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Neder JA. Cardiopulmonary exercise testing applied to respiratory medicine: Myths and facts. Respir Med 2023; 214:107249. [PMID: 37100256 DOI: 10.1016/j.rmed.2023.107249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O2 uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate ("anaerobic") threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO2 output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea "quantity" and "quality". Based on a conceptual framework that links exertional dyspnoea to "excessive" and/or "restrained" breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Department of Medicine, Division of Respirology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada.
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2
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Kelly C, Hamer O, Irving GJ, Jones K, Knighting K, Wat D, Spencer S. Cognitive behavioural approaches for managing dyspnoea in people with chronic obstructive pulmonary disease (COPD). Hippokratia 2021. [DOI: 10.1002/14651858.cd014957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Carol Kelly
- Respiratory Research Centre, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
| | - Oliver Hamer
- Respiratory Research Centre, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
| | - Greg J Irving
- Health Research Institute; Faculty of Health, Social Care & Medicine, Edge Hill University; Ormskirk UK
| | - Karl Jones
- Liverpool John Moores University; Liverpool UK
| | - Katherine Knighting
- Health Research Institute; Faculty of Health, Social Care & Medicine, Edge Hill University; Ormskirk UK
| | - Dennis Wat
- Liverpool Heart and Chest Hospital; Liverpool UK
- Faculty of Life Sciences; University of Liverpool; Liverpool UK
| | - Sally Spencer
- Health Research Institute, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
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3
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Yamaguchi T, Yamamoto A, Oki Y, Sakai H, Misu S, Iwata Y, Kaneko M, Sawada K, Oki Y, Mitani Y, Ono K, Ishikawa A. Reliability and Validity of the Japanese Version of the Barthel Index Dyspnea Among Patients with Respiratory Diseases. Int J Chron Obstruct Pulmon Dis 2021; 16:1863-1871. [PMID: 34188463 PMCID: PMC8232896 DOI: 10.2147/copd.s313583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/01/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Japan has only a few respiratory disease-specific activity of daily living scales that are accepted outside of Japan, and they are not widely used. The Barthel Index dyspnea (BI-d), an improved version of the Barthel Index (BI), may be popular in Japan. The purpose of this study was to develop the Japanese version of BI-d (J-BI-d) and investigate its reliability and validity. Patients and Methods The J-BI-d was developed using the basic guidelines for scale translation. The study included patients with chronic respiratory disease, receiving outpatient care at two centers between January 2019 and February 2020. Scores on the J-BI-d, modified Medical Research Council scale (mMRC scale), BI, respiratory function tests, and 6-minute walk distance (6MWD) test were measured. To verify the test-retest reliability, the J-BI-d was re-administered, and the intraclass correlation coefficient (ICC) was obtained. Internal consistency was verified by Cronbach's alpha reliability coefficient, and criterion-related validity was verified through a correlation analysis of the J-BI-d with mMRC scale and 6MWD test. Divergent validity was verified through correlation analysis between the J-BI-d and BI. Results Data for 57 participants (mean age 74.4 ± 8.3 years) were analyzed, and reliability testing was performed with 42 of them. The mean time to retest was 8.1 ± 3.0 days, and the ICC (2, 1) was 0.76 (95% CI: 0.62-0.85), indicating high reliability. Cronbach's alpha reliability coefficient was 0.81, indicating high internal consistency. Correlation coefficients of the J-BI-d with 6MWD test (r = -0.46, p < 0.01) and mMRC scale (ρ = 0.76, p < 0.01) indicated high criterion-related validity. The J-BI-d and BI had a weak negative correlation (r = -0.29, p < 0.05), indicating high divergent validity. Conclusion The results of this study demonstrate high reliability and appropriate validity of the J-BI-d in patients with chronic respiratory disease.
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Affiliation(s)
- Takumi Yamaguchi
- Department of Rehabilitation, Kobe City Hospital Organization, Kobe City Medical Center West Hospital, Kobe, Hyogo, 653-0013, Japan
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Akio Yamamoto
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
- Department of Faculty of Nursing, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, 569-0095, Japan
| | - Yutaro Oki
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Hideki Sakai
- Department of Rehabilitation, Kobe City Hospital Organization, Kobe City Medical Center West Hospital, Kobe, Hyogo, 653-0013, Japan
| | - Shogo Misu
- Department of Rehabilitation, Kobe City Hospital Organization, Kobe City Medical Center West Hospital, Kobe, Hyogo, 653-0013, Japan
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women’s University, Kobe, Hyogo, 658-0001, Japan
| | - Yusuke Iwata
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Masahiro Kaneko
- Department of Respiratory Medicine, Kobe City Hospital Organization Kobe City Medical Center West Hospital, Kobe, Hyogo, 653-0013, Japan
| | - Kaku Sawada
- Department of Internal Medicine, Keiwakai Nishioka hospital, Sapporo, Hokkaido, 062-0034, Japan
| | - Yukari Oki
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Yuji Mitani
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Kumiko Ono
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
| | - Akira Ishikawa
- Kobe University Graduate School of Health Sciences, Kobe, Hyogo, 654-0142, Japan
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Phillips DB, James MD, Elbehairy AF, Milne KM, Vincent SG, Domnik NJ, de-Torres JP, Neder JA, O'Donnell DE. Reduced exercise tolerance in mild chronic obstructive pulmonary disease: The contribution of combined abnormalities of diffusing capacity for carbon monoxide and ventilatory efficiency. Respirology 2021; 26:786-795. [PMID: 33829588 DOI: 10.1111/resp.14045] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The combination of both reduced resting diffusing capacity of the lung for carbon monoxide (DLCO ) and ventilatory efficiency (increased ventilatory requirement for CO2 clearance [V˙E /V˙CO2 ]) has been linked to exertional dyspnoea and exercise intolerance in chronic obstructive pulmonary disease (COPD) but the underlying mechanisms are poorly understood. The current study examined if low resting DLCO and higher exercise ventilatory requirements were associated with earlier critical dynamic mechanical constraints, dyspnoea and exercise limitation in patients with mild COPD. METHODS In this retrospective analysis, we compared V˙E /V˙CO2 , dynamic inspiratory reserve volume (IRV), dyspnoea and exercise capacity in groups of patients with Global Initiative for Chronic Obstructive Lung Disease stage 1 COPD with (1) a resting DLCO at or greater than the lower limit of normal (≥LLN; Global Lung Function Initiative reference equations [n = 44]) or (2) below the <LLN (n = 33), and age- and sex-matched healthy controls (n = 81). RESULTS Spirometry and resting lung volumes were similar in the two COPD groups. During exercise, V˙E /V˙CO2 (nadir and slope) was consistently higher in the DLCO < LLN compared with the other groups (all p < 0.05). The DLCO < LLN group had lower IRV and greater dyspnoea intensity at standardized submaximal work rates and lower peak work rate and oxygen uptake than the other two groups (all p < 0.05). CONCLUSION Reduced exercise capacity in patients with DLCO < LLN was related to higher ventilatory requirements, a faster rate of decline in dynamic IRV and greater dyspnoea during exercise. These simple measurements should be considered for the clinical evaluation of unexplained exercise intolerance in individuals with ostensibly mild COPD.
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Affiliation(s)
- Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Amany F Elbehairy
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada.,Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kathryn M Milne
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada.,Department of Medicine Clinician Investigator Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Nicolle J Domnik
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Juan P de-Torres
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston General Hospital Campus, Kingston, Ontario, Canada
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5
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Finnegan SL, Pattinson KT, Sundh J, Sköld M, Janson C, Blomberg A, Sandberg J, Ekström M. A common model for the breathlessness experience across cardiorespiratory disease. ERJ Open Res 2021; 7:00818-2020. [PMID: 34195256 PMCID: PMC8236755 DOI: 10.1183/23120541.00818-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/15/2021] [Indexed: 11/16/2022] Open
Abstract
Chronic breathlessness occurs across many different conditions, often independently of disease severity. Yet, despite being strongly linked to adverse outcomes, the consideration of chronic breathlessness as a stand-alone therapeutic target remains limited. Here we use data-driven techniques to identify and confirm the stability of underlying features (factors) driving breathlessness across different cardiorespiratory diseases. Questionnaire data on 182 participants with main diagnoses of asthma (21.4%), COPD (24.7%), heart failure (19.2%), idiopathic pulmonary fibrosis (18.7%), other interstitial lung disease (2.7%), and "other diagnoses" (13.2%) were entered into an exploratory factor analysis (EFA). Participants were stratified based on their EFA factor scores. We then examined model stability using 6-month follow-up data and established the most compact set of measures describing the breathlessness experience. In this dataset, we have identified four stable factors that underlie the experience of breathlessness. These factors were assigned the following descriptive labels: 1) body burden, 2) affect/mood, 3) breathing burden and 4) anger/frustration. Stratifying patients by their scores across the four factors revealed two groups corresponding to high and low burden. These two groups were not related to the primary disease diagnosis and remained stable after 6 months. In this work, we identified and confirmed the stability of underlying features of breathlessness. Previous work in this domain has been largely limited to single-diagnosis patient groups without subsequent re-testing of model stability. This work provides further evidence supporting disease independent approaches to assess breathlessness.
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Affiliation(s)
- Sarah L. Finnegan
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle T.S. Pattinson
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Josefin Sundh
- Dept of Respiratory Medicine, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Magnus Sköld
- Respiratory Medicine Unit, Dept of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Christer Janson
- Dept of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Anders Blomberg
- Dept of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Jacob Sandberg
- Respiratory Medicine and Allergology, Dept of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Magnus Ekström
- Respiratory Medicine and Allergology, Dept of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Abstract
In cardiopulmonary medicine, residual exertional dyspnea (RED) can be defined by the persistence of limiting breathlessness in a patient who is already under the best available therapy for the underlying heart and/or lung disease. RED is a challenge to the pulmonologist because the patient (and the referring physician) assumes that the "lung doctor" should invariably provide a successful plan to fight the symptom. After presenting a simplified framework to understand the neurobiological underpinnings of dyspnea in cardiorespiratory disease, I discuss the seeds of RED associated with 1) increased metabolic cost of work, 2) increased inspiratory constraints, 3) diaphragm dysfunction, 4) impaired right ventricle preload, 5) increased central and/or peripheral chemosensitivity, 6) increased physiological dead space, 7) increased pulmonary venous and/or high left ventricle filling pressures, 8) impaired chronotropic response to exertion, and 9) increased activation of the cortical-limbic circuits. I finalize by outlining the following two common coexistence of diseases in which these multiple mechanisms interact to produce severe RED: chronic obstructive pulmonary disease-heart failure with reduced ejection fraction and chronic pulmonary fibrosis-emphysema. RED exposes the important limitations of the current reductionist approach focused only on the (over)treatment of the poorly reversible cardiopulmonary disease(s). Conversely, recognizing the existence of RED sets the stage for a more holistic approach toward one of the most devastating symptoms known to man.
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Abstract
Lung function testing has undisputed value in the comprehensive assessment and individualized management of chronic obstructive pulmonary disease, a pathologic condition in which a functional abnormality, poorly reversible expiratory airway obstruction, is at the core of its definition. After an overview of the physiologic underpinnings of the disease, the authors outline the role of lung function testing in this disease, including diagnosis, assessment of severity, and indication for and responses to pharmacologic and nonpharmacologic interventions. They discuss the current controversies surrounding test interpretation with these purposes in mind and provide balanced recommendations to optimize their usefulness in different clinical scenarios.
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Elbehairy AF, Faisal A, McIsaac H, Domnik NJ, Milne KM, James MD, Neder JA, O'Donnell DE. Mechanisms of orthopnoea in patients with advanced COPD. Eur Respir J 2020; 57:13993003.00754-2020. [PMID: 32972985 DOI: 10.1183/13993003.00754-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/15/2020] [Indexed: 01/18/2023]
Abstract
Many patients with severe chronic obstructive pulmonary disease (COPD) report an unpleasant respiratory sensation at rest, which is further amplified by adoption of a supine position (orthopnoea). The mechanisms of this acute symptomatic deterioration are poorly understood.Sixteen patients with advanced COPD and a history of orthopnoea and 16 age- and sex-matched healthy controls underwent pulmonary function tests (PFTs) and detailed sensory-mechanical measurements including inspiratory neural drive (IND) assessed by diaphragm electromyography (EMGdi), oesophageal pressure (P es) and gastric pressure (P ga), in both sitting and supine positions.Patients had severe airflow obstruction (forced expiratory volume in 1 s (FEV1): 40±18% pred) and lung hyperinflation. Regardless of the position, patients had lower inspiratory capacity (IC) and higher IND for a given tidal volume (V T) (i.e. greater neuromechanical dissociation (NMD)), higher intensity of breathing discomfort, higher minute ventilation (V'E) and higher breathing frequency (f B) compared with controls (all p<0.05). For controls in a supine position, IC increased by 0.48 L versus sitting erect, with a small drop in V'E, mainly due to reduced f B (all p<0.05). By contrast, IC remained unaltered in patients with COPD, but dynamic lung compliance (C Ldyn) decreased (p<0.05) in the supine position. Breathing discomfort, inspiratory work of breathing (WOB), inspiratory effort, IND, NMD and neuroventilatory uncoupling all increased in COPD patients in the supine position (p<0.05), but not in the healthy controls. Orthopnoea was associated with acute changes in IND (r=0.65, p=0.01), neuroventilatory uncoupling (r=0.76, p=0.001) and NMD (r=0.73, p=0.002).In COPD, onset of orthopnoea coincided with an abrupt increase in elastic loading of the inspiratory muscles in recumbency, in association with increased IND and greater NMD of the respiratory system.
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Affiliation(s)
- Amany F Elbehairy
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada.,Dept of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azmy Faisal
- Dept of Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK.,Faculty of Physical Education for Men, Alexandria University, Alexandria, Egypt
| | - Hannah McIsaac
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Nicolle J Domnik
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Kathryn M Milne
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada.,Clinician Investigator Program, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew D James
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J Alberto Neder
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Division of Respiratory Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
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Heart, lungs, and muscle interplay in worsening activity-related breathlessness in advanced cardiopulmonary disease. Curr Opin Support Palliat Care 2020; 14:157-166. [PMID: 32740275 DOI: 10.1097/spc.0000000000000516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Activity-related breathlessness is a key determinant of poor quality of life in patients with advanced cardiorespiratory disease. Accordingly, palliative care has assumed a prominent role in their care. The severity of breathlessness depends on a complex combination of negative cardiopulmonary interactions and increased afferent stimulation from systemic sources. We review recent data exposing the seeds and consequences of these abnormalities in combined heart failure and chronic obstructive pulmonary disease (COPD). RECENT FINDINGS The drive to breathe increases ('excessive breathing') secondary to an enlarged dead space and hypoxemia (largely COPD-related) and heightened afferent stimuli, for example, sympathetic overexcitation, muscle ergorreceptor activation, and anaerobic metabolism (largely heart failure-related). Increased ventilatory drive might not be fully translated into the expected lung-chest wall displacement because of the mechanical derangements brought by COPD ('inappropriate breathing'). The latter abnormalities, in turn, negatively affect the central hemodynamics which are already compromised by heart failure. Physical activity then decreases, worsening muscle atrophy and dysfunction. SUMMARY Beyond the imperative of optimal pharmacological treatment of each disease, strategies to lessen ventilation (e.g., walking aids, oxygen, opiates and anxiolytics, and cardiopulmonary rehabilitation) and improve mechanics (heliox, noninvasive ventilation, and inspiratory muscle training) might mitigate the burden of this devastating symptom in advanced heart failure-COPD.
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