilation given to patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease reduces mortality and morbidity, but the place of chronic non-invasive ventilatory support remains more controversial.
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Affiliation(s)
- Patrick Brian Murphy
- Lane Fox Clinical Respiratory Physiology Group, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Zaid Zoumot
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Michael Iain Polkey
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK.
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108
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Holm SM, Rodgers W, Haennel RG, MacDonald GF, Bryan TL, Bhutani M, Wong E, Stickland MK. Effect of modality on cardiopulmonary exercise testing in male and female COPD patients. Respir Physiol Neurobiol 2014; 192:30-8. [DOI: 10.1016/j.resp.2013.11.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 11/06/2013] [Accepted: 11/22/2013] [Indexed: 10/25/2022]
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109
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Gargiulo P, Apostolo A, Perrone-Filardi P, Sciomer S, Palange P, Agostoni P. A non invasive estimate of dead space ventilation from exercise measurements. PLoS One 2014; 9:e87395. [PMID: 24498096 PMCID: PMC3907547 DOI: 10.1371/journal.pone.0087395] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 12/21/2013] [Indexed: 11/19/2022] Open
Abstract
Rationale During exercise, heart failure patients (HF) show an out-of-proportion ventilation increase, which in patients with COPD is blunted. When HF and COPD coexist, the ventilatory response to exercise is unpredictable. Objectives We evaluated a human model of respiratory impairment in 10 COPD-free HF patients and in 10 healthy subjects, tested with a progressive workload exercise with different added dead space. We hypothesized that increased serial dead space upshifts the VE vs. VCO2 relationship and that the VE-axis intercept might be an index of dead space ventilation. Measurements All participants performed a cardiopulmonary exercise test with 0, 250 and 500 mL of additional dead space. Since DS does not contribute to gas exchange, ventilation relative to dead space is ventilation at VCO2 = 0, i.e. VE-axis intercept. We compared dead space volume, estimated dividing VE-axis intercept by the intercept on respiratory rate axis of the respiratory rate vs. VCO2 relationship with standard method measured DS. Main results In HF, adding dead space increased VE-axis intercept (+0 mL = 4.98±1.63 L; +250 mL = 9.69±2.91 L; +500 mL = 13.26±3.18 L; p<0.001) and upshifted the VE vs.VCO2 relationship, with a minor slope rise (+0 mL = 27±4 L; +250 = 28±5; +500 = 29±4; p<0.05). In healthy, adding dead space increased VE-axis intercept (+0 mL = 4.9±1.4 L; +250 = 9.3±2.4; +500 = 13.1±3.04; p<0.001) without slope changes. Measured and estimated dead space volumes were similar both in HF and healthy subjects. Conclusions VE-axis intercept is related to dead space ventilation and dead space volume can be non-invasively estimated.
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Affiliation(s)
- Paola Gargiulo
- SDN Foundation, Institute of Diagnostic and Nuclear Development, Naples, Italy
| | | | - Pasquale Perrone-Filardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, “Federico II” University, Naples, Italy
| | - Susanna Sciomer
- Department of Cardiovascular and Respiratory Sciences, “La Sapienza” University, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Division of Pulmonary Research, “La Sapienza” University, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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110
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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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111
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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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112
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Thoraco-abdominal motion/displacement does not affect dyspnea following exercise training in COPD patients. Respir Physiol Neurobiol 2013; 190:124-30. [PMID: 24140573 DOI: 10.1016/j.resp.2013.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 09/02/2013] [Accepted: 10/09/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE The interrelations among chest wall kinematics (displacement and configuration), ventilatory profile and dyspnea relief following cycle exercise training (EXT) have not been systematically evaluated in hyperinflated chronic obstructive pulmonary disease (COPD) patients. We hypothesize that a decrease in ventilation affects dyspnea relief, regardless of the changes in chest wall kinematics. METHODS Fourteen patients were studied before and after 24-session exercise training program. We evaluated the volumes of chest wall and its compartments (rib cage, and abdomen) using optoelectronic plethysmography. RESULTS At iso-time EXT (i) reduced ventilation, respiratory frequency and dyspnea (by Borg scale), mildly improved rib cage configuration, but left operational volumes unchanged; (ii) Borg was much smaller for any comparable inspiratory reserve volume (IRVcw), and a decrease in IRVcw was tolerated much better for any given Borg. CONCLUSIONS Regardless of the changes in chest wall kinematics, a decrease in ventilation attenuates dyspnea following EXT.
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113
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Bronchodilator reversibility in chronic obstructive pulmonary disease: use and limitations. THE LANCET RESPIRATORY MEDICINE 2013; 1:564-73. [PMID: 24461617 DOI: 10.1016/s2213-2600(13)70086-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The change in forced expiratory volume in 1 s (FEV1) after administration of a short-acting bronchodilator has been widely used to identify patients with chronic obstructive pulmonary disease (COPD) who have a potentially different disease course and response to treatment. Despite the apparent simplicity of the test, it is difficult to interpret or rely on. Test performance is affected by the day of testing, the severity of baseline lung-function impairment, and the number of drugs given to test. Recent data suggest that the response to bronchodilators is not enhanced in patients with COPD and does not predict clinical outcomes. In this Review we will discuss the insight that studies of bronchodilator reversibility have provided into the nature of the COPD, and how the abnormal physiology seen in patients with this disorder can be interpreted.
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114
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Smith BM, Kawut SM, Bluemke DA, Basner RC, Gomes AS, Hoffman E, Kalhan R, Lima JAC, Liu CY, Michos ED, Prince MR, Rabbani L, Rabinowitz D, Shimbo D, Shea S, Barr RG. Pulmonary hyperinflation and left ventricular mass: the Multi-Ethnic Study of Atherosclerosis COPD Study. Circulation 2013; 127:1503-11, 1511e1-6. [PMID: 23493320 PMCID: PMC4018203 DOI: 10.1161/circulationaha.113.001653] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 02/26/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Left ventricular (LV) mass is an important predictor of heart failure and cardiovascular mortality, yet determinants of LV mass are incompletely understood. Pulmonary hyperinflation in chronic obstructive pulmonary disease (COPD) may contribute to changes in intrathoracic pressure that increase LV wall stress. We therefore hypothesized that residual lung volume in COPD would be associated with greater LV mass. METHODS AND RESULTS The Multi-Ethnic Study of Atherosclerosis (MESA) COPD Study recruited smokers 50 to 79 years of age who were free of clinical cardiovascular disease. LV mass was measured by cardiac magnetic resonance. Pulmonary function testing was performed according to guidelines. Regression models were used to adjust for age, sex, body size, blood pressure, and other cardiac risk factors. Among 119 MESA COPD Study participants, the mean age was 69±6 years, 55% were male, and 65% had COPD, mostly of mild or moderate severity. Mean LV mass was 128±34 g. Residual lung volume was independently associated with greater LV mass (7.2 g per 1-SD increase in residual volume; 95% confidence interval, 2.2-12; P=0.004) and was similar in magnitude to that of systolic blood pressure (7.6 g per 1-SD increase in systolic blood pressure; 95% confidence interval, 4.3-11; P<0.001). Similar results were observed for the ratio of LV mass to end-diastolic volume (P=0.02) and with hyperinflation measured as residual volume to total lung capacity ratio (P=0.009). CONCLUSIONS Pulmonary hyperinflation, as measured by residual lung volume or residual lung volume to total lung capacity ratio, is associated with greater LV mass.
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Affiliation(s)
- Benjamin M Smith
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
| | - Robert C Basner
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Eric Hoffman
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Ravi Kalhan
- Asthma and COPD Program, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Johns Hopkins University, Baltimore, MD
| | - João AC Lima
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Chia-Ying Liu
- Department of Radiology, Johns Hopkins University, Baltimore, MD
| | - Erin D Michos
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Martin R Prince
- Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - LeRoy Rabbani
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Daichi Shimbo
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Steven Shea
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - R Graham Barr
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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115
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Thomas M, Decramer M, O'Donnell DE. No room to breathe: the importance of lung hyperinflation in COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:101-11. [PMID: 23429861 PMCID: PMC6442765 DOI: 10.4104/pcrj.2013.00025] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/19/2012] [Accepted: 12/22/2012] [Indexed: 11/17/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are progressively limited in their ability to undertake normal everyday activities by a combination of exertional dyspnoea and peripheral muscle weakness. COPD is characterised by expiratory flow limitation, resulting in air trapping and lung hyperinflation. Hyperinflation increases acutely under conditions such as exercise or exacerbations, with an accompanying sharp increase in the intensity of dyspnoea to distressing and intolerable levels. Air trapping, causing increased lung hyperinflation, can be present even in milder COPD during everyday activities. The resulting activity-related dyspnoea leads to a vicious spiral of activity avoidance, physical deconditioning, and reduced quality of life, and has implications for the early development of comorbidities such as cardiovascular disease. Various strategies exist to reduce hyperinflation, notably long-acting bronchodilator treatment (via reduction in flow limitation and improved lung emptying) and an exercise programme (via decreased respiratory rate, reducing ventilatory demand), or their combination. Optimal bronchodilation can reduce exertional dyspnoea and increase a patient's ability to exercise, and improves the chance of successful outcome of a pulmonary rehabilitation programme. There should be a lower threshold for initiating treatments appropriate to the stage of the disease, such as long-acting bronchodilators and an exercise programme for patients with mild-to-moderate disease who experience persistent dyspnoea.
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Affiliation(s)
- Mike Thomas
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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116
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Boerrigter BG, Bogaard HJ, Trip P, Groepenhoff H, Rietema H, Holverda S, Boonstra A, Postmus PE, Westerhof N, Vonk-Noordegraaf A. Ventilatory and cardiocirculatory exercise profiles in COPD: the role of pulmonary hypertension. Chest 2013; 142:1166-1174. [PMID: 22556320 DOI: 10.1378/chest.11-2798] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a well-recognized complication of COPD. The impact of PH on exercise tolerance is largely unknown. We evaluated and compared the circulatory and ventilatory profiles during exercise in patients with COPD without PH, with moderate PH, and with severe PH. METHODS Forty-seven patients, GOLD (Global Initiative for Chronic Obstructive Lung Disease)stages II to IV, underwent cardiopulmonary exercise testing and right-sided heart catheterization at rest and during exercise. Patients were divided into three groups based on mean pulmonary artery pressure (mPAP) at rest: no PH (mPAP, < 25 mm Hg), moderate PH (mPAP, 25-39 mm Hg),and severe PH (mPAP, ≥ 40 mm Hg). Mixed venous oxygen saturation (S VO 2 ) was used for evaluating the circulatory reserve. Pa CO 2 and the calculated breathing reserve were used for evaluation of the ventilatory reserve. RESULTS Patients without PH (n = 24) had an end-exercise S VO 2 of 48%± 9%, an increasing Pa CO 2 with exercise, and a breathing reserve of 22% ± 20%. Patients with moderate PH (n = 14) had an exercise S VO 2 of 40% ± 8%, an increasing Pa CO 2 , and a breathing reserve of 26% ± 15%. Patients with severe PH (n =9) had a significantly lower end-exercise S VO 2 (30% ± 6%), a breathing reserve of 37% ± 11%, and an absence of Pa CO 2 accumulation. CONCLUSION Patients with severe PH showed an exhausted circulatory reserve at the end of exercise.A profile of circulatory reserve in combination with ventilatory impairments was found inpatients with COPD and moderate or no PH. The results suggest that pulmonary vasodilation might only improve exercise tolerance in patients with COPD and severe PH.
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Affiliation(s)
- Bart G Boerrigter
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm J Bogaard
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Pia Trip
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Herman Groepenhoff
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Heleen Rietema
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Sebastiaan Holverda
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Anco Boonstra
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Pieter E Postmus
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Diseases, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands.
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117
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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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Assessing exercise limitation using cardiopulmonary exercise testing. Pulm Med 2012; 2012:824091. [PMID: 23213518 PMCID: PMC3506917 DOI: 10.1155/2012/824091] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 09/26/2012] [Indexed: 01/12/2023] Open
Abstract
The cardiopulmonary exercise test (CPET) is an important physiological investigation that can aid clinicians in their evaluation of exercise intolerance and dyspnea. Maximal oxygen consumption ([Formula: see text]) is the gold-standard measure of aerobic fitness and is determined by the variables that define oxygen delivery in the Fick equation ([Formula: see text] = cardiac output × arterial-venous O(2) content difference). In healthy subjects, of the variables involved in oxygen delivery, it is the limitations of the cardiovascular system that are most responsible for limiting exercise, as ventilation and gas exchange are sufficient to maintain arterial O(2) content up to peak exercise. Patients with lung disease can develop a pulmonary limitation to exercise which can contribute to exercise intolerance and dyspnea. In these patients, ventilation may be insufficient for metabolic demand, as demonstrated by an inadequate breathing reserve, expiratory flow limitation, dynamic hyperinflation, and/or retention of arterial CO(2). Lung disease patients can also develop gas exchange impairments with exercise as demonstrated by an increased alveolar-to-arterial O(2) pressure difference. CPET testing data, when combined with other clinical/investigation studies, can provide the clinician with an objective method to evaluate cardiopulmonary physiology and determination of exercise intolerance.
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O'Donnell DE, O'Donnell CDJ, Webb KA, Guenette JA. Respiratory Consequences of Mild-to-Moderate Obesity: Impact on Exercise Performance in Health and in Chronic Obstructive Pulmonary Disease. Pulm Med 2012; 2012:818925. [PMID: 23097698 PMCID: PMC3477561 DOI: 10.1155/2012/818925] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/26/2012] [Indexed: 02/04/2023] Open
Abstract
In many parts of the world, the prevalence of obesity is increasing at an alarming rate. The association between obesity, multiple comorbidities, and increased mortality is now firmly established in many epidemiological studies. However, the link between obesity and exercise intolerance is less well studied and is the focus of this paper. Although exercise limitation is likely to be multifactorial in obesity, it is widely believed that the respiratory mechanical constraints and the attendant dyspnea are important contributors. In this paper, we examined the evidence that critical ventilatory constraint is a proximate source of exercise limitation in individuals with mild-to-moderate obesity. We first reviewed existing information on exercise performance, including ventilatory and perceptual response patterns, in obese individuals who are otherwise healthy. We then considered the impact of obesity in patients with preexisting respiratory mechanical abnormalities due to chronic obstructive pulmonary disease (COPD), with particular reference to the effect on dyspnea and exercise performance. Our main conclusion, based on the existing and rather sparse literature on the subject, is that abnormalities of dynamic respiratory mechanics are not likely to be the dominant source of dyspnea and exercise intolerance in otherwise healthy individuals or in patients with COPD with mild-to-moderate obesity.
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Affiliation(s)
- Denis E. O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
| | - Conor D. J. O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
| | - Katherine A. Webb
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
| | - Jordan A. Guenette
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
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Laveneziana P, Bruni GI, Presi I, Stendardi L, Duranti R, Scano G. Tidal volume inflection and its sensory consequences during exercise in patients with stable asthma. Respir Physiol Neurobiol 2012; 185:374-9. [PMID: 23026436 DOI: 10.1016/j.resp.2012.08.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 08/09/2012] [Accepted: 08/30/2012] [Indexed: 11/25/2022]
Abstract
Sixteen patients with stable asthma performed a symptom-limited constant work-rate CWR cycle exercise during which breathing pattern, operating lung volumes, dyspnea intensity and its qualitative descriptors were measured. An inflection in the relation between tidal volume (V(T)) and ventilation (V˙(E)) was observed in each subject. The sense of "work/effort" was the dominant dyspnea descriptor selected up to the V(T)/V˙(E) inflection, whereas after it dyspnea intensity and the selection frequency of "unsatisfied inspiration" rose steeply in 37.5% of subjects in whom inspiratory reserve volume (IRV) had decreased to a critical level of 0.6L at the V(T) inflection point. In contrast, dyspnea increased linearly with exercise time and V˙(E), and "work/effort" was the dominant descriptor selected throughout exercise in 62.5% of subjects in whom the V(T)/V˙(E) inflection occurred at a preserved IRV. The V(T) inflection during exercise in patients with stable asthma marked a mechanical event with important sensory consequences only when it occurred at a critical reduced IRV.
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Affiliation(s)
- Pierantonio Laveneziana
- Université Pierre et Marie Curie (Paris VI), Equipe de Recherche ER 10 UPMC, Laboratoire de Physio-Pathologie Respiratoire, Faculté de Médecine Pierre et Marie Curie (site Pitié-Salpêtrière), Paris 75013, France.
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Agustí A, Barnes PJ. Update in chronic obstructive pulmonary disease 2011. Am J Respir Crit Care Med 2012; 185:1171-6. [PMID: 22661523 DOI: 10.1164/rccm.201203-0505up] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alvar Agustí
- Institut del Torax, Hospital Clinic, Villarroel 170, Barcelona, Spain.
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Hareendran A, Leidy NK, Monz BU, Winnette R, Becker K, Mahler DA. Proposing a standardized method for evaluating patient report of the intensity of dyspnea during exercise testing in COPD. Int J Chron Obstruct Pulmon Dis 2012; 7:345-55. [PMID: 22745534 PMCID: PMC3379870 DOI: 10.2147/copd.s29571] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Measuring dyspnea intensity associated with exercise provides insights into dyspnea-limited exercise capacity, and has been used to evaluate treatment outcomes for chronic obstructive pulmonary disease (COPD). Three patient-reported outcome scales commonly cited for rating dyspnea during exercise are the modified Borg scale (MBS), numerical rating scale for dyspnea (NRS-D), and visual analogue scale for dyspnea (VAS-D). Various versions of each scale were found. Our objective was to evaluate the content validity of scales commonly used in COPD studies, to explore their ability to capture patients' experiences of dyspnea during exercise, and to evaluate a standardized version of the MBS. METHODS A two-stage procedure was used, with each stage involving one-on-one interviews with COPD patients who had recently completed a clinic-based exercise event on a treadmill or cycle ergometer. An open-ended elicitation interview technique was used to understand patients' experiences of exercise-induced dyspnea, followed by patients completing the three scales. The cognitive interviewing component of the study involved specific questions to evaluate the patients' perspectives of the content and format of the scales. Results from Stage 1 were used to develop a standardized version of the MBS, which was then subjected to further content validity assessment during Stage 2. RESULTS Thirteen patients participated in the two-stage process (n = 6; n = 7). Mean forced expiratory volume in 1 second (FEV(1)) percent predicted was 40%, mean age 57 years, and 54% were male. Participants used a variety of terms to describe the intensity and variability of exercise-induced dyspnea. Subjects understood the instructions and format of the standardized MBS, and were able to easily select a response to report the level of dyspnea associated with their recent standardized exercise. CONCLUSION This study provides initial evidence in support of using a standardized version of the MBS version for quantifying dyspnea intensity associated with exercise in patients with COPD.
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Albuquerque ALPD, Baldi BG. Hiperinsuflação dinâmica no esforço: ainda muito a ser esclarecido. J Bras Pneumol 2012; 38:1-3. [DOI: 10.1590/s1806-37132012000100001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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