Diving response and arterial oxygen saturation during apnea and exercise in breath-hold divers

Acute ergogenic effects of repetitive maximal breath-holding maneuvers on hematological and physiological responses: a graded exercise test investigation

PURPOSE

Repetitive maximal breath-holds (BHs or apneas) have been noted to induce advantageous hematological and blood buffering changes. Building on this, the hypothesis was formulated that the execution of repeated maximal BH efforts might lead to subsequent enhancements in performance during a time-to-exhaustion test.

METHODS

This study investigated the acute effects of five static maximal breath-holding maneuvers conducted with face immersion in cold water (10 °C) on subsequent graded exercise test (GET) performance. Seventeen well-trained participants completed a GET on a motorized treadmill under two randomized cross-over conditions: baseline measurement (CON) and after five repeated maximal breath-holding efforts (EXP).

RESULTS

The GET protocol consists of incremental increases in speed until exhaustion. After the fifth breath-hold, participants in the EXP condition exhibited significant (P < 0.05) increases in hematocrit, hemoglobin concentration, red blood cell count, and muscle deoxygenation, accompanied by a reduction in blood lactate concentration (4.09 ± 2.21%, 3.9 ± 1.76%, 3.96 ± 2.1%, 81.48 ± 23.83%, and 15.22 ± 17.64%, respectively), compared to CON. During GET, the EXP condition showed a significantly (P < 0.05) delayed onset time of the second ventilatory threshold (3.14 ± 5.85%) and (P < 0.05) increased time to exhaustion (0.75 ± 1.02%).

CONCLUSION

This evidence suggests that repeated maximal static breath-holding maneuvers enhance the oxygen delivery system by increasing the circulation of reserve red blood cells, heightened muscle oxygen deoxygenation, enhanced aerobic metabolism utilization, and postponing the transition from aerobic to anaerobic metabolism, implying a potential ergogenic effect. While pre-exercise breath-holding shows promise for improving time-to-exhaustion and optimizing subsequent distance running performance, further in-depth investigation is essential to fully elucidate the underlying mechanistic factors.

Monitoring the Breath-Hold Training Load during an Ecological Session: A Pilot Study

This study aimed to create a training load index to measure physiological stress during breath-hold (BH) training and examine its relationship with memory performance. Eighteen well-trained BH divers (Age: 35.8±6.6 years, BH training practice: 5.3±4.5 years) participated in this study. During a standard 1.5-hour BH training in the pool, perceived exertion, heart rate, distance, and duration were measured. The training load index was modelled on the basis of a TRIMP (TRaining IMPulse) with four different equations and was used to measure the stress induced by this BH training. A reference value, based on the ratio between the average heart rate during all BHs and the lowest heart rate during BH training, was used for comparing training load index. Memory assessment was conducted both before and after this training. Of the four equations proposed, equation no. 4, named aTRIMP for "apnoea," showed the strongest correlation with our reference value (r=0.652, p<0.01). No difference was found between any of the memory tests before and after the BH training. The aTRIMP was a new representative index for monitoring habitual training of well-trained BH divers. Furthermore, this training had no negative impact on memory performance.

Cardiovascular and hematological responses to a dry dynamic apnea in breath hold divers

The mammalian dive reflex, characterized by bradycardia and peripheral vasoconstriction, occurs in all mammals, including humans, in response to apnea. However, the dive reflex to a single, maximal, dry, dynamic apnea (DYN) and how it compares to a time-matched exercise control trial (EX) or dry static apnea (SA) has not been studied. We examined the hypotheses that, compared with EX and SA, the magnitude of the 1) cardiovascular response and 2) hematological response to DYN would be greater. Cardiovascular parameters [heart rate (HR), systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressure] were continuously collected in 23 (F = 6 females) moderate and elite freedivers, first during a maximal DYN, then during a time-matched SA and EX on a swimming ergometer in randomized order. Venous blood draws were made before and following each trial. The change in calculated oxygen saturation (DYN: -17 ± 13%, EX: -2 ± 1%, ΔSA: -2 ± 1%; P < 0.05, all comparisons) was greater during DYN compared with EX and SA. During DYN, ΔSBP (DYN: 104 ± 31 mmHg; EX: 38 ± 23 mmHg; and SA: 20 ± 11 mmHg), ΔDBP (DYN: 45 ± 12 mmHg; EX: 14 ± 10 mmHg; and SA: 15 ± 8 mmHg), and ΔMAP (DYN: 65 ± 17 mmHg; EX: 22 ± 13 mmHg; and SA: 16 ± 9 mmHg) were increased compared with EX and SA, while ΔHR was greater during EX (DYN: -24 ± 23 beats/min; EX: 33 ± 13 beats/min; and SA: -1 ± 10 beats/min) than either DYN or SA (P < 0.0001, all comparisons). Females had a greater pressor response to EX (ΔSBP: 59 ± 30 mmHg; ΔDBP: 24 ± 14 mmHg; and ΔMAP: 35 ± 8 mmHg) than males (ΔSBP: 31 ± 15 mmHg; ΔDBP: 11 ± 6 mmHg; and ΔMAP: 18 ± 8 mmHg; P < 0.01, all comparisons). Together, these data indicate that DYN elicits a distinct, exaggerated cardiovascular response compared with EX or SA alone.NEW & NOTEWORTHY This study performed a dry dynamic apnea with sport-specific equipment to closely mimic the physiological demands of competition diving. We found the cardiovascular and hematological responses to dynamic apnea were more robust compared with time-matched exercise and dry static apnea control trials.

Fast Competitive Swimmers Demonstrate a Diminished Diving Reflex

Competitive swimmers complete 50-m front crawl swimming without breathing or with a limited number of breaths. Breath holding during exercise can trigger diving reflex including bradycardia and diminished active muscle blood flow, whereas oxygen supply to vital organ such as brain is maintained. We hypothesized that swimmers achieving faster time in 50-m front crawl with limited number of breaths demonstrate a blunted diving reflex of cardiac and active muscle blood flow responses with elevated cerebral perfusion to counteract peripheral and central fatigues. Twenty-eight competitive swimmers (12 females) underwent a 50-m front crawl swimming time trial with minimum respiratory interruptions, following which they were categorized into two groups: Fast (n = 13) and Slow (n = 15). Additionally, they performed knee extension exercises with maximal voluntary breath- holding, wherein leg blood flow (Doppler ultrasound), cardiac output (Modelflow), heart rate (electrocardiogram), and middle cerebral artery mean blood velocity (transcranial Doppler ultrasound) were evaluated. The pattern of leg blood flow response differed between the two groups (p = 0.031) with the Fast group experiencing a delayed onset of reductions in leg blood flow (p = 0.035). The onset of bradycardia was also delayed in the Fast group (p = 0.014), with this group demonstrating a higher value of the lowest heart rate (between-trial difference in average: 15.9 [3.73, 28.2] beats/min) and cardiac output (between-trial difference in median: 2.84 L/min) (both, p ≤ 0.013). Middle cerebral artery mean blood velocity was similar between the groups (all p ≥ 0.112). We show that swimmers with superior performance in 50-m front crawl swim with limited breaths display a diminished diving reflex.

Acute Effects of Breath-Hold Conditions on Aerobic Fitness in Elite Rugby Players

The effects of face immersion and concurrent exercise on the diving reflex evoked by breath-hold (BH) differ, yet little is known about the combined effects of different BH conditions on aerobic fitness in elite athletes. This study aimed to assess the acute effects of various BH conditions on 18 male elite rugby players (age: 23.5 ± 1.8 years; height: 183.3 ± 3.4 cm; body mass: 84.8 ± 8.5 kg) and identify the BH condition eliciting the greatest aerobic fitness activation. Participants underwent five warm-up conditions: baseline regular breathing, dynamic dry BH (DD), static dry BH (SD), wet dynamic BH (WD), and wet static BH (WS). Significant differences (p < 0.05) were found in red blood cells (RBCs), red blood cell volume (RGB), and hematocrit (HCT) pre- and post-warm-up. Peak oxygen uptake (VO2peak) and relative oxygen uptake (VO2/kgpeak) varied significantly across conditions, with BH groups showing notably higher values than the regular breathing group (p < 0.05). Interaction effects of facial immersion and movement conditions were significant for VO2peak, VO2/kgpeak, and the cardiopulmonary optimal point (p < 0.05). Specifically, VO2peak and peak stroke volume (SVpeak) were significantly higher in the DD group compared to that in other conditions. Increases in VO2peak were strongly correlated with changes in RBCs and HCT induced by DD warm-up (r∆RBC = 0.84, r∆HCT = 0.77, p < 0.01). In conclusion, DD BH warm-up appears to optimize subsequent aerobic performance in elite athletes.

The Effect of Static Apnea Diving Training on the Physiological Parameters of People with a Sports Orientation and Sedentary Participants: A Pilot Study

Diver training improves physical and mental fitness, which can also benefit other sports. This study investigates the effect of eight weeks of static apnea training on maximum apnea time, and on the physiological parameters of runners, swimmers, and sedentary participants, such as forced vital capacity (FVC), minimum heart rate (HR), and oxygen saturation (SpO2). The study followed 19 participants, including five runners, swimmers, sedentary participants, and four competitive divers for reference values. The minimum value of SpO2, HR, maximum duration of apnea, and FVC were measured. Apnea training occurred four times weekly, consisting of six apneas with 60 s breathing pauses. Apnea duration was gradually increased by 30 s. The measurement started with a 30 s apnea and ended with maximal apnea. There was a change in SpO2 decreased by 6.8%, maximum apnea length increased by 15.8%, HR decreased by 9.1%, and FVC increased by 12.4% for the groups (p < 0.05). There were intra-groups changes, but no significant inter-groups difference was observed. Eight weeks of apnea training improved the maximum duration of apnea, FVC values and reduced the minimum values of SpO2 and HR in all groups. No differences were noted between groups after training. This training may benefit cardiorespiratory parameters in the population.

Cold stimulation of the oral cavity redistributes blood towards the brain in healthy volunteers

BACKGROUND

The aim of this study was to analyze cold stimulation-induced changes in cerebral and cardiac hemodynamics.

METHODS

Upon ingestion of an ice cube, the changes in resistance index, mean flow velocity and flow index of the middle cerebral arteries (MCA) were assessed using transcranial Doppler sonography. Extracranial duplex sonography was used to measure the mean flow velocity and resistance index of the right internal carotid artery (ICA). The change in mean arterial pressure, heart rate, root mean square of successive differences (RMSSD) and end-tidal carbon dioxide pressure were analyzed additionally. These changes were compared to sham stimulation.

RESULTS

Compared with sham stimulation, cooling of the oral cavity resulted in significant changes in cerebral and cardiac hemodynamics. The cold stimulation decreased the resistance index in the MCA (-4.5% ± 5.4%, p < 0.0001) and right ICA (-6.3% ± 15.6%, p = 0.001). This was accompanied by an increase in mean flow velocity (4.1% ± 8.0%, p < 0.0001) and flow index (10.1% ± 43.6%, p = 0.008) in the MCA. The cardiac effects caused an increase in mean arterial pressure (1.8% ± 11.2%, p = 0.017) and RMSSD (55% ± 112%, p = 0.048), while simultaneously decreasing the heart rate (-4.3% ± 9.6%, p = 0.0001).

CONCLUSION

Cooling of the oral cavity resulted in substantial changes in cerebral and cardiac hemodynamics resulting in a blood flow diversion to the brain.

Construction and Validation of Newly Adapted Sport-Specific Anaerobic Diving Tests

Breath-hold diving is explained as an activity that requires enduring muscle asphyxia and acidosis, high anaerobic capacity, and the tactic of the dive. Therefore, this study aimed to construct and validate tests that will mimic anaerobic processes in the specific media of freedivers. The sample of participants included 34 Croatian freedivers (average age: 26.85 ± 4.0 years, competitive age: 3.82 ± 1.92 years, their body height: 180.14 ± 8.93 cm, and their body mass: 76.82 ± 12.41 kg). The sample of variables consists of anthropometric indices, competitive efficiency (maximal length of a dive (DYN)), and specific anaerobic capacities (100 m and 2 min tests). Newly developed tests included the swimming anaerobic sprint test (SAST) and diving anaerobic sprint test (DAST). DAST and SAST variables included the total time of the test (DAST/SAST) and the fastest interval (DASTmax/SASTmax). The results showed good reliability of the tests with high Cronbach alpha coefficients (DAST: 0.98, DASTmax: 0.97, SAST: 0.99, SASTmax: 0.91). Furthermore, pragmatic validity shows a high correlation among all variables and DAST (DYN: -0.70, 100 m: 0.66, 2 min: -0.68). High relation is also found between 100 m (0.96), 2 min (-0.94), and a moderate result for DYN (-0.43) and the SAST test. A factor analysis extracted one significant factor. The factor analysis involved DAST, SAST, DYN, 100 m, and 2 min tests regarding factor 1. After the examination of all variables, the total time of the DAST test showed the best predictive values for the performance of divers. However, both tests could be used for diagnostics and the evaluation of specific condition abilities in freediving.

First Real-Life Data on the Diving Response in Healthy Children

Swimming and diving are popular recreational activities, representing an effective option in maintaining and improving cardiovascular fitness in healthy people. To date, only little is known about the cardiovascular adaption to submersion in children. This study was conducted to improve an understanding thereof. We used a stepwise apnea protocol with apnea at rest, apnea with facial immersion, and at last apnea during whole body submersion. Continuous measurement of heart rate, oxygen saturation, and peripheral resistance index was done. Physiologic data and analysis of influencing factors on heart rate, oxygen saturation, and peripheral vascular tone response are reported. The current study presents the first data of physiologic diving response in children. Data showed that facial or whole body submersion leads to a major drop in heart rate, and increase of peripheral resistance, while the oxygen saturation seems to be unaffected by static apnea in most children, with apnea times of up to 75 s without change in oxygen saturation.

Do freedivers and spearfishermen differ in local muscle oxygen saturation and anaerobic power?

BACKGROUND

Freediving is defined as an activity where athletes repetitively dive and are exposed to long efforts with limited oxygen consumption. Therefore, anaerobic features are expected to be an important facet of diving performance. This study aimed to investigate differences in anaerobic capacity and local muscle oxygenation in spearfisherman and freedivers.

METHODS

The sample of participants included 17 male athletes (nine freedivers, and eight spearfishermen), with an average age of 37.0±8.8 years, training experience of 10.6±9.5 years, body mass of 82.5±9.5 kg and height of 184.2±5.7 cm. Anthropometric characteristics included: body mass, body height, seated height, and body fat percentage. Wingate anaerobic test was conducted, during which local muscle oxygenation was measured with a NIRS device (Moxy monitor). Wingate power outputs were measured (peak power [W/kg] and average power [W/kg]), together with muscle oxygenation variables (baseline oxygen saturation [%], desaturation slope [%/s], minimum oxygen saturation [%], half time recovery [s], and maximum oxygen saturation [%]).

RESULTS

The differences were not obtained between freedivers and spearfisherman in power outputs (peak power (9.24±2.08 spearfisherman; 10.68±1.04 freedivers; P=0.14); average power (6.85±0.95 spearfisherman; 7.44±0.60 freedivers; P=0.15) and muscle oxygenation parameters. However, analysis of effect size showed a moderate effect in training experience (0.71), PP (0.89), AP (0.75), Desat slope mVLR (0.66), half time recovery mVLR (0.90).

CONCLUSIONS

The non-existence of differences between freedivers and spearfishermen indicates similar training adaptations to the anaerobic demands. However, the results show relatively low anaerobic capacities of our divers that could serve as an incentive for the further development of these mechanisms.

Physiological responses during static apnoea efforts in elite and novice breath-hold divers before and after two weeks of dry apnoea training

This study examined the effect of breath-hold (BH) training on apnoeic performance in novice BH divers (NBH:n = 10) and compared them with data from elite BH divers (EBH:n = 11). Both groups performed 5-maximal BHs (PRE). The NBH group repeated this protocol after two weeks of BH training (POST). The NBH group during BH efforts significantly increased red blood cell concentration (4.56 ± 0.16Mio/μl) by 5.06%, hemoglobin oxygen saturation steady state duration (110.32 ± 29.84 s) by 15.48%, and breath-hold time (BHT:144.19 ± 47.35 s) by 33.77%, primarily due to a 59.70% increase in struggle phase (71.85 ± 30.89 s), in POST. EBH group exhibited longer BHT (283.95 ± 36.93 s) and struggle-phase (150.10 ± 34.69 s) than NBH (POST). Elite divers recorded a higher peak MAP (153.18 ± 12.28 mmHg) compared to novices (PRE:123.70 ± 15.65 mmHg, POST:128.30 ± 19.16 mmHg), suggesting that a higher peak MAP is associated with a better BHT. The concurrent abrupt increase of diaphragmatic activity and MAP, seen only in the EBH group, suggests a potential interaction. Additionally, apnoea training increases red blood cells concentration in repeated apnoea efforts and increases BH stamina.

Unlocking the depths: multiple factors contribute to risk for hypoxic blackout during deep freediving

PURPOSE

To examine the effect of freediving depth on risk for hypoxic blackout by recording arterial oxygen saturation (SpO2) and heart rate (HR) during deep and shallow dives in the sea.

METHODS

Fourteen competitive freedivers conducted open-water training dives wearing a water-/pressure proof pulse oximeter continuously recording HR and SpO2. Dives were divided into deep (> 35 m) and shallow (10-25 m) post-hoc and data from one deep and one shallow dive from 10 divers were compared.

RESULTS

Mean ± SD depth was 53 ± 14 m for deep and 17 ± 4 m for shallow dives. Respective dive durations (120 ± 18 s and 116 ± 43 s) did not differ. Deep dives resulted in lower minimum SpO2 (58 ± 17%) compared with shallow dives (74 ± 17%; P = 0.029). Overall diving HR was 7 bpm higher in deep dives (P = 0.002) although minimum HR was similar in both types of dives (39 bpm). Three divers desaturated early at depth, of which two exhibited severe hypoxia (SpO2 ≤ 65%) upon resurfacing. Additionally, four divers developed severe hypoxia after dives.

CONCLUSIONS

Despite similar dive durations, oxygen desaturation was greater during deep dives, confirming increased risk of hypoxic blackout with increased depth. In addition to the rapid drop in alveolar pressure and oxygen uptake during ascent, several other risk factors associated with deep freediving were identified, including higher swimming effort and oxygen consumption, a compromised diving response, an autonomic conflict possibly causing arrhythmias, and compromised oxygen uptake at depth by lung compression possibly leading to atelectasis or pulmonary edema in some individuals. Individuals with elevated risk could likely be identified using wearable technology.

Effects of hyperventilation on oxygenation, apnea breaking points, diving response, and spleen contraction during serial static apneas

PURPOSE

Hyperventilation is considered a major risk factor for hypoxic blackout during breath-hold diving, as it delays the apnea breaking point. However, little is known about how it affects oxygenation, the diving response, and spleen contraction during serial breath-holding.

METHODS

18 volunteers with little or no experience in freediving performed two series of 5 apneas with cold facial immersion to maximal duration at 2-min intervals. In one series, apnea was preceded by normal breathing and in the other by 15 s of hyperventilation. End-tidal oxygen and end-tidal carbon dioxide were measured before and after every apnea, and peripheral oxygen saturation, heart rate, breathing movements, and skin blood flow were measured continuously. Spleen dimensions were measured every 15 s.

RESULTS

Apnea duration was longer after hyperventilation (133 vs 111 s). Hyperventilation reduced pre-apnea end-tidal CO2 (17.4 vs 29.0 mmHg) and post-apnea end-tidal CO2 (38.5 vs 40.3 mmHg), and delayed onset of involuntary breathing movements (112 vs 89 s). End-tidal O2 after apnea was lower in the hyperventilation trial (83.4 vs 89.4 mmHg) and so was the peripheral oxygen saturation nadir after apnea (90.6 vs 93.6%). During hyperventilation, the nadir peripheral oxygen saturation was lower in the last apnea than in the first (94.0% vs 86.7%). There were no differences in diving response or spleen volume reduction between conditions or across series.

CONCLUSIONS

Serial apneas  revealed a previously undescribed aspect of hyperventilation; a progressively increased desaturation across the series, not observed after normal breathing and could heighten the risk of a blackout.

Underwater pulse oximetry reveals increased rate of arterial oxygen desaturation across repeated freedives to 11 metres of freshwater

INTRODUCTION

Recreational freedivers typically perform repeated dives to moderate depths with short recovery intervals. According to freediving standards, these recovery intervals should be twice the dive duration; however, this has yet to be supported by scientific evidence.

METHODS

Six recreational freedivers performed three freedives to 11 metres of freshwater (mfw), separated by 2 min 30 s recovery intervals, while an underwater pulse oximeter measured peripheral oxygen saturation (SpO2) and heart rate (HR).

RESULTS

Median dive durations were 54.0 s, 103.0 s and 75.5 s (all dives median 81.5 s). Median baseline HR was 76.0 beats per minute (bpm), which decreased during dives to 48.0 bpm in dive one, 40.5 bpm in dive two and 48.5 bpm in dive three (all P < 0.05 from baseline). Median pre-dive baseline SpO2 was 99.5%. SpO2 remained similar to baseline for the first half of the dives, after which the rate of desaturation increased during the second half of the dives with each subsequent dive. Lowest median SpO2 after dive one was 97.0%, after dive two 83.5% (P < 0.05 from baseline) and after dive three 82.5% (P < 0.01 from baseline). SpO2 had returned to baseline within 20 s after all dives.

CONCLUSIONS

We speculate that the enhanced rate of arterial oxygen desaturation across the serial dives may be attributed to a remaining 'oxygen debt', leading to progressively increased oxygen extraction by desaturated muscles. Despite being twice the dive duration, the recovery period may be too short to allow full recovery and to sustain prolonged serial diving, thus does not guarantee safe diving.

Chemoreflex Control as the Cornerstone in Immersion Water Sports: Possible Role on Breath-Hold

Immersion water sports involve long-term apneas; therefore, athletes must physiologically adapt to maintain muscle oxygenation, despite not performing pulmonary ventilation. Breath-holding (i.e., apnea) is common in water sports, and it involves a decrease and increases PaO₂ and PaCO₂, respectively, as the primary signals that trigger the end of apnea. The principal physiological O₂ sensors are the carotid bodies, which are able to detect arterial gases and metabolic alterations before reaching the brain, which aids in adjusting the cardiorespiratory system. Moreover, the principal H⁺/CO₂ sensor is the retrotrapezoid nucleus, which is located at the brainstem level; this mechanism contributes to detecting respiratory and metabolic acidosis. Although these sensors have been characterized in pathophysiological states, current evidence shows a possible role for these mechanisms as physiological sensors during voluntary apnea. Divers and swimmer athletes have been found to displayed longer apnea times than land sports athletes, as well as decreased peripheral O₂ and central CO₂ chemoreflex control. However, although chemosensitivity at rest could be decreased, we recently found marked sympathoexcitation during maximum voluntary apnea in young swimmers, which could activate the spleen (which is a reservoir organ for oxygenated blood). Therefore, it is possible that the chemoreflex, autonomic function, and storage/delivery oxygen organ(s) are linked to apnea in immersion water sports. In this review, we summarized the available evidence related to chemoreflex control in immersion water sports. Subsequently, we propose a possible physiological mechanistic model that could contribute to providing new avenues for understanding the respiratory physiology of water sports.

Enabling Continuous Wearable Reflectance Pulse Oximetry at the Sternum

In light of the recent Coronavirus disease (COVID-19) pandemic, peripheral oxygen saturation (SpO₂) has shown to be amongst the vital signs most indicative of deterioration in persons with COVID-19. To allow for the continuous monitoring of SpO₂, we attempted to demonstrate accurate SpO₂ estimation using our custom chest-based wearable patch biosensor, capable of measuring electrocardiogram (ECG) and photoplethysmogram (PPG) signals with high fidelity. Through a breath-hold protocol, we collected physiological data with a wide dynamic range of SpO₂ from 20 subjects. The ratio of ratios (R) used in pulse oximetry to estimate SpO₂ was robustly extracted from the red and infrared PPG signals during the breath-hold segments using novel feature extraction and PPG_green-based outlier rejection algorithms. Through subject independent training, we achieved a low root-mean-square error (RMSE) of 2.64 ± 1.14% and a Pearson correlation coefficient (PCC) of 0.89. With subject-specific calibration, we further reduced the RMSE to 2.27 ± 0.76% and increased the PCC to 0.91. In addition, we showed that calibration is more efficiently accomplished by standardizing and focusing on the duration of breath-hold rather than the resulting range in SpO₂. The accurate SpO₂ estimation provided by our custom biosensor and the algorithms provide research opportunities for a wide range of disease and wellness monitoring applications.

Blood Adenosine Increase During Apnea in Spearfishermen Reinforces the Efficiency of the Cardiovascular Component of the Diving Reflex

The physiopathology consequences of hypoxia during breath-hold diving are a matter of debate. Adenosine (AD), an ATP derivative, is suspected to be implicated in the adaptive cardiovascular response to apnea, because of its vasodilating and bradycardic properties, two clinical manifestations observed during voluntary apnea. The aim of this study was to evaluate the adenosine response to apnea-induced hypoxia in trained spearfishermen (SFM) who are used to perform repetitive dives for 4-5 h. Twelve SFM (11 men and 1 woman, mean age 41 ± 3 years, apnea experience: 18 ± 9 years) and 10 control (CTL) subjects (age 44 ± 7 years) were enrolled in the study. Subjects were asked to main a dry static apnea and stopped it when they began the struggle phase (average duration: SFM 120 ± 78 s, CTL 78 ± 12 s). Capillary blood samples were collected at baseline and immediately after the apnea and analyzed for standard parameters and adenosine blood concentration ([AD]b). Heart rate (HR), systolic (SBP), and diastolic (DBP) blood pressures were also recorded continuously during the apnea. During the apnea, an increase in SBP and DBP and a decrease in HR were observed in both SFM and CTL. At baseline, [AD]b was higher in SFM compared with CTL (1.05 ± 0.2 vs. 0.73 ± 0.11 μM, p < 0.01). [AD]b increased significantly at the end of the apnea in both groups, but the increase was significantly greater in SFM than in controls (+90.4 vs. +12%, p < 0.01). Importantly, in SFM, we also observed significant correlations between [AD]b and HR (R = -0.8, p = 0.02), SpO₂ (R = -0.69, p = 0.01), SBP (R = -0.89, p = 0.02), and DBP (R = -0.68, p = 0.03). Such associations were absent in CTL. The adenosine release during apnea was associated with blood O₂ saturation and cardiovascular parameters in trained divers but not in controls. These data therefore suggest that adenosine may play a major role in the adaptive cardiovascular response to apnea and could reflect the level of training.

Effects of dynamic apnea training on diving bradycardia and short distance swimming performance

BACKGROUND

Apnea training enhances bradycardia and improves competitive apnea performance, and has been proposed as a training method for other sports, such as swimming. We evaluated the effects of apneic underwater swimming, i.e. dynamic apnea (DYN), in 9 competitive swimmers (TR) who completed ten DYN sessions over 2 weeks.

METHODS

TR performed pre- and post-training tests including a static apnea test with continuous heart rate (HR) and peripheral oxygen saturation measurements, all-out 50m and 100m freestyle tests and an all-out DYN test. Control groups were competitive swimmers (SC; n=10) that trained swimming without DYN, and a non-swimmer group (AC; n=10) performing only static apnea tests.

RESULTS

Post-training, TR mean±SD time for 50m freestyle improved from 25.51±2.01s to 24.64±2.02s (p<0.01) and for 100m from 55.5±4.2s to 54.1±4.4s (p<0.05). SC also improved their 100m time from 56.7±3.3s to 56.0±3.1s (p<0.01; p=0.07 between groups). Only TR performed DYN tests; DYN distance increased from 62.1±11.5m to 70.9±18.9m (p<0.05) while DYN speed decreased from 0.74±0.14m/s to 0.64±0.18m/s (p<0.01). Static apnea duration did not change in any of the groups, but HR-reduction was enhanced posttraining only in TR (24.8±14.8% to 31.1±10.9%, p<0.01; p<0.001 between groups).

CONCLUSIONS

We conclude that 2 weeks of DYN training enhanced DYN performance, which may be caused by the enhanced apnea-induced diving bradycardia. Further research is required to determine whether DYN training enhances short distance freestyle swimming performance.

Heart Rate and Muscle Oxygenation Kinetics During Dynamic Constant Load Intermittent Breath-Holds

Introduction: Acute apnea evokes bradycardia and peripheral vasoconstriction in order to conserve oxygen, which is more pronounced with face immersion. This response is contrary to the tachycardia and increased blood flow to muscle tissue related to the higher oxygen consumption during exercise. The aim of this study was to investigate cardiovascular and metabolic responses of dynamic dry apnea (DRA) and face immersed apnea (FIA).

Methods: Ten female volunteers (17.1 ± 0.6 years old) naive to breath-hold-related sports, performed a series of seven dynamic 30 s breath-holds while cycling at 25% of their peak power output. This was performed in two separate conditions in a randomized order: FIA (15°C) and DRA. Heart rate and muscle tissue oxygenation through near-infrared spectroscopy were continuously measured to determine oxygenated (m[O₂Hb]) and deoxygenated hemoglobin concentration (m[HHb]) and tissue oxygenation index (mTOI). Capillary blood lactate was measured 1 min after the first, third, fifth, and seventh breath-hold.

Results: Average duration of the seven breath-holds did not differ between conditions (25.3 s ± 1.4 s, p = 0.231). The apnea-induced bradycardia was stronger with FIA (from 134 ± 4 to 85 ± 3 bpm) than DRA (from 134 ± 4 to 100 ± 5 bpm, p < 0.001). mTOI decreased significantly from 69.9 ± 0.9% to 63.0 ± 1.3% (p < 0.001) which is reflected in a steady decrease in m[O₂Hb] (p < 0.001) and concomitant increase in m[HHb] (p = 0.001). However, this was similar in both conditions (0.121 < p < 0.542). Lactate was lower after the first apnea with FIA compared to DRA (p = 0.038), while no differences were observed in the other breath-holds.

Conclusion: Our data show strong decreases in heart rate and muscle tissue oxygenation during dynamic apneas. A stronger bradycardia was observed in FIA, while muscle oxygenation was not different, suggesting that FIA did not influence muscle oxygenation. An order of mechanisms was observed in which, after an initial tachycardia, heart rate starts to decrease after muscle tissue deoxygenation occurs, suggesting a role of peripheral vasoconstriction in the apnea-induced bradycardia. The apnea-induced increase in lactate was lower in FIA during the first apnea, probably caused by the stronger bradycardia.

Enhanced splenic volume and contraction in elite endurance athletes

Splenic contraction, which leads to ejection of stored erythrocytes, is greater in athletes involved in regular freediving or high-altitude activities. As this response facilitates oxygen-carrying capacity, similar characteristics may be expected of elite endurance athletes. Therefore, our aims were to compare resting and apnea-induced splenic volume in endurance athletes and untrained individuals, and to assess the athletes' exercise-induced splenic volume. Twelve elite biathletes (7 women) and 12 controls (6 women) performed a maximal effort apnea in a seated position. In addition, the biathletes completed a maximal roller-skiing time trial. Splenic dimensions were measured by ultrasonic imaging for subsequent volume calculations, whereas Hb was analyzed from capillary blood samples and cardiorespiratory variables were monitored continuously. Baseline splenic volume was larger in the biathletes (214 ± 56 mL) compared with controls (157 ± 39 mL, P = 0.008) and apnea-induced splenic contraction was also greater in the biathletes (46 ± 20 mL vs. 30 ± 16 mL, P = 0.035). Hb increased immediately after apnea in the biathletes (4.5 ± 4.8%, P = 0.029) but not in the controls (-0.7 ± 3.1%, P = 0.999). Increases in exercise-induced splenic contraction (P = 0.008) and Hb (P = 0.001) were greater compared with the apnea-induced responses among the athletes. Baseline splenic volume tended to be correlated with V̇o_2max (r = 0.584, P = 0.059). We conclude that elite biathletes have greater splenic volume with a greater ability to contract and elevate Hb compared with untrained individuals. These characteristics may transiently enhance O₂-carrying capacity and possibly increase O₂ uptake, thereby helping biathletes to cope with high intermittent O₂ demands and severe O₂ deficits that occur during biathlon training and competition.NEW & NOTEWORTHY This study demonstrates that elite biathletes have larger splenic volume, apnea-induced splenic contraction, and Hb elevation compared with untrained individuals, which is likely functional to cope with high O₂ demands and substantial O₂ deficits. We believe that enhanced splenic contraction may be of importance during competitions involving cross-country skiing, to regulate circulating Hb and enhance O₂-carrying capacity, which may protect [Formula: see text] and increase O₂ uptake.

Oxygen desaturation rate as a novel intermittent hypoxemia parameter in severe obstructive sleep apnea is strongly associated with hypertension

STUDY OBJECTIVES

To investigate the effects of different intermittent hypoxemia properties on blood pressure (BP) and short-term blood pressure variability (BPV) in severe obstructive sleep apnea (OSA) patients.

METHODS

Nocturnal BP was continuously monitored by measuring pulse transmit time. Apnea-related systolic BP elevation values were used to reflect BPV. Beat-to-beat R-R interval data were incorporated in polysomnography for heart rate variability analysis. The low-frequency/high-frequency band ratio was used to reflect sympathovagal balance. The rate of pulse oxyhemoglobin saturation (SpO₂) decrease was counted as the change in the percentage of SpO₂ per second after obstructive apnea and expressed as the oxygen desaturation rate (ODR). Patients with severe OSA (n = 102) were divided into 2 groups according to the median ODR: faster ODR (FODR group: ODR > 0.37, n = 50) and slower ODR (ODR ≤ 0.37, n = 52).

RESULTS

Comparisons between the 2 groups showed significantly higher systolic BP (SBP) values in the FODR group than in the slower ODR group (awake SBP 149.9 ± 18.3 vs 131.8 ± 15.6 mm Hg; asleep SBP: 149.6 ± 19.9 vs 128.7 ± 15.6 mm Hg; both P < .001), as well as short-term BPV (15.0 ± 4.8 vs 11.6 ± 3.6 mm Hg; P < .001), and the prevalence of hypertension (74.0% vs 26.9%; P < .001). Multiple linear regression analyses revealed that after adjusting for body mass index, functional residual capacity, expiratory reserve volume, and baseline SpO_2, ODR, as assessed by ΔSpO₂/Δt, had the strongest association with both BP and short-term BPV. Correlation analysis showed that ODR was positively correlated with the low-frequency/high-frequency band ratio (r = .288, P = .003).

CONCLUSIONS

ODR, as a novel hypoxemia profile, was more closely associated with the elevation of BP and BPV in patients with severe OSA. FODR might be associated with enhanced sympathetic activity.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Characteristics of Obstructive Sleep Apnea Syndrome Related Hypertension and the Effect of Continuous Positive Airway Pressure Treatment on Blood Pressure; URL: https://clinicaltrials.gov/ct2/show/NCT03246022; Identifier: NCT03246022.

First Evaluation of a Newly Constructed Underwater Pulse Oximeter for Use in Breath-Holding Activities

Studying risk factors in freediving, such as hypoxic blackout, requires development of new methods to enable remote underwater monitoring of physiological variables. We aimed to construct and evaluate a new water- and pressure proof pulse oximeter for use in freediving research. The study consisted of three parts: (I) A submersible pulse oximeter (SUB) was developed on a ruggedized platform for recording of physiological parameters in challenging environments. Two MAX30102 sensors were used to record plethysmograms, and included red and infra-red emitters, diode drivers, photodiode, photodiode amplifier, analog to digital converter, and controller. (II) We equipped 20 volunteers with two transmission pulse oximeters (TPULS) and SUB to the fingers. Arterial oxygen saturation (SpO₂) and heart rate (HR) were recorded, while breathing room air (21% O₂) and subsequently a hypoxic gas (10.7% O₂) at rest in dry conditions. Bland-Altman analysis was used to evaluate bias and precision of SUB relative to SpO₂ values from TPULS. (III) Six freedivers were monitored with one TPULS and SUB placed at the forehead, during a maximal effort immersed static apnea. For dry baseline measurements (n = 20), SpO₂ bias ranged between −0.8 and −0.6%, precision between 1.0 and 1.5%; HR bias ranged between 1.1 and 1.0 bpm, precision between 1.4 and 1.9 bpm. For the hypoxic episode, SpO₂ bias ranged between −2.5 and −3.6%, precision between 3.6 and 3.7%; HR bias ranged between 1.4 and 1.9 bpm, precision between 2.0 and 2.1 bpm. Freedivers (n = 6) performed an apnea of 184 ± 53 s. Desaturation- and resaturation response time of SpO₂ was approximately 15 and 12 s shorter in SUB compared to TPULS, respectively. Lowest SpO₂ values were 76 ± 10% for TPULS and 74 ± 13% for SUB. HR traces for both pulse oximeters showed similar patterns. For static apneas, dropout rate was larger for SUB (18%) than for TPULS (<1%). SUB produced similar SpO₂ and HR values as TPULS, both during normoxic and hypoxic breathing (n = 20), and submersed static apneas (n = 6). SUB responds more quickly to changes in oxygen saturation when sensors were placed at the forehead. Further development of SUB is needed to limit signal loss, and its function should be tested at greater depth and lower saturation.

Using Underwater Pulse Oximetry in Freediving to Extreme Depths to Study Risk of Hypoxic Blackout and Diving Response Phases

Deep freediving exposes humans to hypoxia and dramatic changes in pressure. The effect of depth on gas exchange may enhance risk of hypoxic blackout (BO) during the last part of the ascent. Our aim was to investigate arterial oxygen saturation (SpO2) and heart rate (HR) in shallow and deep freedives, central variables, which have rarely been studied underwater in deep freediving. Four male elite competitive freedivers volunteered to wear a newly developed underwater pulse oximeter for continuous monitoring of SpO2 and HR during self-initiated training in the sea. Two probes were placed on the temples, connected to a recording unit on the back of the freediver. Divers performed one "shallow" and one "deep" constant weight dive with fins. Plethysmograms were recorded at 30 Hz, and SpO2 and HR were extracted. Mean ± SD depth of shallow dives was 19 ± 3 m, and 73 ± 12 m for deep dives. Duration was 82 ± 36 s in shallow and 150 ± 27 s in deep dives. All divers desaturated more during deeper dives (nadir 55 ± 10%) compared to shallow dives (nadir 80 ± 22%) with a lowest SpO2 of 44% in one deep dive. HR showed a "diving response," with similar lowest HR of 42 bpm in shallow and deep dives; the lowest value (28 bpm) was observed in one shallow dive. HR increased before dives, followed by a decline, and upon resurfacing a peak after which HR normalized. During deep dives, HR was influenced by the level of exertion across different diving phases; after an initial drop, a second HR decline occurred during the passive "free fall" phase. The underwater pulse oximeter allowed successful SpO2 and HR monitoring in freedives to 82 m depth - deeper than ever recorded before. Divers' enhanced desaturation during deep dives was likely related to increased exertion and extended duration, but the rapid extreme desaturation to below 50% near surfacing could result from the diminishing pressure, in line with the hypothesis that risk of hypoxic BO may increase during ascent. Recordings also indicated that the diving response is not powerful enough to fully override the exercise-induced tachycardia during active swimming. Pulse oximetry monitoring of essential variables underwater may be an important step to increase freediving safety.

Physiology, pathophysiology and (mal)adaptations to chronic apnoeic training: a state-of-the-art review

Breath-hold diving is an activity that humans have engaged in since antiquity to forage for resources, provide sustenance and to support military campaigns. In modern times, breath-hold diving continues to gain popularity and recognition as both a competitive and recreational sport. The continued progression of world records is somewhat remarkable, particularly given the extreme hypoxaemic and hypercapnic conditions, and hydrostatic pressures these athletes endure. However, there is abundant literature to suggest a large inter-individual variation in the apnoeic capabilities that is thus far not fully understood. In this review, we explore developments in apnoea physiology and delineate the traits and mechanisms that potentially underpin this variation. In addition, we sought to highlight the physiological (mal)adaptations associated with consistent breath-hold training. Breath-hold divers (BHDs) are evidenced to exhibit a more pronounced diving-response than non-divers, while elite BHDs (EBHDs) also display beneficial adaptations in both blood and skeletal muscle. Importantly, these physiological characteristics are documented to be primarily influenced by training-induced stimuli. BHDs are exposed to unique physiological and environmental stressors, and as such possess an ability to withstand acute cerebrovascular and neuronal strains. Whether these characteristics are also a result of training-induced adaptations or genetic predisposition is less certain. Although the long-term effects of regular breath-hold diving activity are yet to be holistically established, preliminary evidence has posed considerations for cognitive, neurological, renal and bone health in BHDs. These areas should be explored further in longitudinal studies to more confidently ascertain the long-term health implications of extreme breath-holding activity.

Cardiac hypoxic resistance and decreasing lactate during maximum apnea in elite breath hold divers

Breath-hold divers (BHD) enduring apnea for more than 4 min are characterized by resistance to release of reactive oxygen species, reduced sensitivity to hypoxia, and low mitochondrial oxygen consumption in their skeletal muscles similar to northern elephant seals. The muscles and myocardium of harbor seals also exhibit metabolic adaptations including increased cardiac lactate-dehydrogenase-activity, exceeding their hypoxic limit. We hypothesized that the myocardium of BHD possesses similar adaptive mechanisms. During maximum apnea ¹⁵O-H₂O-PET/CT (n = 6) revealed no myocardial perfusion deficits but increased myocardial blood flow (MBF). Cardiac MRI determined blood oxygen level dependence oxygenation (n = 8) after 4 min of apnea was unaltered compared to rest, whereas cine-MRI demonstrated increased left ventricular wall thickness (LVWT). Arterial blood gases were collected after warm-up and maximum apnea in a pool. At the end of the maximum pool apnea (5 min), arterial saturation decreased to 52%, and lactate decreased 20%. Our findings contrast with previous MR studies of BHD, that reported elevated cardiac troponins and decreased myocardial perfusion after 4 min of apnea. In conclusion, we demonstrated for the first time with ¹⁵O-H₂O-PET/CT and MRI in elite BHD during maximum apnea, that MBF and LVWT increases while lactate decreases, indicating anaerobic/fat-based cardiac-metabolism similar to diving mammals.

Safety proposals for freediving time limits should consider the metabolic-rate dependence of oxygen stores depletion

INTRODUCTION

There is no required training for breath-hold diving, making dissemination of safety protocols difficult. A recommended breath-hold dive time limit of 60 s was proposed for amateur divers. However, this does not consider the metabolic-rate dependence of oxygen stores depletion. We aimed to measure the effect of apnoea time and metabolic rate on arterial and tissue oxygenation.

METHODS

Fifty healthy participants (23 (SD 3) y, 22 women) completed four periods of apnoea for 60 s (or to tolerable limit) during rest and cycle ergometry at 20, 40, and 60 W. Apnoea was initiated after hyperventilation to achieve P_ETCO₂ of approximately 25 mmHg. Pulse oximetry, frontal lobe oxygenation, and pulmonary gas exchange were measured throughout. We defined hypoxia as SpO₂ < 88%.

RESULTS

Static and exercise (20, 40, 60 W) breath-hold break times were 57 (SD 7), 50 (11), 48 (11), and 46 (11) s (F [2.432, 119.2] = 32.0, P < 0.01). The rise in P_ETCO₂ from initiation to breaking of apnoea was dependent on metabolic rate (time × metabolic rate interaction; F [3,147] = 38.6, P < 0.0001). The same was true for the fall in SpO₂ (F [3,147] = 2.9, P = 0.03). SpO₂ fell to < 88% on 14 occasions in eight participants, all of whom were asymptomatic.

CONCLUSIONS

Independent of the added complexities of a fall in ambient pressure on ascent, the effect of apnoea time on hypoxia depends on the metabolic rate and is highly variable among individuals. Therefore, we contend that a universally recommended time limit for breath-hold diving or swimming is not useful to guarantee safety.

Spleen Size and Function in Sherpa Living High, Sherpa Living Low and Nepalese Lowlanders

High-altitude (HA) natives have evolved some beneficial responses leading to superior work capacity at HA compared to native lowlanders. Our aim was to study two responses potentially protective against hypoxia: the spleen contraction elevating hemoglobin concentration (Hb) and the cardiovascular diving response in Sherpa highlanders, compared to lowlanders. Male participants were recruited from three groups: (1) 21 Sherpa living at HA (SH); (2) seven Sherpa living at low altitude (SL); and (3) ten native Nepalese lowlanders (NL). They performed three apneas spaced by a two-min rest at low altitude (1370 m). Their peripheral oxygen saturation (SpO₂), heart rate (HR), and spleen volume were measured across the apnea protocol. Spleen volume at rest was 198 ± 56 mL in SH and 159 ± 35 mL in SL (p = 0.047). The spleen was larger in Sherpa groups compared to the 129 ± 22 mL in NL (p < 0.001 compared to SH; p = 0.046 compared to SL). Spleen contraction occurred in all groups during apnea, but it was greater in Sherpa groups compared to NL (p < 0.001). HR was lower in Sherpa groups compared to NL both during rest (SL: p < 0.001; SH: p = 0.003) and during maximal apneas (SL: p < 0.001; SH: p = 0.06). The apnea-induced HR reduction was 8 ± 8% in SH, 10 ± 4% in SL (NS), and 18 ± 6% in NL (SH: p = 0.005; SL: p = 0.021 compared to NL). Resting SpO₂ was similar in all groups. The progressively decreasing baseline spleen size across SH, SL, and NL suggests a role of the spleen at HA and further that both genetic predisposition and environmental exposure determine human spleen size. The similar HR responses of SH and SL suggest that a genetic component is involved in determining the cardiovascular diving response.

The Magnitude of Diving Bradycardia During Apnea at Low-Altitude Reveals Tolerance to High Altitude Hypoxia

Acute mountain sickness (AMS) is a potentially life-threatening illness that may develop during exposure to hypoxia at high altitude (HA). Susceptibility to AMS is highly individual, and the ability to predict it is limited. Apneic diving also induces hypoxia, and we aimed to investigate whether protective physiological responses, i.e., the cardiovascular diving response and spleen contraction, induced during apnea at low-altitude could predict individual susceptibility to AMS. Eighteen participants (eight females) performed three static apneas in air, the first at a fixed limit of 60 s (A1) and two of maximal duration (A2-A3), spaced by 2 min, while SaO₂, heart rate (HR) and spleen volume were measured continuously. Tests were conducted in Kathmandu (1470 m) before a 14 day trek to mount Everest Base Camp (5360 m). During the trek, participants reported AMS symptoms daily using the Lake Louise Questionnaire (LLQ). The apnea-induced HR-reduction (diving bradycardia) was negatively correlated with the accumulated LLQ score in A1 (r _s = -0.628, p = 0.005) and A3 (r _s = -0.488, p = 0.040) and positively correlated with SaO₂ at 4410 m (A1: r = 0.655, p = 0.003; A2: r = 0.471, p = 0.049; A3: r = 0.635, p = 0.005). Baseline spleen volume correlated negatively with LLQ score (r _s = -0.479, p = 0.044), but no correlation was found between apnea-induced spleen volume reduction with LLQ score (r _s = 0.350, p = 0.155). The association between the diving bradycardia and spleen size with AMS symptoms suggests links between physiological responses to HA and apnea. Measuring individual responses to apnea at sea-level could provide means to predict AMS susceptibility prior to ascent.

Physiology of static breath holding in elite apneists

NEW FINDINGS

What is the topic of this review? This review provides an up-to-date assessment of the physiology involved with extreme static dry-land breath holding in trained apneists. What advances does it highlight? We specifically highlight the recent findings involved with the cardiovascular, cerebrovascular and metabolic function during a maximal breath hold in elite apneists.

ABSTRACT

Breath-hold-related activities have been performed for centuries, but only recently, within the last ∼30 years, has it emerged as an increasingly popular competitive sport. In apnoea sport, competition relates to underwater distances or simply maximal breath-hold duration, with the current (oxygen-unsupplemented) static breath-hold record at 11 min 35 s. Remarkably, many ultra-elite apneists are able to suppress respiratory urges to the point where consciousness fundamentally limits a breath-hold duration. Here, arterial oxygen saturations as low as ∼50% have been reported. In such cases, oxygen conservation to maintain cerebral functioning is critical, where responses ascribed to the mammalian dive reflex, e.g. sympathetically mediated peripheral vasoconstriction and vagally mediated bradycardia, are central. In defence of maintaining global cerebral oxygen delivery during prolonged breath holds, the cerebral blood flow may increase by ∼100% from resting values. Interestingly, near the termination of prolonged dry static breath holds, recent studies also indicate that reductions in the cerebral oxidative metabolism can occur, probably attributable to the extreme hypercapnia and irrespective of the hypoxaemia. In this review, we highlight and discuss the recent data on the cardiovascular, metabolic and, particularly, cerebrovascular function in competitive apneists performing maximal static breath holds. The physiological adaptation and maladaptation with regular breath-hold training are also summarized, and future research areas in this unique physiological field are highlighted; particularly, the need to determine the potential long-term health impacts of extreme breath holding.

Sudden Unexpected Death and the Mammalian Dive Response: Catastrophic Failure of a Complex Tightly Coupled System

In tightly coupled complex systems, when two or more factors or events interact in unanticipated ways, catastrophic failures of high-risk technical systems happen rarely, but quickly. Safety features are commonly built into complex systems to avoid disasters but are often part of the problem. The human body may be considered as a complex tightly coupled system at risk of rare catastrophic failure (sudden unexpected death, SUD) when certain factors or events interact. The mammalian dive response (MDR) is a built-in safety feature of the body that normally conserves oxygen during acute hypoxia. Activation of the MDR is the final pathway to sudden cardiac (SCD) in some cases of sudden infant death syndrome (SIDS), sudden unexpected death in epilepsy (SUDEP), and sudden cardiac death in water (SCDIW, fatal drowning). There is no single cause in any of these death scenarios, but an array of, unanticipated, often unknown, factors or events that activate or interact with the mammalian dive reflex. In any particular case, the relevant risk factors or events might include a combination of genetic, developmental, metabolic, disease, environmental, or operational influences. Determination of a single cause in any of these death scenarios is unlikely. The common thread among these seemingly different death scenarios is activation of the mammalian dive response. The human body is a complex tightly coupled system at risk of rare catastrophic failure when that "safety feature" is activated.

Mechanisms of sympathetic regulation during Apnea

Volitional Apnea produces a robust peak sympathetic response through several interacting mechanisms. However, the specific contribution of each mechanism has not been elucidated. Muscle sympathetic activity was collected in participants (n = 10; 24 ± 3 years) that performed four maximal volitional apneas aimed at isolating lung-stretch (mechanical) and chemoreflex drive: (Ainslie and Duffin ) end-expiratory breath-hold, (Ainslie et al. ) end-inspiratory breath-hold, (Alpher et al. ) prehyperventilation breath-hold, and (Andersson and Schagatay ) prehyperoxia breath-hold. A final repeated rebreathe breath-hold protocol was performed to measure the peak sympathetic response during successive breath-holds at increasing chemoreflex stress. Finally, the influence of dynamic ventilation was assessed through asphyxic rebreathe. Muscle sympathetic activity was calculated as the change in burst frequency (burst/min), burst incidence (burst/100 heart-beats), and amplitude (au) between baseline and prevolitional breakpoint. Rebreathe was analyzed at similar chemoreflex stress as inspiratory breath-hold. All maneuvers increased muscle sympathetic activity compared to baseline (P < 0.01). However, prehyperoxia exhibited a smaller increase (+22.18 ± 9.13 burst/min; +25.52 ± 11.7 burst/100 heart-beats) compared to inspiratory, expiratory, and prehyperventilation breath-holds. At similar chemoreflex strain, rebreathe sympathetic activity was blunted compared to inspiratory breath-hold (P < 0.01). Finally, muscle sympathetic activity was not different between the repeated rebreathe trials, despite elevated chemoreflex stress and lower breath-hold duration with each subsequent breath-hold. We have demonstrated an obligatory role of the peripheral, but not central, chemoreflex (prehyperventilation vs. prehyperoxia) in producing peak sympathetic responses. At similar chemoreflex stresses the act of dynamic ventilation, but not static lung stretch per se, blunts muscle sympathetic activity. Finally, similar peak sympathetic responses during successive repeated breath-holds suggest a sympathetic ceiling may exist.

Ictal Mammalian Dive Response: A Likely Cause of Sudden Unexpected Death in Epilepsy

Even though sudden unexpected death in epilepsy (SUDEP) takes the lives of thousands of otherwise healthy epilepsy patients every year, the physiopathology associated with this condition remains unexplained. This article explores important parallels, which exist between the clinical observations and pathological responses associated with SUDEP, and the pathological responses that can develop when a set of autonomic reflexes known as the mammalian dive response (MDR) is deployed. Mostly unknown to physicians, this evolutionarily conserved physiological response to prolonged apnea economizes oxygen for preferential use by the brain. However, the drastic cardiovascular adjustments required for its execution, which include severe bradycardia and the sequestration of a significant portion of the total blood volume inside the cardiopulmonary vasculature, can result in many of the same pathological responses associated with SUDEP. Thus, this article advances the hypothesis that prolonged apneic generalized tonic clonic seizures induce augmented forms of the MDR, which, in the most severe cases, cause SUDEP.

Cardiovascular magnetic resonance assessment of acute cardiovascular effects of voluntary apnoea in elite divers

BACKGROUND

Prolonged breath holding results in hypoxemia and hypercapnia. Compensatory mechanisms help maintain adequate oxygen supply to hypoxia sensitive organs, but burden the cardiovascular system. The aim was to investigate human compensatory mechanisms and their effects on the cardiovascular system with regard to cardiac function and morphology, blood flow redistribution, serum biomarkers of the adrenergic system and myocardial injury markers following prolonged apnoea.

METHODS

Seventeen elite apnoea divers performed maximal breath-hold during cardiovascular magnetic resonance imaging (CMR). Two breath-hold sessions were performed to assess (1) cardiac function, myocardial tissue properties and (2) blood flow. In between CMR sessions, a head MRI was performed for the assessment of signs of silent brain ischemia. Urine and blood samples were analysed prior to and up to 4 h after the first breath-hold.

RESULTS

Mean breath-hold time was 297 ± 52 s. Left ventricular (LV) end-systolic, end-diastolic, and stroke volume increased significantly (p < 0.05). Peripheral oxygen saturation, LV ejection fraction, LV fractional shortening, and heart rate decreased significantly (p < 0.05). Blood distribution was diverted to cerebral regions with no significant changes in the descending aorta. Catecholamine levels, high-sensitivity cardiac troponin, and NT-pro-BNP levels increased significantly, but did not reach pathological levels.

CONCLUSION

Compensatory effects of prolonged apnoea substantially burden the cardiovascular system. CMR tissue characterisation did not reveal acute myocardial injury, indicating that the resulting cardiovascular stress does not exceed compensatory physiological limits in healthy subjects. However, these compensatory mechanisms could overly tax those limits in subjects with pre-existing cardiac disease. For divers interested in competetive apnoea diving, a comprehensive medical exam with a special focus on the cardiovascular system may be warranted.

TRIAL REGISTRATION

This prospective single-centre study was approved by the institutional ethics committee review board. It was retrospectively registered under ClinicalTrials.gov (Trial registration: NCT02280226 . Registered 29 October 2014).

Environmental Physiology and Diving Medicine

Man's experience and exploration of the underwater environment has been recorded from ancient times and today encompasses large sections of the population for sport enjoyment, recreational and commercial purpose, as well as military strategic goals. Knowledge, respect and maintenance of the underwater world is an essential development for our future and the knowledge acquired over the last few dozen years will change rapidly in the near future with plans to establish secure habitats with specific long-term goals of exploration, maintenance and survival. This summary will illustrate briefly the physiological changes induced by immersion, swimming, breath-hold diving and exploring while using special equipment in the water. Cardiac, circulatory and pulmonary vascular adaptation and the pathophysiology of novel syndromes have been demonstrated, which will allow selection of individual characteristics in order to succeed in various environments. Training and treatment for these new microenvironments will be suggested with description of successful pioneers in this field. This is a summary of the physiology and the present status of pathology and therapy for the field.

Study of an Oxygen Supply and Oxygen Saturation Monitoring System for Radiation Therapy Associated with the Active Breathing Coordinator

In this study, we designed an oxygen supply and oxygen saturation monitoring (OSOSM) system. This OSOSM system can provide a continuous supply of oxygen and monitor the peripheral capillary oxygen saturation (SpO2) of patients who accept radiotherapy and use an active breathing coordinator (ABC). A clinical test with 27 volunteers was conducted. The volunteers were divided into two groups based on the tendency of SpO2 decline in breath-holding without the OSOSM system: group A (12 cases) showed a decline in SpO2 of less than 2%, whereas the decline in SpO2 in group B (15 cases) was greater than 2% and reached up to 6% in some cases. The SpO2 of most volunteers declined during rest. The breath-holding time of group A without the OSOSM system was significantly longer than that of group B (p < 0.05) and was extended with the OSOSM system by 26.6% and 27.85% in groups A and B, respectively. The SpO2 recovery time was reduced by 36.1%, and the total rest time was reduced by 27.6% for all volunteers using the OSOSM system. In summary, SpO2 declines during breath-holding and rest time cannot be ignored while applying an ABC. This OSOSM system offers a simple and effective way to monitor SpO2 variation and overcome SpO2 decline, thereby lengthening breath-holding time and shortening rest time.

Voluntary apnea during dynamic exercise activates the muscle metaboreflex in humans

Voluntary apnea during dynamic exercise evokes marked bradycardia, peripheral vasoconstriction, and pressor responses. However, the mechanism(s) underlying the cardiovascular responses seen during apnea in exercising humans is unknown. We therefore tested the hypothesis that the muscle metaboreflex contributes to the apnea-induced pressor response during dynamic exercise. Thirteen healthy subjects participated in apnea and control trials. In both trials, subjects performed a two-legged dynamic knee extension exercise at a workload that elicited heart rates at ~100 beats/min. In the apnea trial, after reaching a steady state, subjects began voluntary apnea. Immediately after cessation of the apnea, arterial occlusion was initiated at both thighs and the subjects stopped exercising. The occlusion was sustained for 3 min in the postexercise period. In the control trial, the occlusion was started without subjects performing the apnea. The apnea induced marked bradycardia, pressor responses, and decreases in arterial O₂ saturation, cardiac output, and total vascular conductance. In addition, arterial blood pressure was significantly higher and total vascular conductance was significantly lower in the apnea trials than the control trials throughout the occlusion period. In separate sessions, we measured apnea-induced changes in exercising leg blood flow in the same subjects. Leg blood flow was significantly reduced by apnea and reached the resting level at the peak of the apnea response. We conclude that the muscle metaboreflex is activated by the decrease in O₂ delivery to the working muscle during apnea in exercising humans and contributes to the large pressor response. NEW & NOTEWORTHY We demonstrated that apnea during dynamic exercise activates the muscle metaboreflex in humans. This result indicates that a reduction in O₂ delivery to working muscle triggers the muscle metaboreflex during apnea. Activation of the muscle metaboreflex is one of the mechanisms underlying the marked apnea-induced pressor response.

Effect of swim intensity on responses to dynamic apnoea

The aim of this study was to determine the influence of swim intensity on acute responses to dynamic apnoea. 9 swimmers performed one 50 m front crawl trial in four different conditions: at 400 m velocity (V₄₀₀) with normal breathing (NB), at V₄₀₀ in complete apnoea (Ap), at maximal velocity (V_max) with NB and at V_max in Ap. Peak heart rate (HR_peak), blood lactate concentration after exercise (Lac_{post ex}) and Borg rating of perceived exertion (RPE) were measured. Arterial oxygen saturation (SpO₂) was monitored with a pulse oximeter at forehead level during and after exercise. In Ap, swimming at V₄₀₀ induced a significantly lower HR_peak and Lac_{post ex} than swimming at V_max whilst RPE and the kinetics of SpO₂ were not different at V₄₀₀ and at V_max. The minimal value of SpO₂ in Ap was reached 10 to 11 s after the end of V₄₀₀ and V_max (81.7 ± 10.1% and 84.4 ± 10.6%, respectively). Swimming a 50 m front crawl in Ap resulted in a large decrease in SpO₂ which occurred only after the cessation of exercise. The higher duration of apnoea during submaximal exercise could explain why SpO₂ and RPE reached the same values as for maximal exercise.​.

Physiology Of Drowning: A Review

Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.

Is V̇O2 suppressed during nonapnoeic facial submersion?

The mammalian dive response (DR) is described as oxygen-conserving based on measures of bradycardia, peripheral vasoconstriction, and decreased ventilation (V̇_E). Using a model of simulated diving, this study examined the effect of nonapnoeic facial submersions (NAFS) on oxygen consumption (V̇O₂). 19 participants performed four 2-min NAFS with 8 min of rest between each. Two submersions were performed in 5 °C water, 2 in 25 °C water. Heart rate (HR) was collected using chest strap monitors. A tube connected to the inspired port of a non-rebreathing valve allowed participants to breathe during facial submersion. Expired air was directed to a metabolic cart to determine V̇O₂ and V̇_E. Baseline (BL) HR, V̇O₂, and V̇_E values were determined by the average during the 2 min prior to facial submersion; cold shock response (CSR) values were the maximum during the first 30 s of facial submersion; and NAFS values were the minimum during the last 90 s of facial submersion. A 2-way repeated-measures ANOVA indicated that both HR and V̇_E were greater during the CSR (92.5 ± 3.6 beats/min, 16.3 ± 0.8 L/min) compared with BL (78.9 ± 3.2 beats/min, 8.7 ± 0.4 L/min), while both were decreased from BL during the NAFS (60.0 ± 4.0 beats/min, 6.0 ± 0.4 L/min) (all, p < 0.05). HR_CSR was higher and HR_NAFS lower in 5 °C versus 25 °C water (p < 0.05), while V̇_E was greater in 5 °C conditions (p < 0.05). V̇O₂ exceeded BL during the CSR and decreased below BL during the NAFS (BL: 5.3 ± 0.1, CSR: 9.8 ± 0.4, NAFS: 3.1 ± 0.2 mL·kg^-1·min^-1, p < 0.05). The data illustrate that NAFS alone contributes to the oxygen conservation associated with the human DR.

The oxygen-conserving potential of the diving response: A kinetic-based analysis

We investigated the oxygen-conserving potential of the human diving response by comparing trained breath-hold divers (BHDs) to non-divers (NDs) during simulated dynamic breath-holding (BH). Changes in haemodynamics [heart rate (HR), stroke volume (SV), cardiac output (CO)] and peripheral muscle oxygenation [oxyhaemoglobin ([HbO₂]), deoxyhaemoglobin ([HHb]), total haemoglobin ([tHb]), tissue saturation index (TSI)] and peripheral oxygen saturation (SpO₂) were continuously recorded during simulated dynamic BH. BHDs showed a breaking point in HR kinetics at mid-BH immediately preceding a more pronounced drop in HR (-0.86 bpm.%^-1) while HR kinetics in NDs steadily decreased throughout BH (-0.47 bpm.%^-1). By contrast, SV remained unchanged during BH in both groups (all P > 0.05). Near-infrared spectroscopy (NIRS) results (mean ± SD) expressed as percentage changes from the initial values showed a lower [HHb] increase for BHDs than for NDs at the cessation of BH (+24.0 ± 10.1 vs. +39.2 ± 9.6%, respectively; P < 0.05). As a result, BHDs showed a [tHb] drop that NDs did not at the end of BH (-7.3 ± 3.2 vs. -3.0 ± 4.7%, respectively; P < 0.05). The most striking finding of the present study was that BHDs presented an increase in oxygen-conserving efficiency due to substantial shifts in both cardiac and peripheral haemodynamics during simulated BH. In addition, the kinetic-based approach we used provides further credence to the concept of an "oxygen-conserving breaking point" in the human diving response.

Critical Analysis and Alternative Explanations for Effects of Apnea on the Timing of Motor Representations

This commentary is designed to provide an analysis of issues pertinent to the investigation of the effects of the temporary cessation of breathing (apnea), particularly during water immersion or diving, and its effects on time estimation in general and the timing of motor representation in particular. In addition, this analysis provides alternative explanations of certain unexpected findings reported by Di Rienzo et al. (2014) pertaining to apnea and interval timing. The perspective and guidance that this commentary provides on the relationship between apnea and time estimation is especially relevant considering the scarcity of experimental and clinical studies examining these variables.

Cardiorespiratory responses and reduced apneic time to cold-water face immersion after high intensity exercise

Apnea after exercise may evoke a neurally mediated conflict that may affect apneic time and create a cardiovascular strain. The physiological responses, induced by apnea with face immersion in cold water (10 °C), after a 3-min exercise bout, at 85% of VO2max,were examined in 10 swimmers. A pre-selected 40-s apnea, completed after rest (AAR), could not be met after exercise (AAE), and was terminated with an agonal gasp reflex, and a reduction of apneic time, by 75%. Bradycardia was evident with immersion after both, 40-s of AAR and after AAE (P<0.05). The dramatic elevation of, systolic pressure and pulse pressure, after AAE, were indicative of cardiovascular stress. Blood pressure after exercise without apnea was not equally elevated. The activation of neurally opposing functions as those elicited by the diving reflex after high intensity exercise may create an autonomic conflict possibly related to oxygen-conserving reflexes stimulated by the trigeminal nerve, and those elicited by exercise.

The trigeminocardiac reflex - a comparison with the diving reflex in humans

The trigeminocardiac reflex (TCR) has previously been described in the literature as a reflexive response of bradycardia, hypotension, and gastric hypermotility seen upon mechanical stimulation in the distribution of the trigeminal nerve. The diving reflex (DR) in humans is characterized by breath-holding, slowing of the heart rate, reduction of limb blood flow and a gradual rise in the mean arterial blood pressure. Although the two reflexes share many similarities, their relationship and especially their functional purpose in humans have yet to be fully elucidated. In the present review, we have tried to integrate and elaborate these two phenomena into a unified physiological concept. Assuming that the TCR and the DR are closely linked functionally and phylogenetically, we have also highlighted the significance of these reflexes in humans.

Deep-diving sea lions exhibit extreme bradycardia in long-duration dives

Heart rate and peripheral blood flow distribution are the primary determinants of the rate and pattern of oxygen store utilisation and ultimately breath-hold duration in marine endotherms. Despite this, little is known about how otariids (sea lions and fur seals) regulate heart rate (fH) while diving. We investigated dive fH in five adult female California sea lions (Zalophus californianus) during foraging trips by instrumenting them with digital electrocardiogram (ECG) loggers and time depth recorders. In all dives, dive fH (number of beats/duration; 50±9 beats min(-1)) decreased compared with surface rates (113±5 beats min(-1)), with all dives exhibiting an instantaneous fH below resting (<54 beats min(-1)) at some point during the dive. Both dive fH and minimum instantaneous fH significantly decreased with increasing dive duration. Typical instantaneous fH profiles of deep dives (>100 m) consisted of: (1) an initial rapid decline in fH resulting in the lowest instantaneous fH of the dive at the end of descent, often below 10 beats min(-1) in dives longer than 6 min in duration; (2) a slight increase in fH to ~10-40 beats min(-1) during the bottom portion of the dive; and (3) a gradual increase in fH during ascent with a rapid increase prior to surfacing. Thus, fH regulation in deep-diving sea lions is not simply a progressive bradycardia. Extreme bradycardia and the presumed associated reductions in pulmonary and peripheral blood flow during late descent of deep dives should (a) contribute to preservation of the lung oxygen store, (b) increase dependence of muscle on the myoglobin-bound oxygen store, (c) conserve the blood oxygen store and (d) help limit the absorption of nitrogen at depth. This fH profile during deep dives of sea lions may be characteristic of deep-diving marine endotherms that dive on inspiration as similar fH profiles have been recently documented in the emperor penguin, another deep diver that dives on inspiration.

Acute apnea swimming: metabolic responses and performance

Competitive swimmers regularly perform apnea series with or without fins as part of their training, but the ergogenic and metabolic repercussions of acute and chronic apnea have not been examined. Therefore, we aimed to investigate the cardiovascular, lactate, arterial oxygen saturation and hormonal responses to acute apnea in relation to performance in male swimmers. According to a randomized protocol, 15 national or regional competitive swimmers were monitored while performing four 100-m freestyle trials, each consisting of four 25-m segments with departure every 30 seconds at maximal speed in the following conditions: with normal frequency breathing with fins (F) and without fins (S) and with complete apnea for the four 25-m segments with (FAp) and without fins (SAp). Heart rate (HR) was measured continuously and arterial oxygen saturation, blood, and saliva samples were assessed after 30 seconds, 3 minutes, and 10 minutes of recovery, respectively. Swimming performance was better with fins than without both with normal frequency breathing and apnea (p < 0.001). Apnea induced no change in lactatemia, but a decrease in arterial oxygen saturation in both SAp and FAp (p < 0.001) was noted and a decrease in HR and swimming performance in SAp (p < 0.01). During apnea without fins, performance alteration was correlated with bradycardia (r = 0.63) and arterial oxygen desaturation (r = -0.57). Saliva dehydroepiandrosterone was increased compared with basal values whatever the trial (p ≤ 0.05), whereas no change was found in saliva cortisol or testosterone. Further studies are necessary to clarify the fin effect on HR and performance during apnea swimming.

Using stimulation of the diving reflex in humans to teach integrative physiology

During underwater submersion, the body responds by conserving O2 and prioritizing blood flow to the brain and heart. These physiological adjustments, which involve the nervous, cardiovascular, and respiratory systems, are known as the diving response and provide an ideal example of integrative physiology. The diving reflex can be stimulated in the practical laboratory setting using breath holding and facial immersion in water. Our undergraduate physiology students complete a laboratory class in which they investigate the effects of stimulating the diving reflex on cardiovascular variables, which are recorded and calculated with a Finapres finger cuff. These variables include heart rate, cardiac output, stroke volume, total peripheral resistance, and arterial pressures (mean, diastolic, and systolic). Components of the diving reflex are stimulated by 1) facial immersion in cold water (15°C), 2) breathing with a snorkel in cold water (15°C), 3) facial immersion in warm water (30°C), and 4) breath holding in air. Statistical analysis of the data generated for each of these four maneuvers allows the students to consider the factors that contribute to the diving response, such as the temperature of the water and the location of the sensory receptors that initiate the response. In addition to providing specific details about the equipment, protocols, and learning outcomes, this report describes how we assess this practical exercise and summarizes some common student misunderstandings of the essential physiological concepts underlying the diving response.

Effects of two weeks of daily apnea training on diving response, spleen contraction, and erythropoiesis in novel subjects

Three potentially protective responses to hypoxia have been reported to be enhanced in divers: (1) the diving response, (2) the blood-boosting spleen contraction, and (3) a long-term enhancement of hemoglobin concentration (Hb). Longitudinal studies, however, have been lacking except concerning the diving response. Ten untrained subjects followed a 2-week training program with 10 maximal effort apneas per day, with pre- and posttraining measurements during three maximal duration apneas, and an additional post-training series when the apneic duration was kept identical to that before training. Cardiorespiratory parameters and venous blood samples were collected across tests, and spleen diameters were measured via ultrasound imaging. Maximal apneic duration increased by 44 s (P < 0.05). Diving bradycardia developed 3 s earlier and was more pronounced after training (P < 0.05). Spleen contraction during apneas was similar during all tests. The arterial hemoglobin desaturation (SaO2) nadir after apnea was 84% pretraining and 89% after the duration-mimicked apneas post-training (P < 0.05), while it was 72% (P < 0.05) after maximal apneas post-training. Baseline Hb remained unchanged after training, but reticulocyte count increased by 15% (P < 0.05). We concluded that the attenuated SaO2 decrease during mimic apneas was due mainly to the earlier and more pronounced diving bradycardia, as no enhancement of spleen contraction or Hb had occurred. Increased reticulocyte count suggests augmented erythropoiesis.

Dynamic cerebral autoregulation is acutely impaired during maximal apnoea in trained divers

Aims

To examine whether dynamic cerebral autoregulation is acutely impaired during maximal voluntary apnoea in trained divers.

Methods

Mean arterial pressure (MAP), cerebral blood flow-velocity (CBFV) and end-tidal partial pressures of O₂ and CO₂ (PETO₂ and PETCO₂) were measured in eleven trained, male apnoea divers (28±2 yr; 182±2 cm, 76±7 kg) during maximal “dry” breath holding. Dynamic cerebral autoregulation was assessed by determining the strength of phase synchronisation between MAP and CBFV during maximal apnoea.

Results

The strength of phase synchronisation between MAP and CBFV increased from rest until the end of maximal voluntary apnoea (P<0.05), suggesting that dynamic cerebral autoregulation had weakened by the apnoea breakpoint. The magnitude of impairment in dynamic cerebral autoregulation was strongly, and positively related to the rise in PETCO₂ observed during maximal breath holding (R² = 0.67, P<0.05). Interestingly, the impairment in dynamic cerebral autoregulation was not related to the fall in PETO₂ induced by apnoea (R² = 0.01, P = 0.75).

Conclusions

This study is the first to report that dynamic cerebral autoregulation is acutely impaired in trained divers performing maximal voluntary apnoea. Furthermore, our data suggest that the impaired autoregulatory response is related to the change in PETCO₂, but not PETO₂, during maximal apnoea in trained divers.

The Effects of Involuntary Respiratory Contractions on Cerebral Blood Flow during Maximal Apnoea in Trained Divers

The effects of involuntary respiratory contractions on the cerebral blood flow response to maximal apnoea is presently unclear. We hypothesised that while respiratory contractions may augment left ventricular stroke volume, cardiac output and ultimately cerebral blood flow during the struggle phase, these contractions would simultaneously cause marked ‘respiratory’ variability in blood flow to the brain. Respiratory, cardiovascular and cerebrovascular parameters were measured in ten trained, male apnoea divers during maximal ‘dry’ breath holding. Intrathoracic pressure was estimated via oesophageal pressure. Left ventricular stroke volume, cardiac output and mean arterial pressure were monitored using finger photoplethysmography, and cerebral blood flow velocity was obtained using transcranial ultrasound. The increasingly negative inspiratory intrathoracic pressure swings of the struggle phase significantly influenced the rise in left ventricular stroke volume (R² = 0.63, P<0.05), thereby contributing to the increase in cerebral blood flow velocity throughout this phase of apnoea. However, these contractions also caused marked respiratory variability in left ventricular stroke volume, cardiac output, mean arterial pressure and cerebral blood flow velocity during the struggle phase (R² = 0.99, P<0.05). Interestingly, the magnitude of respiratory variability in cerebral blood flow velocity was inversely correlated with struggle phase duration (R² = 0.71, P<0.05). This study confirms the hypothesis that, on the one hand, involuntary respiratory contractions facilitate cerebral haemodynamics during the struggle phase while, on the other, these contractions produce marked respiratory variability in blood flow to the brain. In addition, our findings indicate that such variability in cerebral blood flow negatively impacts on struggle phase duration, and thus impairs breath holding performance.