Associative conditioning of the exercise ventilatory response in humans

Inaugural Review Prize 2023: The exercise hyperpnoea dilemma: A 21st-century perspective

During mild or moderate exercise, alveolar ventilation increases in direct proportion to metabolic rate, regulating arterial CO2 pressure near resting levels. Mechanisms giving rise to the hyperpnoea of exercise are unsettled despite over a century of investigation. In the past three decades, neuroscience has advanced tremendously, raising optimism that the 'exercise hyperpnoea dilemma' can finally be solved. In this review, new perspectives are offered in the hope of stimulating original ideas based on modern neuroscience methods and current understanding. We first describe the ventilatory control system and the challenge exercise places upon blood-gas regulation. We highlight relevant system properties, including feedforward, feedback and adaptive (i.e., plasticity) control of breathing. We then elaborate a seldom explored hypothesis that the exercise ventilatory response continuously adapts (learns and relearns) throughout life and ponder if the memory 'engram' encoding the feedforward exercise ventilatory stimulus could reside within the cerebellum. Our hypotheses are based on accumulating evidence supporting the cerebellum's role in motor learning and the numerous direct and indirect projections from deep cerebellar nuclei to brainstem respiratory neurons. We propose that cerebellar learning may be obligatory for the accurate and adjustable exercise hyperpnoea capable of tracking changes in life conditions/experiences, and that learning arises from specific cerebellar microcircuits that can be interrogated using powerful techniques such as optogenetics and chemogenetics. Although this review is speculative, we consider it essential to reframe our perspective if we are to solve the till-now intractable exercise hyperpnoea dilemma.

Perceptual and Ventilatory Responses to Hypercapnia in Athletes and Sedentary Individuals

Purpose

Hypercapnic chemosensitivity traditionally captures the ventilatory response to elevated pressures of carbon dioxide in the blood. However, hypercapnia also contributes to subjective breathing perceptions, and previously we demonstrated a closer matching of perception to changes in ventilation in athletes compared to controls. Here we investigated any potential underlying hypercapnic chemosensitivity differences between groups, and explored whether these measures relate to ventilatory and perceptual responses during exercise as well as trait levels of affect.

Methods

A hypercapnic challenge, incremental maximal exercise test and affective questionnaires were completed by 20 endurance athletes and 20 age-/sex-matched sedentary controls. The hypercapnic challenge involved elevating end-tidal PCO₂ by 0.8% (6.1 mmHg) and 1.5% (11.2 mmHg) for 3 min each (randomised), with constant end-tidal oxygen. Ventilatory and perceptual responses to hypercapnia were compared between groups, and within each group the relationships between hypercapnic chemosensitivity (slope analyses) and exercising ventilation and perceptions were calculated using Spearman’s non-parametric correlations.

Results

While absolute ventilation differences during hypercapnia and exercise were observed, no group differences were found across hypercapnic chemosensitivity (slope) measures. Correlation analyses revealed the anxiety hypercapnic response was related to maximal exercise anxiety, but only in sedentary individuals.

Conclusion

Ventilatory and perceptual hypercapnic chemosensitivity do not differ between athletes and sedentary individuals. However, ventilatory and anxiety hypercapnic chemosensitivities were related to ventilatory and anxiety responses during exercise in untrained individuals only. Athletes may employ additional strategies during exercise to reduce the influence of chemosensitivity on ventilatory and perceptual responses.

Veterans with Gulf War Illness exhibit distinct respiratory patterns during maximal cardiopulmonary exercise

INTRODUCTION

The components of minute ventilation, respiratory frequency and tidal volume, appear differentially regulated and thereby afford unique insight into the ventilatory response to exercise. However, respiratory frequency and tidal volume are infrequently reported, and have not previously been considered among military veterans with Gulf War Illness. Our purpose was to evaluate respiratory frequency and tidal volume in response to a maximal cardiopulmonary exercise test in individuals with and without Gulf War Illness.

MATERIALS AND METHODS

20 cases with Gulf War Illness and 14 controls participated in this study and performed maximal cardiopulmonary exercise test on a cycle ergometer. Ventilatory variables (minute ventilation, respiratory frequency and tidal volume) were obtained and normalized to peak exercise capacity. Using mixed-design analysis of variance models, with group and time as factors, we analyzed exercise ventilatory patterns for the entire sample and for 11 subjects from each group matched for race, age, sex, and height.

RESULTS

Despite similar minute ventilation (p = 0.57, η2p = 0.01), tidal volume was greater (p = 0.02, η2p = 0.16) and respiratory frequency was lower (p = 0.004, η2p = 0.24) in Veterans with Gulf War Illness than controls. The findings for respiratory frequency remained significant in the matched subgroup (p = 0.004, η2p = 0.35).

CONCLUSION

In our sample, veterans with Gulf War Illness adopt a unique exercise ventilatory pattern characterized by reduced respiratory frequency, despite similar ventilation relative to controls. Although the mechanism(s) by which this pattern is achieved remains unresolved, our findings suggest that the components of ventilation should be considered when evaluating clinical conditions with unexplained exertional symptoms.

Short- and long-term modulation of the exercise ventilatory response

The importance of adaptive control strategies (modulation and plasticity) in the control of breathing during exercise has become recognized only in recent years. In this review, we discuss new evidence for modulation of the exercise ventilatory response in humans, specifically, short- and long-term modulation. Short-term modulation is proposed to be an important regulatory mechanism that helps maintain blood gas homeostasis during exercise.

Influence of cycling history on the ventilatory response to cycle-ergometry in humans: a role for respiratory memory?

The ventilatory (V' E) mechanisms subserving stability of alveolar and arterial PCO2 (PACO2, PaCO2) during moderate exercise (< lactate threshold, thetaL) remain controversial. As long-term modulation has been argued to be an important contributor to this control process, we proposed that subjects with no experience of cycling (NEx) might provide insight into this issue. With no exercise familiarization, 9 sedentary NEx subjects and 9 age-, sex-, and activity-matched controls (C) who had cycled regularly for recreational purposes since childhood completed a square-wave (6-min stage) cycle-ergometry test: 10 W-WR1-WR2-WR1-10 W; WR1 range 25-45 W, WR2 range 50-90 W. WRs were subsequently confirmed to <thetaL. The NEx V'E-V'CO2 slope, V'E-intercept, mean PACO2 and estimated alveolar ventilation were not different from C. In conclusion, these findings provide no support for, and possibly support for no, V'E control during moderate exercise being modulated by influences related to long-term exercise history.

Homeostasis of exercise hyperpnea and optimal sensorimotor integration: the internal model paradigm

Homeostasis is a basic tenet of biomedicine and an open problem for many physiological control systems. Among them, none has been more extensively studied and intensely debated than the dilemma of exercise hyperpnea - a paradoxical homeostatic increase of respiratory ventilation that is geared to metabolic demands instead of the normal chemoreflex mechanism. Classical control theory has led to a plethora of "feedback/feedforward control" or "set point" hypotheses for homeostatic regulation, yet so far none of them has proved satisfactory in explaining exercise hyperpnea and its interactions with other respiratory inputs. Instead, the available evidence points to a far more sophisticated respiratory controller capable of integrating multiple afferent and efferent signals in adapting the ventilatory pattern toward optimality relative to conflicting homeostatic, energetic and other objectives. This optimality principle parsimoniously mimics exercise hyperpnea, chemoreflex and a host of characteristic respiratory responses to abnormal gas exchange or mechanical loading/unloading in health and in cardiopulmonary diseases - all without resorting to a feedforward "exercise stimulus". Rather, an emergent controller signal encoding the projected metabolic level is predicted by the principle as an exercise-induced 'mental percept' or 'internal model', presumably engendered by associative learning (operant conditioning or classical conditioning) which achieves optimality through continuous identification of, and adaptation to, the causal relationship between respiratory motor output and resultant chemical-mechanical afferent feedbacks. This internal model self-tuning adaptive control paradigm opens a new challenge and exciting opportunity for experimental and theoretical elucidations of the mechanisms of respiratory control - and of homeostatic regulation and sensorimotor integration in general.

Respiratory control at exercise onset: an integrated systems perspective

The near-immediate increase in breathing that accompanies the onset of constant load, dynamic exercise has remained a topic of interest to respiratory physiologists for the better part of a century. During this time, several theories have been proposed and tested in an attempt to explain what has been called the phase I response of exercise hyperpnoea, or the fast neural drive to breathe, and much controversy still remains as to what mediates this response. 'Central motor command' and 'afferent feedback' mechanisms, as described in animal models, have been centre stage in the debate, with much supportive evidence for their involvement. This review presents three relatively recent and controversial mechanisms and examines the increasing evidence for their involvement in the initial phase of exercise hyperpnoea: (1) the vascular distension hypothesis, (2) the vestibular feedback hypothesis and (3) the behavioral state hypothesis. Some outstanding fundamental questions and directions for future research are presented throughout, always with a focus on mechanistic efficacy in the integrated system response.

Layers of exercise hyperpnea: modulation and plasticity

Despite the fundamental biological significance of the ventilatory response to mild or moderate physical activity (the exercise hyperpnea), we still know remarkably little concerning its underlying mechanisms. Part of the difficulty in revealing those mechanisms may arise due to confusion between multiple mechanistic layers, each contributing to the impressive degree of regulation achieved. The primary, feedforward exercise stimulus or stimuli increase ventilation in approximate proportion to changes in metabolic rate. Chemoreceptor feedback then minimizes deviations from optimal blood gas regulation, most often preventing excessive hypocapnia in non-human mammals. Recent evidence has accumulated, suggesting that adaptive control strategies including modulation and plasticity may adjust the feedforward and/or feedback contributions when blood gas homeostasis proves inadequate. In this review, we present evidence from a goat model of exercise hyperpnea concerning the existence of modulation and plasticity, and specifically mechanisms known as short-term and long-term modulation of the exercise ventilatory response. Throughout the review, we consider available evidence concerning the relevance of these mechanisms to humans. Plasticity is a property only recently recognized in the neural system subserving respiratory control, and the application of these concepts to the exercise ventilatory response in humans is in its infancy. Modulation and plasticity may confer an ability of individuals to adapt their exercise ventilatory response so that it remains appropriate in the face of life-long changes in endogenous (e.g. development, aging, onset of disease) or exogenous (e.g. altitude, wearing a breathing apparatus during physical exertion) physiological conditions.

Associative conditioning with leg cycling and inspiratory resistance enhances the early exercise ventilatory response in humans

Repeated trials of hypercapnic exercise [deltaPET CO2 = 7 (1) mmHg] augment the increase in inspired minute ventilation and tidal volume (V(T)) in the early phase of subsequent trials of unencumbered exercise alone. The increase in V(T) in the first 20 s of exercise was correlated to the increase in V(T) evoked during hypercapnic exercise trials, suggesting that the evoked increase in V(T) during conditioning may be a factor in mediating associative conditioning. To test this hypothesis, inspiratory resistive loading (IRL) was employed to evoke an increase in V(T) [deltaV(T) = 0.4 (0.1) I(BTPS)] during conditioning exercise trials [IRL + EX; deltaP(ET)CO2 = 2 (l) mmHg]. IRL + EX associative conditioning elicited a significant augmentation of the early minute ventilation (+46%) and V(T) (+100%) responses to subsequent unencumbered exercise. The latter was correlated to the evoked increase in V(T) during associative conditioning with IRL + EX. The results support the hypothesis that an evoked increase in V(T) during associative conditioning could be a factor in eliciting long-term modulation of minute ventilation in subsequent unencumbered exercise. The results further indicated that the modulation of ventilation early in exercise is not due to sensitisation to repeated trials of either IRL or exercise alone. Associative conditioning may shape the ventilatory response to exercise through a process of motor learning. Data are presented as mean (SEM) unless otherwise stated.

Absence of long-term modulation of ventilation by dead-space loading during moderate exercise in humans

The stability of arterial PCO(2) (P(a)CO(2)) during moderate exercise in humans suggests a CO(2)-linked control that matches ventilation (V(E)) to pulmonary CO(2) clearance (VCO(2)). An alternative view is that V(E) is subject to long-term modulation (LTM) induced by "hyperpnoeic history". LTM has been reported with associative conditioning via dead-space (V(D)) loading in exercising goats (Martin and Mitchell 1993). Whether this prevails in humans is less clear, which may reflect differences in study design (e.g. subject familiarisation; V(D) load; whether or not V(E) is expressed relative to VCO(2); choice of P(a)CO(2) estimator). After familiarisation, nine healthy males performed moderate constant-load cycle-ergometry (20 W-80 W-20 W; <lactate threshold, theta;(L)): day 1, pre-conditioning, n=3; day 2, conditioning (V(D)=1.59 l, doubling V(E) at 20 W and 80 W), n=8 with 10 min rest between tests; and, after 1 h rest, post-conditioning, n=3. Gas exchange was determined breath-by-breath. Post-conditioning, neither the transient [phase 1, phase 2 (capital EF, Cyrillic1, capital EF, Cyrillic2)] nor steady-state V(E) exercise responses, nor their proportionality to VCO(2), differed from pre-conditioning. For post-conditioning trial 1, steady-state V(E) was 28.1 (4.7) l min(-1) versus 29.1 (3.8) l min(-1) pre-conditioning, and mean-alveolar PCO(2) (a validated P(a)CO(2) estimator) was 5.53 (0.48) kPa [41.5 (3.6) mmHg] versus 5.59 (0.49) kPa [41.9 (3.7) mmHg]; the capital EF, Cyrillic1 V(E) increment was 4.2 (2.9) l min(-1) versus 5.2 (1.9) l min(-1); the capital EF, Cyrillic2 V(E) time-constant (tau) was 64.4 (24.1) s versus 64.1 (25.3) s; tauV(E)/tauVCO(2) was 1.12 (0.04) versus 1.10 (0.04); and the V(E)-VCO(2) slope was 21.7 (3.4) versus 21.2 (3.2). In conclusion, we could find no evidence to support ventilatory control during moderate exercise being influenced by hyperpnoeic history associated with dead-space loading in humans.

A learned component of the ventilatory response to exercise in man

The ventilatory response to mild-to-moderate exercise in humans is isocapnic, or 'error-free'. It has been suggested that this response is learned over many repetitions of exercise through the process of minimising any deviations from normal in the blood gas tensions, as sensed by the chemoreceptors. However, relatively limited training programmes have failed to produce any convincing evidence in humans that forcibly altering the blood gas tensions during repeated periods of exercise alters the subsequent steady-state ventilatory response to exercise. In this study, eight healthy young subjects were exposed, over a 7 day training period, to a total of 70 repeated bouts of exercise paired with a simultaneous airway CO2 load to stimulate the chemoreceptors (protocol EX + CO2). The ventilatory response to exercise was measured before and after training to determine whether it had been modified. Two further training protocols were undertaken as controls. One employed repeated exercise without an airway CO2 load, and the other employed repeated airway CO2 loading without exercise. On the 1st and 2nd days following training with protocol EX + CO2, end-tidal PCO2 was regulated at a lower level during steady-state exercise than following training with the control protocols and than before training (mean +/- S.E.M. reduction in end-tidal PCO2 = 1.32 +/- 0.36 Torr, ANOVA, P < 0.05). In contrast to previous studies, this finding demonstrates that the steady-state ventilatory response to exercise can be modified by a prior period of altered chemoreception during exercise. This suggests that ventilation is matched to metabolic rate during exercise by a mechanism that involves learning and memory.

Long term modulation of the leg exercise ventilatory response is not elicited by hypercapnic arm exercise

The aim of the present investigation was to test the hypothesis that long-term modulation (LTM) of the exercise ventilatory response, evidenced as an augmentation in minute ventilation (V(I)) and tidal volume (VT) during the early phase of exercise, is only evident when the muscle groups recruited are the same during testing and during hypercapnic exercise conditioning. Measurements of cardiorespiratory variables were made at rest and during leg cycling (fH=107+/-5) exercise in eight male subjects, 1 week before and 1 h after conditioning. Conditioning involved either: (a) ten trials of arm cranking exercise (V(I)=29.0+/-4.4), or (b) ten trials of arm cranking exercise paired with external respiratory dead space (1400 ml; V(I)=57.3+/-6.5). Neither arm conditioning paradigm evoked any of the modulatory responses described in previous studies. We, therefore, conclude that the general upregulation of the spinal respiratory motoneuron pool excitability after conditioning (the "final common pathway" hypothesis), may be inadequate to fully explain the underlying mechanisms of LTM of ventilation in humans.

Neuroplasticity in respiratory motor control

Although recent evidence demonstrates considerable neuroplasticity in the respiratory control system, a comprehensive conceptual framework is lacking. Our goals in this review are to define plasticity (and related neural properties) as it pertains to respiratory control and to discuss potential sites, mechanisms, and known categories of respiratory plasticity. Respiratory plasticity is defined as a persistent change in the neural control system based on prior experience. Plasticity may involve structural and/or functional alterations (most commonly both) and can arise from multiple cellular/synaptic mechanisms at different sites in the respiratory control system. Respiratory neuroplasticity is critically dependent on the establishment of necessary preconditions, the stimulus paradigm, the balance between opposing modulatory systems, age, gender, and genetics. Respiratory plasticity can be induced by hypoxia, hypercapnia, exercise, injury, stress, and pharmacological interventions or conditioning and occurs during development as well as in adults. Developmental plasticity is induced by experiences (e.g., altered respiratory gases) during sensitive developmental periods, thereby altering mature respiratory control. The same experience later in life has little or no effect. In adults, neuromodulation plays a prominent role in several forms of respiratory plasticity. For example, serotonergic modulation is thought to initiate and/or maintain respiratory plasticity following intermittent hypoxia, repeated hypercapnic exercise, spinal sensory denervation, spinal cord injury, and at least some conditioned reflexes. Considerable work is necessary before we fully appreciate the biological significance of respiratory plasticity, its underlying cellular/molecular and network mechanisms, and the potential to harness respiratory plasticity as a therapeutic tool.