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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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Porszasz J, Wang CY, Ferguson C, Ma S, Girardi M, Stringer WW. Letter to the editor in response to Hoskote "Corrected formula for rectangular area ratio (RAR), a parameter used to quantify airflow limitation on expiratory flow-volume curves" Respiratory Medicine 2022; 204: 107032. Respir Med 2023:107304. [PMID: 37257784 DOI: 10.1016/j.rmed.2023.107304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Janos Porszasz
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA.
| | - Chu-Yi Wang
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA
| | - Carrie Ferguson
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA
| | - Shuyi Ma
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA
| | - Michele Girardi
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA
| | - William W Stringer
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson St. Torrance, CA, 90502, USA
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Lukacsovits J, Szollosi G, Varga JT. Cardiovascular effects of exercise induced dynamic hyperinflation in COPD patients-Dynamically hyperinflated and non-hyperinflated subgroups. PLoS One 2023; 18:e0274585. [PMID: 36662787 PMCID: PMC9858323 DOI: 10.1371/journal.pone.0274585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 08/29/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION An increase in respiratory rate and expiratory flow limitation can facilitate dynamic hyperinflation (DH), which may cause an element of the intrathoracic pressure in connection with the worsening of venous return, with negative effect on stroke volume (SV) and cardiac output (CO). It has been unclassified, whether poor circulatory adaptation to exercise can be attributed to DH or poor cardio-vascular performance itself in COPD. Only a subset of COPD patients exhibit dynamic hyperinflation during exercise. PATIENTS AND METHODS We designed a study to show how lung mechanical and cardiovascular parameters change in hyperinflated and non-hyperinflated COPD patients during exercise with a new experimental set-up. Thirty-three COPD patients with similar severity of COPD and left ventricular performance (20 men, 13 women, mean±SD age: 65,36±6,95 years) participated. We measured the cardiovascular parameters with a non-invasive device (Finometer-pro) including the left ventricular ejection time index (LVETi) and estimated the change of DH with inspiratory capacity (IC) manoeuvres during exercise. RESULTS Twenty-one subjects exhibited DH (DH group) and 12 did not (non-DH group). The measurement results were given in mean ± SD and difference between the values measured during maximal load and rest also (ΔX = Xmax.load-Xrest). ΔSV and ΔCO were significantly higher in non-DH vs. DH patients (ΔSV: non-DH 9,7 ± 13,22 ml vs. DH -3,6 ± 14,34 ml, p = 0.0142; ΔCO: non-DH 2,26 ± 1,46 l/min vs. DH 0,88 ± 1,35 l/min, p = 0.0024). LVETi was not different between the two groups. Calculated oxygen delivery (DO2) during maximal load was significantly higher in non-DH group. CONCLUSION We concluded that worse cardiovascular adaptation to exercise of COPD patients can be associated with exercise-induced DH in a similar cardiovascular aged COPD group.
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Affiliation(s)
| | - Gergo Szollosi
- Department of Interventional Epidemiology, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Janos T. Varga
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
- Department of Pulmonary Rehabilitation, National Koranyi Institute of Pulmonology, Budapest, Hungary
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Hoskote SS. Corrected formula for rectangular area ratio (RAR), a parameter used to quantify airflow limitation on expiratory flow-volume curves. Respir Med 2022; 204:107032. [DOI: 10.1016/j.rmed.2022.107032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
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Fekete M, Szarvas Z, Fazekas-Pongor V, Feher A, Dosa N, Lehoczki A, Tarantini S, Varga JT. COVID-19 infection in patients with chronic obstructive pulmonary disease: From pathophysiology to therapy. Mini-review. Physiol Int 2022; 109:9-19. [PMID: 35230261 DOI: 10.1556/2060.2022.00172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/06/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) are a vulnerable group in terms of the outcome of coronavirus infection in relation to their disease or its treatment, with a higher risk of developing serious complications compared to the healthy population. AIM The aim of our summary study is to review the background and health outcomes of chronic obstructive pulmonary disease and COVID-19 infection in the presence of both diseases. METHODS Review of national and international medical databases (PubMed, MEDLINE, and MOB) with keywords COPD, COVID-19, disease risk, cause, prevention, complications, and prognosis. RESULTS Meta-analyses show that COPD is one of the most common underlying conditions in patients hospitalized for COVID-19. Such patients are five times more likely to develop a serious complication due to oxygen supply problems therefore they are more likely to be admitted to intensive care units, where they may require mechanical ventilation. In the case of underlying COPD, the usual care plan for COVID-19 infection should be followed, as well as all public health recommendations to minimize the risk of developing and transmitting COVID-19. CONCLUSION Coronavirus infection is especially dangerous for COPD patients, who are much more likely to become seriously ill, so increased surveillance, prevention, early detection, adequate treatment and rehabilitation of the disease group are of paramount importance.
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Affiliation(s)
- Monika Fekete
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Zsofia Szarvas
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Vince Fazekas-Pongor
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Agnes Feher
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Norbert Dosa
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Andrea Lehoczki
- 2 Department of Hematology and Stem Cell Transplantation, National Institute for Hematology and Infectious Diseases, South Pest Central Hospital, Budapest, Hungary
| | - Stefano Tarantini
- 1 Department of Public Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
- 3 Department of Biochemistry and Molecular Biology at University of Oklahoma Health Sciences Center, Oklahoma City, OK,USA
| | - Janos Tamas Varga
- 4 Department of Pulmonology, Semmelweis University, Budapest, Hungary
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Tiller NB, Cao M, Lin F, Yuan W, Wang CY, Abbasi A, Calmelat R, Soriano A, Rossiter HB, Casaburi R, Stringer WW, Porszasz J. Dynamic airway function during exercise in COPD assessed via impulse oscillometry before and after inhaled bronchodilators. J Appl Physiol (1985) 2021; 131:326-338. [PMID: 34013748 PMCID: PMC8325613 DOI: 10.1152/japplphysiol.00148.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Assessing airway function during exercise provides useful information regarding mechanical properties of the airways and the extent of ventilatory limitation in COPD. The primary aim of this study was to use impulse oscillometry (IOS) to assess dynamic changes in airway impedance across a range of exercise intensities in patients with GOLD 1-4, before and after albuterol administration. A secondary aim was to assess the reproducibility of IOS measures during exercise. Fifteen patients with COPD (8 males/7 females; age = 66 ± 8 yr; prebronchodilator FEV1 = 54.3 ± 23.6%Pred) performed incremental cycle ergometry before and 90 min after inhaled albuterol. Pulmonary ventilation and gas exchange were measured continuously, and IOS-derived indices of airway impedance were measured every 2 min immediately preceding inspiratory capacity maneuvers. Test-retest reproducibility of exercise IOS was assessed as mean difference between replicate tests in five healthy subjects (3 males/2 females). At rest and during incremental exercise, albuterol significantly increased airway reactance (X5) and decreased airway resistance (R5, R5-R20), impedance (Z5), and end-expiratory lung volume (60% ± 12% vs. 58% ± 12% TLC, main effect P = 0.003). At peak exercise, there were moderate-to-strong associations between IOS variables and IC, and between IOS variables and concavity in the expiratory limb of the spontaneous flow-volume curve. Exercise IOS exhibited moderate reproducibility in healthy subjects which was strongest with R5 (mean diff. = -0.01 ± 0.05 kPa/L/s; ICC = 0.68), R5-R20 (mean diff. = -0.004 ± 0.028 kPa/L/s; ICC = 0.65), and Z5 (mean diff. = -0.006 ± 0.021 kPa/L/s; ICC = 0.69). In patients with COPD, exercise evoked increases in airway resistance and decreases in reactance that were ameliorated by inhaled bronchodilators. The technique of exercise IOS may aid in the clinical assessment of dynamic airway function during exercise.NEW & NOTEWORTHY This study provides a novel, mechanistic insight into dynamic airway function during exercise in COPD, before and after inhaled bronchodilators. The use of impulse oscillometry (IOS) to evaluate airway function is unique among exercise studies. We show strong correlations among IOS variables, dynamic hyperinflation, and shape-changes in the spontaneous expiratory flow-volume curve. This approach may aid in the clinical assessment of airway function during exercise.
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Affiliation(s)
- Nicholas B. Tiller
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Min Cao
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California,2Department of Respiratory and Critical Care Medicine, Beijing Chest Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fang Lin
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California,3Department of Respiratory, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Yuan
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California,3Department of Respiratory, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chu-Yi Wang
- 4Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, California
| | - Asghar Abbasi
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Robert Calmelat
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - April Soriano
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Harry B. Rossiter
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Richard Casaburi
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - William W. Stringer
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Janos Porszasz
- 1Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
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Fekete M, Fazekas-Pongor V, Balazs P, Tarantini S, Szollosi G, Pako J, Nemeth AN, Varga JT. Effect of malnutrition and body composition on the quality of life of COPD patients. Physiol Int 2021; 108:238-250. [PMID: 34224400 DOI: 10.1556/2060.2021.00170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pathological alterations in nutritional status may develop in Chronic Obstructive Pulmonary Disease (COPD) patients through production of inflammatory cytokines and inadequate diet. OBJECTIVE The aim of our study was to determine the correlation between nutritional status and quality of life of COPD patients. METHODS We evaluated the nutritional status of COPD patients of Hungarian National Koranyi Institute for Pulmonology using the Malnutrition Universal Screening Tool (MUST) and bioelectrical impedance analysis (BIA) between January 1 and June 1, 2019. Lung function, physical fitness, and respiratory muscle strength were included in the assessment. RESULTS Fifty patients (mean age was 66.3 ± 9.6 years) participated in our study. Mean body mass index (BMI) was 26.2 ± 6.1 kg/m2 and mean fat-free mass index (FFMI) was 16.8 ± 2.4 kg/m2. Overweight patients had better lung function values (FEV1ref%: 46.3 ± 15.2) than normal (FEV1ref%: 45.1 ± 20.9) and underweight patients (FEV1ref%: 43.8 ± 16.0). The Modified Medical Research Council Dyspnea Scale (mMRC) was significantly associated with various parameters; strongest correlation was found with FFMI (r = -0.537, P < 0.001), skeletal muscle mass index (SMMI) (r = -0.530, P < 0.001), and 6-minute walking distance (6MWD) (r = -0.481, P < 0.001). CONCLUSIONS Our results indicate that malnourished COPD patients may have reduced lung function and lower quality of life compared to normal weight patients. Thus, our findings suggest that nutritional therapy be included in the treatment of COPD patients combined with nutritional risk screening and BIA during the follow-up.
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Affiliation(s)
- M Fekete
- 1Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - V Fazekas-Pongor
- 1Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - P Balazs
- 1Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - S Tarantini
- 2Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- 3Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - G Szollosi
- 4Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - J Pako
- 6National Korányi Institute for Pulmonology, Budapest, Hungary
| | - A N Nemeth
- 1Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - J T Varga
- 5Department of Pulmonology, Semmelweis University, Budapest, Hungary
- 6National Korányi Institute for Pulmonology, Budapest, Hungary
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Erram J, Bari M, Domingo A, Cannon DT. Pulmonary function with expiratory resistive loading in healthy volunteers. PLoS One 2021; 16:e0252916. [PMID: 34115812 PMCID: PMC8195373 DOI: 10.1371/journal.pone.0252916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 05/25/2021] [Indexed: 11/19/2022] Open
Abstract
Expiratory flow limitation is a key characteristic in obstructive pulmonary diseases. To study abnormal lung mechanics isolated from heterogeneities of obstructive disease, we measured pulmonary function in healthy adults with expiratory loading. Thirty-seven volunteers (25±5 yr) completed spirometry and body plethysmography under control and threshold expiratory loading of 7, 11 cmH2O, and a subset at 20 cmH2O (n = 11). We analyzed the shape of the flow-volume relationship with rectangular area ratio (RAR; Ma et al., Respir Med 2010). Airway resistance was increased (p<0.0001) with 7 and 11 cmH2O loading vs control (9.20±1.02 and 11.76±1.68 vs. 2.53± 0.80 cmH2O/L/s). RAR was reduced (p = 0.0319) in loading vs control (0.45±0.07 and 0.47±0.09L vs. 0.48±0.08). FEV1 was reduced (p<0.0001) in loading vs control (3.24±0.81 and 3.23±0.80 vs. 4.04±1.05 L). FVC was reduced (p<0.0001) in loading vs control (4.11±1.01 and 4.14±1.03 vs. 5.03±1.34 L). Peak expiratory flow (PEF) was reduced (p<0.0001) in loading vs control (6.03±1.67 and 6.02±1.84 vs. 8.50±2.81 L/s). FEV1/FVC (p<0.0068) was not clinically significant and FRC (p = 0.4) was not different in loading vs control. Supra-physiologic loading at 20 cmH2O did not result in further limitation. Expiratory loading reduced FEV1, FVC, PEF, but there were no clinically meaningful differences in FEV1/FVC, FRC, or RAR. Imposed expiratory loading likely leads to high airway pressures that resist dynamic airway compression. Thus, a concave expiratory flow-volume relationship was consistently absent-a key limitation for model comparison with pulmonary function in COPD. Threshold loading may be a useful strategy to increase work of breathing or induce dynamic hyperinflation.
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Affiliation(s)
- Jyotika Erram
- School of Exercise & Nutritional Sciences, San Diego State University, San Diego, California, United States of America
| | - Monica Bari
- School of Exercise & Nutritional Sciences, San Diego State University, San Diego, California, United States of America
| | - Antoinette Domingo
- School of Exercise & Nutritional Sciences, San Diego State University, San Diego, California, United States of America
| | - Daniel T. Cannon
- School of Exercise & Nutritional Sciences, San Diego State University, San Diego, California, United States of America
- * E-mail:
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Pellegrini M, Gudmundsson M, Bencze R, Segelsjö M, Freden F, Rylander C, Hedenstierna G, Larsson AS, Perchiazzi G. Expiratory Resistances Prevent Expiratory Diaphragm Contraction, Flow Limitation, and Lung Collapse. Am J Respir Crit Care Med 2020; 201:1218-1229. [PMID: 32150440 DOI: 10.1164/rccm.201909-1690oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Tidal expiratory flow limitation (tidal-EFL) is not completely avoidable by applying positive end-expiratory pressure and may cause respiratory and hemodynamic complications in ventilated patients with lungs prone to collapse. During spontaneous breathing, expiratory diaphragmatic contraction counteracts tidal-EFL. We hypothesized that during both spontaneous breathing and controlled mechanical ventilation, external expiratory resistances reduce tidal-EFL.Objectives: To assess whether external expiratory resistances 1) affect expiratory diaphragmatic contraction during spontaneous breathing, 2) reduce expiratory flow and make lung compartments more homogeneous with more similar expiratory time constants, and 3) reduce tidal atelectasis, preventing hyperinflation.Methods: Three positive end-expiratory pressure levels and four external expiratory resistances were tested in 10 pigs after lung lavage. We analyzed expiratory diaphragmatic electric activity and respiratory mechanics. On the basis of computed tomography scans, four lung compartments-not inflated (atelectasis), poorly inflated, normally inflated, and hyperinflated-were defined.Measurements and Main Results: Consequently to additional external expiratory resistances, and mainly in lungs prone to collapse (at low positive end-expiratory pressure), 1) the expiratory transdiaphragmatic pressure decreased during spontaneous breathing by >10%, 2) expiratory flow was reduced and the expiratory time constants became more homogeneous, and 3) the amount of atelectasis at end-expiration decreased from 24% to 16% during spontaneous breathing and from 32% to 18% during controlled mechanical ventilation, without increasing hyperinflation.Conclusions: The expiratory modulation induced by external expiratory resistances preserves the positive effects of the expiratory brake while minimizing expiratory diaphragmatic contraction. External expiratory resistances optimize lung mechanics and limit tidal-EFL and tidal atelectasis, without increasing hyperinflation.
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Affiliation(s)
- Mariangela Pellegrini
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Magni Gudmundsson
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Reka Bencze
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Monica Segelsjö
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden; and
| | - Filip Freden
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Hedenstierna
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders S Larsson
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Gaetano Perchiazzi
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
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Stringer W, Marciniuk D. The Role of Cardiopulmonary Exercise Testing (CPET) in Pulmonary Rehabilitation (PR) of Chronic Obstructive Pulmonary Disease (COPD) Patients. COPD 2018; 15:621-631. [PMID: 30595047 DOI: 10.1080/15412555.2018.1550476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common multisystem inflammatory disease with ramifications involving essentially all organ systems. Pulmonary rehabilitation is a comprehensive program designed to prevent and mitigate these disparate systemic effects and improve patient quality of life, functional status, and social functioning. Although initial patient assessment is a prominent component of any pulmonary rehabilitation (PR) program, cardiopulmonary exercise testing (CPET) is not regularly performed as a screening physiologic test prior to PR in COPD patients. Further, CPET is not often used to assess or document the improvement in exercise capacity related to completion of PR. In this review we will describe the classic physiologic abnormalities related to COPD on CPET parameters, the role of CPET in Risk Stratification/Safety prior to PR, the physiologic changes that occur in CPET parameters with PR, and the literature regarding the use of CPET to assess PR results. Finally, we will compare CPET to 6MW in COPD PR, the common minimal clinically important difference (MCID) is associated with CPET, and the potential future roles of CPET in PR and Research.
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Affiliation(s)
- William Stringer
- a Chronic Diseases Clinical Research Center (CDCRC), Los Angeles Biomedical Institute at Harbor-UCLA Medical Center , David Geffen School of Medicine at UCLA , Torrance , CA , USA
| | - Darcy Marciniuk
- b Respiratory Research Center, Royal University Hospital , University of Saskatchewan , Saskatoon , Canada
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11
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A Novel Approach to the Identification of Compromised Pulmonary Systems in Smokers by Exploiting Tidal Breathing Patterns. SENSORS 2018; 18:s18051322. [PMID: 29693559 PMCID: PMC5981858 DOI: 10.3390/s18051322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 11/16/2022]
Abstract
Smoking causes unalterable physiological abnormalities in the pulmonary system. This is emerging as a serious threat worldwide. Unlike spirometry, tidal breathing does not require subjects to undergo forceful breathing maneuvers and is progressing as a new direction towards pulmonary health assessment. The aim of the paper is to evaluate whether tidal breathing signatures can indicate deteriorating adult lung condition in an otherwise healthy person. If successful, such a system can be used as a pre-screening tool for all people before some of them need to undergo a thorough clinical checkup. This work presents a novel systematic approach to identify compromised pulmonary systems in smokers from acquired tidal breathing patterns. Tidal breathing patterns are acquired during restful breathing of adult participants. Thereafter, physiological attributes are extracted from the acquired tidal breathing signals. Finally, a unique classification approach of locally weighted learning with ridge regression (LWL-ridge) is implemented, which handles the subjective variations in tidal breathing data without performing feature normalization. The LWL-ridge classifier recognized compromised pulmonary systems in smokers with an average classification accuracy of 86.17% along with a sensitivity of 80% and a specificity of 92%. The implemented approach outperformed other variants of LWL as well as other standard classifiers and generated comparable results when applied on an external cohort. This end-to-end automated system is suitable for pre-screening people routinely for early detection of lung ailments as a preventive measure in an infrastructure-agnostic way.
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Porszasz J, Carraro N, Cao R, Gore A, Ma S, Jiang T, Maltais F, Ferguson GT, O'Donnell DE, Shaikh A, Rossiter HB, Casaburi R. Effect of tiotropium on spontaneous expiratory flow-volume curves during exercise in GOLD 1-2 COPD. Respir Physiol Neurobiol 2018; 251:8-15. [PMID: 29438808 DOI: 10.1016/j.resp.2018.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/12/2018] [Accepted: 02/08/2018] [Indexed: 11/27/2022]
Abstract
This substudy of a large, randomized, controlled trial (NCT01072396) examined tiotropium (18 μg qd) effects on dynamic hyperinflation during constant work rate treadmill exercise. Areas-under-the-spontaneous expiratory flow-volume (SEFV)-curves were compared in 20 COPD patients and 16 age-matched untreated controls, using rectangular area ratio (RAR) between peak intrabreath and end-expiratory flow. Seven patients exhibited SEFV curve concavity with RAR ≤ 0.5 (RARlow) in ≥1 test without tiotropium; (mean ± SD FEV1: 1.60 ± 0.59 L; 63.4 ± 14.0%predicted). In RARlow patients, tiotropium increased end-exercise inspiratory capacity (IC, 2.10 ± 0.05 vs. 1.89 ± 0.05 L, tiotropium vs. placebo; p = 0.045) and RAR (0.57 ± 0.02 vs. 0.53 ± 0.02; p < 0.001). Patients without SEFV curve concavity with RAR > 0.5 (n = 13; RARhigh), had higher screening FEV1 (2.15 ± 0.47 L; 79.6 ± 10.1%predicted) versus RARlow patients and no difference in end-exercise IC and RAR between tiotropium and placebo (IC: 2.24 ± 0.03 vs. 2.17 ± 0.03 L; RAR: 0.63 ± 0.005 vs. 0.62 ± 0.005). RAR and%predicted IC at peak exercise were positively correlated in RARlow patients (R2 = 0.43, p = 0.0002). Tiotropium increased exercise RAR in GOLD 1-2 patients with SEFV curve concavity.
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Affiliation(s)
- Janos Porszasz
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.
| | - Nicolò Carraro
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Robert Cao
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.
| | - Ashwani Gore
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Shuyi Ma
- Center for Infectious Disease Research, Seattle, WA, USA.
| | - Thomas Jiang
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada.
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA.
| | - Denis E O'Donnell
- Department of Medicine, Queen's University & Kingston General Hospital, Kingston, ON, Canada.
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA.
| | - Harry B Rossiter
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA; Faculty of Biological Sciences, University of Leeds, Leeds, UK.
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.
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Varga J, Casaburi R, Ma S, Hecht A, Hsia D, Somfay A, Porszasz J. Relation of concavity in the expiratory flow-volume loop to dynamic hyperinflation during exercise in COPD. Respir Physiol Neurobiol 2016; 234:79-84. [PMID: 27575552 DOI: 10.1016/j.resp.2016.08.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 12/15/2022]
Abstract
Active expiration during exercise can increase intrathoracic pressure yielding concavity in the expiratory flow-volume loop in COPD. We investigated the relationship between this concavity and dynamic hyperinflation (DH). 17 COPD patients (FEV1: 38±10%pred, GOLD stage 3-4) and 12 healthy subjects performed cycle ergometer incremental exercise. Expiratory limb of the spontaneous flow-volume loop was analyzed breath-by-breath using a geometric approach (rectangular area ratio (RAR), Respir. Med., 104(3):389-96, 2010). RAR below 0.5 demonstrates expiratory limb concavity. DH was determined with serial inspiratory capacity maneuvers. 5 of 17 patients displayed little end-exercise concavity (RAR=0.52±0.04, group LCONC). 12 patients had concavity at rest and end-exercise RAR reached 0.40±0.03 (group HCONC). Healthy subjects showed no concavity. End-exercise RAR correlated with resting FEV1%pred (R2=0.81, P<0.05). Group HCONC, compared to groups LCONC and H, reached significantly lower work rate, minute ventilation, and more dyspnea. DH inversely correlated with RAR (R2=0.81, P<0.05). Detection of concavity in spontaneous flow-volume loops may help assess DH and exercise limitation in COPD.
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Affiliation(s)
- Janos Varga
- Department of Pulmonology, University of Szeged, Deszk, Hungary; Department of Pulmonary Rehabilitation, National Koranyi Institute for TB and Pulmonology, Budapest, Hungary
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.
| | - Shuyi Ma
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ariel Hecht
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David Hsia
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Janos Porszasz
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
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Lee J, Lee CT, Lee JH, Cho YJ, Park JS, Oh YM, Lee SD, Yoon HI. Graphic analysis of flow-volume curves: a pilot study. BMC Pulm Med 2016; 16:18. [PMID: 26801632 PMCID: PMC4724104 DOI: 10.1186/s12890-016-0182-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/15/2016] [Indexed: 12/02/2022] Open
Abstract
Background Conventional spirometric parameters have shown poor correlation with symptoms and health status of chronic obstructive pulmonary disease (COPD). While it is well-known that the pattern of the expiratory flow-volume curve (EFVC) represents ventilatory dysfunction, little attempts have been made to derive quantitative parameters by analyzing the curve. In this study, we aimed to derive useful parameters from EFVC via graphic analysis and tried to validate them in patients with COPD. Methods Using Graphical Analysis 3.4 Vernier Software, we derived from the EFVC such parameters as area of obstruction (Ao), area of triangle (AT), area of rectangle (AR) and ratio of volume at 75 and 25 % peak expiratory flow (PEF) (0.25/0.75 V). For validation, we reviewed clinical and spirometric data of 61 COPD patients from Seoul National University Airway Registry (SNUAR) and Korean obstructive Lung Disease (KOLD) cohorts. Results Of all parameters, only RV/TLC significantly correlated with scores from St. George’s Respiratory Questionnaire (SGRQ) (r = 0.447, p = 0.037). Six-minute walking distance (6MWD) highly correlated with Ao/AR (r = −0.618, p = 0.005) and Ao/PEF (r = −0.581, p = 0.009) whereas neither FEV1 nor FEV1/FVC had significant correlation with 6MWD. Conclusions Ao/AR and Ao/PEF are promising parameters which correlate well with the exercising capacity of COPD patients. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0182-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jungsil Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Choon-Taek Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Jae Ho Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Young-Jae Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Jong Sun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Ho Il Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, 463-707, Seongnam-si, Gyeonggi-do, Republic of Korea.
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15
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Williams EM, Powell T, Eriksen M, Neill P, Colasanti R. A pilot study quantifying the shape of tidal breathing waveforms using centroids in health and COPD. J Clin Monit Comput 2013; 28:67-74. [PMID: 23881418 DOI: 10.1007/s10877-013-9497-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
During resting tidal breathing the shape of the expiratory airflow waveform differs with age and respiratory disease. While most studies quantifying these changes report time or volume specific metrics, few have concentrated on waveform shape or area parameters. The aim of this study was to derive and compare the centroid co-ordinates (the geometric centre) of inspiratory and expiratory flow-time and flow-volume waveforms collected from participants with or without COPD. The study does not aim to test the diagnostic potential of these metrics as an age matched control group would be required. Twenty-four participants with COPD and thirteen healthy participants who underwent spirometry had their resting tidal breathing recorded. The flow-time data was analysed using a Monte Carlo simulation to derive the inspiratory and expiratory flow-time and flow-volume centroid for each breath. A comparison of airflow waveforms show that in COPD, the breathing rate is faster (17 ± 4 vs 14 ± 3 min(-1)) and the time to reach peak expiratory flow shorter (0.6 ± 0.2 and 1.0 ± 0.4 s). The expiratory flow-time and flow-volume centroid is left-shifted with the increasing asymmetry of the expired airflow pattern induced by airway obstruction. This study shows that the degree of skew in expiratory airflow waveforms can be quantified using centroids.
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Affiliation(s)
- E M Williams
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK,
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16
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Methods for Assessing Expiratory Flow Limitation during Tidal Breathing in COPD Patients. Pulm Med 2012; 2012:234145. [PMID: 23008769 PMCID: PMC3447366 DOI: 10.1155/2012/234145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 08/10/2012] [Indexed: 11/17/2022] Open
Abstract
Patients with severe COPD often exhale along the same flow-volume curve during quite breathing as during forced expiratory vital capacity manoeuvre, and this has been taken as indicating expiratory flow limitation at rest (EFLT). Therefore, EFLT, namely, attainment of maximal expiratory flow during tidal expiration, occurs when an increase in transpulmonary pressure causes no increase in expiratory flow. EFLT leads to small airway injury and promotes dynamic pulmonary hyperinflation with concurrent dyspnoea and exercise limitation. In fact, EFLT occurs commonly in COPD patients (mainly in GOLD III and IV stage) in whom the latter symptoms are common. The existing up-to-date physiological methods for assessing expiratory flow limitation (EFLT) are reviewed in the present work. Among the currently available techniques, the negative expiratory pressure (NEP) has been validated in a wide variety of settings and disorders. Consequently, it should be regarded as a simple, non invasive, most practical, and accurate new technique.
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17
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Chang ET, Silberstein D, Rambod M, Porszasz J, Casaburi R. Heart rate variability during constant work rate exercise at and above the critical power in patients with severe chronic obstructive pulmonary disease. Tzu Chi Med J 2011. [DOI: 10.1016/j.tcmj.2011.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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