The effect of adding CO2 to hypoxic inspired gas on cerebral blood flow velocity and breathing during incremental exercise

The Acute Effects of a Single Dose of Molecular Hydrogen Supplements on Responses to Ergogenic Adjustments during High-Intensity Intermittent Exercise in Humans

This research examined the effects of single-dose molecular hydrogen (H₂) supplements on acid-base status and local muscle deoxygenation during rest, high-intensity intermittent training (HIIT) performance, and recovery. Ten healthy, trained subjects in a randomized, double-blind, crossover design received H₂-rich calcium powder (HCP) (1500 mg, containing 2.544 μg of H₂) or H₂-depleted placebo (1500 mg) supplements 1 h pre-exercise. They performed six bouts of 7 s all-out pedaling (HIIT) at 7.5% of body weight separated by 40 s pedaling intervals, followed by a recovery period. Blood gases’ pH, PCO₂, and HCO₃⁻ concentrations were measured at rest. Muscle deoxygenation (deoxy[Hb + Mb]) and tissue O₂ saturation (S_tO₂) were determined via time-resolved near-infrared spectroscopy in the vastus lateralis (VL) and rectus femoris (RF) muscles from rest to recovery. At rest, the HCP group had significantly higher PCO₂ and HCO₃⁻ concentrations and a slight tendency toward acidosis. During exercise, the first HIIT bout’s peak power was significantly higher in HCP (839  ±  112 W) vs. Placebo (816  ±  108 W, p = 0.001), and HCP had a notable effect on significantly increased deoxy[Hb + Mb] concentration during HIIT exercise, despite no differences in heart rate response. The HCP group showed significantly greater O₂ extraction in VL and microvascular (Hb) volume in RF during HIIT exercise. The HIIT exercise provided significantly improved blood flow and muscle reoxygenation rates in both the RF and VL during passive recovery compared to rest in all groups. The HCP supplement might exert ergogenic effects on high-intensity exercise and prove advantageous for improving anaerobic HIIT exercise performance.

Brain-muscle interplay during endurance self-paced exercise in normobaric and hypobaric hypoxia

Purpose: Hypoxia is one major environmental factor, supposed to mediate central motor command as well as afferent feedbacks at rest and during exercise. By using a comparison of normobaric (NH) and hypobaric (HH) hypoxia with the same ambient pressure in oxygen, we examined the potential differences on the cerebrovascular and muscular regulation interplay during a self-paced aerobic exercise.

Methods: Sixteen healthy subjects performed three cycling time-trials (250 kJ) in three conditions: HH, NH and normobaric normoxia (NN) after 24 h of exposure. Cerebral and muscular oxygenation were assessed by near-infrared spectroscopy, cerebral blood flow by Doppler ultrasound system. Gas exchanges, peripheral oxygen saturation, power output and associated pacing strategies were also continuously assessed.

Results: The cerebral oxygen delivery was lower in hypoxia than in NN but decreased similarly in both hypoxic conditions. Overall performance and pacing were significantly more down-regulated in HH versus NH, in conjunction with more impaired systemic (e.g. saturation and cerebral blood flow) and prefrontal cortex oxygenation during exercise.

Conclusions: The difference in pacing was likely the consequence of a complex interplay between systemic alterations and cerebral oxygenation observed in HH compared to NH, aiming to maintain an equivalent cerebral oxygen delivery despite higher adaptive cost (lower absolute power output for the same relative exercise intensity) in HH compared to NH.

CO2-Enriched Air Inhalation Modulates the Ventilatory and Metabolic Responses of Endurance Runners During Incremental Running in Hypobaric Hypoxia

Cao, Yinhang, Naoto Fujii, Tomomi Fujimoto, Yin-Feng Lai, Takeshi Ogawa, Tsutomu Hiroyama, Yasushi Enomoto, and Takeshi Nishiyasu. CO₂-enriched air inhalation modulates the ventilatory and metabolic responses of endurance runners during incremental running in hypobaric hypoxia. High Alt Med Biol. 23:125-134, 2022. Aim: We measured the effects of breathing CO₂-enriched air on ventilatory and metabolic responses during incremental running exercise under moderately hypobairc hypoxic (HH) conditions. Materials and Methods: Ten young male endurance runners [61.4 ± 6.0 ml/(min·kg)] performed incremental running tests under three conditions: (1) normobaric normoxia (NN), (2) HH (2,500 m), and (3) HH with 5% CO₂ inhalation (HH+CO₂). The test under NN was always performed first, and then, the two remaining tests were completed in random and counterbalanced order. Results: End-tidal CO₂ partial pressure (55 ± 3 vs. 35 ± 1 mmHg), peak ventilation (163 ± 14 vs. 152 ± 12 l/min), and peak oxygen uptake [52.3 ± 5.5 vs. 50.5 ± 4.9 ml/(min·kg)] were all higher in the HH+CO₂ than HH trial (all p < 0.01), respectively. However, the duration of the incremental test did not differ between HH+CO₂ and HH trials. Conclusion: These data suggest that chemoreflex activation by breathing CO₂-enriched air stimulates breathing and aerobic metabolism during maximal intensity exercise without affecting exercise performance in male endurance runners under a moderately hypobaric hypoxic environment.

Tent versus Mask-On Acute Effects during Repeated-Sprint Training in Normobaric Hypoxia and Normoxia

Repeated sprint in hypoxia (RSH) is used to improve supramaximal cycling capacity, but little is known about the potential differences between different systems for creating normobaric hypoxia, such as a chamber, tent, or mask. This study aimed to compare the environmental (carbon dioxide (CO₂) and wet-globe bulb temperature (WGBT)), perceptual (pain, respiratory difficulty, and rate of perceived exertion (RPE)), and external (peak and mean power output) and internal (peak heart rate (HRpeak), muscle oxygen saturation (SmO₂), arterial oxygen saturation (SpO₂), blood lactate and glucose) workload acute effects of an RSH session when performed inside a tent versus using a mask. Twelve well-trained cyclists (age = 29 ± 9.8 years, VO₂max = 70.3 ± 5.9 mL/kg/min) participated in this single-blind, randomized, crossover trial. Participants completed four sessions of three sets of five repetitions × 10 s:20 s (180 s rest between series) of all-out in different conditions: normoxia in a tent (RSNTent) and mask-on (RSNMask), and normobaric hypoxia in a tent (RSHTent) and mask-on (RSHMask). CO₂ and WGBT levels increased steadily in all conditions (p < 0.01) and were lower when using a mask (RSNMask and RSHMask) than when inside a tent (RSHTent and RSNTent) (p < 0.01). RSHTent presented lower SpO₂ than the other three conditions (p < 0.05), and hypoxic conditions presented lower SpO₂ than normoxic ones (p < 0.05). HRpeak, RPE, blood lactate, and blood glucose increased throughout the training, as expected. RSH could lead to acute conditions such as hypoxemia, which may be exacerbated when using a tent to simulate hypoxia compared to a mask-based system.

Cardiorespiratory Response and Power Output During Submaximal Exercise in Normobaric Versus Hypobaric Hypoxia: A Pilot Study Using a Specific Chamber that Controls Environmental Factors

Takezawa, Toshihiro, Shohei Dobashi, and Katsuhiro Koyama. Cardiorespiratory response and power output during submaximal exercise in normobaric versus hypobaric hypoxia: a pilot study using a specific chamber that controls environmental factors. High Alt Med Biol. 22: 201-208, 2021. Background: Many previous studies have examined hypoxia-induced physiological responses using various conditions, e.g., artificially reduced atmospheric oxygen concentration [normobaric hypoxia (NH) condition] or low barometric pressure at a mountain [hypobaric hypoxia (HH) condition]. However, when comparing the results from these previous studies conducted in artificial NH and HH including real high altitude, we must consider the possibility that environmental factors, such as temperature, humidity, and fraction of inspired carbon dioxide, might affect the physiological responses. Therefore, we examined cardiorespiratory responses and exercise performances during low- to high-intensity exercise at a fixed heart rate (HR) in both NH and HH using a specific chamber where atmospheric oxygen concentration and barometric pressure as well as the abovementioned environmental factors were precisely controlled. Methods: Ten well-trained university students (eight males and two females) performed the exercise test consisting of two 20-minute submaximal pedaling at the intensity corresponding to 50% (low) and 70% (high) of their HR reserve, under three conditions [NH (fraction of inspired oxygen, 0.135; barometric pressure, 754 mmHg), HH (fraction of inspired oxygen, 0.209; barometric pressure, 504 mmHg), and normobaric normoxia (NN; fraction of inspired oxygen, 0.209; barometric pressure, 754 mmHg)]. Peripheral oxygen saturation (SpO₂) to estimate arterial oxygen saturation and partial pressure of end-tidal carbon dioxide (P_ETCO₂) were monitored throughout the experiment. Results: SpO₂, P_ETCO₂, and power output at fixed HRs (i.e., pedaling efficiency) in NH and HH were all significantly lower than those in NN. Moreover, high-intensity exercise in HH induced greater decreases in SpO₂ and power output than did high-intensity exercise in NH (NH vs. HH; SpO₂, 78.2% ± 5.0% vs. 75.1% ± 7.1%; power output, 120.7 ± 24.9 W vs. 112.4 ± 23.2 W, both p < 0.05). However, high-intensity exercise in HH induced greater increases in P_ETCO₂ than did high-intensity exercise in NH (NH vs. HH; 54.2 ± 5.9 mmHg vs. 57.2 ± 3.4 mmHg, p < 0.01). Conclusions: These results suggest that physiological responses and power output at a fixed HR during hypoxic exposure might depend on the method used to generate the hypoxic condition.

CO2 supplementation dissociates cerebral oxygenation and middle cerebral artery blood velocity during maximal cycling

This study evaluated whether the reduction of prefrontal cortex oxygenation (ScO₂ ) during maximal exercise depends on the hyperventilation-induced hypocapnic attenuation of middle cerebral artery blood velocity (MCA V_mean ). Twelve endurance-trained males (age: 25 ± 3 years, height: 183 ± 8 cm, weight: 75 ± 9 kg; mean ± SD) performed in three separate laboratory visits, a maximal oxygen uptake (VO₂ max) test, an isocapnic (end-tidal CO₂ tension (PetCO₂ ) clamped at 40 ± 1 mmHg), and an ambient air controlled-pace constant load high-intensity ergometer cycling to exhaustion, while MCA V_mean (transcranial Doppler ultrasound) and ScO₂ (near-infrared spectroscopy) were determined. Duration of exercise (12 min 25 s ± 1 min 18 s) was matched by performing the isocapnic trial first. Pulmonary VO₂ was 90 ± 6% versus 93 ± 5% of the maximal value (P = .012) and PetCO₂ 40 ± 1 versus 34 ± 4 mmHg (P < .05) during the isocapnic and control trials, respectively. During the isocapnic trial MCA V_mean increased by 16 ± 13% until clamping was applied and continued to increase (by 14 ± 28%; P = .017) until the end of exercise, while there was no significant change during the control trial (P = .071). In contrast, ScO₂ decreased similarly in both trials (-3.2 ± 5.1% and -4.1 ± 9.6%; P < .001, isocapnic and control, respectively) at exhaustion. The reduction in prefrontal cortex oxygenation during maximal exercise does not depend solely on lowered cerebral blood flow as indicated by middle cerebral blood velocity.

Oral Nitrate Supplementation Differentially Modulates Cerebral Artery Blood Velocity and Prefrontal Tissue Oxygenation During 15 km Time-Trial Cycling in Normoxia but Not in Hypoxia

Background: Nitrate is a precursor of nitric oxide (NO), an important regulator of cerebral perfusion in normoxic and hypoxic conditions. Nitrate supplementation could be used to improve cerebral perfusion and oxygenation during exercise in hypoxia. The effects of dietary nitrate supplementation on cerebral haemodynamics during exercise in severe hypoxia (arterial O₂ saturation < 70%) have not been explored.

Methods: In twelve trained male cyclists, we measured blood pressure (BP), middle cerebral artery blood velocity (MCAv), cerebrovascular resistance (CVR) and prefrontal oxyhaemoglobin and deoxyhaemoglobin concentration (O₂Hb and HHb, respectively) during 15 km cycling time trials (TT) in normoxia and severe hypoxia (11% inspired O₂, peripheral O₂ saturation ∼66%) following 3-day oral supplementation with placebo or sodium nitrate (0.1 mmol/kg/day) in a randomised, double-blinded manner. We tested the hypothesis that dietary nitrate supplementation increases MCAv and cerebral O₂Hb during TT in severe hypoxia.

Results: During TT in normoxia, nitrate supplementation lowered MCAv by ∼2.3 cm/s and increased cerebral O₂Hb by ∼6.8 μM and HHb by ∼2.1 μM compared to normoxia placebo (p ≤ 0.01 for all), while BP tended to be lowered (p = 0.06). During TT in severe hypoxia, nitrate supplementation elevated MCAv (by ∼2.5 cm/s) and BP (by ∼5 mmHg) compared to hypoxia placebo (p < 0.01 for both), while it had no effect on cerebral O₂Hb (p = 0.98), HHb (p = 0.07) or PETCO₂ (p = 0.12). Dietary nitrate had no effect of CVR during TT in normoxia or hypoxia (p = 0.19).

Conclusion: Our findings indicate that during normoxic TT, the modulatory effect of dietary nitrate on regional and global cerebral perfusion is heterogeneous. Meanwhile, the lack of major changes in cerebral perfusion with dietary nitrate during hypoxic TT alludes to an exhausted cerebrovascular reserve.

Exercise-induced Fatigue in Severe Hypoxia after an Intermittent Hypoxic Protocol

PURPOSE

Exercise-induced central fatigue is alleviated after acclimatization to high altitude. The adaptations underpinning this effect may also be induced with brief, repeated exposures to severe hypoxia. The purpose of this study was to determine whether (i) exercise tolerance in severe hypoxia would be improved after an intermittent hypoxic (IH) protocol and (ii) exercise-induced central fatigue would be alleviated after an IH protocol.

METHODS

Nineteen recreationally active men were randomized into two groups who completed ten 2-h exposures in severe hypoxia (IH: partial pressure of inspired O2 82 mm Hg; n = 11) or normoxia (control; n = 8). Seven sessions involved cycling for 30 min at 25% peak power (W˙peak) in IH and at a matched heart rate in normoxia. Participants performed baseline constant-power cycling to task failure in severe hypoxia (TTF-Pre). After the intervention, the cycling trial was repeated (TTF-Post). Before and after exercise, responses to transcranial magnetic stimulation and supramaximal femoral nerve stimulation were obtained to assess central and peripheral contributions to neuromuscular fatigue.

RESULTS

From pre- to postexercise in TTF-Pre, maximal voluntary contraction (MVC), cortical voluntary activation (VATMS), and potentiated twitch force (Qtw,pot) decreased in both groups (all P < 0.05). After IH, TTF-Post was improved (535 ± 213 s vs 713 ± 271 s, P < 0.05) and an additional isotime trial was performed. After the IH intervention only, the reduction in MVC and VATMS was attenuated at isotime (P < 0.05). No differences were observed in the control group.

CONCLUSIONS

Whole-body exercise tolerance in severe hypoxia was prolonged after a protocol of IH. This may be related to an alleviation of the central contribution to neuromuscular fatigue.

Pulmonary hemodynamics responses to hypoxia and/or CO2 inhalation during moderate exercise in humans

In this study, we hypothesized that adding CO₂ to an inhaled hypoxic gas mixture will limit the rise of pulmonary artery pressure (PAP) induced by a moderate exercise. Eight 20-year-old males performed four constant-load exercise tests on cycle at 40% of maximal oxygen consumption in four conditions: ambient air, normobaric hypoxia (12.5% O₂), inhaled CO₂ (4.5% CO₂), and combination of hypoxia and inhaled CO₂. Doppler echocardiography was used to measure systolic (s)PAP, cardiac output (CO). Total pulmonary resistance (TPR) was calculated. Arterialized blood pH was 7.40 at exercise in ambient and hypoxia conditions, whereas CO₂ inhalation and combined conditions showed acidosis. sPAP increases from rest in ambient air to exercise ranged as follows: ambient + 110%, CO₂ inhalation + 135%, combined + 184%, hypoxia + 217% (p < 0.001). CO was higher when inhaling O₂-poor gas mixtures with or without CO₂ (~ 17 L min^-1) than in the other conditions (~ 14 L min^-1, p < 0.001). Exercise induced a significant decrease in TPR in the four conditions (p < 0.05) but less marked in hypoxia (- 19% of the resting value in ambient air) than in ambient (- 33%) and in both CO₂ inhalation and combined condition (- 29%). We conclude that (1) acute CO₂ inhalation did not significantly modify pulmonary hemodynamics during moderate exercise. (2) CO₂ adjunction to hypoxic gas mixture did not modify CO, despite a higher CaO₂ in combined condition than in hypoxia. (3) TPR was lower in combined than in hypoxia condition, limiting sPAP increase in combined condition.

Regulation of cerebral blood flow and metabolism during exercise

NEW FINDINGS

What is the topic of this review? The manuscript collectively combines the experimental observations from >100 publications focusing on the regulation of cerebral blood flow and metabolism during exercise from 1945 to the present day. What advances does it highlight? This article highlights the importance of traditional and historical assessments of cerebral blood flow and metabolism during exercise, as well as traditional and new insights into the complex factors involved in the integrative regulation of brain blood flow and metabolism during exercise. The overarching theme is the importance of quantifying cerebral blood flow and metabolism during exercise using techniques that consider multiple volumetric cerebral haemodynamics (i.e. velocity, diameter, shear and flow). Cerebral function in humans is crucially dependent upon continuous oxygen delivery, metabolic nutrients and active regulation of cerebral blood flow (CBF). As a consequence, cerebrovascular function is precisely titrated by multiple physiological mechanisms, characterized by complex integration, synergism and protective redundancy. At rest, adequate CBF is regulated through reflexive responses in the following order of regulatory importance: fluctuating arterial blood gases (in particularly, partial pressure of carbon dioxide), cerebral metabolism, arterial blood pressure, neurogenic activity and cardiac output. Unfortunately, the magnitude that these integrative and synergistic relationships contribute to governing the CBF during exercise remains unclear. Despite some evidence indicating that CBF regulation during exercise is dependent on the changes of blood pressure, neurogenic activity and cardiac output, their role as a primary governor of the CBF response to exercise remains controversial. In contrast, the balance between the partial pressure of carbon dioxide and cerebral metabolism continues to gain empirical support as the primary contributor to the intensity-dependent changes in CBF observed during submaximal, moderate and maximal exercise. The goal of this review is to summarize the fundamental physiology and mechanisms involved in regulation of CBF and metabolism during exercise. The clinical implications of a better understanding of CBF during exercise and new research directions are also outlined.

An integrated view on the oxygenation responses to incremental exercise at the brain, the locomotor and respiratory muscles

In the past two decades oxygenation responses to incremental ramp exercise, measured non-invasively by means of near-infrared spectroscopy at different locations in the body, have advanced the insights on the underpinning mechanisms of the whole-body pulmonary oxygen uptake ([Formula: see text]) response. In healthy subjects the complex oxygenation responses at the level of locomotor and respiratory muscles, and brain were simplified and quantified by the detection of breakpoints as a deviation in the ongoing response pattern as work rate increases. These breakpoints were located in a narrow intensity range between 75 and 90 % of the maximal [Formula: see text] and were closely related to traditionally determined thresholds in pulmonary gas exchange (respiratory compensation point), blood lactate measurements (maximal lactate steady state), and critical power. Therefore, it has been assumed that these breakpoints in the oxygenation patterns at different sites in the body might be equivalent and could, therefore, be used interchangeably. In the present review the typical oxygenation responses (at locomotor and respiratory muscle level, and cerebral level) are described and a possible framework is provided showing the physiological events that might link the breakpoints at different body sites with the thresholds determined from pulmonary gas exchange and blood lactate measurements. However, despite a possible physiological association, several arguments prevent the current practical application of these breakpoints measured at a single site as markers of exercise intensity making it highly questionable whether measurements of the oxygenation response at one single site can be used as a reflection of whole-body responses to different exercise intensities.

CO2 Clamping, Peripheral and Central Fatigue during Hypoxic Knee Extensions in Men

INTRODUCTION

The central nervous system can play a critical role in limiting exercise performance during hypoxic conditions. Hypocapnia, which is associated with hypoxia-induced hyperventilation, may affect cerebral perfusion. We hypothesized that CO2 clamping during hypoxic isometric knee extensions would improve cerebral oxygenation and reduce central fatigue.

METHODS

Fifteen healthy men (mean ± SD: age, 25 ± 8 yr; body mass, 72 ± 11 kg; height, 179 ± 7 cm) performed intermittent isometric knee extensions at ∼50% of maximal voluntary contraction to task failure in normoxia, hypoxia with CO2 clamping (arterial O2 saturation, 80% ± 2%; end-tidal CO2 partial pressure, 40 ± 2 mm Hg), and hypoxia without CO2 clamping (arterial O2 saturation, 80% ± 3%). Transcranial magnetic stimulation and femoral nerve electrical stimulation were used to assess central and peripheral determinants of fatigue. Prefrontal cortex and quadriceps femoris oxygenation were monitored by multichannel near-infrared spectroscopy.

RESULTS

Exercise duration was reduced to a similar extent in hypoxia with CO2 clamping (997 ± 460 s) or hypoxia without CO2 clamping (929 ± 412 s) compared to normoxia (1473 ± 876 s; P < 0.001). Prefrontal cortex and quadriceps oxygenation were increased (+5.3 ± 8.6 and +2.6 ± 3.0 μmol·cm at task failure, respectively; P < 0.01) during hypoxia with CO2 clamping compared to hypoxia without CO2 clamping. Transcranial magnetic stimulation maximal voluntary activation decreased to a greater extent at task failure in hypoxia without CO2 clamping (-18% ± 8%) compared to hypoxia with CO2 clamping (-9% ± 9%; P < 0.01) and normoxia (-10% ± 7%; P < 0.05). Conversely, exercise-induced peripheral fatigue was larger in hypoxia with CO2 clamping than in hypoxia without CO2 clamping (e.g., Db10-to-Db100 ratio of 0.54 ± 0.12 and 0.63 ± 0.11 at task failure, respectively; P < 0.05).

CONCLUSION

The results demonstrate that CO2 clamping can alter central and peripheral mechanisms that contribute to neuromuscular fatigue during hypoxic isometric knee extensions in men. Hypocapnia impairs cerebral oxygenation and central drive but exerts a protective effect against fatigability in muscles.

AltitudeOmics: impaired pulmonary gas exchange efficiency and blunted ventilatory acclimatization in humans with patent foramen ovale after 16 days at 5,260 m

A patent foramen ovale (PFO), present in ∼40% of the general population, is a potential source of right-to-left shunt that can impair pulmonary gas exchange efficiency [i.e., increase the alveolar-to-arterial Po2 difference (A-aDO2)]. Prior studies investigating human acclimatization to high-altitude with A-aDO2 as a key parameter have not investigated differences between subjects with (PFO+) or without a PFO (PFO-). We hypothesized that in PFO+ subjects A-aDO2 would not improve (i.e., decrease) after acclimatization to high altitude compared with PFO- subjects. Twenty-one (11 PFO+) healthy sea-level residents were studied at rest and during cycle ergometer exercise at the highest iso-workload achieved at sea level (SL), after acute transport to 5,260 m (ALT1), and again at 5,260 m after 16 days of high-altitude acclimatization (ALT16). In contrast to PFO- subjects, PFO+ subjects had 1) no improvement in A-aDO2 at rest and during exercise at ALT16 compared with ALT1, 2) no significant increase in resting alveolar ventilation, or alveolar Po2, at ALT16 compared with ALT1, and consequently had 3) an increased arterial Pco2 and decreased arterial Po2 and arterial O2 saturation at rest at ALT16. Furthermore, PFO+ subjects had an increased incidence of acute mountain sickness (AMS) at ALT1 concomitant with significantly lower peripheral O2 saturation (SpO2). These data suggest that PFO+ subjects have increased susceptibility to AMS when not taking prophylactic treatments, that right-to-left shunt through a PFO impairs pulmonary gas exchange efficiency even after acclimatization to high altitude, and that PFO+ subjects have blunted ventilatory acclimatization after 16 days at altitude compared with PFO- subjects.

Intermittent hypoxia in childhood: the harmful consequences versus potential benefits of therapeutic uses

Intermittent hypoxia (IH) often occurs in early infancy in both preterm and term infants and especially at 36-44 weeks postmenstrual age. These episodes of IH could result from sleep-disordered breathing or may be temporally unrelated to apnea or bradycardia events. There are numerous reports indicating adverse effects of IH on development, behavior, academic achievement, and cognition in children with sleep apnea syndrome. It remains uncertain about the exact causative relationship between the neurocognitive and behavioral morbidities and IH and/or its associated sleep fragmentation. On the other hand, well-controlled and moderate IH conditioning/training has been used in sick children for treating their various forms of bronchial asthma, allergic dermatoses, autoimmune thyroiditis, cerebral palsy, and obesity. This review article provides an updated and impartial analysis on the currently available evidence in supporting either side of the seemingly contradictory scenarios. We wish to stimulate a comprehensive understanding of such a complex physiological phenomenon as intermittent hypoxia, which may be accompanied by other confounding factors (e.g., hypercapnia, polycythemia), in order to prevent or reduce its harmful consequences, while maximizing its potential utility as an effective therapeutic tool in pediatric patients.

Repeated pre-syncope from increased inspired CO2 in a background of severe hypoxia

We describe a case of experimentally induced pre-syncope in a healthy young man when exposed to increased inspired CO2 in a background of hypoxia. Acute severe hypoxia (FIO2=0.10) was tolerated, but adding CO2 to the inspirate caused pre-syncope symptoms accompanied by hypotension and large reductions in both mean and diastolic middle cerebral artery velocity, while systolic flow velocity was maintained. The mismatch of cerebral perfusion pressure and vascular tone caused unique retrograde cerebral blood flow at the end of systole and a reduction in cerebral tissue oxygenation. We speculate that this occurrence of pre-syncope was due to hypoxia-induced inhibition of brain regions responsible for compensatory sympathetic activity to relative hypercapnia.

Effect of end-tidal CO2 clamping on cerebrovascular function, oxygenation, and performance during 15-km time trial cycling in severe normobaric hypoxia: the role of cerebral O2 delivery

During heavy exercise, hyperventilation-induced hypocapnia leads to cerebral vasoconstriction, resulting in a reduction in cerebral blood flow (CBF). A reduction in CBF would impair cerebral O₂ delivery and potentially account for reduced exercise performance in hypoxia. We tested the hypothesis that end-tidal Pco₂ (PETCO₂) clamping in hypoxic exercise would prevent the hypocapnia-induced reduction in CBF during heavy exercise, thus improving exercise performance. We measured PETCO₂, middle cerebral artery velocity (MCAv; index of CBF), prefrontal cerebral cortex oxygenation (cerebral O₂Hb; index of cerebral oxygenation), cerebral O₂ delivery (DO₂), and leg muscle oxygenation (muscle O₂Hb) in 10 healthy men (age 27 ± 7 years; VO₂max 63.3 ± 6.6 mL/kg/min; mean ± SD) during simulated 15-km time trial cycling (TT) in normoxia and hypoxia (FIO₂ = 0.10) with and without CO₂ clamping. During exercise, hypoxia elevated MCAv and lowered cerebral O₂Hb, cerebral DO₂, and muscle O₂Hb (P < 0.001). CO₂ clamping elevated PETCO₂ and MCAv during exercise in both normoxic and hypoxic conditions (P < 0.001 and P = 0.024), but had no effect on either cerebral and muscle O₂Hb (P = 0.118 and P = 0.124). Nevertheless, CO₂ clamping elevated cerebral DO₂ during TT in both normoxic and hypoxic conditions (P < 0.001). CO₂ clamping restored cerebral DO₂ to normoxic values during TT in hypoxia and tended to have a greater effect on TT performance in hypoxia compared to normoxia (P = 0.097). However, post hoc analysis revealed no effect of CO₂ clamping on TT performance either in normoxia (P = 0.588) or in hypoxia (P = 0.108). Our findings confirm that the hyperventilation-induced hypocapnia and the subsequent drop in cerebral oxygenation are unlikely to be the cause of the reduced endurance exercise performance in hypoxia.