Effect of chronic pulmonary denervation on ventilatory responses to exercise

Differential control of respiratory frequency and tidal volume during exercise

The lack of a testable model explaining how ventilation is regulated in different exercise conditions has been repeatedly acknowledged in the field of exercise physiology. Yet, this issue contrasts with the abundance of insightful findings produced over the last century and calls for the adoption of new integrative perspectives. In this review, we provide a methodological approach supporting the importance of producing a set of evidence by evaluating different studies together-especially those conducted in 'real' exercise conditions-instead of single studies separately. We show how the collective assessment of findings from three domains and three levels of observation support the development of a simple model of ventilatory control which proves to be effective in different exercise protocols, populations and experimental interventions. The main feature of the model is the differential control of respiratory frequency (f_R) and tidal volume (V_T); f_R is primarily modulated by central command (especially during high-intensity exercise) and muscle afferent feedback (especially during moderate exercise) whereas V_T by metabolic inputs. Furthermore, V_T appears to be fine-tuned based on f_R levels to match alveolar ventilation with metabolic requirements in different intensity domains, and even at a breath-by-breath level. This model reconciles the classical neuro-humoral theory with apparently contrasting findings by leveraging on the emerging control properties of the behavioural (i.e. f_R) and metabolic (i.e. V_T) components of minute ventilation. The integrative approach presented is expected to help in the design and interpretation of future studies on the control of f_R and V_T during exercise.

Sensory nerves in lung and airways

Sensory nerves innervating the lung and airways play an important role in regulating various cardiopulmonary functions and maintaining homeostasis under both healthy and disease conditions. Their activities conducted by both vagal and sympathetic afferents are also responsible for eliciting important defense reflexes that protect the lung and body from potential health-hazardous effects of airborne particulates and chemical irritants. This article reviews the morphology, transduction properties, reflex functions, and respiratory sensations of these receptors, focusing primarily on recent findings derived from using new technologies such as neural immunochemistry, isolated airway-nerve preparation, cultured airway neurons, patch-clamp electrophysiology, transgenic mice, and other cellular and molecular approaches. Studies of the signal transduction of mechanosensitive afferents have revealed a new concept of sensory unit and cellular mechanism of activation, and identified additional types of sensory receptors in the lung. Chemosensitive properties of these lung afferents are further characterized by the expression of specific ligand-gated ion channels on nerve terminals, ganglion origin, and responses to the action of various inflammatory cells, mediators, and cytokines during acute and chronic airway inflammation and injuries. Increasing interest and extensive investigations have been focused on uncovering the mechanisms underlying hypersensitivity of these airway afferents, and their role in the manifestation of various symptoms under pathophysiological conditions. Several important and challenging questions regarding these sensory nerves are discussed. Searching for these answers will be a critical step in developing the translational research and effective treatments of airway diseases.

Control of breathing during exercise

During exercise by healthy mammals, alveolar ventilation and alveolar-capillary diffusion increase in proportion to the increase in metabolic rate to prevent PaCO2 from increasing and PaO2 from decreasing. There is no known mechanism capable of directly sensing the rate of gas exchange in the muscles or the lungs; thus, for over a century there has been intense interest in elucidating how respiratory neurons adjust their output to variables which can not be directly monitored. Several hypotheses have been tested and supportive data were obtained, but for each hypothesis, there are contradictory data or reasons to question the validity of each hypothesis. Herein, we report a critique of the major hypotheses which has led to the following conclusions. First, a single stimulus or combination of stimuli that convincingly and entirely explains the hyperpnea has not been identified. Second, the coupling of the hyperpnea to metabolic rate is not causal but is due to of these variables each resulting from a common factor which link the circulatory and ventilatory responses to exercise. Third, stimuli postulated to act at pulmonary or cardiac receptors or carotid and intracranial chemoreceptors are not primary mediators of the hyperpnea. Fourth, stimuli originating in exercising limbs and conveyed to the brain by spinal afferents contribute to the exercise hyperpnea. Fifth, the hyperventilation during heavy exercise is not primarily due to lactacidosis stimulation of carotid chemoreceptors. Finally, since volitional exercise requires activation of the CNS, neural feed-forward (central command) mediation of the exercise hyperpnea seems intuitive and is supported by data from several studies. However, there is no compelling evidence to accept this concept as an indisputable fact.

[Response of tidal volume to inspiratory time ratio during incremental exercise]

OBJECTIVE

There is some debate about the participation of the Hering-Breuer reflex during exercise in human beings. This study aimed to investigate breathing pattern response during an incremental exercise test with a cycle ergometer. Participation of the Hering-Breuer reflex in the control of breathing was to be indirectly investigated by analyzing the ratio of tidal volume (VT) to inspiratory time (tI).

SUBJECTS AND METHODS

The 9 active subjects who participated the study followed an incremental protocol on a cycle ergometer until peak criteria were reached. During exercise, VT/ti can be described in 2 phases, separated by activation of the Hering-Breuer reflex (inspiratory off-switch threshold). In phase 1, ventilation increases because VT increases, resulting in a slight decrease in tI, whereas, in phase 2, increased ventilation is due to both an increase in VT and a decrease in tI.

RESULTS

The mean (SD) inspiratory off-switch threshold was 84.6% (6.3%) when expressed relative to peak VT (mean, 3065 [566.8] mL) and 48% (7.2%) relative to the forced vital capacity measured by resting spirometry. The inspiratory off-switch threshold correlated positively (r=0.93) with the second ventilatory threshold, or respiratory compensation point.

CONCLUSIONS

The inspiratory off-switch threshold and VT/ti are directly related to one another. The inspiratory off-switch threshold was related to the second ventilatory threshold, suggesting that the Hering-Breuer reflex participates in control of the breathing pattern during exercise. Activation of the reflex could contribute by signaling the respiratory centers to change the breathing pattern.

Ventilatory response to exercise in diabetic subjects with autonomic neuropathy

We have used diabetic autonomic neuropathy as a model of chronic pulmonary denervation to study the ventilatory response to incremental exercise in 20 diabetic subjects, 10 with (Dan+) and 10 without (Dan-) autonomic dysfunction, and in 10 normal control subjects. Although both Dan+ and Dan- subjects achieved lower O2 consumption and CO2 production (VCO2) than control subjects at peak of exercise, they attained similar values of either minute ventilation (VE) or adjusted ventilation (VE/maximal voluntary ventilation). The increment of respiratory rate with increasing adjusted ventilation was much higher in Dan+ than in Dan- and control subjects (P < 0.05). The slope of the linear VE/VCO2 relationship was 0.032 +/- 0.002, 0.027 +/- 0.001 (P < 0.05), and 0.025 +/- 0.001 (P < 0.001) ml/min in Dan+, Dan-, and control subjects, respectively. Both neuromuscular and ventilatory outputs in relation to increasing VCO2 were progressively higher in Dan+ than in Dan- and control subjects. At peak of exercise, end-tidal PCO2 was much lower in Dan+ (35.9 +/- 1.6 Torr) than in Dan- (42.1 +/- 1.7 Torr; P < 0.02) and control (42.1 +/- 0.9 Torr; P < 0.005) subjects. We conclude that pulmonary autonomic denervation affects ventilatory response to stressful exercise by excessively increasing respiratory rate and alveolar ventilation. Reduced neural inhibitory modulation from sympathetic pulmonary afferents and/or increased chemosensitivity may be responsible for the higher inspiratory output.

Contribution of acid-base changes to control of breathing during exercise

The mechanisms mediating the exercise hyperpnea remain controversial; there is no unequivocal evidence that any of numerous proposed mechanisms mediates the hyperpnea. However, a great deal has been learned including the potential role of changes in PCO2, [H+], strong ion differences (SID), weak acids, or any other acid-base component. The contribution of acid-base changes to the hyperpnea during exercise is likely through known or postulated chemoreceptors. Two of these, pulmonary and intracranial chemoreceptors, do not appear critical for the ventilatory adjustments to meet the metabolic demands of exercise. A third, the carotid chemoreceptors, appear to fine-tune alveolar ventilation during exercise to minimize disruptions in arterial blood gases. The role of the fourth chemoreceptors, those within skeletal muscles, is least clear. However, there is evidence that they do contribute to the hyperpnea, and it is quite clear that a muscle chemoreflex contributes to the exercise muscle pressor reflex; thus the contribution of these chemoreceptors to the exercise hyperpnea requires additional study.

Tidal volume and respiratory rate changes during CO2 rebreathing after lung transplantation

To evaluate the contribution of the respiratory pattern to the ventilatory response after lung transplantation, we studied the changes in minute ventilation, tidal volume, and respiratory rate during CO2 rebreathing in 14 patients with severe obstructive pulmonary disease, and compared them with 10 normal subjects. Seven patients underwent a bilateral lung transplantation and 7 patients had single-lung transplantation. Single-lung transplant recipients increased their respiratory rate by the last postoperative test compared with either preoperative or initial test periods (0.38 +/- 0.13 versus 0.027 +/- 0.24 or 0.12 +/- 0.08 breaths.min-1.mm Hg-1; p < 0.005). Bilateral lung transplant recipients showed a diminished ability to augment their respiratory rate by the last postoperative test compared with either preoperative or initial test periods (0.13 +/- 0.23 versus 0.54 +/- 0.25 or 0.25 +/- 0.29 breaths.min-1.mm Hg-1; p < 0.06). The restored ventilatory response by the fourth postoperative week was due to a statistically significant increase in tidal volume for both single and bilateral lung transplant recipients. This study demonstrates that when lung transplant recipients have an appropriate ventilatory response to CO2 rebreathing, single-lung transplant recipients have a respiratory pattern similar to normal; whereas the bilateral lung transplant recipients show the effects of total pulmonary denervation. We conclude that the preserved ventilatory response in lung transplant recipients is composed of a respiratory pattern that is influenced by the presence or absence of vagal inputs.

The effects of locomotion on respiratory muscle activity in the awake dog

Using 6 chronically-instrumented awake dogs, we characterized the response of the respiratory muscles to mild and moderate treadmill exercise in terms of (1) the magnitude and timing of the EMGs of the costal and crural diaphragm, triangularis sterni and transverse abdominal muscles, and (2) the concomitant changes in esophageal (PE) and gastric (PG) pressures during treadmill exercise. Dogs wore a bivalved breathing mask which constrained breathing frequency and prevented some of the exercise-induced hypocapnia. Inspiratory and chest expiratory muscle EMGs increased linearly with a 1.5-fold tidal volume (VT) change during exercise. Abdominal muscle recruitment occurred during most exercise levels and exhibited (1) phasic activity coincident with footplant and (2) tonic activation evidenced by a baseline shift in PG and EMG activities. During control, inspiratory and expiratory flow preceded the onset of respiratory muscle EMG activity, but during exercise, electrical activation of these muscles coincided with the onset of mechanical flow. We conclude that phasic and tonic activation of expiratory muscles during exercise in the dog is significantly influenced by both respiratory and locomotory requirements. These patterns of expiratory muscle recruitment may assist inspiration by lengthening inspiratory muscles through decrements in end-expiratory lung volume and by passive recoil of the rib cage and abdominal compartments.

Time-series analysis of heart rate variability during submaximal exercise. Evidence for reduced cardiac vagal tone in animals susceptible to ventricular fibrillation

Periodic fluctuations in the R-R interval have been used as noninvasive measures of cardiac autonomic tone. For example, a reduced heart rate variability has been shown to correlate with an increased mortality in patients recovering from myocardial infarction. The effects that physiologic perturbations such as exercise have on this heart rate variability have not been investigated. Therefore, heart rate variability was measured throughout a submaximal exercise test in 36 mongrel dogs with healed anterior myocardial infarctions. The amplitude of the respiratory component (0.24-1.04 Hz) was determined by time-series analysis techniques and was used as an index of cardiac vagal tone. On a subsequent day, a 2-minute coronary occlusion was initiated during the last minute of exercise. Twenty-two animals developed ventricular fibrillation (susceptible), whereas 14 animals did not (resistant). Exercise elicited a significantly greater increase in heart rate (resistant, 205.4 +/- 7.1; susceptible, 227.0 +/- 5.4 beats/min) in susceptible animals, which was accompanied by a greater reduction in the cardiac vagal tone index (resistant, 2.7 +/- 0.3; susceptible, 1.1 +/- 0.2 ln msec2) as compared with resistant animals. Conversely, atropine sulfate (50 micrograms/kg) given during exercise elicited a greater heart rate increase in the resistant dogs (heart rate change: resistant, 54.2 +/- 7.0; susceptible, 18.7 +/- 4.4 beats/min). Taken together, these data suggest that exercise elicited a greater reduction in cardiac vagal tone in animals known to be susceptible to ventricular fibrillation.

Evidence of an altered pattern of breathing during exercise in recipients of heart-lung transplants

Recipients of heart-lung transplants represent an unusual opportunity to study the regulation of ventilation, because the neural pathways between the lungs and the central nervous system are disrupted in these patients. We compared the ventilation response in seven recipients of heart-lung transplants who had normal pulmonary function and seven recipients of heart transplants, all of whom performed incremental bicycle ergometry. The level of ventilation in recipients of heart-lung transplants was similar to that in heart-transplant recipients for equivalent levels of carbon dioxide production. Arterial pH and partial pressure of carbon dioxide at maximal exercise were normal and not significantly different in the two groups, also suggesting that levels of ventilation were appropriate in both groups. However, the rate of the rise in respiratory rate for increasing levels of ventilation was significantly lower in recipients of heart-lung transplants than in heart-transplant recipients, and the initial increase in tidal volume was more rapid in the former group than in the latter. Thus, recipients of heart-lung transplants have an appropriate level of ventilation during exercise as the result of a disproportionate increase in tidal volume at a reduced respiratory rate. We speculate that intrapulmonary receptors are important in regulating the pattern, but not the absolute level, of ventilation during exercise.

Possible mechanisms of the anaerobic threshold. A review

The anaerobic threshold consists of a lactate threshold and a ventilatory threshold. In some conditions there may actually be 2 ventilatory thresholds. Much of the work detailing the lactate threshold is strongly based on blood lactate concentration. Since, in most cases, blood lactate concentration does not reflect production in active skeletal muscle, inferences about the metabolic state of contracting muscle will not be valid based only on blood lactate concentration measurements. Numerous possible mechanisms may be postulated as generating a lactate threshold. However, it is very difficult to design a study to influence only one variable. One may ask, does reducing F1O2 cause an earlier occurrence of a lactate threshold during progressive exercise by reducing oxygen availability at the mitochondria? By stimulating catecholamine production? By shifting more blood flow away from tissues which remove lactate from the blood? Or by some other mechanism? Processes considered essential to the generation of a lactate threshold include: (a) substrate utilisation in which the ability of contracting muscle cells to oxidise fats reaches maximal power at lactate threshold; and (b) catecholaminergic stimulation, for without the presence of catecholamines it appears a lactate threshold cannot be generated. Other mechanisms discussed which probably enhance the lactate threshold, but are not considered essential initiators are: (a) oxygen limitation; (b) motor unit recruitment order; (c) lactate removal; (d) muscle temperature receptors; (e) metabolic stimulation; and (f) a threshold of lactate efflux. Some mechanisms reviewed which may induce or contribute to a ventilatory threshold are the effects of: (a) the carotid bodies; (b) respiratory mechanics; (c) temperature; and (d) skeletal muscle receptors. It is not yet possible to determine the hierarchy of effects essential for generating a ventilatory threshold. This may indicate that the central nervous system integrates a broad range of input signals in order to generate a non-linear increase in ventilation. Evidence indicates that the occurrence of the lactate threshold and the ventilatory threshold may be dissociated; sometimes the occurrence of the lactate threshold significantly precedes the ventilatory threshold and at other times the ventilatory threshold significantly precedes the lactate threshold. It is concluded that the 2 thresholds are not subserved by the same mechanism.

Breathing during exercise: demands, regulation, limitations

In humans alveolar ventilation (VA) is adjusted almost perfectly to the metabolic demands of mild and moderate exercise. For example, in exercise transitions and in the steady state, PaCO2 rarely deviates by more than 1 to 3 mmHg from the value at rest. This near-homeostasis contrasts to most other mammalian species; equines for example, demonstrate a progressive hypocapnia and alkalosis as exercise intensity is increased to moderate levels. In equines, the control systems seem programmed for a specific hyperventilation that contributes to maintenance of PaO2 homeostasis. Generally, during heavy exercise all species hyperventilate creating hypocapnia, increased PAO2, widened A-a O2 gradient, and PaO2 homeostasis. The origin of the metabolic ventilatory stimulus remains controversial. Evidence exists for: a) "neural" mediation, either central command or peripheral afferent in nature; and b) "humoral" mediation with an intra-thoracic metabolite receptor being a possibility. The mechanism of the species differences in hyperventilation during exercise does not appear to be due to species variation in chemoreceptor "fine tuning". Contrary to traditional thinking, recent findings suggest that the hyperventilation during heavy exercise might not be mediated by lactacidosis stimulation of chemoreceptors. The increase in VA during exercise is achieved efficiently in that airway diameter is modulated and the pattern of breathing and the recruitment of respiratory muscles are set to minimize the O2 cost of breathing. It has been postulated that mechanoreceptors in airways, lung parenchyma and the chest wall are important to efficient breathing. Their role and contribution to the exercise hyperpnea has been shown by reductions in respiratory neural output within breath when respiratory impedance is reduced via helium breathing. Hilar nerve afferents do not appear to be critical to this response. However, carotid chemoreceptors appear essential for "fine tuning" of VA when respiratory impedance is reduced. In most healthy exercising mammals, the efficiency component of the exercise stimulus does not compromise VA. There are two known major exceptions. One is the extremely fit human athlete during very high workloads when atypically there is minimal or no hyperventilation resulting in arterial hypoxemia. That indeed the high O2 cost of breathing compromises VA is indicated by hyperventilation and alleviation of hypoxemia with resistance unloading through helium breathing. A second example of a compromise of VA is that of a galloping racehorse at very high workloads.(ABSTRACT TRUNCATED AT 400 WORDS)