1
|
Staes M, Gyselinck I, Goetschalckx K, Troosters T, Janssens W. Identifying limitations to exercise with incremental cardiopulmonary exercise testing: a scoping review. Eur Respir Rev 2024; 33:240010. [PMID: 39231595 PMCID: PMC11372471 DOI: 10.1183/16000617.0010-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/28/2024] [Indexed: 09/06/2024] Open
Abstract
Cardiopulmonary exercise testing (CPET) is a comprehensive and invaluable assessment used to identify the mechanisms that limit exercise capacity. However, its interpretation remains poorly standardised. This scoping review aims to investigate which limitations to exercise are differentiated by the use of incremental CPET in literature and which criteria are used to identify them. We performed a systematic, electronic literature search of PubMed, Embase, Cochrane CENTRAL, Web of Science and Scopus. All types of publications that reported identification criteria for at least one limitation to exercise based on clinical parameters and CPET variables were eligible for inclusion. 86 publications were included, of which 57 were primary literature and 29 were secondary literature. In general, at the level of the cardiovascular system, a distinction was often made between a normal physiological limitation and a pathological one. Within the respiratory system, ventilatory limitation, commonly identified by a low breathing reserve, and gas exchange limitation, mostly identified by a high minute ventilation/carbon dioxide production slope and/or oxygen desaturation, were often described. Multiple terms were used to describe a limitation in the peripheral muscle, but all variables used to identify this limitation lacked specificity. Deconditioning was a frequently mentioned exercise limiting factor, but there was no consensus on how to identify it through CPET. There is large heterogeneity in the terminology, the classification and the identification criteria of limitations to exercise that are distinguished using incremental CPET. Standardising the interpretation of CPET is essential to establish an objective and consistent framework.
Collapse
Affiliation(s)
- Michaël Staes
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Iwein Gyselinck
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Kaatje Goetschalckx
- Research Unit Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Clinical Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Thierry Troosters
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Wim Janssens
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Chuang ML. Analyzing key elements of breathing patterns, deriving remaining variables, and identifying cutoff values in individuals with chronic respiratory disease and healthy subjects. Respir Physiol Neurobiol 2024; 324:104242. [PMID: 38432595 DOI: 10.1016/j.resp.2024.104242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/05/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Pulmonary physiology encompasses intricate breathing patterns (BPs), characterized by breathing frequency (Bf), volumes, and flows. The complexities intensify in the presence of interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD), especially during exercise. This study seeks to identify pivotal factors driving changes among these variables and establish cutoff values, comparing their efficacy in differentiating BPs to traditional methods, specifically a breathing reserve (BR) of 30% and a Bf of 50 bpm. METHODS Screening 267 subjects revealed 23 with ILD, 126 with COPD, 33 healthy individuals, and the exclusion of 85 subjects. Lung function tests and ramp-pattern cardiopulmonary exercise testing (CPET) were conducted, identifying crucial BP elements. Changes were compared between groups at peak exercise. The area under the receiver operating characteristic curve (AUC) analysis determined cutoff values. RESULTS Inspiratory time (TI) remained constant at peak exercise for all subjects (two-group comparisons, all p=NS). Given known differences in expiratory time (TE) and tidal volume (VT) among ILD, COPD, and healthy states, constant TI could infer patterns for Bf, total breathing cycle time (TTOT=60/Bf), I:E ratio, inspiratory duty cycle (IDC, TI/TTOT), rapid shallow breathing index (Bf/VT), tidal inspiratory and expiratory flows (VT/TI and VT/TE), and minute ventilation (V̇E=Bf×VT) across conditions. These inferences aligned with measurements, with potential type II errors causing inconsistencies. RSBI of 23 bpm/L and VT/TI of 104 L/min may differentiate ILD from control, while V̇E of 54 L/min, BR of 30%, and VT/TE of 108 may differentiate COPD from control. BR of 21%, TE of 0.99 s, and IDC of .45 may differentiate ILD from COPD. The algorithm outperformed traditional methods (AUC 0.84-0.91 versus 0.59-0.90). CONCLUSION The quasi-fixed TI, in conjunction with TE and VT, proves effective in inferring time-related variables of BPs. The findings have the potential to significantly enhance medical education in interpreting cardiopulmonary exercise testing. Moreover, the study introduces a novel algorithm for distinguishing BPs among individuals with ILD, COPD, and those who are healthy.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan, ROC; School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC.
| |
Collapse
|
3
|
Holley AB, Fabyan KD, Haynes ZA, Holtzclaw AW, Huprikar NA, Shumar JN, Sheth PS, Hightower SL. Cardiopulmonary exercise testing in younger patients with persistent dyspnea following acute, outpatient COVID-19 infection. Physiol Rep 2024; 12:e15934. [PMID: 38320756 PMCID: PMC10846960 DOI: 10.14814/phy2.15934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/12/2023] [Accepted: 01/08/2024] [Indexed: 02/12/2024] Open
Abstract
Studies using cardiopulmonary exercise testing (CPET) to evaluate persistent dyspnea following infection with COVID-19 have focused on older patients with co-morbid diseases who are post-hospitalization. Less attention has been given to younger patients with post-COVID-19 dyspnea treated as outpatients for their acute infection. We sought to determine causes of persistent dyspnea in younger patients recovering from acute COVID-19 infection that did not require hospitalization. We collected data on all post-COVID-19 patients who underwent CPET in our clinic in the calendar year 2021. Data on cardiac function and respiratory response were abstracted, and diagnoses were assigned using established criteria. CPET data on 45 patients (238.3 ± 124 days post-test positivity) with a median age of 27.0 (22.0-40.0) were available for analysis. All but two (95.6%) were active-duty service members. The group showed substantial loss of aerobic capacity-average VO2 peak (L/min) was 84.2 ± 23% predicted and 25 (55.2%) were below the threshold for normal. Spirometry, diffusion capacity, high-resolution computed tomography, and echocardiogram were largely normal and were not correlated with VO2 peak. The two most common contributors to dyspnea and exercise limitation following comprehensive evaluation were deconditioning and dysfunctional breathing (DB). Younger active-duty military patients with persistent dyspnea following outpatient COVID-19 infection show a substantial reduction in aerobic capacity that is not driven by structural cardiopulmonary disease. Deconditioning and DB breathing are common contributors to their exercise limitation. The chronicity and severity of symptoms accompanied by DB could be consistent with an underlying myopathy in some patients, a disorder that cannot be differentiated from deconditioning using non-invasive CPET.
Collapse
Affiliation(s)
- Aaron B. Holley
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Kimberly D. Fabyan
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Zachary A. Haynes
- Department of MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Arthur W. Holtzclaw
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Nikhil A. Huprikar
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - John N. Shumar
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | | | - Stephanie L. Hightower
- Department of Pulmonary/Sleep and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| |
Collapse
|
4
|
Donadio MVF, Barbosa MA, Vendrusculo FM, Ramirez TI, Santana-Sosa E, Sanz-Santiago V, Perez-Ruiz M. Mechanisms of ventilatory limitation to maximum exercise in children and adolescents with chronic airway diseases. Pediatr Pulmonol 2023; 58:3293-3302. [PMID: 37671821 DOI: 10.1002/ppul.26659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 08/08/2023] [Accepted: 08/19/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Exercise intolerance is common in chronic airway diseases (CAD), but its mechanisms are still poorly understood. The aim of this study was to evaluate exercise capacity and its association with lung function, ventilatory limitation, and ventilatory efficiency in children and adolescents with cystic fibrosis (CF) and asthma when compared to healthy controls. METHODS Cross-sectional study including patients with mild-to-moderate asthma, CF and healthy children and adolescents. Anthropometric data, lung function (spirometry) and exercise capacity (cardiopulmonary exercise testing) were evaluated. Primary outcomes were peak oxygen consumption (VO2 peak), forced expiratory volume in 1 s (FEV1 ), breathing reserve (BR), ventilatory equivalent for oxygen consumption (VE /VO2 ) and for carbon dioxide production (VE /VCO2 ), both at the ventilatory threshold (VT1 ) and peak exercise. RESULTS Mean age of 147 patients included was 11.8 ± 3.0 years. There were differences between asthmatics and CF children when compared to their healthy peers for anthropometric and lung function measurements. Asthmatics showed lower VO2 peak when compared to both healthy and CF subjects, although no differences were found between healthy and CF patients. A lower BR was found when CF patients were compared to both healthy and asthmatic. Both CF and asthmatic patients presented higher values for VE /VO2 and VE /VCO2 at VT1 when compared to healthy individuals. For both VE /VO2 and VE /VCO2 at peak exercise CF patients presented higher values when compared to their healthy peers. CONCLUSION Patients with CF achieved good exercise capacity despite low ventilatory efficiency, low BR, and reduced lung function. However, asthmatics reported reduced cardiorespiratory capacity and normal ventilatory efficiency at peak exercise. These results demonstrate differences in the mechanisms of ventilatory limitation to maximum exercise testing in children and adolescents with CAD.
Collapse
Affiliation(s)
- Márcio Vinícius Fagundes Donadio
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
- Laboratory of Pediatric Physical Activity, Infant Center, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Marta Amor Barbosa
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Fernanda Maria Vendrusculo
- Laboratory of Pediatric Physical Activity, Infant Center, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Tamara Iturriaga Ramirez
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Spain
| | - Elena Santana-Sosa
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Spain
| | - Veronica Sanz-Santiago
- Department of Pulmonology, Hospital Universitario Infantil Niño Jesús de Madrid, Madrid, Spain
| | - Margarita Perez-Ruiz
- Department of Health and Human Performance, Faculty of Physical Activity and Sport Sciences-INEF, Universidad Politécnica de Madrid (UPM), Madrid, Spain
| |
Collapse
|
5
|
Chuang ML. A comparative study of dynamic lung hyperinflation and tidal volume to total lung capacity ratios during exercise in patients with chronic respiratory disease and healthy individuals. Respir Physiol Neurobiol 2023; 316:104124. [PMID: 37499989 DOI: 10.1016/j.resp.2023.104124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Current measures of tidal volume/forced vital capacity (VT/FVC) and VT/inspiratory capacity (VT/IC) at peak exercise cannot differentiate restrictive from obstructive ventilation patterns. This study aimed to investigate the utility of VT/total lung capacity (VT/TLC) as a marker for dynamic lung hyperinflation (DH) in patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). METHODS 267 subjects were screened: 23 ILD, 126 COPD, and 33 healthy individuals were enrolled. Lung function tests and cardiopulmonary exercise tests with repeated IC maneuver were conducted and compared at three exercise efforts: unloaded, middle of exercise, and peak exercise. RESULTS During exercise, ILD patients demonstrated normal end-expiratory lung volume/TLC (EELV/TLC) ratios, but elevated end-inspiratory lung volume/TLC (EILV/TLC) ratios, except for peak exercise. COPD patients exhibited elevated ratios for both EELV/TLC and EILV/TLC during exercise with a larger EELV/TLC ratio compared to ILD patients at peak exercise (p < 0.05). The VT/TLC ratio distinguished ILD, COPD, and healthy controls at peak exercise (p < 0.05). A VT/TLC ratio of ≤ 0.22 or ≥ 0.30 indicated airflow obstruction with hyperinflation or normal lung expansion, respectively (AUC: 0.74 or 0.88). Furthermore, VT/TLC outperformed VT/FVC and VT/IC in differentiating lung expansion between ILD and COPD during exercise (all p < 0.05). CONCLUSION Exercise-induced DH was absent in ILD patients but observed in COPD patients. Excessive lung expansion occurred in all patients during exercise, except for limited expansion in ILD at peak exercise probably due to specific lung properties. VT/TLC can distinguish between restrictive, obstructive, and normal ventilatory patterns.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan, ROC; School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan, ROC.
| |
Collapse
|
6
|
Rinaldo RF, Imeri G, Mondoni M, Parazzini EM, Vigo B, Masseroni A, Centanni S, Di Marco F. Does the severity of asthma affect exercise capacity and daily physical activity? J Asthma 2023:1-10. [PMID: 36650704 DOI: 10.1080/02770903.2023.2169932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Exercise capacity, daily physical activity, and psychological profile are crucial aspects in the management of asthmatic patients. Whether these features are expressed in a different way in mild-moderate (MMA) and severe asthma (SA) is unknown. METHODS In this observational cross-sectional study, patients matching the American Thoracic Society/European Respiratory Society (ATS/ERS) definition for SA underwent incremental cardiopulmonary exercise testing (CPET), full lung function testing, and an evaluation of daily step count and physical activity. Questionnaires on quality of life, general fatigue, and presence of anxiety and depression traits (Hospital Anxiety and Depression Scale - HADS) were administered. Patients were compared with a cohort of age- and gender-matched MMA patients. RESULTS We enrolled 16 SA, 17 MMA patients, and 16 healthy subjects. Compared to MMA, SA subjects showed a median (interquartile range) reduced peak oxygen consumption during CPET (20.4 (17.2-23.3) vs. 25.6 (18.5-30.3) ml/min/kg; p = 0.019), a reduced resting lung function (FEV1% of predicted 77 (67-84) vs. 96 (84-100); p < 0.001) and a pronounced anxiety trait at HADS (9.5 (3-11.7) vs. 4.0 (2.0-7.5); p = 0.023). In addition, SA patients showed a significantly higher reduction in inspiratory capacity from rest to peak (310 (160-520) vs. 110 (-65-325) ml; p = 0.031). We found no significant differences in mean daily step count or quality of life. CONCLUSIONS Compared to MMA, SA patients present a reduced exercise capacity and a more pronounced anxiety trait, but not worse daily physical activity or quality of life. These aspects should be considered in the clinical management and research development of SA.
Collapse
Affiliation(s)
- Rocco Francesco Rinaldo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Gianluca Imeri
- Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Department of Health Sciences, University of Milan, Bergamo, Italy
| | - Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Elena Maria Parazzini
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Beatrice Vigo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Alessandra Masseroni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Fabiano Di Marco
- Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Department of Health Sciences, University of Milan, Bergamo, Italy
| |
Collapse
|
7
|
Faleiro RC, Mancuzo EV, Lanza FC, Queiroz MVNP, de Oliveira LFL, Ganem VO, Lasmar LB. Exercise Limitation in Children and Adolescents With Severe Refractory Asthma: A Lack of Asthma Control? Front Physiol 2021; 11:620736. [PMID: 33574767 PMCID: PMC7870485 DOI: 10.3389/fphys.2020.620736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
Background Patients with severe refractory asthma (SRA), even when using high doses of multiple controller medications in a regular and appropriate way, can have persistent complaints of exercise limitation. Methods This was a cross-sectional study involving patients with SRA (treated with ≥ 800 μg of budesonide or equivalent, with ≥ 80% adherence, appropriate inhaler technique, and comorbidities treated), who presented no signs of a lack of asthma control other than exercise limitation. We also evaluated healthy controls, matched to the patients for sex, age, and body mass index. All participants underwent cardiopulmonary exercise testing (CPET) on a cycle ergometer, maximum exertion being defined as ≥ 85% of the predicted heart rate, with a respiratory exchange ratio ≥ 1.0 for children and ≥ 1.1 for adolescents. Physical deconditioning was defined as oxygen uptake (VO2) < 80% of predicted at peak exercise, without cardiac impairment or ventilatory limitation. Exercise-induced bronchoconstriction (EIB) was defined as a forced expiratory volume in one second ≥ 10% lower than the baseline value at 5, 10, 20, and 30 minutes after CPET. Results We evaluated 20 patients with SRA and 19 controls. In the sample as a whole, the mean age was 12.9 ± 0.4 years. The CPET was considered maximal in all participants. In terms of the peak VO2 (VO2 peak), there was no significant difference between the patients and controls, (P = 0.10). Among the patients, we observed isolated EIB in 30%, isolated physical deconditioning in 25%, physical deconditioning accompanied by EIB in 25%, and exercise-induced symptoms not supported by the CPET data in 15%. Conclusion and Clinical Relevance Physical deconditioning, alone or accompanied by EIB, was the determining factor in reducing exercise tolerance in patients with SRA and was not therefore found to be associated with a lack of asthma control.
Collapse
Affiliation(s)
- Rita C Faleiro
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Eliane V Mancuzo
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Fernanda C Lanza
- School of Physical Education, Physiotherapy and Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Mônica V N P Queiroz
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luciano F L de Oliveira
- School of Physical Education, Physiotherapy and Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vinicius O Ganem
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Laura B Lasmar
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| |
Collapse
|
8
|
Schindel CS, Schiwe D, Heinzmann-Filho JP, Gheller MF, Campos NE, Pitrez PM, Donadio MVF. Determinants of exercise capacity in children and adolescents with severe therapy-resistant asthma. J Asthma 2020; 59:115-125. [PMID: 33026845 DOI: 10.1080/02770903.2020.1833915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the exercise capacity of children and adolescents with severe therapy resistant asthma (STRA) aiming to identify its main determinants. METHODS Cross-sectional study including individuals aged 6-18 years with a diagnosis of STRA. Clinical (age and gender), anthropometric (weight, height and body mass index) and disease control data were collected. Lung function (spirometry), cardiopulmonary exercise testing (CPET) and exercise-induced bronchoconstriction (EIB) test were performed. RESULTS Twenty-four patients aged 11.5 ± 2.6 years were included. The mean forced expiratory volume in one second (FEV1) was 91.3 ± 9.2%. EIB occurred in 54.2% of patients. In CPET, the peak oxygen uptake (VO2peak) was 34.1 ± 7.8 mL kg-1 min-1. A significant correlation between ventilatory reserve and FEV1 (r = 0.57; p = 0.003) was found. Similarly, there was a significant correlation between CPET and percent of FEV1 fall in the EIB test for both VE/VO2 (r = 0.47; p = 0.02) and VE/VCO2 (r = 0.46; p = 0.02). Patients with FEV1<80% had lower ventilatory reserve (p = 0.009). In addition, resting heart rate correlated with VO2peak (r=-0.40; p = 0.04), VE/VO2 (r = 0.46; p = 0.02) and VE/VCO2 (r = 0.48; p = 0.01). CONCLUSIONS Exercise capacity is impaired in approximately 30% of children and adolescents with STRA. The results indicate that different aspects of aerobic fitness are influenced by distinct determinants, including lung function and EIB.
Collapse
Affiliation(s)
- Cláudia Silva Schindel
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Daniele Schiwe
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - João Paulo Heinzmann-Filho
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Mailise Fátima Gheller
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Natália Evangelista Campos
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Paulo Márcio Pitrez
- Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) and Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Márcio Vinícius Fagundes Donadio
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| |
Collapse
|
9
|
Boutou AK, Daniil Z, Pitsiou G, Papakosta D, Kioumis I, Stanopoulos I. Cardiopulmonary exercise testing in patients with asthma: What is its clinical value? Respir Med 2020; 167:105953. [PMID: 32280032 DOI: 10.1016/j.rmed.2020.105953] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/29/2020] [Accepted: 03/31/2020] [Indexed: 01/28/2023]
Abstract
Asthma is one of the most common respiratory disorders, characterized by fully or largely reversible airflow limitation. Asthma symptoms can be triggered or magnified during exertion, while physical activity limitation is often present among asthmatic patients. Cardiopulmonary exercise testing (CPET) is a dynamic, non-invasive technique which provides a thorough assessment of exercise physiology, involving the integrative assessment of cardiopulmonary, neuromuscular and metabolic responses during exercise. This review summarizes current evidence regarding the utility of CPET in the diagnostic work-up, functional evaluation and therapeutic intervention among patients with asthma, highlighting its potential role for thorough patient assessment and physician clinical desicion-making.
Collapse
Affiliation(s)
- Afroditi K Boutou
- Department of Respiratory Medicine, "G. Papanikolaou" Hospital, Thessaloniki, Greece.
| | - Zoi Daniil
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Georgia Pitsiou
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Papakosta
- Department of Respiratory Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kioumis
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Stanopoulos
- Department of Respiratory Failure, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
10
|
Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
Collapse
Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| |
Collapse
|
11
|
McDowell PJ, Heaney LG. Different endotypes and phenotypes drive the heterogeneity in severe asthma. Allergy 2020; 75:302-310. [PMID: 31267562 DOI: 10.1111/all.13966] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/05/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
The identification of sputum eosinophilia indicating corticosteroid responsiveness in subjects with severe asthma heralded the beginning of phenotyping asthmatic subjects based on airways inflammation. Since then, the heterogeneity of severe asthma has been explored and the importance of immunobiology has come sharply into focus with the identification of the key type-2 cytokine pathways driving eosinophilic inflammation. The development of molecules targeting these type-2 pathways has transformed severe asthma treatment, but necessitates robust clinical evaluation, biomarker profiling and assessment of comorbid factors to identify subjects most likely to benefit from these therapies. It has also become clear that targeting these pathways does not eradicate asthma symptoms and exacerbation risk; further work is needed to clarify underlying non-type-2 mechanisms in severe asthma pathways and possible therapeutic targets. This review addresses progress to date in clinical assessment and management of severe asthma and some of the challenges and unmet needs in severe asthma to achieve the goal of delivering individualized patient care.
Collapse
Affiliation(s)
- P. Jane McDowell
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
| | - Liam G. Heaney
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
| |
Collapse
|
12
|
Developing a New Marker of Dynamic Hyperinflation in Patients with Obstructive Airway Disease - an observational study. Sci Rep 2019; 9:7514. [PMID: 31101856 PMCID: PMC6525207 DOI: 10.1038/s41598-019-43893-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 05/03/2019] [Indexed: 12/13/2022] Open
Abstract
Tidal volume at peak exercise and vital capacity ratio (VTpeak/VC) and VTpeak/inspiratory capacity (IC) were used to differentiate lung expansion in subjects with normal health and chronic obstructive pulmonary disease (COPD) from that in subjects with restrictive ventilation. However, VC and IC variably change due to pseudorestriction of lung volumes. Thus, these variables are currently not recommended. In contrast, total lung capacity (TLC) does little change during exercise. The aims of the study investigated whether VTpeak/TLC is more significantly correlated with static air trapping and lung hyperinflation in patients with COPD than VTpeak/IC, VTpeak/FVC, and VTpeak/SVC (study 1), and developed a marker to replace dynamic IC maneuvers by evaluation of the relationship between end-expiratory lung volume (EELV) and VTpeak/TLC and identification of a cutoff value for VTpeak/TLC (study 2). One hundred adults with COPD (study 1) and 23 with COPD and 19 controls (study 2) were analyzed. Spirometry, lung volume, diffusing capacity, incremental cardiopulmonary exercise tests with dynamic IC maneuvers were compared between groups. An ROC curve was generated to identify a cut off value for VTpeak/TLC. In study 1, VTpeak/TLC was more significantly associated with airflow obstruction, static air trapping and hyperinflation. In study 2, VTpeak/TLC was highly correlated with EELV in the patients (r = -0.83), and VTpeak/TLC ≥ 0.27 predicted that 18% of the patients with static air trapping and hyperinflation can expand their VT equivalent to the controls. In conclusions, VTpeak/TLC was superior to other VTpeak/capacities. VTpeak/TLC may be a marker of dynamic hyperinflation in subjects with COPD, thereby avoiding the need for dynamic IC maneuvers. VTpeak/TLC < 0.27 identified approximately 82% of subjects with COPD who could not adequately expand their tidal volume. As most of our participants were male, further studies are required to elucidate whether the results of this study can be applied to female patients with COPD.
Collapse
|
13
|
Bellocq A, Gaspard W, Couffignal C, Vigan M, Guerder A, Ambard J, Caruana S, Similowski T, Garcia G, Taillé C. Outpatient pulmonary rehabilitation for severe asthma with fixed airway obstruction: Comparison with COPD. J Asthma 2019; 56:1325-1333. [PMID: 30693816 DOI: 10.1080/02770903.2018.1541351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: The benefit of exercise has been demonstrated in asthma, but the role of pulmonary rehabilitation (PR) in people with severe asthma, especially with airway obstruction, has been less investigated. The activity limitation mechanisms differ in asthma and COPD, so the effect of a PR program not specific to asthma is unclear. Methods: We retrospectively compared the effect of an ambulatory PR program in nonsmoking patients with severe asthma and airway obstruction (FEV1/FVC ratio <70% and FEV1 < 80% measured twice, not under an exacerbation) and sex-, age-, FEV1-, and BMI-matched COPD controls. Results: We included 29 patients, each with asthma and COPD. Airway obstruction was moderate (median FEV1 57% [44-64]). VO2 at peak was higher for asthma than COPD patients (19.0 [15.7-22.2] vs 16.1 [15.3-19.6] ml.min-1.kg-1, p = 0.05). After PR, asthma and COPD groups showed a significant and similar increase in constant work cycling test of 378 [114-831] s and 377 [246-702] s. Changes in Hospital Anxiety and Depression Scale (HAD) total score were similar (-2.5 [-7.0 to 0.0] vs -2.0 [-5.0 to 2.0], p > 0.05). Quality of life on the St. George's Respiratory Questionnaire (SGRQ) was significantly improved in both groups (-14.0 [-17.7 to -2.0], p < 0.005 and -8.3 [-13.0 to -3.6], p < 0.0001). Conclusion: Outpatient PR is feasible and well tolerated in patients with severe asthma with fixed airway obstruction. A nondedicated program strongly improves HAD and SGRQ scores and constant work-rate sub-maximal cycling, with similar amplitude as with COPD.
Collapse
Affiliation(s)
- Agnès Bellocq
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service d'Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée du Département R3S, Paris, France.,Sorbonne Université, INSERM, UMRS1158, Paris, France
| | - Wanda Gaspard
- Service des Maladies Respiratoires, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Camille Couffignal
- Assistance Publique-Hôpitaux de Paris, Department of Epidemiology, Biostatistic and Clinical Research, Bichat Hospital, Paris, France
| | - Marie Vigan
- Assistance Publique-Hôpitaux de Paris, Department of Epidemiology, Biostatistic and Clinical Research, Bichat Hospital, Paris, France
| | - Antoine Guerder
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et de Réanimation Médicale du Département R3S, Paris, France
| | - Julien Ambard
- Réseau Recup'Air, Agence Régionale de Santé Ile de France, Paris, France
| | - Sylvie Caruana
- Réseau Recup'Air, Agence Régionale de Santé Ile de France, Paris, France
| | - Thomas Similowski
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et de Réanimation Médicale du Département R3S, Paris, France
| | - Gilles Garcia
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service de Pneumologie, Le Kremlin-Bicetre, France
| | - Camille Taillé
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, DHU FIRE, Service de Pneumologie, INSERM UMR1152, Université Paris Diderot, Labex Inflamex, Paris, France
| |
Collapse
|
14
|
Siedlecki P, Sanzo P, Zerpa C, Newhouse I. End-tidal carbon dioxide levels in patients with post-concussion syndrome during neurocognitive and physical tasks compared to a normative control group. Brain Inj 2018; 32:1824-1833. [DOI: 10.1080/02699052.2018.1506945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Patrick Siedlecki
- School of Kinesiology, Lakehead University, Thunder Bay, ON, Canada
- School of Kinesiology, Western University, London, ON, Canada
| | - Paolo Sanzo
- School of Kinesiology, Lakehead University, Thunder Bay, ON, Canada
- Northern Ontario School of Medicine, Lakehead University, Thunder Bay, ON, Canada
| | - Carlos Zerpa
- School of Kinesiology, Lakehead University, Thunder Bay, ON, Canada
| | - Ian Newhouse
- School of Kinesiology, Lakehead University, Thunder Bay, ON, Canada
| |
Collapse
|
15
|
Herdy AH, Ritt LEF, Stein R, Araújo CGSD, Milani M, Meneghelo RS, Ferraz AS, Hossri C, Almeida AEMD, Fernandes-Silva MM, Serra SM. Cardiopulmonary Exercise Test: Background, Applicability and Interpretation. Arq Bras Cardiol 2017; 107:467-481. [PMID: 27982272 PMCID: PMC5137392 DOI: 10.5935/abc.20160171] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 02/19/2016] [Indexed: 11/22/2022] Open
Abstract
Cardiopulmonary exercise test (CPET) has been gaining importance as a method of
functional assessment in Brazil and worldwide. In its most frequent
applications, CPET consists in applying a gradually increasing intensity
exercise until exhaustion or until the appearance of limiting symptoms and/or
signs. The following parameters are measured: ventilation; oxygen consumption
(VO2); carbon dioxide production (VCO2); and the other
variables of conventional exercise testing. In addition, in specific situations,
pulse oximetry and flow-volume loops during and after exertion are measured. The
CPET provides joint data analysis that allows complete assessment of the
cardiovascular, respiratory, muscular and metabolic systems during exertion,
being considered gold standard for cardiorespiratory functional
assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can
cause symptoms, such as dyspnea, and correlate them with changes in the
cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be
used to provide the prognostic assessment of patients with heart or lung
diseases, and in the preoperative period, in addition to aiding in a more
careful exercise prescription to healthy subjects, athletes and patients with
heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication
of several scientific contributions from Brazilian researchers in high-impact
journals. Therefore, this study aimed at providing a comprehensive review on the
applicability of CPET to different clinical situations, in addition to serving
as a practical guide for the interpretation of that test.
Collapse
Affiliation(s)
- Artur Haddad Herdy
- Instituto de Cardiologia de Santa Catarina, São José, SC.,Universidade do Sul de Santa Catarina (UNISUL), Florianópolis, SC.,Sociedade Brasileira de Cardiologia (SBC), Rio de Janeiro, RJ
| | - Luiz Eduardo Fonteles Ritt
- Hospital Cardio Pulmonar da Bahia, Salvador, BA.,Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia, Salvador, BA
| | - Ricardo Stein
- Serviço de Cardiologia - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS.,Grupo de Pesquisa em Cardiologia do Exercício do Hospital de Clínicas de Porto Alegre, Porto Alegre, RS.,Vitta Centro de Bem Estar Físico, Porto Alegre, RS
| | - Claudio Gil Soares de Araújo
- Instituto do Coração Edson Saad Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ.,Clínica de Medicina do Exercício, CLINIMEX, Rio de Janeiro, RJ
| | | | - Romeu Sérgio Meneghelo
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP.,Hospital Israelita Albert Einstein, São Paulo, SP
| | | | | | - Antonio Eduardo Monteiro de Almeida
- Hospital Universitário Lauro Wanderley e Departamento de Educação Física (UFPB), João Pessoa, PB.,Cardio Lógica Métodos Diagnósticos, João Pessoa, PB
| | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brazil
| |
Collapse
|
16
|
Todd S, Walsted ES, Grillo L, Livingston R, Menzies-Gow A, Hull JH. Novel assessment tool to detect breathing pattern disorder in patients with refractory asthma. Respirology 2017; 23:284-290. [PMID: 28905471 DOI: 10.1111/resp.13173] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Breathing pattern disorder (BPD) can co-exist with and mimic asthma, acting to amplify symptoms and confound assessment of disease control, resulting in inappropriate treatment escalation. The aim of this research was to report the utility of a novel breathing pattern assessment tool (BPAT) to detect BPD in treatment-refractory asthma. METHODS As a component of a multidisciplinary assessment, adult patients referred with treatment-refractory asthma underwent respiratory physiotherapy assessment to diagnose BPD. Based on this assessment, patients were classified as having asthma, asthma + BPD or BPD alone. BPAT data were collected in addition to questionnaire data (Asthma Quality of Life Questionnaire (AQLQ) and Nijmegen Questionnaire (NQ)), pulmonary function and an assessment of exercise capacity. RESULTS Data were retrospectively analysed for 150 (female; 69%) patients, mean (SD) age of 43 (14) years; characterized as asthma-only (n = 54, 36%), asthma + BPD (n = 63, 42%) and BPD-only (n = 33, 22%). Of the total population, 113 (76%) had an NQ score ≥23, but of these only 68% had physiotherapy evidence of BPD. Exercise capacity and AQLQ were lower in the asthma + BPD group than in the asthma-only group (P < 0.05), whilst lung function was similar between groups. Sensitivity analysis indicated that a BPAT score of ≥4 corresponded to a sensitivity of 0.92 and a specificity of 0.75 for diagnosis of BPD in this cohort. CONCLUSION Breathing pattern irregularities are highly prevalent in individuals referred with treatment-refractory asthma and can be characterized using the BPAT. Further work is needed to determine inter-observer and within-subject variability and ensure the BPAT is a robust clinical tool. Watch the video abstract.
Collapse
Affiliation(s)
- Sarah Todd
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Emil S Walsted
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Lizzie Grillo
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Rebecca Livingston
- Department of Respiratory Medicine, University College Hospital, London, UK
| | | | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| |
Collapse
|
17
|
Patterns of Oxygen Pulse Curve in Response to Incremental Exercise in Patients with Chronic Obstructive Pulmonary Disease - An Observational Study. Sci Rep 2017; 7:10929. [PMID: 28883532 PMCID: PMC5589739 DOI: 10.1038/s41598-017-11189-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/15/2017] [Indexed: 11/30/2022] Open
Abstract
In COPD, pulmonary hyperinflation causes decreased stroke volume thereby decreased oxygen pulse (O2P). While O2P flattening is related to myocardial ischemia in cardiac patients, O2P patterns have seldom been explored in COPD. The aims of the study were to investigate O2P-curve patterns and associated factors in COPD. Seventy-five patients with stable COPD were enrolled. The demographics, cardiac size, physiological measurements and stress EKG were compared among O2P-curve pattern groups. An algorithm to identify O2P-curve patterns was developed in 28 patients. In the remaining 45 patients after excluding two with poor effort, this algorithm revealed 20 (44%) flattening, 16 (36%) increasing, and nine (20%) decreasing patterns. The flattening-type group had lower body mass, cardiac size, and diffusing capacity, and larger lung volumes (p = 0.05–<0.0001) compared to the increasing-type group. During exercise, the flattening-type group had a lower operable O2P and more hyperventilation and dyspnea (p = 0.02–<0.01). None had ST-T changes. Most differences were related to body mass and mildly to inspiratory fraction. The decreasing-type group performed higher effort than the increasing-type group (p < 0.05). In conclusion, O2P flattening was common and was associated with reduced body mass and pulmonary hyperinflation rather than with myocardial ischemia. The decreasing-type may be caused by motivation to exercise.
Collapse
|
18
|
Carr TF, Kraft M. Management of Severe Asthma before Referral to the Severe Asthma Specialist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:877-886. [PMID: 28689838 PMCID: PMC5526085 DOI: 10.1016/j.jaip.2017.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022]
Abstract
Severe asthma is associated with significant morbidity and can be challenging to assess and control, due to heterogeneity of disease, complexity of diagnosis, and impact of comorbidities. A structured approach to the assessment and management of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. In patients who are either not responding to treatment, or who require high doses of medication to control symptoms, it is highly possible that disease mimickers or comorbidities are present and can inhibit therapeutic responsiveness. The assessment and management of common comorbidities of asthma may dramatically impact disease control and thus medication requirement. Determining medication adherence and optimizing drug dose and delivery may separate out truly severe asthmatics from those not using medications regularly or properly. Next, although true personalized medicine for severe asthma is not yet realized, for those individuals with severe asthma, phenotypic characteristics of each patient may guide which therapeutic options may be most effective for that patient. Finally, evaluation and management of severe asthma at a referral center can add additional phenotyping, therapeutic, and diagnostic strategies.
Collapse
Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| |
Collapse
|
19
|
Weatherald J, Lougheed MD, Taillé C, Garcia G. Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series "Exertional dyspnoea" Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni. Eur Respir Rev 2017; 26:26/144/170015. [PMID: 28615308 DOI: 10.1183/16000617.0015-2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/17/2017] [Indexed: 11/05/2022] Open
Abstract
Asthma is a heterogeneous condition, with dyspnoea during exercise affecting individuals to a variable degree. This narrative review explores the mechanisms and measurement of exertional dyspnoea in asthma and summarises the available evidence for the efficacy of various interventions on exertional dyspnoea. Studies on the mechanisms of dyspnoea in asthma have largely utilised direct bronchoprovocation challenges, rather than exercise, which may invoke different physiological mechanisms. Thus, the description of dyspnoea during methacholine challenge can differ from what is experienced during daily activities, including exercise. Dyspnoea perception during exercise is influenced by many interacting variables, such as asthma severity and phenotype, bronchoconstriction, dynamic hyperinflation, respiratory drive and psychological factors. In addition to the intensity of dyspnoea, the qualitative description of dyspnoea may give important clues as to the underlying mechanism and may be an important endpoint for future interventional studies. There is currently little evidence demonstrating whether pharmacological or non-pharmacological interventions specifically improve exertional dyspnoea, which is an important area for future research.
Collapse
Affiliation(s)
- Jason Weatherald
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France.,Division of Respirology, Dept of Medicine, University of Calgary, Calgary, AB, Canada
| | - M Diane Lougheed
- Division of Respirology, Dept of Medicine, Queen's University, Kingston, ON, Canada.,Dept of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Camille Taillé
- Service de Pneumologie et Centre de Compétence des Maladies Pulmonaires Rares, Hôpital Bichat, AP-HP, Paris, France.,Département Hospitalo-Universitaire FIRE, Université Paris Diderot, INSERM UMR 1152, LabEx Inflamex, Paris, France
| | - Gilles Garcia
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France .,INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France.,Service de Physiologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| |
Collapse
|
20
|
O'Donnell DE, Elbehairy AF, Berton DC, Domnik NJ, Neder JA. Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases. Front Physiol 2017; 8:82. [PMID: 28275353 PMCID: PMC5319975 DOI: 10.3389/fphys.2017.00082] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 11/13/2022] Open
Abstract
Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.
Collapse
Affiliation(s)
- Denis E. O'Donnell
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Amany F. Elbehairy
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
- Department of Chest Diseases, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
| | - Danilo C. Berton
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Nicolle J. Domnik
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - J. Alberto Neder
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| |
Collapse
|
21
|
Depiazzi J, Everard ML. Dysfunctional breathing and reaching one's physiological limit as causes of exercise-induced dyspnoea. Breathe (Sheff) 2016; 12:120-9. [PMID: 27408630 PMCID: PMC4933621 DOI: 10.1183/20734735.007216] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Key points This review provides an overview of the spectrum of conditions that can present as exercise-induced breathlessness experienced by young subjects participating in sport and aims to promote understanding of the need for accurate assessment of an individual’s symptoms. We will highlight the high incidence of nonasthmatic causes, which simply require reassurance or simple interventions from respiratory physiotherapists or speech pathologists. Breathlessness: accurate assessment and diagnosis is essential in order to provide correct advice and assistancehttp://ow.ly/4nrW8z
Collapse
Affiliation(s)
- Julie Depiazzi
- Physiotherapy Dept, Princess Margaret Hospital, Subiaco, Australia
| | - Mark L Everard
- Dept of Respiratory Medicine, Princess Margaret Hospital, Subiaco, Australia; University of Western Australia, Crawley, Australia
| |
Collapse
|
22
|
Vermeulen F, Garcia G, Ninane V, Laveneziana P. Activity limitation and exertional dyspnea in adult asthmatic patients: What do we know? Respir Med 2016; 117:122-30. [PMID: 27492522 DOI: 10.1016/j.rmed.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/11/2016] [Accepted: 06/06/2016] [Indexed: 12/21/2022]
Abstract
Limitation of activity is the most cited symptom described by uncontrolled asthma patients. Assessment of activity limitation can be undertaken through several ways, more or less complex, subjective or objective. Yet little is known about the link between patients sensations and objective measurements. The present review reports the current knowledge regarding activity limitation and symptom perception (i.e., exertional dyspnea) in adult patients with asthma. This work is based on references indexed by PubMed, irrespective of the year of publication. Overall, patients with stable asthma do not have a more sedentary lifestyle than healthy subjects. However, during a cycle ergometric test, the maximal load is reduced when FEV1, FVC and muscle strengths are decreased. Additionally, during the six-minute walking test, mild asthma patients walk less than healthy subjects even if the minimal clinically important difference is not reached. The major complaint of asthma patients when exercising is dyspnea that is mainly related to the inspiratory effort and also to dynamic hyperinflation in some circumstances. Finally, the administration of bronchodilator does not improve the ventilatory pattern and the exercise capacity of asthma patients and little is known on its effect on exertional dyspnea. The present review allows to conclude that until now there is no gold standard test allowing the objective assessment of "activity limitation and exertional dyspnea" in asthma patients.
Collapse
Affiliation(s)
| | - Gilles Garcia
- AP-HP, University Hospital Bicêtre, Pulmonary Function Laboratory, Reference Centre for Severe Pulmonary Hypertension, DHU TORINO "Thorax Innovation", Le Kremlin-Bicêtre, France; University Paris-South 11, Faculty of Medicine, Le Kremlin-Bicêtre, France; INSERM U999, LabEx LERMIT, Surgical Centre Marie Lannelongue, Le Plessis-Robinson, France
| | - Vincent Ninane
- Chest Service, St Pierre University Hospital, Brussels, Belgium; Université Libre de Bruxelles, Faculty of Medicine, Bruxelles, Belgium
| | - Pierantonio Laveneziana
- University Sorbonne, UPMC University Paris 06, INSERM, UMRS1158 Clinical and Experimental Respiratory Neurophysiology, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Unit of Respiration, Exercise and Dyspnea Assessment (Unit EFRED, Department "R3S", Pôle PRAGUES), Paris, France
| |
Collapse
|
23
|
Majd S, Apps LD, Hudson N, Hewitt S, Eglinton E, Murphy A, Bradding P, Singh S, Green R, Evans R. Protocol for a feasibility study to inform the development of a multicentre randomised controlled trial of asthma-tailored pulmonary rehabilitation versus usual care for individuals with severe asthma. BMJ Open 2016; 6:e010574. [PMID: 27009149 PMCID: PMC4809086 DOI: 10.1136/bmjopen-2015-010574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Pulmonary rehabilitation with core components of exercise training and multiprofessional education is an integral part of the management of patients with chronic lung disease. International guidelines for individuals with asthma recommend exercise as exercise improves symptoms, indices of cardiopulmonary efficiency, health status and psychosocial outcome. However, there is little published evidence evaluating safety and acceptability of exercise training for individuals with severe asthma and there are concerns regarding exercise-induced asthma. We propose a feasibility study for a multicentre randomised controlled trial (RCT) of asthma-tailored pulmonary rehabilitation (asthma-tailored PR) versus usual care in individuals with severe asthma. METHODS AND ANALYSIS The study will be conducted in three stages. Adults with severe asthma will be included if they have persistent symptoms despite being at step 4 or 5 of the British Thoracic Society guidelines. Stage 1: semistructured interviews will be used in a sample of 20-30 individuals with severe asthma to understand the experience and attitudes of this population towards exercise. Stage 2: eight focus groups of at least six healthcare professionals involved in the care of patients with severe asthma will be conducted to understand their attitudes towards exercise for this population. Stage 3: a small-scale RCT of the proposed multicentre RCT of asthma-tailored PR versus usual care for individuals with severe asthma will be conducted. The primary outcome measures will be recruitment, retention and adverse event rates. Semistructured interviews with participants of stage 3 will be used to identify further barriers or facilitators to participation in PR and the trial. Thematic analysis will be used for the interpretation of all interviews. ETHICS AND DISSEMINATION The study results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee East Midland approved the study protocol. TRIAL REGISTRATION NUMBER ISRCTN96143888.
Collapse
Affiliation(s)
- Sally Majd
- Centre for Exercise Rehabilitation Science, Leicester, UK
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Lindsay D Apps
- Centre for Exercise Rehabilitation Science, Leicester, UK
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Nicky Hudson
- School of Applied Social Sciences, DeMontfort University, Leicester, UK
| | - Stacey Hewitt
- Centre for Exercise Rehabilitation Science, Leicester, UK
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | | | - Anna Murphy
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital, Leicester, UK
- School of Pharmacy, DeMontfort University, Leicester, UK
| | - Peter Bradding
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital, Leicester, UK
| | - Sally Singh
- Centre for Exercise Rehabilitation Science, Leicester, UK
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital, Leicester, UK
| | - Ruth Green
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital, Leicester, UK
| | - Rachael Evans
- Centre for Exercise Rehabilitation Science, Leicester, UK
- Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital, Leicester, UK
| |
Collapse
|
24
|
Pereira LFF, Mancuzo EV, Rezende CF, Côrrea RDA. Six-minute walk test and respiratory muscle strength in patients with uncontrolled severe asthma: a pilot study. J Bras Pneumol 2016; 41:211-8. [PMID: 26176518 PMCID: PMC4541755 DOI: 10.1590/s1806-37132015000004483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/10/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE: To evaluate respiratory muscle strength and six-minute walk test (6MWT) variables in patients with uncontrolled severe asthma (UCSA). METHODS: This was a cross-sectional study involving UCSA patients followed at a university hospital. The patients underwent 6MWT, spirometry, and measurements of respiratory muscle strength, as well as completing the Asthma Control Test (ACT). The Mann-Whitney test was used in order to analyze 6MWT variables, whereas the Kruskal-Wallis test was used to determine whether there was an association between the use of oral corticosteroids and respiratory muscle strength. RESULTS: We included 25 patients. Mean FEV1 was 58.8 ± 21.8% of predicted, and mean ACT score was 14.0 ± 3.9 points. No significant difference was found between the median six-minute walk distance recorded for the UCSA patients and that predicted for healthy Brazilians (512 m and 534 m, respectively; p = 0.14). During the 6MWT, there was no significant drop in SpO2. Mean MIP and MEP were normal (72.9 ± 15.2% and 67.6 ± 22.2%, respectively). Comparing the patients treated with at least four courses of oral corticosteroids per year and those treated with three or fewer, we found no significant differences in MIP (p = 0.15) or MEP (p = 0.45). CONCLUSIONS: Our findings suggest that UCSA patients are similar to normal subjects in terms of 6MWT variables and respiratory muscle strength. The use of oral corticosteroids has no apparent impact on respiratory muscle strength.
Collapse
|
25
|
Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2015.04.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
26
|
Price OJ, Hull JH, Backer V, Hostrup M, Ansley L. The impact of exercise-induced bronchoconstriction on athletic performance: a systematic review. Sports Med 2015; 44:1749-61. [PMID: 25129699 DOI: 10.1007/s40279-014-0238-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) describes the phenomenon of transient airway narrowing in association with physical activity. Although it may seem likely that EIB would have a detrimental impact on athletic performance, this has yet to be established. OBJECTIVES The aim of this review is to provide a systematic appraisal of the current status of knowledge regarding EIB and exercise performance and to highlight potential mechanisms by which performance may be compromised by EIB. DATA SOURCES AND STUDY SELECTION PubMed/Medline and EBSCO databases were searched up to May 2014 using the search parameter: [('exercise' OR 'athlete') AND ('asthma' OR 'bronchoconstriction' OR 'hypersensitivity') AND 'performance']. This search string returned 243 citations. After systematically reviewing all of the abstracts, 101 duplicate papers were removed, with 132 papers excluded for not including an exercise performance outcome measure. RESULTS The remaining ten studies that met the initial criteria were included in this review; six evaluated the performance of physically active individuals with asthma and/or EIB while four assessed the effects of medication on performance in a comparable population. CONCLUSION The evidence concludes that whilst it is reasonable to suspect that EIB does impact athletic performance, there is currently insufficient evidence to provide a definitive answer.
Collapse
Affiliation(s)
- Oliver J Price
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK,
| | | | | | | | | |
Collapse
|
27
|
Barreiro E, Bustamante V, Cejudo P, Gáldiz JB, Gea J, de Lucas P, Martínez-Llorens J, Ortega F, Puente-Maestu L, Roca J, Rodríguez-González Moro JM. Guidelines for the evaluation and treatment of muscle dysfunction in patients with chronic obstructive pulmonary disease. Arch Bronconeumol 2015; 51:384-95. [PMID: 26072153 DOI: 10.1016/j.arbres.2015.04.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 03/24/2015] [Accepted: 04/23/2015] [Indexed: 01/09/2023]
Abstract
In patients with chronic obstructive pulmonary disease (COPD), skeletal muscle dysfunction is a major comorbidity that negatively impacts their exercise capacity and quality of life. In the current guidelines, the most recent literature on the various aspects of COPD muscle dysfunction has been included. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scale has been used to make evidence-based recommendations on the different features. Compared to a control population, one third of COPD patients exhibited a 25% decline in quadriceps muscle strength, even at early stages of their disease. Although both respiratory and limb muscles are altered, the latter are usually more severely affected. Numerous factors and biological mechanisms are involved in the etiology of COPD muscle dysfunction. Several tests are proposed in order to diagnose and evaluate the degree of muscle dysfunction of both respiratory and limb muscles (peripheral), as well as to identify the patients' exercise capacity (six-minute walking test and cycloergometry). Currently available therapeutic strategies including the different training modalities and pharmacological and nutritional support are also described.
Collapse
Affiliation(s)
- Esther Barreiro
- Servei de Pneumologia, Unitat de Recerca en Múscul i Aparell Respiratori (URMAR), IMIM-Hospital del Mar, CEXS, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Víctor Bustamante
- Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, Universidad del País Vasco, Bilbao, España; Servicio de Neumología y Unidad de Investigación, Hospital de Cruces, Universidad del País Vasco , Barakaldo, España
| | - Pilar Cejudo
- Servicio de Neumología y Unidad de Investigación, Hospital de Cruces, Universidad del País Vasco , Barakaldo, España
| | - Juan B Gáldiz
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, Universidad del País Vasco, Bilbao, España
| | - Joaquim Gea
- Servei de Pneumologia, Unitat de Recerca en Múscul i Aparell Respiratori (URMAR), IMIM-Hospital del Mar, CEXS, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - Pilar de Lucas
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Juana Martínez-Llorens
- Servei de Pneumologia, Unitat de Recerca en Múscul i Aparell Respiratori (URMAR), IMIM-Hospital del Mar, CEXS, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - Francisco Ortega
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología y Unidad de Investigación, Hospital de Cruces, Universidad del País Vasco , Barakaldo, España
| | - Luis Puente-Maestu
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Josep Roca
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital General Gregorio Marañón, Universidad Complutense de Madrid, Madrid, España; Servei de Pneumologia, Hospital Clínic de Barcelona, Barcelona, España
| | | | | |
Collapse
|
28
|
Chuang ML, Huang SF, Su CH. Cardiovascular and respiratory dysfunction in chronic obstructive pulmonary disease complicated by impaired peripheral oxygenation. Int J Chron Obstruct Pulmon Dis 2015; 10:329-37. [PMID: 25709427 PMCID: PMC4334300 DOI: 10.2147/copd.s76209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Impaired peripheral oxygenation (IPO)-related variables readily achieved with cardiopulmonary exercise testing (CPET) represent cardiovascular dysfunction. These variables include peak oxygen uptake (
(V˙O2)<85% predicted, anaerobic threshold
<40%V˙O2max predicted,
V˙O2-work rate slope <8.6 mL/watt, oxygen pulse <80% predicted, and ventilatory equivalents for O2 and CO2 at nadir of >31 and >34, respectively. Some of these six variables may be normal while the others are abnormal in patients with chronic obstructive pulmonary disease (COPD). This may result in confusion when using the interpretation algorithm for diagnostic purposes. We therefore hypothesized that patients found to have abnormal values for all six variables would have worse cardiovascular function than patients with abnormal values for none or some of these variables. Methods In this cross-sectional comparative study, 58 COPD patients attending a university teaching hospital underwent symptom-limited CPET with multiple lactate measurements. Patients with abnormal values in all six IPO-related variables were assigned to an IPO group while those who did not meet the requirements for the IPO group were assigned to a non-IPO group. Cardiovascular function was measured by two-dimensional echocardiography and
Δlactate/ΔV˙O2, and respiratory dynamics were compared between the two groups. Results Fourteen IPO and 43 non-IPO patients were entered into the study. Both groups were similar with regard to left ventricular ejection fraction and right ventricular morphology (P>0.05 for both). At peak exercise, both groups reached a similar heart rate level and
Δlactate/ΔV˙O2. The IPO patients had an unfavorable dead space to tidal volume ratio, mean inspiratory tidal flow, and shallow breathing (P<0.05–P<0.001). Conclusion Our IPO and non-IPO patients with COPD had similar cardiovascular performance at rest and at peak exercise, indicating that IPO variables are non-specific for cardiovascular function in these patients. COPD patients with full IPO variables have more deranged ventilatory function.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China ; School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Shih-Feng Huang
- Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chun-Hung Su
- School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China ; Division of Cardiology and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| |
Collapse
|
29
|
Barker N, Everard ML. Getting to grips with 'dysfunctional breathing'. Paediatr Respir Rev 2015; 16:53-61. [PMID: 25499573 DOI: 10.1016/j.prrv.2014.10.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/03/2014] [Indexed: 11/25/2022]
Abstract
Dysfunctional breathing (DB) is common, frequently unrecognised and responsible for a substantial burden of morbidity. Previously lack of clarity in the use of the term and the use of multiple terms to describe the same condition has hampered our understanding. DB can be defined as an alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms. It can be subdivided into thoracic and extra thoracic forms. Thoracic DB is characterised by breathing patterns involving relatively inefficient, excessive upper chest wall activity with or without accessory muscle activity. This is frequently associated with increased residual volume, frequent sighing and an irregular pattern of respiratory effort. It may be accompanied by true hyperventilation in the minority of subjects. Extra thoracic forms include paradoxical vocal cord dysfunction and the increasingly recognised supra-glottic 'laryngomalacia' commonly seen in young sportsmen and women. While the two forms would appear to be two discreet entities they often share common factors in aetiology and respond to similar interventions. Hence both forms are considered in this review which aims to generate a more coherent approach to understanding, diagnosing and treating these conditions.
Collapse
Affiliation(s)
- Nicki Barker
- Department of Respiratory Medicine, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK
| | - Mark L Everard
- School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital for Children, Roberts Road, Subiaco 6008, Western Australia.
| |
Collapse
|
30
|
Chuang ML, Lin IF. Clinical characteristics and lung function in chronic obstructive pulmonary disease complicated with impaired peripheral oxygenation. Intern Emerg Med 2014; 9:633-40. [PMID: 24062273 DOI: 10.1007/s11739-013-0989-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022]
Abstract
During exercise testing, patients with chronic obstructive pulmonary disease (COPD) often present with ventilatory limitations and various combinations of impaired peripheral oxygenation (IPO) to the exercising muscles. The entities of IPO include anemia, circulation impairment and deconditioning. COPD-IPO is not widely accepted as being a subgroup of COPD. Therefore, the aim of this study was to evaluate the clinical features of COPD-IPO patients. Forty-seven COPD patients underwent cardiopulmonary exercise testing. COPD-IPO was identified when all IPO variables had abnormal values. The patients who did not meet the COPD-IPO criteria were defined as the NIPO group. The variables with abnormal values included peak oxygen uptake (VO₂) <85% predicated, anaerobic threshold <40% VO₂max pred, VO₂-work rate slope <8.6 ml/watt, oxygen pulse <80%pred, and ventilatory equivalents for O₂ and CO₂ at nadir (>31 and >34, respectively). Anthropometrics, biochemistry, and lung function were compared between the groups. Forty-six COPD patients were enrolled after excluding one patient who had technical difficulties in performing the exercise tests. Despite FEV1 and FVC being similarly reduced (p = NS) between the groups, the COPD-IPO (n = 13, 28%) patients had lower body mass index and were taller, and had impaired diffusing capacity and larger total lung capacity and air-trapping (all p < 0.05). We concluded that COPD patients with all six variables having abnormal values are a unique subgroup and that identification of these patients is worthwhile for further investigations and management such as exercise training and nutritional supplements.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, #110, Section 1, Chien-Kuo North Road, South District, Taichung, 40201, ROC Taiwan,
| | | |
Collapse
|
31
|
Pastré J, Prévotat A, Tardif C, Langlois C, Duhamel A, Wallaert B. Determinants of exercise capacity in cystic fibrosis patients with mild-to-moderate lung disease. BMC Pulm Med 2014; 14:74. [PMID: 24884656 PMCID: PMC4011768 DOI: 10.1186/1471-2466-14-74] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 04/23/2014] [Indexed: 11/30/2022] Open
Abstract
Background Adult patients with cystic fibrosis (CF) frequently have reduced exercise tolerance, which is multifactorial but mainly due to bronchial obstruction. The aim of this retrospective analysis was to determine the mechanisms responsible for exercise intolerance in patients with mild-to-moderate or severe disease. Methods Cardiopulmonary exercise testing with blood gas analysis at peak exercise was performed in 102 patients aged 28 ± 11 years: 48 patients had severe lung disease (FEV1 < 50%, group 1) and 54 had mild-to-moderate lung disease (FEV1 ≥ 50%, group 2). VO2 peak was measured and correlated with clinical, biological, and functional parameters. Results VO2 peak for all patients was 25 ± 9 mL/kg/min (65 ± 21% of the predicted value) and was < 84% of predicted in 82% of patients (100% of group 1, 65% of group 2). VO2 peak was correlated with body mass index, C-reactive protein, FEV1, FVC, RV, DLCO, VE/VCO2 peak, VD/VT, PaO2, PaCO2, P(A-a)O2, and breathing reserve. In multivariate analysis, FEV1 and overall hyperventilation during exercise were independent determinants of exercise capacity (R2 = 0.67). FEV1 was the major significant predictor of VO2 peak impairment in group 1, accounting for 31% of VO2 peak alteration, whereas excessive overall hyperventilation (reduced or absent breathing reserve and VE/VCO2) accounted for 41% of VO2 alteration in group 2. Conclusion Exercise limitation in adult patients with CF is largely dependent on FEV1 in patients with severe lung disease and on the magnitude of the ventilatory response to exercise in patients with mild-to-moderate lung disease.
Collapse
Affiliation(s)
| | | | | | | | | | - Benoit Wallaert
- Université Lille 2 et Clinique des Maladies Respiratoires, CRCM Hôpital Calmette, CHRU Lille, France.
| |
Collapse
|
32
|
Holley AB, Cohee B, Walter RJ, Shah AA, King CS, Roop S. Eucapnic voluntary hyperventilation is superior to methacholine challenge testing for detecting airway hyperreactivity in nonathletes. J Asthma 2012; 49:614-9. [PMID: 22793526 DOI: 10.3109/02770903.2012.697955] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Response to eucapnic voluntary hyperventilation (EVH) has not been compared with methacholine challenge testing (MCCT) in nonathletes being evaluated for dyspnea on exertion. OBJECTIVE To determine the airway response to EVH and MCCT in a population of nonathletes who exercise regularly but have symptoms with exertion. METHODS We reviewed records for all patients with exercise symptoms who underwent both EVH and MCCT. Presenting symptoms, comorbid diseases, and results of bronchoprovocation (BP) testing were recorded. This study was approved by the institutional review board at our hospital. RESULTS A total of 131 patients (mean age 32.3 ± 11.6, body mass index (BMI) 27.1 ± 4.7 kg/m(2), 59.5% male) had an EVH, MCCT, and clinical evaluation performed. Overall, 37 (28.2%) patients had positive BP testing and met criteria for exercise-induced bronchoconstriction (EIB). There were 32 (24.4%) patients with a positive EVH, compared with only 11 patients with a positive MCCT (8.4%). There were 26 patients (19.8%) who had a positive EVH but a negative MCCT, and correlation between the two tests was poor to moderate (r = 0.11-0.57). A complaint of chest pain and younger age were independent predictors for a positive EVH, whereas a history of tobacco use and a decreased FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) predicted a positive MCCT. A previous diagnosis of asthma was an independent predictor for a response to either test. Discussion. In a population of nonathletes who exercise regularly and have symptoms with exertion, EIB is common. Correlation between EVH and MCCT in this population is poor, and although the tests are somewhat complementary, a large percentage of patients had a negative MCCT but a positive EVH. CONCLUSIONS EIB is common in nonathletes with exercise-induced symptoms, and EVH is the preferred test for this population. CLINICAL IMPLICATIONS EIB is common in nonathletes who exercise regularly. In this population, MCCT will miss most patients with EIB, and MCCT and EVH show only poor-to-moderate correlation. CAPSULE SUMMARY EVH has not been compared with MCCT in nonathletes without a diagnosis of asthma. Our study shows that the two tests are complementary in this population, but EVH is positive more often.
Collapse
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Abstract
The obese asthma phenotype is an increasingly common encounter in our clinical practice. Epidemiological data indicate that obesity increases the prevalence and incidence of asthma, and evidence that obesity precedes the development of asthma raises the possibility of a causal association. Obese patients with asthma experience more symptoms and increased morbidity compared with non-obese asthma patients. Despite more than a decade of research into this association, the exact mechanisms that underlie the interaction of obesity with asthma remain unclear. It is unlikely that the asthma-obesity association is simply due to comorbidities such as obstructive sleep apnoea or gastroesophageal reflux disease. Although inflammatory pathways are purported to play a role, there is scant direct evidence in humans that systemic inflammation modulates the behaviour of the asthmatic airway or the expression of symptoms in the obese. The role of non-eosinophilic airway inflammation also requires further study. Obesity results in important changes to the mechanical properties of the respiratory system, and these obesity-related factors appear to exert an additive effect to the asthma-related changes seen in the airways. An understanding of the various physiological perturbations that might be contributing to symptoms in obese patients with asthma will allow for a more targeted and rational treatment approach for these patients.
Collapse
Affiliation(s)
- Claude S Farah
- The Woolcock Institute of Medical Research, Cooperative Research Centre for Asthma and Airways, Glebe, and The University of Sydney, Sydney, New South Wales, Australia.
| | | |
Collapse
|
34
|
Current World Literature. Curr Opin Anaesthesiol 2012; 25:260-9. [DOI: 10.1097/aco.0b013e3283521230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|