The classic potentiation of exercise ventilatory response by increased dead space in humans is more than short-term modulation

Exertional dyspnea associated with chest wall strapping is reduced when external dead space substitutes for part of the exercise stimulus to ventilation

Chest wall strapping has been used to assess mechanisms of dyspnea with restrictive lung disease. This study examined the hypothesis that dyspnea with restriction depends principally on the degree of reflex ventilatory stimulation. We compared dyspnea at the same (iso)ventilation when added dead space provided a component of the ventilatory stimulus during exercise. Eleven healthy men undertook a randomized controlled crossover trial that compared four constant work exercise conditions: 1) control (CTRL): unrestricted breathing at 90% gas exchange threshold (GET); 2) CTRL+dead space (DS): unrestricted breathing with 0.6-l dead space, at isoventilation to CTRL due to reduced exercise intensity; 3) CWS: chest wall strapping at 90% GET; and 4) CWS+DS: chest strapping with 0.6-l dead space, at isoventilation to CWS with reduced exercise intensity. Chest strapping reduced forced vital capacity by 30.4 ± 2.2% (mean ± SE). Dyspnea at isoventilation was unchanged with CTRL+DS compared with CTRL (1.93 ± 0.49 and 2.17 ± 0.43, 0–10 numeric rating scale, respectively; P = 0.244). Dyspnea was lower with CWS+DS compared with CWS (3.40 ± 0.52 and 4.51 ± 0.53, respectively; P = 0.003). Perceived leg fatigue was reduced with CTRL+DS compared with CTRL (2.36 ± 0.48 and 2.86 ± 0.59, respectively; P = 0.049) and lower with CWS+DS compared with CWS (1.86 ± 0.30 and 4.00 ± 0.79, respectively; P = 0.006). With unrestricted breathing, dead space did not change dyspnea at isoventilation, suggesting that dyspnea does not depend on the mode of reflex ventilatory stimulation in healthy individuals. With chest strapping, dead space presented a less potent stimulus to dyspnea, raising the possibility that leg muscle work contributes to dyspnea perception independent of the ventilatory stimulus.

NEW & NOTEWORTHY Chest wall strapping was applied to healthy humans to simulate restrictive lung disease. With chest wall strapping, dyspnea was reduced when dead space substituted for part of a constant exercise stimulus to ventilation. Dyspnea associated with chest wall strapping depended on the contribution of leg muscle work to ventilatory stimulation. Chest wall strapping might not be a clinically relevant model to determine whether an alternative reflex ventilatory stimulus mimics the intensity of exertional dyspnea.

Type III-IV muscle afferents are not required for steady-state exercise hyperpnea in healthy subjects and patients with COPD or heart failure

Blockade of group III-IV muscle afferents by intrathecal injection of the μ-opioid agonist fentanyl (IF) in humans has been variously reported to depress exercise hyperpnea in some studies but not others. A key unanswered question is whether such an effect is transient or persists in the steady state. Here we show that in healthy subjects undergoing constant-load cycling exercise IF significantly slows the transient exercise ventilatory kinetics but has no discernible effect on the ventilatory response when exercise is sufficiently prolonged. Thus, the ventilatory response to group III-IV muscle afferents input in healthy subjects is not a simple reflex but acts like a high-pass filter with maximum sensitivity during early-phase exercise and is reset in the late phase. In patients with chronic heart failure (CHF) IF causes sustained CO2 retention not only during exercise but also in the resting state, where muscle afferents feedback is minimal. In patients with chronic obstructive pulmonary disease (COPD), IF also elicits sustained decreases in the exercise ventilatory response but with little or no resultant CO2 retention due to concomitant decreases in physiological VD/VT (dead space-to-ventilation ratio). These results support the proposition that optimal long-term regulation of exercise hyperpnea in health and in disease is determined centrally by the respiratory controller through the continuing adaptation of an internal model which dynamically tracks the metabolic CO2 load and the ventilatory inefficiency 1/1-VD/VT that must be overcome for the maintenance of arterial PCO2 homeostasis, rather than being reflexively driven by group III-IV muscle afferents feedback per se.

Submissive hypercapnia: Why COPD patients are more prone to CO2 retention than heart failure patients

Patients with late-stage chronic obstructive pulmonary disease (COPD) are prone to CO2 retention, a condition which has been often attributed to increased ventilation-perfusion mismatch particularly during oxygen therapy. However, patients with mild-to-moderate COPD or chronic heart failure (CHF) also suffer similar ventilatory inefficiency but they remain near-normocapnic at rest and during exercise with an augmented respiratory effort to compensate for the wasted dead space ventilation. In severe COPD, the augmented exercise ventilation progressively reverses as the disease advances, resulting in hypercapnia at peak exercise as ventilatory limitation due to increasing expiratory flow limitation and dynamic lung hyperinflation sets in. Submissive hypercapnia is an emerging paradigm for understanding optimal ventilatory control and cost/benefit decision-making under prohibitive respiratory chemical-mechanical constraints, where the need to maintain normocapnia gives way to the mounting need to conserve the work of breathing. In severe/very severe COPD, submissive hypercapnia epitomizes the respiratory controller's 'can't breathe, so won't breathe' say-uncle policy when faced with insurmountable ventilatory limitation. Even in health, submissive hypercapnia ensues during CO2 breathing/rebreathing when the inhaled CO2 renders normocapnia difficult to restore even with maximal respiratory effort, hence the respiratory controller's 'ain't fresh, so won't breathe' modus operandi. This 'wisdom of the body' with a principled decision to tolerate hypercapnia when faced with prohibitive ventilatory or gas exchange limitations rather than striving for untenable normocapnia at all costs is analogous to the notion of permissive hypercapnia in critical care, a clinical strategy to minimize the risks of ventilator-induced lung injury in patients receiving mechanical ventilation.

OPTIMAL RESPIRATORY CONTROL SIMULATION AND COMPARATIVE STUDY OF HYPERCAPNIC VENTILATORY RESPONSES TO EXTERNAL DEAD SPACE LOADING

There has been considerable research effort regarding ventilatory responses to breathing with an imposed external dead space, and inhalation of fixed levels of CO 2 by human subjects. A human respiratory control model incorporating the optimality hypothesis can successfully demonstrate ventilatory responses to both chemical stimuli and muscular exercise. In this study, to verify the model behavior of the optimal chemical–mechanical respiratory control model, we simulated the ventilatory control under dead space loading and CO 2 inhalation. The simulation was provided by a LabVIEW® based human respiratory control simulator and signal monitoring system. The dead space measurement was described with two distinct models, derived from Gray and Coon, and predicted behaviors with corresponding ventilatory responses were investigated and compared with experimental findings. While both dead space models produced satisfactory predictions on simulated optimal [Formula: see text] versus Pa CO 2, [Formula: see text] versus Pa CO 2, F versus PI CO 2, VT versus PI CO 2, VD-total versus VT, VD- total /VT versus VT, [Formula: see text] versus VT and [Formula: see text] versus VT relationships, Gray's model provided better correlation and more consistent results throughout most of the ventilatory responses. The study of relative behavior of respiratory signals and comparative relationship of the ventilator responses between dead space loading during rest and CO 2 inhalation will certainly provide valuable understanding of increases in central respiratory motor command output of human respiratory control, which is also associated with Dyspnea on exertion, and give potential clinical perspective to realize the impaired ability to excrete CO 2 in patients diagnosed with acute respiratory distress syndrome.

Mechanism of augmented exercise hyperpnea in chronic heart failure and dead space loading

Patients with chronic heart failure (CHF) suffer increased alveolar VD/VT (dead-space-to-tidal-volume ratio), yet they demonstrate augmented pulmonary ventilation such that arterial [Formula: see text] ( [Formula: see text] ) remains remarkably normal from rest to moderate exercise. This paradoxical effect suggests that the control law governing exercise hyperpnea is not merely determined by metabolic CO2 production ( [Formula: see text] ) per se but is responsive to an apparent (real-feel) metabolic CO2 load ( [Formula: see text] ) that also incorporates the adverse effect of physiological VD/VT on pulmonary CO2 elimination. By contrast, healthy individuals subjected to dead space loading also experience augmented ventilation at rest and during exercise as with increased alveolar VD/VT in CHF, but the resultant response is hypercapnic instead of eucapnic, as with CO2 breathing. The ventilatory effects of dead space loading are therefore similar to those of increased alveolar VD/VT and CO2 breathing combined. These observations are consistent with the hypothesis that the increased series VD/VT in dead space loading adds to [Formula: see text] as with increased alveolar VD/VT in CHF, but this is through rebreathing of CO2 in dead space gas thus creating a virtual (illusory) airway CO2 load within each inspiration, as opposed to a true airway CO2 load during CO2 breathing that clogs the mechanism for CO2 elimination through pulmonary ventilation. Thus, the chemosensing mechanism at the respiratory controller may be responsive to putative drive signals mediated by within-breath [Formula: see text] oscillations independent of breath-to-breath fluctuations of the mean [Formula: see text] level. Skeletal muscle afferents feedback, while important for early-phase exercise cardioventilatory dynamics, appears inconsequential for late-phase exercise hyperpnea.

Optimal interaction of respiratory and thermal regulation at rest and during exercise: role of a serotonin-gated spinoparabrachial thermoafferent pathway

Recent evidence indicates that the lateral parabrachial nucleus (LPBN) in dorsolateral pons is pivotal in mediating the feedback control of inspiratory drive by central chemoreceptor input and feedforward control of body temperature by cutaneous thermoreceptor input. The latter is subject to descending serotonergic inhibition which gates the transmission of ascending thermoafferent information from spinal dorsal horn to the LPBN. Here, a model is proposed which suggests that the LPBN may be important in balancing respiratory and thermal homeostasis, two conflicting goals that are heightened by environmental heat/cold stress or exercise where the effects of respiratory thermolysis become prominent. This optimization model of respiratory-thermoregulatory interaction is supported by a host of recent studies which demonstrate that animals with serotonin (5-HT) dysfunction at the spinal dorsal horn--due to 5-HT antagonism, genetic 5-HT defects or spinal cord injury--all display similar respiratory abnormalities that are consistent with hyperactivity of the spinoparabrachial thermoafferent (and pain) pathway.