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Hijleh AA, Berton DC, Neder-Serafini I, James M, Vincent S, Domnik N, Phillips D, O'Donnell DE, Neder JA. Sex- and age-adjusted reference values for dynamic inspiratory constraints during incremental cycle ergometry. Respir Physiol Neurobiol 2024; 327:104297. [PMID: 38871042 DOI: 10.1016/j.resp.2024.104297] [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: 04/08/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 06/15/2024]
Abstract
Activity-related dyspnea in chronic lung disease is centrally related to dynamic (dyn) inspiratory constraints to tidal volume expansion. Lack of reference values for exertional inspiratory reserve (IR) has limited the yield of cardiopulmonary exercise testing in exposing the underpinnings of this disabling symptom. One hundred fifty apparently healthy subjects (82 males) aged 40-85 underwent incremental cycle ergometry. Based on exercise inspiratory capacity (ICdyn), we generated centile-based reference values for the following metrics of IR as a function of absolute ventilation: IRdyn1 ([1-(tidal volume/ICdyn)] x 100) and IRdyn2 ([1-(end-inspiratory lung volume/total lung capacity] x 100). IRdyn1 and IRdyn2 standards were typically lower in females and older subjects (p<0.05 for sex and age versus ventilation interactions). Low IRdyn1 and IRdyn2 significantly predicted the burden of exertional dyspnea in both sexes (p<0.01). Using these sex and age-adjusted limits of reference, the clinician can adequately judge the presence and severity of abnormally low inspiratory reserves in dyspneic subjects undergoing cardiopulmonary exercise testing.
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Affiliation(s)
- Abed A Hijleh
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Danilo C Berton
- Pulmonary Function Tests Laboratory, Federal University of Rio Grande to Sul, Rua Ramiro Barcelos, 2350 Bloco A, Av. Protásio Alves, 211 - Bloco B e C - Santa Cecília, Porto Alegre, RS 90035-903, Brazil
| | - Igor Neder-Serafini
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Matthew James
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Sandra Vincent
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Nicolle Domnik
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Devin Phillips
- School of Kinesiology and Health Science, Faculty of Health, York University, Norman Bethune College, 170 Campus Walk Room 341, Toronto, ON M3J 1P3, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada.
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Phillips DB, James MD, Vincent SG, Elbehairy AF, Neder JA, Kirby M, Ora J, Day AG, Tan WC, Bourbeau J, O'Donnell DE. Physiological Characterization of Preserved Ratio Impaired Spirometry in the CanCOLD Study: Implications for Exertional Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med 2024; 209:1314-1327. [PMID: 38170674 DOI: 10.1164/rccm.202307-1184oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/03/2024] [Indexed: 01/05/2024] Open
Abstract
Rationale: It is increasingly recognized that adults with preserved ratio impaired spirometry (PRISm) are prone to increased morbidity. However, the underlying pathophysiological mechanisms are unknown. Objectives: Evaluate the mechanisms of increased dyspnea and reduced exercise capacity in PRISm. Methods: We completed a cross-sectional analysis of the CanCOLD (Canadian Cohort Obstructive Lung Disease) population-based study. We compared physiological responses in 59 participants meeting PRISm spirometric criteria (post-bronchodilator FEV1 < 80% predicted and FEV1/FVC ⩾ 0.7), 264 control participants, and 170 ever-smokers with chronic obstructive pulmonary disease (COPD), at rest and during cardiopulmonary exercise testing. Measurements and Main Results: Individuals with PRISm had lower total lung, vital, and inspiratory capacities than healthy controls (all P < 0.05) and minimal small airway, pulmonary gas exchange, and radiographic parenchymal lung abnormalities. Compared with healthy controls, individuals with PRISm had higher dyspnea/[Formula: see text]o2 ratio at peak exercise (4.0 ± 2.2 vs. 2.9 ± 1.9 Borg units/L/min; P < 0.001) and lower [Formula: see text]o2peak (74 ± 22% predicted vs. 96 ± 25% predicted; P < 0.001). At standardized submaximal work rates, individuals with PRISm had greater Vt/inspiratory capacity (Vt%IC; P < 0.001), reflecting inspiratory mechanical constraint. In contrast to participants with PRISm, those with COPD had characteristic small airways dysfunction, dynamic hyperinflation, and pulmonary gas exchange abnormalities. Despite these physiological differences among the three groups, the relationship between increasing dyspnea and Vt%IC during cardiopulmonary exercise testing was similar. Resting IC significantly correlated with [Formula: see text]o2peak (r = 0.65; P < 0.001) in the entire sample, even after adjusting for airflow limitation, gas trapping, and diffusing capacity. Conclusions: In individuals with PRISm, lower exercise capacity and higher exertional dyspnea than healthy controls were mainly explained by lower resting lung volumes and earlier onset of dynamic inspiratory mechanical constraints at relatively low work rates. Clinical trial registered with www.clinicaltrials.gov (NCT00920348).
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Affiliation(s)
- Devin B Phillips
- School of Kinesiology and Health Science, Faculty of Health, and
- Muscle Health Research Center, York University, Toronto, Ontario, Canada
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Amany F Elbehairy
- Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Division of Infection, Immunity, and Respiratory Medicine, The University of Manchester, and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Miranda Kirby
- Department of Physics, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Andrew G Day
- Kingston General Hospital Research Institute, Kingston, Ontario, Canada
| | - Wan C Tan
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia, Canada; and
| | - Jean Bourbeau
- Research Institute of the McGill University Health Centre, Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, and
- Division of Respiratory Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
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Lorenzana I, Galera R, Casitas R, Martínez-Cerón E, Castillo MA, Alfaro E, Cubillos-Zapata C, García-Río F. Dynamic hyperinflation is a risk factor for mortality and severe exacerbations in COPD patients. Respir Med 2024; 225:107597. [PMID: 38499274 DOI: 10.1016/j.rmed.2024.107597] [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: 09/11/2023] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To assess if dynamic hyperinflation is an independent risk factor for mortality and severe exacerbations in COPD patients. METHODS A cohort of 141 patients with stable COPD and moderate to very severe airflow limitation, treated according to conventional guidelines, was followed for a median of 9 years. Clinical characteristics were recorded and arterial blood gases, pulmonary function tests, 6-min walk and incremental exercise test with measurement of respiratory pattern and operative lung volumes were performed. Endpoints were all-cause mortality and hospitalization for COPD exacerbation. RESULTS 58 patients died during the follow-up period (1228 patients x year). The mortality rate was higher in patients with dynamic hyperinflation (n = 106) than in those without it (n = 35) (14.6; 95% CI, 14.5-14.8 vs. 7.2; 95% CI, 7.1-7.4 per 1000 patients-year). After adjusting for sex, age, body mass index, pack-years and treatment with inhaled corticosteroids, dynamic hyperinflation was associated with a higher mortality risk (adjusted hazard ratio [aHR], 2.725; 95% CI, 1.010-8.161), and in a multivariate model, comorbidity, peak oxygen uptake and dynamic hyperinflation were retained as independent predictors of mortality. The time until first severe exacerbation was shorter for patients with dynamic hyperinflation (aHR, 3.961; 95% CI, 1.385-11.328), and dynamic hyperinflation, FEV1 and diffusing capacity were retained as independent risk factors for severe exacerbation. Moreover, patients with dynamic hyperinflation had a higher hospitalization risk than those without it (adjusted incidence rate ratio, 1.574; 95% CI, 1.087-2.581). CONCLUSION In stable COPD patients, dynamic hyperinflation is an independent prognostic factor for mortality and severe exacerbations.
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Affiliation(s)
- Isabel Lorenzana
- Medicine Department, School of Medicine, Universidad Autónoma de Madrid, Spain
| | - Raúl Galera
- Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Raquel Casitas
- Medicine Department, School of Medicine, Universidad Autónoma de Madrid, Spain; Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Elisabet Martínez-Cerón
- Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | | | - Enrique Alfaro
- Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Carolina Cubillos-Zapata
- Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Francisco García-Río
- Medicine Department, School of Medicine, Universidad Autónoma de Madrid, Spain; Respiratory Department, Hospital Universitario La Paz, IdiPaz, Spain; CIBERes, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain.
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Sietsema KE, Rossiter HB. Exercise Physiology and Cardiopulmonary Exercise Testing. Semin Respir Crit Care Med 2023; 44:661-680. [PMID: 37429332 DOI: 10.1055/s-0043-1770362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Aerobic, or endurance, exercise is an energy requiring process supported primarily by energy from oxidative adenosine triphosphate synthesis. The consumption of oxygen and production of carbon dioxide in muscle cells are dynamically linked to oxygen uptake (V̇O2) and carbon dioxide output (V̇CO2) at the lung by integrated functions of cardiovascular, pulmonary, hematologic, and neurohumoral systems. Maximum oxygen uptake (V̇O2max) is the standard expression of aerobic capacity and a predictor of outcomes in diverse populations. While commonly limited in young fit individuals by the capacity to deliver oxygen to exercising muscle, (V̇O2max) may become limited by impairment within any of the multiple systems supporting cellular or atmospheric gas exchange. In the range of available power outputs, endurance exercise can be partitioned into different intensity domains representing distinct metabolic profiles and tolerances for sustained activity. Estimates of both V̇O2max and the lactate threshold, which marks the upper limit of moderate-intensity exercise, can be determined from measures of gas exchange from respired breath during whole-body exercise. Cardiopulmonary exercise testing (CPET) includes measurement of V̇O2 and V̇CO2 along with heart rate and other variables reflecting cardiac and pulmonary responses to exercise. Clinical CPET is conducted for persons with known medical conditions to quantify impairment, contribute to prognostic assessments, and help discriminate among proximal causes of symptoms or limitations for an individual. CPET is also conducted in persons without known disease as part of the diagnostic evaluation of unexplained symptoms. Although CPET quantifies a limited sample of the complex functions and interactions underlying exercise performance, both its specific and global findings are uniquely valuable. Some specific findings can aid in individualized diagnosis and treatment decisions. At the same time, CPET provides a holistic summary of an individual's exercise function, including effects not only of the primary diagnosis, but also of secondary and coexisting conditions.
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Affiliation(s)
- Kathy E Sietsema
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
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Neder JA. Cardiopulmonary exercise testing applied to respiratory medicine: Myths and facts. Respir Med 2023; 214:107249. [PMID: 37100256 DOI: 10.1016/j.rmed.2023.107249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O2 uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate ("anaerobic") threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO2 output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea "quantity" and "quality". Based on a conceptual framework that links exertional dyspnoea to "excessive" and/or "restrained" breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Department of Medicine, Division of Respirology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada.
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Smyth RM, Neder JA, James MD, Vincent SG, Milne KM, Marillier M, de-Torres JP, Moran-Mendoza O, O'Donnell DE, Phillips DB. Physiological underpinnings of exertional dyspnoea in mild fibrosing interstitial lung disease. Respir Physiol Neurobiol 2023; 312:104041. [PMID: 36858334 DOI: 10.1016/j.resp.2023.104041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/20/2023] [Accepted: 02/26/2023] [Indexed: 03/03/2023]
Abstract
The functional disturbances driving "out-of-proportion" dyspnoea in patients with fibrosing interstitial lung disease (f-ILD) showing only mild restrictive abnormalities remain poorly understood. Eighteen patients (10 with idiopathic pulmonary fibrosis) showing preserved spirometry and mildly reduced total lung capacity (≥70% predicted) and 18 controls underwent an incremental cardiopulmonary exercise test with measurements of operating lung volumes and Borg dyspnoea scores. Patients' lower exercise tolerance was associated with higher ventilation (V̇E)/carbon dioxide (V̇CO2) compared with controls (V̇E/V̇CO2 nadir=35 ± 3 versus 29 ± 2; p < 0.001). Patients showed higher tidal volume/inspiratory capacity and lower inspiratory reserve volume at a given exercise intensity, reporting higher dyspnoea scores as a function of both work rate and V̇E. Steeper dyspnoea-work rate slopes were associated with lower lung diffusing capacity, higher V̇E/V̇CO2, and lower peak O2 uptake (p < 0.05). Heightened ventilatory demands in the setting of progressively lower capacity for tidal volume expansion on exertion largely explain higher-than-expected dyspnoea in f-ILD patients with largely preserved dynamic and "static" lung volumes at rest.
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Affiliation(s)
- Reginald M Smyth
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - J Alberto Neder
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Matthew D James
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Sandra G Vincent
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Kathryn M Milne
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada; Centre for Heart Lung Innovation, Providence Health Care Research Institute, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada.
| | - Mathieu Marillier
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University, Grenoble, France.
| | - Juan P de-Torres
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Onofre Moran-Mendoza
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Denis E O'Donnell
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
| | - Devin B Phillips
- Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital, Kingston, ON, Canada.
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Phillips DB, James MD, O'Donnell CJD, Vincent SG, Webb KA, de-Torres JP, Neder JA, O'Donnell DE. Physiological Predictors of Morbidity and Mortality in COPD: The Relative Importance of Reduced Inspiratory Capacity and Inspiratory Muscle Strength. J Appl Physiol (1985) 2022; 133:679-688. [PMID: 35952349 DOI: 10.1152/japplphysiol.00352.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Low resting inspiratory capacity (IC) and low maximal inspiratory pressure (MIP) have previously been linked to exertional dyspnea, exercise limitation and poor survival in chronic obstructive pulmonary disease (COPD). The interaction and relative contributions of these two related variables to important clinical outcomes are unknown. The objective of the current study was to examine the interaction between resting IC and MIP (both % predicted), exertional dyspnea, exercise capacity and long-term survival in patients with COPD. Two hundred and eighty-five patients with mild to advanced COPD completed standard lung function testing and a cycle cardiopulmonary exercise test. Multiple regression determined predictors of the exertional dyspnea-ventilation slope and peak oxygen uptake (V̇O2peak). Cox regression determined predictors of 10-year mortality. IC was associated with the dyspnea-ventilation slope (standardized β=-0.44, p<0.001), while MIP was excluded from the regression model (p=0.713). IC and MIP were included in the final model to predict V̇O2peak. However, the standardized β was greater for IC (0.49) than MIP (0.22). After adjusting for age, sex, body mass index, cardiovascular risk, airflow obstruction and diffusing capacity, resting IC was independently associated with 10-year all-cause mortality (hazard ratio=1.25, confidence interval5-95%=1.16-1.34, p<0.001), while MIP was excluded from the final model (all p=0.829). Low resting IC was consistently linked to heightened dyspnea intensity, low V̇O2peak and worse survival in COPD even after accounting for airway obstruction, inspiratory muscle strength, and diffusing capacity. These results support the use of resting IC as an important physiological biomarker closely linked to key clinical outcomes in COPD.
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Affiliation(s)
- Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Conor J D O'Donnell
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Katherine A Webb
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Juan Pablo de-Torres
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine and Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
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Evidence of ventilatory constraints during exercise in hypermobile Ehlers-Danlos syndrome. Eur J Appl Physiol 2022; 122:2367-2374. [PMID: 35941284 DOI: 10.1007/s00421-022-05017-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Hypermobile Ehlers-Danlos syndrome (hEDS) is a connective tissue disorder with many different symptoms such as pain, fatigue, dysautonomia, or respiratory symptoms. Among the respiratory manifestations described, the most frequent are exertional dyspnea and breathing difficulties. Mechanical ventilatory constraints during exercise could participate in these respiratory manifestations. The objective of this study was to explore the response of pulmonary flow-volume loops to exercise in patients with hEDS and to look for dynamic hyperinflation and expiratory flow limitation during exercise. METHODS For this purpose, breathing pattern and tidal exercise flow-volume loops were recorded at two workloads (30% and 80% of the peak power output) of a constant load exercise test. RESULTS Twelve patients were included (11 women, mean age 41 ± 14 years). The results showed a decrease (p = 0.028) in the inspiratory capacity (from 3.12 ± 0.49 L to 2.97 ± 0.52 L), an increase (p = 0.025) in the end-expiratory lung volume (from 0.73 ± 0.68 L to 0.88 ± 0.66 L, i.e., from EELV comprising 17 ± 12% to 21 ± 12% of forced vital capacity) between the two workloads in favor of dynamic hyperinflation, and half of the patients had expiratory flow limitations. CONCLUSION This exploratory study provides evidence for mechanical ventilatory constraints during exercise in patients with hEDS, which may induce discomfort during exercise and could contribute to the respiratory symptomatology. TRIAL REGISTRATION NUMBER This study is part of a larger clinical trial (ID: NCT04680793, December 2020).
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Gonzalez-Garcia M, Aguirre-Franco CE, Vargas-Ramirez L, Barrero M, Torres-Duque CA. Effect of pulmonary hypertension on exercise capacity and gas exchange in patients with chronic obstructive pulmonary disease living at high altitude. Chron Respir Dis 2022; 19:14799731221104095. [PMID: 35603864 PMCID: PMC9127868 DOI: 10.1177/14799731221104095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is associated with decreased exercise tolerance in chronic obstructive pulmonary disease (COPD) patients, but in the altitude the response to exercise in those patients is unknown. Our objective was to compare exercise capacity, gas exchange and ventilatory alterations between COPD patients with PH (COPD-PH) and without PH (COPD-nonPH) residents at high altitude (2640 m). Methods: One hundred thirty-two COPD-nonPH, 82 COPD-PH, and 47 controls were included. Dyspnea by Borg scale, oxygen consumption (VO2), work rate (WR), ventilatory equivalents (VE/VCO2), dead space to tidal volume ratio (VD/VT), alveolar-arterial oxygen tension gradient (AaPO2), and arterial-end-tidal carbon dioxide pressure gradient (Pa-ETCO2) were measurement during a cardiopulmonary exercise test. For comparison of variables between groups, Kruskal-Wallis or one-way ANOVA tests were used, and stepwise regression analysis to test the association between PH and exercise capacity. Results: All COPD patients had a lower exercise capacity and higher PaCO2, A-aPO2 and VD/VT than controls. The VO2 % predicted (61.3 ± 20.6 vs 75.3 ± 17.9; p < 0.001) and WR % predicted (65.3 ± 17.9 vs 75.3 ± 17.9; p < 0.001) were lower in COPD-PH than in COPD-nonPH. At peak exercise, dyspnea was higher in COPD-PH (p = 0.011). During exercise, in COPD-PH, the PaO2 was lower (p < 0.001), and AaPO2 (p < 0.001), Pa-ETCO2 (p = 0.033), VE/VCO2 (p = 0.019), and VD/VT (p = 0.007) were higher than in COPD-nonPH. In the multivariate analysis, PH was significantly associated with lower peak VO2 and WR (p < 0.001). Conclusion: In COPD patients residing at high altitude, the presence of PH was an independent factor related to the exercise capacity. Also, in COPD-PH patients there were more dyspnea and alterations in gas exchange during the exercise than in those without PH.
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Affiliation(s)
- Mauricio Gonzalez-Garcia
- Pulmonary Function Testing Laboratory, Fundación Neumológica Colombiana, Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, Chía, Colombia
- Faculty of Medicine, Sports Medicine Group, Universidad El Bosque, Bogotá, Colombia
| | - Carlos Eduardo Aguirre-Franco
- Pulmonary Function Testing Laboratory, Fundación Neumológica Colombiana, Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, Chía, Colombia
| | - Leslie Vargas-Ramirez
- Pulmonary Function Testing Laboratory, Fundación Neumológica Colombiana, Bogotá, Colombia
- Instituto Neumológico del Oriente, Bucaramanga, Colombia
| | - Margarita Barrero
- Pulmonary Function Testing Laboratory, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - Carlos A Torres-Duque
- Pulmonary Function Testing Laboratory, Fundación Neumológica Colombiana, Bogotá, Colombia
- Faculty of Medicine, Universidad de la Sabana, Chía, Colombia
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Reuveny R, Vilozni D, Dagan A, Ashkenazi M, Velner A, Segel MJ. The role of inspiratory capacity and tidal flow in diagnosing exercise ventilatory limitation in Cystic Fibrosis. Respir Med 2021; 192:106713. [PMID: 35033964 DOI: 10.1016/j.rmed.2021.106713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Exercise ventilatory limitation conventionally defined by reduced breathing reserve (BR) may underestimate the effect of lung disease on exercise capacity in patients with mild to moderate obstructive lung diseases. OBJECTIVE To investigate whether ventilatory limitation may be present despite a normal BR in Cystic Fibrosis (CF). METHODS Twenty adult CF patients (age 16-58y) with a wide range of pulmonary obstruction severity completed a symptom-limited incremental exercise test on a cycle ergometer. Operating lung volumes were derived from inspiratory capacity (IC) measurement during exercise and exercise tidal flow volume loop analysis. RESULTS six patients had a severe airway obstruction (FEV1<45% predicted) and conventional evidence of ventilatory limitation (low BR). Fourteen patients had mild to moderate-severe airway obstructive (FEV1 46-103% predicted), and a normal BR [12-62 L/min, BR% (17-40)]. However, dynamic respiratory mechanics demonstrated that even CF patients with mild to moderate-severe lung disease had clear evidence of ventilatory limitation during exercise. IC was decreased by (median) 580 ml (range 90-1180 ml) during exercise, indicating dynamic hyperinflation. Inspiratory reserve volume at peak exercise was 445 ml (241-1350 ml) indicating mechanical constraint on the respiratory system. The exercise tidal flow met or exceeded the expiratory boundary of the maximal flow volume loop over 72% of the expiratory volume (range 40-90%), indicating expiratory flow limitation. CONCLUSION Reduced BR as a sole criterion underestimates ventilatory limitation during exercise in mild to moderate-severe CF patients. Assessment of dynamic respiratory mechanics during exercise revealed ventilatory limitation, present even in patients with mild obstruction.
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Affiliation(s)
- Ronen Reuveny
- Pulmonary Institute, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
| | - Daphna Vilozni
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; National CF Center, Paediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel
| | - Adi Dagan
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; National CF Center, Paediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel
| | - Moshe Ashkenazi
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; National CF Center, Paediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel
| | - Ariela Velner
- Pulmonary Institute, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel
| | - Michael J Segel
- Pulmonary Institute, Sheba Medical Center, Tel-HaShomer, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Gonzalez-Garcia M, Barrero M, Maldonado D. Exercise Capacity, Ventilatory Response, and Gas Exchange in COPD Patients With Mild to Severe Obstruction Residing at High Altitude. Front Physiol 2021; 12:668144. [PMID: 34220533 PMCID: PMC8249805 DOI: 10.3389/fphys.2021.668144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Abstract
Background Exercise intolerance, desaturation, and dyspnea are common features in patients with chronic obstructive pulmonary disease (COPD). At altitude, the barometric pressure (BP) decreases, and therefore the inspired oxygen pressure and the partial pressure of arterial oxygen (PaO2) also decrease in healthy subjects and even more in patients with COPD. Most of the studies evaluating ventilation and arterial blood gas (ABG) during exercise in COPD patients have been conducted at sea level and in small populations of people ascending to high altitudes. Our objective was to compare exercise capacity, gas exchange, ventilatory alterations, and symptoms in COPD patients at the altitude of Bogotá (2,640 m), of all degrees of severity. Methods Measurement during a cardiopulmonary exercise test of oxygen consumption (VO2), minute ventilation (VE), tidal volume (VT), heart rate (HR), ventilatory equivalents of CO2 (VE/VCO2), inspiratory capacity (IC), end-tidal carbon dioxide tension (PETCO2), and ABG. For the comparison of the variables between the control subjects and the patients according to the GOLD stages, the non-parametric Kruskal–Wallis test or the one-way analysis of variance test was used. Results Eighty-one controls and 525 patients with COPD aged 67.5 ± 9.1 years were included. Compared with controls, COPD patients had lower VO2 and VE (p < 0.001) and higher VE/VCO2 (p = 0.001), A-aPO2, and VD/VT (p < 0.001). In COPD patients, PaO2 and saturation decreased, and delta IC (p = 0.004) and VT/IC increased (p = 0.002). These alterations were also seen in mild COPD and progressed with increasing severity of the obstruction. Conclusion The main findings of this study in COPD patients residing at high altitude were a progressive decrease in exercise capacity, increased dyspnea, dynamic hyperinflation, restrictive mechanical constraints, and gas exchange abnormalities during exercise, across GOLD stages 1–4. In patients with mild COPD, there were also lower exercise capacity and gas exchange alterations, with significant differences from controls. Compared with studies at sea level, because of the lower inspired oxygen pressure and the compensatory increase in ventilation, hypoxemia at rest and during exercise was more severe; PaCO2 and PETCO2 were lower; and VE/VO2 was higher.
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Affiliation(s)
- Mauricio Gonzalez-Garcia
- Pulmonary Function Testing Laboratory, Fundación Neumologica Colombiana, Bogotá, Colombia.,Faculty of Medicine, Universidad de La Sabana, Bogotá, Colombia
| | - Margarita Barrero
- Pulmonary Function Testing Laboratory, Fundación Neumologica Colombiana, Bogotá, Colombia
| | - Dario Maldonado
- Pulmonary Function Testing Laboratory, Fundación Neumologica Colombiana, Bogotá, Colombia
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