Pulmonary artery pressure during exercise in the horse after inhibition of nitric oxide synthase

Exercise-induced pulmonary hemorrhage: where are we now?

As the Thoroughbreds race for the final stretch, 44 hooves flash and thunder creating a cacophony of tortured air and turf. Orchestrated by selective breeding for physiology and biomechanics, expressed as speed, the millennia-old symphony of man and beast reaches its climax. At nearly 73 kilometers per hour (45 mph) over half a ton of flesh and bone dwarfs its limpet-like jockey as, eyes wild and nostrils flaring, their necks stretch for glory. Beneath each resplendent livery-adorned, latherin-splattered coat hides a monstrous heart trilling at 4 beats per second, and each minute, driving over 400 L (105 gallons) of oxygen-rich blood from lungs to muscles. Matching breath to stride frequency, those lungs will inhale 16 L (4 gallons) of air each stride moving >1,000 L/min in and out of each nostril - and yet failing. Engorged with blood and stretched to breaking point, those lungs can no longer redden the arterial blood but leave it dusky and cyanotic. Their exquisitely thin blood-gas barrier, a mere 10.5 μm thick (1/50,000 of an inch), ruptures, and red cells invade the lungs. After the race is won and lost, long after the frenetic crowd has quieted and gone, that blood will clog and inflame the airways. For a few horses, those who bleed extensively, it will overflow their lungs and spray from their nostrils incarnadining the walls of their stall: a horrifically poignant canvas that strikes at horse racing's very core. That exercise-induced pulmonary hemorrhage (EIPH) occurs is a medical and physiological reality. That every reasonable exigency is not taken to reduce/prevent it would be a travesty. This review is not intended to provide an exhaustive coverage of EIPH for which the reader is referred to recent reviews, rather, after a brief reminder of its physiologic and pathologic bases, focus is brought on the latest developments in EIPH discovery as this informs state-of-the-art knowledge, the implementation of that knowledge and recommendations for future research and treatment.

Nitric oxide synthase inhibition in thoroughbred horses augments O2 extraction at rest and submaximal exercise, but not during short-term maximal exercise

REASON FOR PERFORMING STUDY

Work is required to establish the role of endogenous nitric oxide (NO) in metabolism of resting and exercising horses.

OBJECTIVES

To examine the effects of NO synthase inhibition on O2 extraction and anaerobic metabolism at rest, and during submaximal and maximal exertion.

METHODS

Placebo and NO synthase inhibition (with Nomega-nitro-L-arginine methyl ester [L-NAME] administered at 20 mg/kg bwt i.v.) studies were performed in random order, 7 days apart on 7 healthy, exercise-trained Thoroughbred horses at rest and during incremental exercise leading to 120 sec of maximal exertion at 14 m/sec on a 3.5% uphill grade.

RESULTS

At rest, NO synthase inhibition significantly augmented the arterial to mixed-venous blood O2 content gradient and O2 extraction as mixed-venous blood O2 tension and saturation decreased significantly. While NO synthase inhibition did not affect arterial blood-gas tensions in exercising horses, the exercise-induced increment in haemoglobin concentration and arterial O2 content was attenuated. In the L-NAME study, during submaximal exercise, mixed-venous blood O2 tension and haemoglobin-O2 saturation decreased to a greater extent causing O2 extraction to increase significantly. During maximal exertion, arterial hypoxaemia, desaturation of haemoglobin and hypercapnia of a similar magnitude developed in both treatments. Also, the changes in mixed-venous blood O2 tension and haemoglobin-O2 saturation, arterial to mixed-venous blood O2 content gradient, O2 extraction and markers of anaerobic metabolism (lactate and ammonia production, and metabolic acidosis) were not different from those in the placebo study.

CONCLUSION

Endogenous NO production augments O2 extraction at rest and during submaximal exertion, but not the during short-term maximal exercise. Also, NO synthase inhibition does not affect anaerobic metabolism at rest or during exertion.

POTENTIAL RELEVANCE

It is unlikely that endogenous NO release modifies aerobic or anaerobic metabolism in horses performing short-term maximal exertion.

Exercise-induced pulmonary hemorrhage

EIPH is a condition affecting virtually all horses during intense exercise worldwide. The hemorrhage originates from the pulmonary vasculature and is distributed predominantly bilaterally in the dorsocaudal lung lobes. As the condition progresses, the lung abnormalities extend cranially along the dorsal portions of the lung. An inflammatory response occurs in association with the hemorrhage and may contribute to the chronic sequela. Although conflicting opinions exist as to its affect on performance, it is a syndrome that is thought to increase in severity with age. The most commonly performed method to diagnose EIPH at the present time is endoscopy of the upper airway alone or in combination with tracheal wash analysis for the presence of erythrocytes and hemosiderophages. Because horses may not bleed to the same extent every time and the bleeding may originate from slightly different locations, these diagnostic procedures may not be extremely sensitive or quantitative. At this time, there is no treatment that is considered a panacea, and the currently allowed treatments have not proven to be effective in preventing EIPH. Future directions for therapeutic intervention may need to include limiting inflammatory responses to blood remaining within the lungs after EIPH.

NO inhalation reduces pulmonary arterial pressure but not hemorrhage in maximally exercising horses

In horses, the exercise-induced elevation of pulmonary arterial pressure (Ppa) is thought to play a deterministic role in exercise-induced pulmonary hemorrhage (EIPH), and thus treatment designed to lower Ppa might reasonably be expected to reduce EIPH. Five Thoroughbred horses were run on a treadmill to volitional fatigue (incremental step test) under nitric oxide (NO; inhaled 80 ppm) and control (N(2), same flow rate as per NO run) conditions (2 wk between trials; order randomized) to test the hypothesis that NO inhalation would reduce maximal Ppa but that this reduction may not necessarily reduce EIPH. Before each investigation, a microtipped pressure transducer was placed in the pulmonary artery 8 cm past the pulmonic valve to monitor Ppa. EIPH severity was assessed via bronchoalveolar lavage (BAL) 30 min postrun. Exercise time did not differ between the two trials (P > 0.05). NO administration resulted in a small but consistent and significant reduction in peak Ppa (N(2), 102.3 +/- 4.4; NO, 98.6 +/- 4.3 mmHg, P < 0.05). In the face of lowered Ppa, EIPH severity was significantly higher in the NO trial (N(2), 22.4 +/- 6.8; NO, 42.6 +/- 15.4 x 10(6) red blood cells/ml BAL fluid, P < 0.05). These findings support the notion that extremely high Ppa may reflect, in part, an arteriolar vasoconstriction that serves to protect the capillary bed from the extraordinarily high Ppa evoked during maximal exercise in the Thoroughbred horse. Furthermore, these data suggest that exogenous NO treatment during exercise in horses may not only be poor prophylaxis but may actually exacerbate the severity of EIPH.

Nitric oxide synthase inhibition does not affect the exercise-induced arterial hypoxemia in Thoroughbred horses

Because sensitivity of equine pulmonary vasculature to endogenous as well as exogenous nitric oxide (NO) has been demonstrated, we examined whether endogenous NO production plays a role in exercise-induced arterial hypoxemia. We hypothesized that inhibition of NO synthase may alter the distribution of ventilation-perfusion mismatching, which may affect the exercise-induced arterial hypoxemia. Arterial blood-gas variables were examined in seven healthy, sound Thoroughbred horses at rest and during incremental exercise protocol leading to galloping at maximal heart rate without (control; placebo = saline) and with N(omega)-nitro-L-arginine methyl ester (L-NAME) administration (20 mg/kg iv). The experiments were carried out in random order, 7 days apart. At rest, L-NAME administration caused systemic hypertension, pulmonary hypertension, and bradycardia. During 120 s of galloping at maximal heart rate, significant arterial hypoxemia, desaturation of hemoglobin, hypercapnia, hyperthermia, and acidosis occurred in the control as well as in NO synthase inhibition experiments. However, statistically significant differences between the treatments were not found. In both treatments, exercise caused a significant rise in hemoglobin concentration, but the increment was significantly attenuated in the NO synthase inhibition experiments, and, therefore, arterial O(2) content (Ca(O(2))) increased to significantly lower values. These data suggest that, whereas L-NAME administration does not affect pulmonary gas exchange in exercising horses, it may affect splenic contraction, which via an attenuation of the rise in hemoglobin concentration and Ca(O(2)) may limit performance at higher workloads.

Cardiorespiratory impact of the nitric oxide synthase inhibitor L-NAME in the exercising horse

To investigate the role of nitric oxide, NO, in facilitating cardiorespiratory function during exercise, five horses ran on a treadmill at speeds that yielded 50, 80 and 100% of peak pulmonary oxygen uptake (V(O(2)) peak) as determined on a maximal incremental test. Each horse underwent one control (C) and one (NO-synthase inhibitor; N(G)-L-nitro-arginine methyl ester (L-NAME), 20 mg/kg) trial in randomized order. Pulmonary gas exchange (open flow system), arterial and mixed-venous blood gases, cardiac output (Fick Principle), and pulmonary and systemic conductances were determined. L-NAME reduced exercise tolerance, as well as cardiac output (C, 291+/-34; L-NAME, 246+/-38 L/min), body O(2) delivery (C, 74.4+/-5. 5; L-NAME, 62.1+/-5.6 L/min), and both pulmonary (C, 3.07+/-0.26; L-NAME, 2.84+/-0.35 L/min per mmHg) and systemic (C, 1.55+/-0.24; L-NAME, 1.17+/-0.16 L/min per mmHg) effective vascular conductances at peak running speeds (all P<0.05). On the 50 and 80% trials, L-NAME increased O(2) extraction, which compensated for the reduced body O(2) delivery and prevented a fall in V(O(2)). However, at peak running speed in the L-NAME trial, an elevated O(2) extraction (P<0. 05) was not sufficient to prevent V(O(2)) from falling consequent to the reduced O(2) delivery. At the 50 and 80% running speeds (as for peak), L-NAME reduced pulmonary and systemic effective conductances. These data demonstrate that the NO synthase inhibitor, L-NAME, induces a profound hemodynamic impairment at submaximal and peak running speeds in the horse thereby unveiling a potentially crucial role for NO in mediating endothelial function during exercise.

Oral nitroglycerin paste did not lower pulmonary capillary pressure during treadmill exercise

We hypothesised that 22.5 mg of oral nitroglycerin would cause pulmonary vasodilation and therefore decrease pulmonary capillary pressure in horses during strenuous exercise. Six horses were assigned to exercise twice, once with no medication (control) and once with nitroglycerin (22.5 mg orally) in random order. Horses were exercised for 3 min each at 75, 90 and 100% of maximal heart rate (HRmax) with a 2 min period of walking between each period of exertion. Pulmonary artery and oesophageal pressures were recorded continuously. Subsequent analysis was carried out on the pulmonary arterial pressure signal with the oesophageal pressure subtracted, hence pulmonary vascular pressures reported in this paper approximate transmural pressures. Pulmonary arterial pressure, pulmonary arterial wedge pressure, pulmonary capillary pressure, heart rate and arterial blood gas tensions were determined for each level of exercise. Pulmonary arterial wedge and pulmonary capillary pressures were determined from the pulmonary artery waveform after dynamic occlusion of a branch of the pulmonary artery. The resulting decay in pulmonary artery pressure was submitted to an exponential curve fitting and the amplitude at the moment of occlusion on this curve was recorded as pulmonary capillary pressure. The effects of nitroglycerin on the various parameters were evaluated using a 3-way ANOVA blocked on horse treatment, and exercise intensity, followed by Tukey's multiple comparison procedure. Resting pulmonary artery pressure decreased from mean +/- s.e. 34.0 +/- 5.5 mmHg to 24.0 +/- 3.9 mmHg 5 min after administration of nitroglycerin (P < 0.05) but there were no significant effects on pulmonary capillary or wedge pressures. Nitroglycerin at this dose resulted in no significant differences in pulmonary artery, pulmonary capillary, and pulmonary wedge pressure, heart rate, arterial oxygen tension or arterial carbon dioxide tension at 75, 90 and 100% of HRmax. This dose of nitroglycerin does not appear significantly to protect the pulmonary vascular bed from exercise-induced hypertension. These data do not support the use of this dose of oral nitroglycerin in the prevention of EIPH.

L-NAME does not affect exercise-induced pulmonary hypertension in thoroughbred horses

The present study was carried out to examine the effects of nitric oxide synthase inhibition with Nomega-nitro-L-arginine methyl ester (L-NAME) on the right atrial as well as on the pulmonary arterial, capillary, and venous blood pressures of horses during rest and exercise performed at maximal heart rate (HRmax). Experiments were carried out on seven healthy, sound, exercise-trained Thoroughbred horses. Using catheter-tip manometers, with signals referenced at the point of the shoulder, we determined phasic and mean right atrial and pulmonary vascular pressures in two sets of experiments [control (no medications) and L-NAME (20 mg/kg iv given 10 min before exercise studies)]. The studies were carried out in random order 7 days apart. Measurements were made at rest and during treadmill exercise performed on a 5% uphill grade at 6, 8, and 14.2 m/s. Exercise on a 5% uphill grade at 14.2 m/s elicited HRmax and could not be sustained for >90 s. In quietly standing horses, L-NAME administration caused a significant rise in right atrial, as well as pulmonary arterial, capillary, and venous pressures. This indicates that nitric oxide synthase inhibition modifies the basal pulmonary vasomotor tone. In both treatments, exercise caused progressive significant increments in right atrial and pulmonary vascular pressures, but the values recorded in the L-NAME study were not different from those in the control study. The extent of exercise-induced tachycardia was significantly decreased in the L-NAME study at 6 and 8 m/s but not at 14.2 m/s. Thus, L-NAME administration may not modify the equine pulmonary vascular tone during exercise at HRmax. However, as indicated by a significant reduction in heart rate, L-NAME seems to modify the sympathoneurohumoral response to submaximal exercise.

Nitric oxide and thermoregulation during exercise in the horse

The effect of inhibition of nitric oxide production on sweating rate (SR) and on core, rectal, and tail skin temperatures was measured in five Thoroughbred horses during exercise of variable intensity on a high-speed treadmill. A standard exercise test consisting of three canters [approximately 55% maximum O2 uptake (VO2max)], with walking (approximately 9% VO2max) and trotting (approximately 22% VO2max) between each canter, was performed twice (control or test), in random order, by each horse. N(G)-nitro-L-arginine methyl ester (L-NAME; 20 mg/kg), a competitive inhibitor of nitric oxide synthase, was infused into the central circulation and induced a significant reduction in the SR measured on the neck (31.6 +/- 6.4 vs. 9.7 +/- 4.2 g x min(1) x m(-2); 69%) and rump (14.7 +/- 5.2 vs. 4.8 +/- 1.6 g x min(-1) x m(-2); 67%) of the horses during canter (P < 0.05). Significant increases in core, rectal, and tail skin temperatures were also measured (P < 0.05). L-Arginine (200 mg/kg iv) partially reversed the inhibitory effects of L-NAME on SR, but core, rectal, and tail skin temperatures continued to increase (P < 0.05), suggesting a cumulation of body heat. The results support the contention that nitric oxide synthase inhibition diminishes SR, resulting in elevated core and peripheral temperatures leading to deranged thermoregulation during exercise. The inhibition of sweating by L-NAME may be related to peripheral vasoconstriction but may also involve the neurogenic control of sweating.

Effects of nitric oxide inhibition on thermoregulation during exercise in the horse

We investigated the role of NO in the control of thermoregulation. We measured sweating rate and body temperatures (core, rectal and skin) in five thoroughbred horses during exercise of variable intensity on a high-speed treadmill. A standard exercise test (SET) consisting of three canters (8 m s-1), with walking and trotting between each canter, was performed twice, in random order, by each horse and N omega-nitro-L-arginine methyl ester (L-NAME; 20 mg ml-1), a competitive inhibitor of nitric oxide synthase (NOS), was infused into the central circulation after the first canter in the test SET only. L-Arginine (200 mg ml-1), a substrate of NOS, was injected after the second canter in both control and test SETs. L-NAME significantly (p < 0.05) reduced the sweating rate measured on the neck (31.6 +/- 6.4 versus 9.7 +/- 4.2 g/min/m2) and rump (14.7 +/- 5.2 versus 4.8 +/- 1.6 g/min/m2) while raising the core temperature (39.7 +/- 0.2 versus 40.6 +/- 0.7 degrees C, p < 0.05) during the second canter. In the third canter, sweating rate had increased after giving L-arginine during the test SET, but had not returned to levels measured at similar times during the control SET. Core, rectal and skin temperatures continued to rise and were significantly higher than control levels, despite giving L-arginine. The results show that inhibition of NO production reduces sweating rate in the horse during exercise thereby inducing a rise in body temperatures.

Oxidant injury, nitric oxide and pulmonary vascular function: implications for the exercising horse

The athletic ability of the horse is facilitated by vital physiological adaptations to high-intensity exercise, including a thin (but strong) pulmonary blood-gas barrier, a large pulmonary functional reserve capacity and a consequent maximum oxygen uptake (VO2max) far higher than in other species. A high pulmonary artery pressure also serves to enhance pulmonary function, although stress failure of lung capillaries at high pulmonary transmural pressures, and the contribution of other factors which act in the exercising horse to increase pulmonary vascular tone, may lead to pathological or pathophysiological sequelae, such as exercise-induced pulmonary haemorrhage (EIPH). Reactive oxygen species (ROS) are an important component of the mammalian inflammatory response. They are released during tissue injury and form a necessary component of cellular defences against pathogens and disease processes. The effects of ROS are normally limited or neutralized by a multifactorial system of antioxidant defences, although excessive production and/or deficient antioxidant defences may expose healthy tissue to oxidant damage. In the lung, ROS can damage pulmonary structures both directly and by initiating the release of other inflammatory mediators, including proteases and eicosanoids. Vascular endothelial cells are particularly susceptible to ROS-induced oxidant injury in the lung, and both the destruction of the pulmonary blood-gas barrier and the action of vasoactive substances will increase pulmonary vascular resistance. Moreover, ROS can degrade endothelium-derived nitric oxide (NO), a major pulmonary vasodilator, thereby, with exercise, synergistically increasing the likelihood of stress failure of pulmonary capillaries, a contributing factor to EIPH. This review considers the implications for the exercising horse of oxidant injury, pulmonary vascular function and NO and the contribution of these factors to the pathogenesis of equine respiratory diseases.