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The effect of exercise training and physiotherapy on left and right heart function in heart failure with preserved ejection fraction: a systematic literature review. Heart Fail Rev 2023; 28:193-206. [PMID: 35831689 PMCID: PMC9902326 DOI: 10.1007/s10741-022-10259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 02/07/2023]
Abstract
The impact of exercise training and physiotherapy on heart function and pulmonary circulation parameters in heart failure with preserved ejection fraction (HFpEF) patients is uncertain. Hence, we performed a systematic review of published trials studying physical training in HFpEF population, with a focus on exercise and physiotherapy effect on left ventricular (LV), right ventricular (RV) morphological, functional, and pulmonary circulation parameters. We searched Cochrane Library and MEDLINE/PubMed for trials that evaluated the effect of exercise training and/or physiotherapy in adult HFpEF patients (defined as LVEF ≥ 45%), including publications until March 2021. Our systematic review identified eighteen articles (n = 418 trained subjects, 4 to 52 weeks of training) and covered heterogeneous trials with various populations, designs, methodologies, and interventions. Five of twelve trials revealed a significant reduction of mitral E/e' ratio after the training (- 1.2 to - 4.9). Seven studies examined left atrial volume index; three of them showed its decrease (- 3.7 to - 8 ml/m2). Findings were inconsistent regarding improvement of cardiac output, E/A ratio, and E wave DecT and uncertain for RV function and pulmonary hypertension parameters. For now, no reliable evidence about rehabilitation effect on HFpEF cardiac mechanisms is available. There are some hypotheses generating findings on potential positive effects to parameters of LV filling pressure (E/e'), left atrium size, cardiac output, and RV function. This encourages a broader and more complex assessment of parameters reflecting cardiac function in future HFpEF exercise training studies.
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Tuesta M, Yáñez-Sepúlveda R, Verdugo-Marchese H, Mateluna C, Alvear-Ordenes I. Near-Infrared Spectroscopy Used to Assess Physiological Muscle Adaptations in Exercise Clinical Trials: A Systematic Review. BIOLOGY 2022; 11:biology11071073. [PMID: 36101451 PMCID: PMC9312707 DOI: 10.3390/biology11071073] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/18/2022]
Abstract
Simple Summary In recent years, physical exercise has been used as a therapeutic strategy in various clinical conditions, with pleiotropic benefits. Near-infrared spectroscopy (NIRS) has been positioned as a tool to analyze effects on muscle oxygenation, also allowing knowledge of adaptations on microvascular levels and muscle metabolism in subjects with central and peripheral vascular alterations, as well as cardiovascular, metabolic, and/or musculoskeletal diseases. This knowledge can help to guide therapeutic exercise specialists in decision making regarding the prescription and follow up of physical exercise as a therapeutic tool in the observation of acute or chronic adaptations to improve efficiency in the treatment and recovery of these patients. This review presents an overview of the effects of exercise clinical trials on muscle oxygenation in different pathologies and the technical characteristics related to the equipment used. Abstract Using muscle oxygenation to evaluate the therapeutic effects of physical exercise in pathologies through near-infrared spectroscopy (NIRS) is of great interest. The aim of this review was to highlight the use of muscle oxygenation in exercise interventions in clinical trials and to present the technological characteristics related to the equipment used in these studies. PubMed, WOS, and Scopus databases were reviewed up to December 2021. Scientific articles that evaluated muscle oxygenation after exercise interventions in the sick adult population were selected. The PEDro scale was used to analyze the risk of bias (internal validity). The results were presented grouped in tables considering the risk of bias scores, characteristics of the devices, and the effects of exercise on muscle oxygenation. All the stages were carried out using preferred reporting items for systematic reviews and meta-analyses (PRISMA). The search strategy yielded 820 clinical studies, of which 18 met the eligibility criteria. This review detailed the characteristics of 11 NIRS devices used in clinical trials that used physical exercise as an intervention. The use of this technology made it possible to observe changes in muscle oxygenation/deoxygenation parameters such as tissue saturation, oxyhemoglobin, total hemoglobin, and deoxyhemoglobin in clinical trials of patients with chronic disease. It was concluded that NIRS is a non-invasive method that can be used in clinical studies to detect the effects of physical exercise training on muscle oxygenation, hemodynamics, and metabolism. It will be necessary to unify criteria such as the measurement site, frequency, wavelength, and variables for analysis. This will make it possible to compare different models of exercise/training in terms of time, intensity, frequency, and type to obtain more precise conclusions about their benefits for patients.
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Affiliation(s)
- Marcelo Tuesta
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago 7591538, Chile;
- Laboratory of Sport Sciences, Centro de Medicina Deportiva Sports MD, Viña del Mar 2521156, Chile;
| | - Rodrigo Yáñez-Sepúlveda
- Applied Physiology Laboratory (FISAP), Institute of Biomedicine (IBIOMED), University of León, 24071 León, Spain;
- School of Education, Pedagogy in Physical Education, Universidad Viña del Mar, Viña del Mar 2572007, Chile
| | | | - Cristián Mateluna
- Physical Education School, Pontificia Universidad Católica de Valparaíso, Valparaíso 2530388, Chile;
| | - Ildefonso Alvear-Ordenes
- Applied Physiology Laboratory (FISAP), Institute of Biomedicine (IBIOMED), University of León, 24071 León, Spain;
- Correspondence:
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3
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Demirel M, Külahçıoğlu Ş, Tokgöz HC, Akbal ÖY, Hakgör A, Karagöz A, Tanyeri S, Keskin B, Kültürsay B, Efe SÇ, Bayram Z, Tanboğa İH, Özdemir N, Kaymaz C. Impaired endothelium-dependent and endothelium-independent systemic vasodilatory reserve in pulmonary hypertension regardless the clinical group: A generalized dysfunction beyond the pulmonary arteries? Anatol J Cardiol 2021; 25:733-740. [PMID: 34622788 DOI: 10.5152/anatoljcardiol.2021.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Endothelium-dependent (ED) and endothelium-independent (EI) flow-mediated vasodilatation (FMD) have been used as measures of systemic arterial vasodilatory reserve. In this study, we aimed to assess both ED-FMD and EI-FMD in different groups with pulmonary hypertension (PH), and to investigate the relationship of these measures with clinical, echocardiographic, and invasive parameters of diseases severity and targeted treatment status. METHODS Our study population comprised 41 patients with PH [28 (68.2%) women, age 46.3±19.6 years] including idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, and chronic thromboembolic PH in whom diagnosis were confirmed in accordance with current guidelines and 17 age and sex-matched healthy controls. The brachial artery (BA) was used for assessment of FMD with Duplex ultrasound, and serial changes in diameter were recorded at baseline, 1, and 3 minutes after termination of 2-minute external occlusive compression for ED-FMD, and after sublingual intake of glycerol trinitrate for EI-FMD, respectively. RESULTS Compared with controls, overall the PH group showed significantly lower ED-FMD (0.65±0.21 vs. 0.30±0.23 and 0.65±0.18 vs. 0.24±0.21) and EI-FMD (0.67±0.15 vs. 0.37±0.25 and 0.75±0.20 vs. 0.32±0.24) responses at 1st and 3rd min (p<0.001 for all). All these changes in the values of ED-FMD and EI-FMD were comparable among the PH subgroups. Neither ED-FMD nor EI-FMD were correlated with measures of PH severity and targeted therapy (TT) status (p>0.05). CONCLUSION Our results suggest an impaired BA vasodilatory reserve in patients with PH regardless of the clinical subgroup. Although these findings seem to be consistent with systemic dysfunction, acute FMD may not reflect the severity of PH and cannot be used as a potential surrogate for outcome in this setting.
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Affiliation(s)
- Muhittin Demirel
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Şeyhmus Külahçıoğlu
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Hacer Ceren Tokgöz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Özgür Y Akbal
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Aykun Hakgör
- Department of Cardiology, Bingöl State Hospital; Bingöl-Turkey
| | - Ali Karagöz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Seda Tanyeri
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Berhan Keskin
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Barkın Kültürsay
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Zübeyde Bayram
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | | | - Nihal Özdemir
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
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4
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Demirel M, Külahçıoğlu Ş, Tokgöz HC, Akbal ÖY, Hakgör A, Karagöz A, Tanyeri S, Keskin B, Kültürsay B, Efe SÇ, Bayram Z, Tanboğa İH, Özdemir N, Kaymaz C. Impaired endothelium-dependent and endothelium-independent systemic vasodilatory reserve in pulmonary hypertension regardless the clinical group: A generalized dysfunction beyond the pulmonary arteries? Anatol J Cardiol 2021. [PMID: 34622788 DOI: 10.5152/anatoljcardiol.2021.474)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Endothelium-dependent (ED) and endothelium-independent (EI) flow-mediated vasodilatation (FMD) have been used as measures of systemic arterial vasodilatory reserve. In this study, we aimed to assess both ED-FMD and EI-FMD in different groups with pulmonary hypertension (PH), and to investigate the relationship of these measures with clinical, echocardiographic, and invasive parameters of diseases severity and targeted treatment status. METHODS Our study population comprised 41 patients with PH [28 (68.2%) women, age 46.3±19.6 years] including idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, and chronic thromboembolic PH in whom diagnosis were confirmed in accordance with current guidelines and 17 age and sex-matched healthy controls. The brachial artery (BA) was used for assessment of FMD with Duplex ultrasound, and serial changes in diameter were recorded at baseline, 1, and 3 minutes after termination of 2-minute external occlusive compression for ED-FMD, and after sublingual intake of glycerol trinitrate for EI-FMD, respectively. RESULTS Compared with controls, overall the PH group showed significantly lower ED-FMD (0.65±0.21 vs. 0.30±0.23 and 0.65±0.18 vs. 0.24±0.21) and EI-FMD (0.67±0.15 vs. 0.37±0.25 and 0.75±0.20 vs. 0.32±0.24) responses at 1st and 3rd min (p<0.001 for all). All these changes in the values of ED-FMD and EI-FMD were comparable among the PH subgroups. Neither ED-FMD nor EI-FMD were correlated with measures of PH severity and targeted therapy (TT) status (p>0.05). CONCLUSION Our results suggest an impaired BA vasodilatory reserve in patients with PH regardless of the clinical subgroup. Although these findings seem to be consistent with systemic dysfunction, acute FMD may not reflect the severity of PH and cannot be used as a potential surrogate for outcome in this setting.
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Affiliation(s)
- Muhittin Demirel
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Şeyhmus Külahçıoğlu
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Hacer Ceren Tokgöz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Özgür Y Akbal
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Aykun Hakgör
- Department of Cardiology, Bingöl State Hospital; Bingöl-Turkey
| | - Ali Karagöz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Seda Tanyeri
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Berhan Keskin
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Barkın Kültürsay
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Zübeyde Bayram
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | | | - Nihal Özdemir
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Hamidiye Faculty of Medicine, Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey
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5
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Müller J, Lichtblau M, Saxer S, Calendo LR, Carta AF, Schneider SR, Berlier C, Furian M, Bloch KE, Schwarz EI, Ulrich S. Effect of Breathing Oxygen-Enriched Air on Exercise Performance in Patients With Pulmonary Hypertension Due to Heart Failure With Preserved Ejection Fraction: A Randomized, Placebo-Controlled, Crossover Trial. Front Med (Lausanne) 2021; 8:692029. [PMID: 34395475 PMCID: PMC8357069 DOI: 10.3389/fmed.2021.692029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the effects of breathing oxygen-enriched air (oxygen) on exercise performance in patients with pulmonary hypertension due to heart failure with preserved ejection fraction (PH-HFpEF). Methods: Ten patients with PH-HFpEF (five women, age 60 ± 9 y, mPAP 37 ± 14 mmHg, PAWP 18 ± 2 mmHg, PVR 3 ± 3 WU, resting SpO2 98 ± 2%) performed two-cycle incremental exercise tests (IET) and two constant-work-rate exercise test (CWRET) at 75% maximal work-rate (Wmax), each with ambient air (FiO2 0.21) and oxygen (FiO2 0.5) in a randomized, single-blinded, cross-over design. The main outcomes were the change in Wmax (IET) and cycling time (CWRET) with oxygen vs. air. Blood gases at rest and end-exercise, dyspnea by Borg CR10 score at end-exercise; continuous SpO2, minute ventilation (V'E), carbon dioxide output (V'CO2), and cerebral and quadricep muscle tissue oxygenation (CTO and QMTO) were measured. Results: With oxygen vs. air, Wmax (IET) increased from 94 ± 36 to 99 ± 36 W, mean difference (95% CI) 5.4 (0.9–9.8) W, p = 0.025, and cycling time (CWRET) from 532 ± 203 to 680 ± 76 s, +148 (31.8–264) s, p = 0.018. At end-exercise with oxygen, Borg dyspnea score and V'E/V'CO2 were lower, whereas PaO2 and end-tidal PaCO2 were higher. Other parameters were unchanged. Conclusion: Patients with PH-HFpEF not revealing resting hypoxemia significantly improved their exercise performance while breathing oxygen-enriched air along with less subjective dyspnea sensation, a better blood oxygenation, and an enhanced ventilatory efficiency. Future studies should investigate whether prolonged training with supplemental oxygen would increase the training effect and, potentially, daily activity for PH-HFpEF patients. Clinical Trial Registration: [clinicaltrials.gov], identifier [NCT04157660].
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Affiliation(s)
- Julian Müller
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Mona Lichtblau
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Stéphanie Saxer
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Luigi-Riccardo Calendo
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Arcangelo F Carta
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Simon R Schneider
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Charlotte Berlier
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Michael Furian
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Konrad E Bloch
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland.,Centre for Integrative Human Physiology, University of Zürich, Zürich, Switzerland
| | - Esther I Schwarz
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Silvia Ulrich
- Pulmonary Clinic, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University of Zürich, Zürich, Switzerland.,Centre for Integrative Human Physiology, University of Zürich, Zürich, Switzerland
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6
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Lichtblau M, Berlier C, Saxer S, Carta AF, Mayer L, Groth A, Bader PR, Schneider SR, Furian M, Schwarz EI, Swenson ER, Bloch KE, Ulrich S. Acute Hemodynamic Effect of Acetazolamide in Patients With Pulmonary Hypertension Whilst Breathing Normoxic and Hypoxic Gas: A Randomized Cross-Over Trial. Front Med (Lausanne) 2021; 8:681473. [PMID: 34368187 PMCID: PMC8341560 DOI: 10.3389/fmed.2021.681473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/24/2021] [Indexed: 01/30/2023] Open
Abstract
Aims: To test the acute hemodynamic effect of acetazolamide in patients with pulmonary hypertension (PH) under ambient air and hypoxia. Methods: Patients with pulmonary arterial or chronic thromboembolic PH (PAH/CTEPH) undergoing right heart catheterization were included in this randomized, placebo-controlled, double-blinded, crossover trial. The main outcome, pulmonary vascular resistance (PVR), further hemodynamics, blood- and cerebral oxygenation were measured 1 h after intravenous administration of 500 mg acetazolamide or placebo-saline on ambient air (normoxia) and at the end of breathing hypoxic gas (FIO2 0.15, hypoxia) for 15 min. Results: 24 PH-patients, 71% men, mean ± SD age 59 ± 14 years, BMI 28 ± 5 kg/m2, PVR 4.7 ± 2.1 WU participated. Mean PVR after acetazolamide vs. placebo was 5.5 ± 3.0 vs. 5.3 ± 3.0 WU; mean difference (95% CI) 0.2 (−0.2–0.6, p = 0.341). Heart rate was higher after acetazolamide (79 ± 12 vs. 77 ± 11 bpm, p = 0.026), pH was lower (7.40 ± 0.02 vs. 7.42 ± 0.03, p = 0.002) but PaCO2 and PaO2 remained unchanged while cerebral tissue oxygenation increased (71 ± 6 vs. 69 ± 6%, p = 0.017). In acute hypoxia, acetazolamide decreased PVR by 0.4 WU (0.0–0.9, p = 0.046) while PaO2 and PaCO2 were not changed. No adverse effects occurred. Conclusions: In patients with PAH/CTEPH, i.v. acetazolamide did not change pulmonary hemodynamics compared to placebo after 1 hour in normoxia but it reduced PVR after subsequent acute exposure to hypoxia. Our findings in normoxia do not suggest a direct acute pulmonary vasodilator effect of acetazolamide. The reduction of PVR during hypoxia requires further corroboration. Whether acetazolamide improves PH when given over a prolonged period by stimulating ventilation, increasing oxygenation, and/or altering vascular inflammation and remodeling remains to be investigated.
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Affiliation(s)
- Mona Lichtblau
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Arcangelo F Carta
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Laura Mayer
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Alexandra Groth
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Patrick R Bader
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Simon R Schneider
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Furian
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, WA, United States
| | - Konrad E Bloch
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
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Malenfant S, Lebret M, Breton-Gagnon É, Potus F, Paulin R, Bonnet S, Provencher S. Exercise intolerance in pulmonary arterial hypertension: insight into central and peripheral pathophysiological mechanisms. Eur Respir Rev 2021; 30:200284. [PMID: 33853885 PMCID: PMC9488698 DOI: 10.1183/16000617.0284-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/08/2020] [Indexed: 11/05/2022] Open
Abstract
Exercise intolerance is a cardinal symptom of pulmonary arterial hypertension (PAH) and strongly impacts patients' quality of life (QoL). Although central cardiopulmonary impairments limit peak oxygen consumption (V' O2peak ) in patients with PAH, several peripheral abnormalities have been described over the recent decade as key determinants in exercise intolerance, including impaired skeletal muscle (SKM) morphology, convective O2 transport, capillarity and metabolism indicating that peripheral abnormalities play a greater role in limiting exercise capacity than previously thought. More recently, cerebrovascular alterations potentially contributing to exercise intolerance in patients with PAH were also documented. Currently, only cardiopulmonary rehabilitation has been shown to efficiently improve the peripheral components of exercise intolerance in patients with PAH. However, more extensive studies are needed to identify targeted interventions that would ultimately improve patients' exercise tolerance and QoL. The present review offers a broad and comprehensive analysis of the present literature about the complex mechanisms and their interactions limiting exercise in patients and suggests several gaps in knowledge that need to be addressed in the future for a better understanding of exercise intolerance in patients with PAH.
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Affiliation(s)
- Simon Malenfant
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Marius Lebret
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Émilie Breton-Gagnon
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - François Potus
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
| | - Roxane Paulin
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Steeve Provencher
- Pulmonary Hypertension and Vascular Biology Research Group, Quebec Heart and Lung Institute Research Center, Quebec City, Canada
- Dept of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
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8
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Boutou AK, Dipla K, Zafeiridis A, Markopoulou A, Papadopoulos S, Kritikou S, Panagiotidou E, Stanopoulos I, Pitsiou G. A randomized placebo-control trial of the acute effects of oxygen supplementation on exercise hemodynamics, autonomic modulation, and brain oxygenation in patients with pulmonary hypertension. Respir Physiol Neurobiol 2021; 290:103677. [PMID: 33957299 DOI: 10.1016/j.resp.2021.103677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 04/05/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The integrative physiological effects of O2 treatment on patients with pulmonary hypertension (PH) during exercise, have not been fully investigated. We simultaneously evaluated, for the first time, the effect of oxygen supplementation on hemodynamic responses, autonomic modulation, tissue oxygenation, and exercise performance in patients with pulmonary arterial hypertension (PAH)/Chronic Thromboembolic PH(CTEPH). MATERIAL-METHODS In this randomized, cross-over, placebo-controlled trial, stable outpatients with PAH/CTEPH underwent maximal cardiopulmonary exercise testing, followed by two submaximal trials, during which they received supplementary oxygen (O2) or medical-air. Continuous, non-invasive hemodynamics were monitored via photophlythesmography. Cerebral and quadriceps muscle oxygenation were recorded via near-infrared spectroscopy. Autonomic function was assessed by heart rate variability; root mean square of successive differences (RMSSD) and standard-deviation-Poincare-plot (SD1) were used as indices of parasympathetic output. Baroreceptor sensitivity (BRS) was assessed throughout the protocols. RESULTS Nine patients (51.4 ± 9.4 years) were included. With O2-supplementation patients exercised for longer (p = 0.01), maintained higher cerebral oxygenated hemoglobin (O2Hb;p = 0.02) levels, exhibited an amelioration in cortical deoxygenation (HHb;p = 0.02), and had higher average cardiac output (CO) during exercise (p < 0.05), compared to medical air; with no differences in muscle oxygenation. With O2-supplementation patients exhibited higher BRS and sample-entropy throughout the protocol (p < 0.05) vs. medical air, and improved the blunted RMSSD, SD1 responses during exercise (p = 0.024). CONCLUSION We show that O2 administration improves BRS and autonomic function during submaximal exercise in PAH/CTEPH, without significantly affecting muscle oxygenation. The improved autonomic function, along with enhancements in cardiovascular function and cerebral oxygenation, probably contributes to increased exercise tolerance with O2-supplementation in PH patients.
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Affiliation(s)
- Afroditi K Boutou
- Department of Respiratory Medicine, "G. Papanikolaou Hospital", Thessaloniki, Greece.
| | - Konstantina Dipla
- Exercise Physiology & Biochemistry Laboratory, Dept. of Sport Sciences at Serres, Aristotle University of Thessaloniki, Greece
| | - Andreas Zafeiridis
- Exercise Physiology & Biochemistry Laboratory, Dept. of Sport Sciences at Serres, Aristotle University of Thessaloniki, Greece
| | | | - Stavros Papadopoulos
- Exercise Physiology & Biochemistry Laboratory, Dept. of Sport Sciences at Serres, Aristotle University of Thessaloniki, Greece
| | - Stella Kritikou
- Exercise Physiology & Biochemistry Laboratory, Dept. of Sport Sciences at Serres, Aristotle University of Thessaloniki, Greece
| | - Evangelia Panagiotidou
- Respiratory Failure Department, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Greece
| | - Ioannis Stanopoulos
- Respiratory Failure Department, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Greece
| | - Georgia Pitsiou
- Respiratory Failure Department, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Greece
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9
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Nickel NP, Yuan K, Dorfmuller P, Provencher S, Lai YC, Bonnet S, Austin ED, Koch CD, Morris A, Perros F, Montani D, Zamanian RT, de Jesus Perez VA. Beyond the Lungs: Systemic Manifestations of Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2020; 201:148-157. [PMID: 31513751 DOI: 10.1164/rccm.201903-0656ci] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease characterized by progressive loss and remodeling of the pulmonary arteries, resulting in right heart failure and death. Until recently, PAH was seen as a disease restricted to the pulmonary circulation. However, there is growing evidence that patients with PAH also exhibit systemic vascular dysfunction, as evidenced by impaired brachial artery flow-mediated dilation, abnormal cerebral blood flow, skeletal myopathy, and intrinsic kidney disease. Although some of these anomalies are partially due to right ventricular insufficiency, recent data support a mechanistic link to the genetic and molecular events behind PAH pathogenesis. This review serves as an introduction to the major systemic findings in PAH and the evidence that supports a common mechanistic link with PAH pathophysiology. In addition, it discusses recent studies describing morphological changes in systemic vessels and the possible role of bronchopulmonary anastomoses in the development of plexogenic arteriopathy. On the basis of available evidence, we propose a paradigm in which metabolic abnormalities, genetic injury, and systemic vascular dysfunction contribute to systemic manifestations in PAH. This concept not only opens exciting research possibilities but also encourages clinicians to consider extrapulmonary manifestations in their management of patients with PAH.
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Affiliation(s)
- Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Ke Yuan
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Peter Dorfmuller
- Department of Pathology, University of Giessen, Giessen, Germany
| | - Steeve Provencher
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Quebec, Canada
| | - Yen-Chun Lai
- Division of Pulmonary and Critical Care Medicine, Indiana University, Bloomington, Indiana
| | - Sebastien Bonnet
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Quebec, Canada
| | - Eric D Austin
- Division of Pediatric Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville Tennessee
| | - Carl D Koch
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alison Morris
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frédéric Perros
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Quebec, Canada.,Inserm Université Paris Sud-Centre chirurgical Marie Lannelongue 999, Université Paris Sud-Paris Saclay, Hôpital Marie Lannelongue, Le Plessis Robinson, France; and
| | - David Montani
- Inserm Université Paris Sud-Centre chirurgical Marie Lannelongue 999, Université Paris Sud-Paris Saclay, Hôpital Marie Lannelongue, Le Plessis Robinson, France; and.,Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Roham T Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
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10
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Malenfant S, Brassard P, Paquette M, Le Blanc O, Chouinard A, Bonnet S, Provencher S. Continuous reduction in cerebral oxygenation during endurance exercise in patients with pulmonary arterial hypertension. Physiol Rep 2020; 8:e14389. [PMID: 32189447 PMCID: PMC7080869 DOI: 10.14814/phy2.14389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Patients with pulmonary arterial hypertension (PAH) have lower cerebral blood flow (CBF) and oxygenation compared to healthy sedentary subjects, the latter negatively correlating with exercise capacity during incremental cycling exercise. We hypothesized that patients would also exhibit altered CBF and oxygenation during endurance exercise, which would correlate with endurance time. METHODS Resting and exercise cardiorespiratory parameters, blood velocity in the middle cerebral artery (MCAv; transcranial doppler) and cerebral oxygenation (relative changes in cerebral tissue oxygenation index (ΔcTOI) and cerebral deoxyhemoglobin (ΔcHHb); near-infrared spectroscopy) were continuously monitored in nine PAH patients and 10 healthy-matched controls throughout endurance exercise. Cardiac output (CO), systemic blood pressure (BP) and oxygen saturation (SpO2 ), ventilatory metrics and end-tidal CO2 pressure (PET CO2 ) were also assessed noninvasively. RESULTS Despite a lower workload and endurance oxygen consumption, similar CO and systemic BP, ΔcTOI was lower in PAH patients compared to controls (p < .01 for interaction). As expected during exercise, patients were characterized by an altered MCAv response to exercise, a lower PET CO2 and SpO2 , as wells as a higher minute-ventilation/CO2 production ratio ( V ˙ E / V ˙ CO 2 ratio). An uncoupling between changes in MCAv and PET CO2 during the cycling endurance exercise was also progressively apparent in PAH patients, but absent in healthy controls. Both cHHb and ΔcTOI correlated with V ˙ E / V ˙ CO 2 ratio (r = 0.50 and r = -0.52; both p < .05 respectively), but not with endurance time. CONCLUSION PAH patients present an abnormal cerebrovascular profile during endurance exercise with a lower cerebral oxygenation that correlate with hyperventilation but not endurance exercise time. These findings complement the physiological characterization of the cerebral vascular responses to exercise in PAH patients.
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Affiliation(s)
- Simon Malenfant
- Pulmonary Hypertension and Vascular Biology Research GroupQuebec CityQCCanada
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of MedicineFaculty of MedicineUniversité LavalQuebec CityQCCanada
- Department of KinesiologyFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Patrice Brassard
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of KinesiologyFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Myriam Paquette
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of KinesiologyFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Olivier Le Blanc
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of KinesiologyFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Audrey Chouinard
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of KinesiologyFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Sébastien Bonnet
- Pulmonary Hypertension and Vascular Biology Research GroupQuebec CityQCCanada
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of MedicineFaculty of MedicineUniversité LavalQuebec CityQCCanada
| | - Steeve Provencher
- Pulmonary Hypertension and Vascular Biology Research GroupQuebec CityQCCanada
- Quebec Heart and Lung Institute Research CenterUniversité LavalQuebec CityQCCanada
- Department of MedicineFaculty of MedicineUniversité LavalQuebec CityQCCanada
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11
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Hasler ED, Saxer S, Schneider SR, Furian M, Lichtblau M, Schwarz EI, Bloch KE, Ulrich S. Effect of Breathing Oxygen-Enriched Air on Exercise Performance in Patients with Chronic Obstructive Pulmonary Disease: Randomized, Placebo-Controlled, Cross-Over Trial. Respiration 2020; 99:213-224. [PMID: 32050198 DOI: 10.1159/000505819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) experience dyspnea and hypoxemia during exercise. OBJECTIVE The aim of this study was to evaluate the effects of breathing oxygen-enriched air on exercise performance and associated physiological changes in patients with COPD. METHODS In a randomized, placebo-controlled, single-blind, cross-over trial, 20 patients with COPD (11 women, age 65 ± 6 years, FEV1 64 ± 19% pred., resting SpO2 ≥90%) performed 4 cycle ergospirometries to exhaustion using an incremental exercise test (IET) and a constant work rate (at 75% maximal workload with air) exercise test (CWRET), each with ambient (FiO2 0.21) and oxygen-enriched (FiO2 0.5) air. The main outcomes were the change in maximal workload in the IET and the change in exercise duration in the CWRET with oxygen versus air. Electrocardiogram, pulmonary gas exchange, thoracic volumes by inductance plethysmography, arterial blood gases, and cerebral and quadriceps muscle tissue oxygenation (CTO and MTO) were additionally measured. RESULTS In the IET, maximal workload increased from 96 ± 21 to 104 ± 28 W with oxygen. In the CWRET, exercise duration increased from 605 ± 274 to 963 ± 444 s with oxygen. At end-exercise with oxygen, CTO, MTO, PaO2, and PaCO2 were increased, while V'E/V'CO2 was reduced and thoracic volumes were similar. At the corresponding time to end of exercise with ambient air, oxygen decreased heart rate, respiratory rate, minute ventilation, and V'E/V'CO2, while oxygenation was increased. CONCLUSION In COPD patients without resting hypoxemia, breathing oxygen-enriched air improves exercise performance. This relates to a higher arterial oxygen saturation promoting oxygen availability to muscle and cerebral tissue and an enhanced ventilatory efficiency. COPD patients may benefit from oxygen therapy during exercise training.
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Affiliation(s)
| | - Stéphanie Saxer
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | | | - Michael Furian
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | | | - Konrad E Bloch
- Pulmonary Clinic, University Hospital Zurich and Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Pulmonary Clinic, University Hospital Zurich and Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland,
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12
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Zhang J, Li J, Huang Z, Xu J, Fan Y. A meta‐analysis of randomized controlled trials in targeted treatments of chronic thromboembolic pulmonary hypertension. CLINICAL RESPIRATORY JOURNAL 2019; 13:467-479. [PMID: 31059198 DOI: 10.1111/crj.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Jing Zhang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jing‐Meng Li
- Department of Thoracic Surgery Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Zan‐Sheng Huang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jian‐Cheng Xu
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Ye Fan
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
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13
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Ulrich S, Saxer S, Hasler ED, Schwarz EI, Schneider SR, Furian M, Bader PR, Lichtblau M, Bloch KE. Effect of domiciliary oxygen therapy on exercise capacity and quality of life in patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension: a randomised, placebo-controlled trial. Eur Respir J 2019; 54:13993003.002762019. [DOI: 10.1183/13993003.002762019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/27/2019] [Indexed: 11/05/2022]
Abstract
Study questionWe investigated whether domiciliary oxygen therapy (DOXT) increases exercise capacity and quality of life in patients with pulmonary arterial or distal chronic thromboembolic pulmonary hypertension (PAH/CTEPH) presenting with mild resting hypoxaemia and exercise-induced oxygen desaturation.Materials and methods30 patients with PAH/CTEPH, mean±sdage 60±15 years, pulmonary artery pressure 39±11 mmHg, resting arterial oxygen saturation measured by pulse oximetry (SpO2) ≥90%,SpO2drop during a 6-min walk test ≥4%, on pulmonary hypertension-targeted medication, were randomised in a double-blind crossover protocol to DOXT and placebo (ambient air) treatment, each over 5 weeks, at 3 L·min−1vianasal cannula overnight and when resting during the day. Treatment periods were separated by 2 weeks of washout. Co-primary outcomes were changes in 6-min walk distance (6MWD, breathing ambient air) and physical functioning scale of the 36-item short-form medical outcome questionnaire during treatment periods.ResultsDOXT increased the 6MWD from baseline 478±113 m by a mean (95% CI) of 19 (6–32) m, and physical functioning from 52±29 by 4 (0–8) points. Corresponding changes with placebo were 1 (−11–13) m in 6MWD and −2 (−6–2) points in physical functioning. Between-treatment differences in changes were 6MWD 18 (1–35) m (p=0.042) and physical functioning 6 (1–11) points (p=0.029). DOXT significantly improved the New York Heart Association functional classversusplacebo.Answer to the questionThis first randomised trial in PAH/CTEPH patients with exercise-induced hypoxaemia demonstrates that DOXT improves exercise capacity, quality of life and functional class. The results support large long-term randomised trials of DOXT in PAH/CTEPH.
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14
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Grünig E, Eichstaedt C, Barberà JA, Benjamin N, Blanco I, Bossone E, Cittadini A, Coghlan G, Corris P, D'Alto M, D'Andrea A, Delcroix M, de Man F, Gaine S, Ghio S, Gibbs S, Gumbiene L, Howard LS, Johnson M, Jurevičienė E, Kiely DG, Kovacs G, MacKenzie A, Marra AM, McCaffrey N, McCaughey P, Naeije R, Olschewski H, Pepke-Zaba J, Reis A, Santos M, Saxer S, Tulloh RM, Ulrich S, Vonk Noordegraaf A, Peacock AJ. ERS statement on exercise training and rehabilitation in patients with severe chronic pulmonary hypertension. Eur Respir J 2018; 53:13993003.00332-2018. [DOI: 10.1183/13993003.00332-2018] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022]
Abstract
Objectives of this European Respiratory Society task force were to summarise current studies, to develop strategies for future research and to increase availability and awareness of exercise training for pulmonary hypertension (PH) patients.An evidence-based approach with clinical expertise of the task force members, based on both literature search and face-to-face meetings was conducted. The statement summarises current knowledge and open questions regarding clinical effects of exercise training in PH, training modalities, implementation strategies and pathophysiological mechanisms.In studies (784 PH patients in total, including six randomised controlled trials, three controlled trials, 10 prospective cohort studies and four meta-analyses), exercise training has been shown to improve exercise capacity, muscular function, quality of life and possibly right ventricular function and pulmonary haemodynamics. Nevertheless, further studies are needed to confirm these data, to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.As exercise training appears to be effective, cost-efficient and safe, but is scarcely reimbursed, support from healthcare institutions, commissioners of healthcare and research funding institutions is greatly needed. There is a strong need to establish specialised rehabilitation programmes for PH patients to enhance patient access to this treatment intervention.
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15
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Furian M, Hartmann SE, Latshang TD, Flueck D, Murer C, Scheiwiller PM, Osmonov B, Ulrich S, Kohler M, Poulin MJ, Bloch KE. Exercise Performance of Lowlanders with COPD at 2,590 m: Data from a Randomized Trial. Respiration 2018; 95:422-432. [PMID: 29502125 DOI: 10.1159/000486450] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/20/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Effects of hypobaric hypoxia at altitude on exercise performance of lowlanders with chronic obstructive pulmonary disease (COPD) have not been studied in detail. OBJECTIVES To quantify changes in exercise performance and associated physiologic responses in lowlanders with COPD travelling to moderate altitude. METHODS A total of 31 COPD patients with a median age (quartiles) of 66 years (59; 69) and FEV1 of 56% predicted (49; 69) living below 800 m performed a constant-load bicycle exercise to exhaustion at 60% of the maximal work rate at 490 m (Zurich) and at an identical work rate at 2,590 m (Davos) in randomized order. Pulmonary gas exchange, pulse oximetry (SpO2), cerebral tissue oxygenation (CTO; near-infrared spectroscopy), and middle cerebral artery peak blood flow velocity (MCAv) by Doppler ultrasound during 30 s at end exercise were compared between altitudes. RESULTS With ascent from 490 to 2,590 m, the median endurance time (quartiles) was reduced from 500 s (256; 795) to 205 s (139; 297) by a median (95% CI) of 303 s (150-420) (p < 0.001). End exercise SpO2 decreased from 92% (89; 94) to 81% (77; 84) and CTO from 62% (56; 66) to 55% (50; 60); end exercise minute ventilation increased from 40.6 L/min (35.5; 47.8) to 47.2 L/min (39.6; 58.7) (p < 0.05; all comparisons 2,590 vs. 490 m). MCAv increased similarly from rest to end exercise at 490 m (+25% [17; 36]) and at 2,590 m (+21% [14; 30]). However, the ratio of MCAv increase to SpO2 drop during exercise decreased from +6%/% (3; 12) at 490 m to +3%/% (2; 5) at 2,590 m (p < 0.05). CONCLUSIONS In lowlanders with COPD travelling to 2,590 m, exercise endurance is reduced by more than half compared to 490 m in association with reductions in systemic and cerebral oxygen availability.
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Affiliation(s)
- Michael Furian
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.,Institute of Human Movement Sciences and Sport, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Sara E Hartmann
- Department of Physiology and Pharmacology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tsogyal D Latshang
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Deborah Flueck
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christian Murer
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Batyr Osmonov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Marc J Poulin
- Department of Physiology and Pharmacology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Konrad E Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
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16
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Ulrich S, Hasler ED, Saxer S, Furian M, Müller-Mottet S, Keusch S, Bloch KE. Effect of breathing oxygen-enriched air on exercise performance in patients with precapillary pulmonary hypertension: randomized, sham-controlled cross-over trial. Eur Heart J 2017; 38:1159-1168. [PMID: 28329240 DOI: 10.1093/eurheartj/ehx099] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/01/2017] [Indexed: 11/13/2022] Open
Abstract
Aims The purpose of the current trial was to test the hypothesis that breathing oxygen-enriched air increases exercise performance of patients with pulmonary arterial or chronic thrombo-embolic pulmonary hypertension (PAH/CTEPH) and to investigate involved mechanisms. Methods and results Twenty-two patients with PAH/CTEPH, eight women, means ± SD 61 ± 14 years, resting mPAP 35 ± 9mmHg, PaO2 ambient air >7.3 kPa, underwent four bicycle ergospirometries to exhaustion on different days, while breathing oxygen-enriched (FiO2 0.50, hyperoxia) or ambient air (FiO2 0.21, normoxia) using progressively increased or constant load protocols (with 75% maximal work rate under FiO2 0.21), according to a randomized, sham-controlled, single-blind, cross-over design. ECG, pulmonary gas-exchange, arterial blood gases, cerebral and quadriceps muscle tissue oxygenation (CTO and QMTO) by near-infrared spectroscopy were measured. In ramp exercise, maximal work rate increased from 113 ± 38 W with normoxia to 132 ± 48 W with hyperoxia, mean difference 19.7 (95% CI 10.5-28.9) W, P < 0.001. Constant load exercise endurance increased from 571 ± 443 to 1242 ± 514 s, mean difference 671 (95% CI 392-951) s, P < 0.001. At end-exercise with hyperoxia PaO2, CTO, QMTO, and PaCO2 were increased, and ventilatory equivalents for CO2 were reduced while the physiological dead space/tidal volume ratio remained unchanged. Conclusion In patients with PAH/CTEPH, breathing oxygen-enriched air provides major increases in exercise performance. This is related to an improved arterial oxygenation that promotes oxygen availability in muscles and brain and to a reduction of the excessive ventilatory response to exercise thereby enhancing ventilatory efficiency. Patients with PAH/CTEPH may therefore benefit from oxygen therapy during daily physical activities and training. Trial registration clinicaltrials.gov Identifier: NCT01748474.
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17
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Ulrich S, Schneider SR, Bloch KE. Effect of hypoxia and hyperoxia on exercise performance in healthy individuals and in patients with pulmonary hypertension: a systematic review. J Appl Physiol (1985) 2017; 123:1657-1670. [PMID: 28775065 DOI: 10.1152/japplphysiol.00186.2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Exercise performance is determined by oxygen supply to working muscles and vital organs. In healthy individuals, exercise performance is limited in the hypoxic environment at altitude, when oxygen delivery is diminished due to the reduced alveolar and arterial oxygen partial pressures. In patients with pulmonary hypertension (PH), exercise performance is already reduced near sea level due to impairments of the pulmonary circulation and gas exchange, and, presumably, these limitations are more pronounced at altitude. In studies performed near sea level in healthy subjects, as well as in patients with PH, maximal performance during progressive ramp exercise and endurance of submaximal constant-load exercise were substantially enhanced by breathing oxygen-enriched air. Both in healthy individuals and in PH patients, these improvements were mediated by a better arterial, muscular, and cerebral oxygenation, along with a reduced sympathetic excitation, as suggested by the reduced heart rate and alveolar ventilation at submaximal isoloads, and an improved pulmonary gas exchange efficiency, especially in patients with PH. In summary, in healthy individuals and in patients with PH, alterations in the inspiratory Po2 by exposure to hypobaric hypoxia or normobaric hyperoxia reduce or enhance exercise performance, respectively, by modifying oxygen delivery to the muscles and the brain, by effects on cardiovascular and respiratory control, and by alterations in pulmonary gas exchange. The understanding of these physiological mechanisms helps in counselling individuals planning altitude or air travel and prescribing oxygen therapy to patients with PH.
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Affiliation(s)
- Silvia Ulrich
- Pulmonary Division and Center for Human Integrative Physiology, University of Zurich , Zurich , Switzerland
| | - Simon R Schneider
- Pulmonary Division and Center for Human Integrative Physiology, University of Zurich , Zurich , Switzerland
| | - Konrad E Bloch
- Pulmonary Division and Center for Human Integrative Physiology, University of Zurich , Zurich , Switzerland
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18
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Treptow E, Oliveira MF, Soares A, Ramos RP, Medina L, Lima R, Alencar MC, Ferreira EV, Ota-Arakaki JS, Tufik S, Nery LE, Bittencourt LR, Neder JA. Cerebral microvascular blood flow and CO 2 reactivity in pulmonary arterial hypertension. Respir Physiol Neurobiol 2016; 233:60-65. [PMID: 27521776 DOI: 10.1016/j.resp.2016.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/17/2022]
Abstract
Hypocapnia and endothelial dysfunction might impair microvascular cerebral blood flow (CBFmicr) and cerebrovascular reactivity to CO2 (CVRCO2). Pulmonary arterial hypertension (PAH) is characteristically associated with chronic alveolar hyperventilation and microvascular endothelial dysfunction. We therefore determined CBFmicr (pre-frontal blood flow index (BFI) by the indocyanine green-near infrared spectroscopy methodology) during hypocapnia and hypercapnia in 25 PAH patients and 10 gender- and age-matched controls. Cerebral BFI was lower in patients than controls at similar transcutaneous PCO2 (PtcCO2) levels in both testing conditions. In fact, while BFI increased from hypocapnia to hypercapnia in all controls, it failed to increase in 17/25 (68%) patients. Thus, BFI increased to a lesser extent from hypo to hypercapnia ("Δ") in patients, i.e., they showed lower Δ BFI/Δ PtcCO2 ratios than controls. In conclusion, CBFmicr and CVRCO2 are lessened in clinically stable, mildly-impaired patients with PAH. These abnormalities might be associated with relevant clinical outcomes (hyperventilation and dyspnea, cognition, cerebrovascular disease) being potentially amenable to pharmacological treatment.
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Affiliation(s)
- Erika Treptow
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil; Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Mayron F Oliveira
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Aline Soares
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Roberta P Ramos
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil; Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Luiz Medina
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Rita Lima
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Maria Clara Alencar
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Eloara Vieira Ferreira
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil; Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia da Universidade Federal de São Paulo (UNIFESP), Brazil
| | - Luiz E Nery
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil
| | - Lia Rita Bittencourt
- Departamento de Psicobiologia da Universidade Federal de São Paulo (UNIFESP), Brazil
| | - J Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine (UNIFESP-EPM), Brazil; Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil; Laboratory of Clinical Exercise Physiology (LACEP), Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Canada.
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Somaini G, Stamm A, Müller-Mottet S, Hasler E, Keusch S, Hildenbrand FF, Furian M, Speich R, Bloch KE, Ulrich S. Disease-Targeted Treatment Improves Cognitive Function in Patients with Precapillary Pulmonary Hypertension. Respiration 2015; 90:376-83. [PMID: 26447714 DOI: 10.1159/000439227] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/24/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with pulmonary hypertension (PH) may suffer from cognitive deficits that potentially relate to reduced oxygen delivery and cerebral tissue oxygenation (CTO). OBJECTIVE To evaluate the hypothesis that cognitive function improves with therapy, along with improved CTO. METHODS Twenty incident patients with arterial or chronic thromboembolic PH had CTO monitoring by near-infrared spectroscopy during diagnostic right heart catheterization. Cognitive tests [Trail Making Tests (TMTs), Victoria Stroop tests and the Five-Point Test (5PT)], the 6-min walk distance (6MWD) test, New York Heart Association (NYHA) class and health-related quality of life (HRQoL) were assessed and repeated after 3 months of disease-targeted medication. RESULTS At baseline, 45% of PH patients had cognitive deficits. At 3 months, the patients had improved on the TMT A and the Stroop 2 test [37 s (27; 55) versus 30 s (24; 42), p < 0.05, and 18 s (16; 22) versus 16 s (15; 20), p < 0.01], whereas CTO remained unchanged. Arterial oxygen saturation, NYHA class, 6MWD and HRQoL had also improved. Baseline CTO was the strongest predictor of cognitive function, even in multivariate analysis including age, 6MWD and HRQoL. Improvements in cognitive function were not associated with changes in CTO. CONCLUSIONS In patients with PH, 3 months of disease-targeted medication resulted in better cognitive function. Although CTO was the strongest predictor of cognitive function at baseline, it did not change during target therapy. The results of this pilot study should be confirmed in an adequately powered controlled trial.
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Affiliation(s)
- Gina Somaini
- Pulmonology Clinic, University Hospital Zurich, Zurich, Switzerland
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