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Miki K, Tsujino K, Fukui M, Miki M, Kitajima T, Sumitani H, Hashimoto K, Yokoyama M, Hashimoto H, Nii T, Matsuki T, Kida H. Laryngeal widening and adequate ventilation by expiratory pressure load training improve aerobic capacity in COPD: a randomised controlled trial. Thorax 2023; 79:23-34. [PMID: 37696622 PMCID: PMC10803957 DOI: 10.1136/thorax-2022-219755] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 07/26/2023] [Indexed: 09/13/2023]
Abstract
RATIONALE Despite strategies acting on peripheral airway obstruction in chronic obstructive pulmonary disease (COPD), exercise intolerance remains inadequately improved. We hypothesised that laryngeal narrowing is a potential treatment target of expiratory pressure load training (EPT) to improve exercise intolerance in COPD. METHODS The effect of 3-month EPT was assessed in 47 patients with COPD divided into Global Initiative for Chronic Obstructive Lung Disease (GOLD) mild-to-moderate (I-II) and severe-to-very severe (III-IV), randomly allocating 1:1 to EPT or control groups. The primary outcome was endurance time in the constant work rate exercise test in GOLD III-IV patients. RESULTS Compared with controls, EPT increased: (1) endurance time, with estimated treatment effect: +703 (95% CI: 379 to 1031) s, p=0.0008 (GOLD I-II); +390 (95% CI: 205 to 574) s, p=0.0006 (GOLD III-IV); (2) peak oxygen uptake (p=0.0086 in GOLD I-II; p=0.0004 in GOLD III-IV); (3) glottic dilatation ratio at maximum collapse on laryngoscopy in the submaximal exercise (p=0.0062 in GOLD I-II; p=0.0001 in GOLD III-IV); and (4) the inflection point of expiratory tidal volume relative to minute ventilation during the incremental exercise (p=0.0015 in GOLD I-II; p=0.0075 in GOLD III-IV). Across GOLD grades, the responses of glottic dilatation ratio at maximum collapse and the expiratory tidal volume at the inflection point were selected as more influential variables correlating with the improvement in peak oxygen uptake and endurance time, respectively. CONCLUSION These results show that EPT improved aerobic capacity and endurance time with larger laryngeal widening and adequate ventilation despite advanced COPD. TRIAL REGISTRATION NUMBER UMIN000041250.
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Affiliation(s)
- Keisuke Miki
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Kazuyuki Tsujino
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Mari Miki
- Department of Internal Medicine, LIAA Tokushima Prefecture Naruto Hospital, Naruto, Japan
| | - Takamasa Kitajima
- Respiratory Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Hitoshi Sumitani
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Kazuki Hashimoto
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Masashi Yokoyama
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Hisako Hashimoto
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Takuro Nii
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Takanori Matsuki
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
| | - Hiroshi Kida
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan
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Reeve J, Mooney S, Jepsen N, White D. The Utility and Acceptability of a New Noninvasive Ventilatory Assist Device, Rest-Activity Cycler-Positive Airways Pressure, During Exercise in a Population of Healthy Adults: Cohort Study. JMIR Rehabil Assist Technol 2022; 9:e35494. [PMID: 35916705 PMCID: PMC9379794 DOI: 10.2196/35494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Noninvasive ventilation has been demonstrated to benefit people who have moderate to severe chronic obstructive pulmonary disease during acute exacerbations. Studies have begun to investigate the effectiveness of noninvasive ventilation during pulmonary rehabilitation to improve outcomes for people with chronic obstructive pulmonary disease; however, the lack of portability and humidification of these devices means their use is limited, especially when performing activities of daily living. A new prototype device, RACer-PAP (rest-activity cycler-positive airways pressure), delivers battery-operated positive airway pressure via a nasal interface while regulating nasal airway apportionment bias, removing the need for supplementary humidification. This device may offer people with chronic obstructive pulmonary disease an improved ability to participate in pulmonary rehabilitation and activities of daily living. Objective To assess the feasibility of exercising with the RACer-PAP in situ and the acceptability of the device during exercise in normal, healthy individuals. Methods A total of 15 healthy adults were invited to attend 2 exercise sessions, each 1 week apart. Sessions lasted approximately 1 hour and included 2 baseline 6-minute walk distance assessments, once with and once without the RACer-PAP in situ. Vital signs and spirometry results were monitored throughout, and spirometry was performed pre- and posttesting with RACer-PAP. Subjective questionnaires ascertained participant feedback on exercising with the device in situ. Results Of the 15 initial participants, 14 (93%) completed both sessions. There were no adverse events associated with exercising with the device in situ. There were no differences in vital signs or 6-minute walk distance whether exercising with or without the device in situ. There were small increases in maximum dyspnea score (on the Borg scale) when exercising with the device in situ (median score 2.0, IQR 0.5-3.0, vs 3.0, IQR 2.0-3.25). There were small increases in forced vital capacity following exercise with the RACer-PAP. None of the participants reported symptoms associated with airway drying. Participant feedback provided recommendations for modifications for the next iteration of the device prior to piloting the device with people with chronic obstructive pulmonary disease. Conclusions This study has shown RACer-PAP to be safe and feasible to use during exercise and has provided feedback for modifications to the device to improve its use during exercise. We now propose to consider the application of the device in a small pilot feasibility study to assess the safety, feasibility, and utility of the device in a population of people with moderate to severe chronic obstructive pulmonary disease. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12619000478112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375477
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Affiliation(s)
- Julie Reeve
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Sarah Mooney
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicola Jepsen
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - David White
- Department of Mechanical Engineering, Auckland University of Technology, Auckland, New Zealand
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James MD, Phillips DB, Vincent SG, Abdallah SJ, Donovan AA, de-Torres JP, Neder JA, Smith BM, Jensen D, O'Donnell DE. Exertional dyspnoea in patients with mild-to-severe chronic obstructive pulmonary disease (COPD): Neuromechanical mechanisms. J Physiol 2022; 600:4227-4245. [PMID: 35861594 DOI: 10.1113/jp283252] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/11/2022] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Dyspnoea during exercise is a common and troublesome symptom reported by patients with chronic obstructive pulmonary disease (COPD) and is linked to an elevated inspiratory neural drive (IND). The precise mechanisms of elevated IND and dyspnoea across the continuum of airflow obstruction severity in COPD remains unclear. The present study sought to determine the mechanisms of elevated IND [by diaphragm EMG, EMGdi (%max)] and dyspnoea during cardiopulmonary exercise testing (CPET) across the continuum of COPD severity. There was a strong association between increasing dyspnoea intensity and EMGdi (%max) during CPET across the COPD continuum despite significant heterogeneity in underlying pulmonary gas exchange and respiratory mechanical impairments. Critical inspiratory constraints occurred at progressively lower ventilation during exercise with worsening severity of COPD. This was associated with the progressively lower resting inspiratory capacity with worsening disease severity. Earlier critical inspiratory constraint was associated with earlier neuromechanical dissociation and greater likelihood of reporting the sensation of 'unsatisfied inspiration'. ABSTRACT In patients with COPD, exertional dyspnoea generally arises when there is imbalance between ventilatory demand and capacity, but the neurophysiological mechanisms are unclear. We therefore determined if disparity between elevated inspiratory neural drive (IND) and tidal volume (VT ) responses (neuromechanical dissociation) impacted dyspnoea intensity and quality during exercise, across the COPD severity spectrum. In this two-centre, cross-sectional observational study, 89 participants with COPD divided into tertiles of FEV1 %predicted (Tertile 1 = FEV1 = 87 ± 9%, Tertile 2 = 60 ± 9%, Tertile 3 = 32 ± 8%) and 18 non-smoking controls, completed a symptom-limited cardiopulmonary exercise tests (CPET) with measurement of IND by diaphragm electromyography [EMGdi (%max)]. The association between increasing dyspnoea intensity and EMGdi (%max) during CPET was strong (r = 0.730, P < 0.001) and not different between the four groups who showed marked heterogeneity in pulmonary gas exchange and mechanical abnormalities. Significant inspiratory constraints (tidal volume/inspiratory capacity (VT /IC) ≥ 70%) and onset of neuromechanical dissociation (EMGdi (%max):VT /IC > 0.75) occurred at progressively lower V̇E from Control to Tertile 3. Lower resting IC meant earlier onset of neuromechanical dissociation, heightened dyspnoea intensity and greater propensity (93% in Tertile 3) to select qualitative descriptors of 'unsatisfied inspiration'. We concluded that, regardless of marked variation in mechanical and pulmonary gas exchange abnormalities in our study sample, exertional dyspnoea intensity was linked to the magnitude of EMGdi (%max). Moreover, onset of critical inspiratory constraints and attendant neuromechanical dissociation amplified dyspnoea intensity at higher exercise intensities. Simple measurements of IC and breathing pattern during CPET provide useful insights into mechanisms of dyspnoea and exercise intolerance in individuals with COPD. Abstract figure legend As chronic obstructive pulmonary disease severity increases, worsening gas exchange and respiratory mechanical impairment causes increased afferent receptor stimulation, increasing inspiratory neural drive at a given ventilation. The widening disparity between progressively greater inspiratory neural drive and reduced ventilatory output causes, 'neuromechanical dissociation'. This is strongly associated with a rapid increase in the intensity of dyspnea during exercise, and the onset of the sensation of 'unsatisfied inspiration'. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sara J Abdallah
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, Quebec, Canada.,Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Adamo A Donovan
- Division of Respiratory Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Juan P de-Torres
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Benjamin M Smith
- Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada.,Division of Respiratory Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dennis Jensen
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, Quebec, Canada.,Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
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- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
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Dempsey JA, Neder JA, Phillips DB, O'Donnell DE. The physiology and pathophysiology of exercise hyperpnea. HANDBOOK OF CLINICAL NEUROLOGY 2022; 188:201-232. [PMID: 35965027 DOI: 10.1016/b978-0-323-91534-2.00001-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In health, the near-eucapnic, highly efficient hyperpnea during mild-to-moderate intensity exercise is driven by three obligatory contributions, namely, feedforward central command from supra-medullary locomotor centers, feedback from limb muscle afferents, and respiratory CO2 exchange (V̇CO2). Inhibiting each of these stimuli during exercise elicits a reduction in hyperpnea even in the continuing presence of the other major stimuli. However, the relative contribution of each stimulus to the hyperpnea remains unknown as does the means by which V̇CO2 is sensed. Mediation of the hyperventilatory response to exercise in health is attributed to the multiple feedback and feedforward stimuli resulting from muscle fatigue. In patients with COPD, diaphragm EMG amplitude and its relation to ventilatory output are used to decipher mechanisms underlying the patients' abnormal ventilatory responses, dynamic lung hyperinflation and dyspnea during exercise. Key contributions to these exercise-limiting responses across the spectrum of COPD severity include high dead space ventilation, an excessive neural drive to breathe and highly fatigable limb muscles, together with mechanical constraints on ventilation. Major controversies concerning control of exercise hyperpnea are discussed along with the need for innovative research to uncover the link of metabolism to breathing in health and disease.
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Affiliation(s)
- Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, United States.
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
| | - Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
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Dennis CJ, Menadue C, Schneeberger T, Leitl D, Schoenheit-Kenn U, Hoyos CM, Harmer AR, Barnes DJ, Koczulla RA, Kenn K, Alison JA. Bilevel Noninvasive Ventilation During Exercise Reduces Dynamic Hyperinflation and Improves Cycle Endurance Time in Severe to Very Severe COPD. Chest 2021; 160:2066-2079. [PMID: 34224690 DOI: 10.1016/j.chest.2021.06.050] [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: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND During exercise, dynamic hyperinflation (DH), measured by a reduction in inspiratory capacity (IC), increases exertional dyspnea and reduces functional capacity in many patients with severe COPD. Although noninvasive ventilation (NIV) during exercise can improve exercise duration, the effect on DH is unclear. RESEARCH QUESTIONS In people with COPD, resting hyperinflation, and evidence of DH during exercise, does bilevel NIV during exercise reduce DH and increase endurance time compared with exercise with no NIV, and does NIV with an individually titrated expiratory positive airway pressure (T-EPAP) reduce DH and increase exercise endurance time more than does NIV with standardized EPAP (S-EPAP) of 5 cm H2O? STUDY DESIGN AND METHODS A randomized crossover trial in which investigators and participants were blinded between NIV interventions was performed. Participants (N = 19; FEV1 of 1.02 ± 0.24 L (39% ± 6% predicted) completed three constant work rate endurance cycle tests in random order-no NIV, NIV with S-EPAP, and NIV with T-EPAP-during exercise. Primary outcomes were isotime IC and exercise endurance time. Outcome measures from each intervention were compared at isotime and at end exercise by using a linear mixed-model analysis. RESULTS Compared with those with no NIV, isotime IC and endurance time were greater with both NIV with S-EPAP (mean difference: 95% CI, 0.19 L [0.10-0.28]; 95% CI, 153 s [24-280], respectively) and T-EPAP (95% CI, 0.22 L [0.13-0.32]; 95% CI, 145 s [28-259], respectively). There was no difference between NIV with S-EPAP and NIV with T-EPAP. INTERPRETATION In people with COPD and DH during exercise, NIV during exercise reduced DH and increased cycle endurance time. An S-EPAP of 5 cm H2O was adequate to obtain these benefits. TRIAL REGISTRY Australian New Zealand Clinical Trials Registry; No.: ACTRN12613000804785; URL: http://www.anzctr.org.au.
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Affiliation(s)
- Clancy J Dennis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Collette Menadue
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Tessa Schneeberger
- Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany; Department of Pulmonary Rehabilitation, Philipps-University of Marburg, German Centre for Lung Research (DZL), Marburg, Germany
| | - Daniela Leitl
- Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany; Department of Pulmonary Rehabilitation, Philipps-University of Marburg, German Centre for Lung Research (DZL), Marburg, Germany
| | - Ursula Schoenheit-Kenn
- Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany
| | - Camilla M Hoyos
- School of Psychology, University of Sydney, Sydney, NSW, Australia; Woolcock Institute of Medical Research, Centre for Sleep and Chronobiology, Sydney, NSW, Australia
| | - Alison R Harmer
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - David J Barnes
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rembert A Koczulla
- Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany; Department of Pulmonary Rehabilitation, Philipps-University of Marburg, German Centre for Lung Research (DZL), Marburg, Germany; Teaching Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Klaus Kenn
- Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany; Department of Pulmonary Rehabilitation, Philipps-University of Marburg, German Centre for Lung Research (DZL), Marburg, Germany
| | - Jennifer A Alison
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Sydney Local Health District, Allied Health, Sydney, NSW, Australia
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(The expiratory muscle training in patients with chronic heart failure). COR ET VASA 2021. [DOI: 10.33678/cor.2020.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Crouse SF, Lytle JR, Boutros S, Benton W, Moreno M, McCulloch PC, Lambert BS. Wearable positive end-expiratory pressure valve improves exercise performance. SPORTS MEDICINE AND HEALTH SCIENCE 2020; 2:159-165. [PMID: 35782287 PMCID: PMC9219351 DOI: 10.1016/j.smhs.2020.06.002] [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] [Received: 05/13/2020] [Revised: 06/13/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022] Open
Abstract
We tested a PEEP (4.2 cmH2O) mouthpiece (PMP) on maximal cycling performance in healthy adults. Experiment-1, PMP vs. non-PMP mouthpiece (CON) [n = 9 (5♂), Age = 30 ± 2 yr]; Experiment-2, PMP vs. no mouthpiece (NMP) [n = 10 (7♂), Age = 27 ± 1 yr]. At timepoint 1 in both experiments (mouthpiece condition randomized) subjects performed graded cycling testing (GXT) (Corival® cycle ergometer) to determine V˙O2peak (ml∗kg∗min−1), O2pulse (mlO2∗bt−1), GXT endurance time (GXT-T(s)), and V˙O2(ml∗kg∗min−1)-at-ventilatory-threshold (V˙O2 @VT). At timepoint 2 72 h later, subjects completed a ventilatory-threshold-endurance-ride [VTER(s)] timed to exhaustion at V˙O2 @VT power (W). One week later at timepoints 3 and 4 (time-of-day controlled), subjects repeated testing protocols under the alternate mouthpiece condition. Selected results (paired T-test, p<0.05): Experiment 1 PMP vs. CON, respectively: V˙O2peak = 45.2 ± 2.4 vs. 42.4 ± 2.3 p<0.05; V˙O2@VT = 33.7 ± 2.0 vs. 32.3 ± 1.6; GXT-TTE = 521.7 ± 73.4 vs. 495.3 ± 72.8 (p<0.05); VTER = 846.2 ± 166.0 vs. 743.1 ± 124.7; O2pulse = 24.5 ± 1.4 vs. 23.1 ± 1.3 (p<0.05). Experiment 2 PMP vs. NMP, respectively: V˙O2peak = 43.3 ± 1.6 vs. 41.7 ± 1.6 (p<0.05); V˙O2@VT = 31.1 ± 1.2 vs. 29.1 ± 1.3 (p<0.05); GXT-TTE = 511.7 ± 49.6 vs. 486.4 ± 49.6 (p<0.05); VTER 872.4 ± 134.0 vs. 792.9 ± 122.4; O2pulse = 24.1 ± 0.9 vs. 23.4 ± 0.9 (p<0.05). Results demonstrate that the PMP conferred a significant performance benefit to cyclists completing high intensity cycling exercise.
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Affiliation(s)
- Stephen F. Crouse
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
- Corresponding author. Department of Health and Kinesiology Texas A&M University, 4245 TAMU, College Station, TX, 77843, USA.
| | - Jason R. Lytle
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - Sean Boutros
- My Houston Surgeons, 9230 Katy Freeway, Suite 600, Houston, TX, USA
| | - William Benton
- PEEP Performance, LLC., 96 Siwanoy Blvd, Eastchester, NY, USA
| | - Michael Moreno
- Department of Mechanical Engineering, Texas A&M University, College Station, TX, USA
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Expiratory muscle dysfunction in critically ill patients: towards improved understanding. Intensive Care Med 2019; 45:1061-1071. [PMID: 31236639 PMCID: PMC6667683 DOI: 10.1007/s00134-019-05664-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022]
Abstract
Introduction This narrative review summarizes current knowledge on the physiology and pathophysiology of expiratory muscle function in ICU patients, as shared by academic professionals from multidisciplinary, multinational backgrounds, who include clinicians, clinical physiologists and basic physiologists. Results The expiratory muscles, which include the abdominal wall muscles and some of the rib cage muscles, are an important component of the respiratory muscle pump and are recruited in the presence of high respiratory load or low inspiratory muscle capacity. Recruitment of the expiratory muscles may have beneficial effects, including reduction in end-expiratory lung volume, reduction in transpulmonary pressure and increased inspiratory muscle capacity. However, severe weakness of the expiratory muscles may develop in ICU patients and is associated with worse outcomes, including difficult ventilator weaning and impaired airway clearance. Several techniques are available to assess expiratory muscle function in the critically ill patient, including gastric pressure and ultrasound. Conclusion The expiratory muscles are the "neglected component" of the respiratory muscle pump. Expiratory muscles are frequently recruited in critically ill ventilated patients, but a fundamental understanding of expiratory muscle function is still lacking in these patients.
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Lozano-García M, Sarlabous L, Moxham J, Rafferty GF, Torres A, Jané R, Jolley CJ. Surface mechanomyography and electromyography provide non-invasive indices of inspiratory muscle force and activation in healthy subjects. Sci Rep 2018; 8:16921. [PMID: 30446712 PMCID: PMC6240075 DOI: 10.1038/s41598-018-35024-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022] Open
Abstract
The current gold standard assessment of human inspiratory muscle function involves using invasive measures of transdiaphragmatic pressure (Pdi) or crural diaphragm electromyography (oesEMGdi). Mechanomyography is a non-invasive measure of muscle vibration associated with muscle contraction. Surface electromyogram and mechanomyogram, recorded transcutaneously using sensors placed over the lower intercostal spaces (sEMGlic and sMMGlic respectively), have been proposed to provide non-invasive indices of inspiratory muscle activation, but have not been directly compared to gold standard Pdi and oesEMGdi measures during voluntary respiratory manoeuvres. To validate the non-invasive techniques, the relationships between Pdi and sMMGlic, and between oesEMGdi and sEMGlic were measured simultaneously in 12 healthy subjects during an incremental inspiratory threshold loading protocol. Myographic signals were analysed using fixed sample entropy (fSampEn), which is less influenced by cardiac artefacts than conventional root mean square. Strong correlations were observed between: mean Pdi and mean fSampEn |sMMGlic| (left, 0.76; right, 0.81), the time-integrals of the Pdi and fSampEn |sMMGlic| (left, 0.78; right, 0.83), and mean fSampEn oesEMGdi and mean fSampEn sEMGlic (left, 0.84; right, 0.83). These findings suggest that sMMGlic and sEMGlic could provide useful non-invasive alternatives to Pdi and oesEMGdi for the assessment of inspiratory muscle function in health and disease.
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Affiliation(s)
- Manuel Lozano-García
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain.
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain.
| | - Leonardo Sarlabous
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - John Moxham
- Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
| | - Gerrard F Rafferty
- King's College Hospital NHS Foundation Trust, King's Health Partners, London, United Kingdom
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
| | - Abel Torres
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - Raimon Jané
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - Caroline J Jolley
- King's College Hospital NHS Foundation Trust, King's Health Partners, London, United Kingdom
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
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Respiratory Muscle Effort during Expiration in Successful and Failed Weaning from Mechanical Ventilation. Anesthesiology 2018; 129:490-501. [DOI: 10.1097/aln.0000000000002256] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Respiratory muscle weakness in critically ill patients is associated with difficulty in weaning from mechanical ventilation. Previous studies have mainly focused on inspiratory muscle activity during weaning; expiratory muscle activity is less well understood. The current study describes expiratory muscle activity during weaning, including tonic diaphragm activity. The authors hypothesized that expiratory muscle effort is greater in patients who fail to wean compared to those who wean successfully.
Methods
Twenty adult patients receiving mechanical ventilation (more than 72 h) performed a spontaneous breathing trial. Tidal volume, transdiaphragmatic pressure, diaphragm electrical activity, and diaphragm neuromechanical efficiency were calculated on a breath-by-breath basis. Inspiratory (and expiratory) muscle efforts were calculated as the inspiratory esophageal (and expiratory gastric) pressure–time products, respectively.
Results
Nine patients failed weaning. The contribution of the expiratory muscles to total respiratory muscle effort increased in the “failure” group from 13 ± 9% at onset to 24 ± 10% at the end of the breathing trial (P = 0.047); there was no increase in the “success” group. Diaphragm electrical activity (expressed as the percentage of inspiratory peak) was low at end expiration (failure, 3 ± 2%; success, 4 ± 6%) and equal between groups during the entire expiratory phase (P = 0.407). Diaphragm neuromechanical efficiency was lower in the failure versus success groups (0.38 ± 0.16 vs. 0.71 ± 0.36 cm H2O/μV; P = 0.054).
Conclusions
Weaning failure (vs. success) is associated with increased effort of the expiratory muscles and impaired neuromechanical efficiency of the diaphragm but no difference in tonic activity of the diaphragm.
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Pathophysiological mechanisms of exertional breathlessness in chronic obstructive pulmonary disease and interstitial lung disease. Curr Opin Support Palliat Care 2018; 12:237-245. [PMID: 30074922 DOI: 10.1097/spc.0000000000000377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Breathlessness is a common and distressing symptom in patients with chronic obstructive pulmonary disease (COPD) and fibrotic interstitial lung disease (ILD), particularly during exercise. Effective medical management of exertional breathlessness in people living with COPD and fibrotic ILD is challenging for healthcare providers and requires an understanding of its mechanisms. Thus, in this brief review we summarize recent advances in our understanding of the pathophysiological mechanisms of exertional breathlessness in COPD and fibrotic ILD. RECENT FINDINGS The collective results of recent physiological and clinical trials suggest that higher intensity ratings of exertional breathlessness in both COPD and fibrotic ILD compared to healthy control individuals is mechanistically linked to the awareness of greater neural respiratory drive (quantified using inspiratory muscle electromyography) needed to compensate for pathophysiological abnormalities in respiratory mechanics and pulmonary gas exchange efficiency. SUMMARY Any therapeutic intervention capable of decreasing intrinsic mechanical loading of the respiratory system and/or increasing pulmonary gas exchange efficiency has the potential to decrease the prevalence and severity of activity-related breathlessness and improve related clinical and patient-reported outcomes (e.g., exercise tolerance and health-related quality of life) by decreasing neural respiratory drive in people with COPD and fibrotic ILD.
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Layoun ME, Aboulhosn JA, Tobis JM. Potential Role of Patent Foramen Ovale in Exacerbating Hypoxemia in Chronic Pulmonary Disease. Tex Heart Inst J 2017; 44:189-197. [PMID: 28761399 DOI: 10.14503/thij-16-6027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.
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MESH Headings
- Coronary Circulation
- Disease Progression
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Hypoxia/diagnosis
- Hypoxia/etiology
- Hypoxia/physiopathology
- Hypoxia/therapy
- Male
- Middle Aged
- Pulmonary Circulation
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Risk Factors
- Severity of Illness Index
- Treatment Outcome
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Anekwe D, de Marchie M, Spahija J. Effects of Pressure Support Ventilation May Be Lost at High Exercise Intensities in People with COPD. COPD 2017; 14:284-292. [PMID: 28388225 DOI: 10.1080/15412555.2017.1304533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pressure support ventilation (PSV) may be used for exercise training in chronic obstructive pulmonary disease (COPD), but its acute effect on maximum exercise capacity is not fully known. The objective of this study was to evaluate the effect of 10 cm H2O PSV and a fixed PSV level titrated to patient comfort at rest on maximum exercise workload (WLmax), breathing pattern and metabolic parameters during a symptom-limited incremental bicycle test in individuals with COPD. Eleven individuals with COPD (forced expiratory volume in one second: 49 ± 16%; age: 64 ± 7 years) performed three exercise tests: without a ventilator, with 10 cm H2O of PSV and with a fixed level titrated to comfort at rest, using a SERVO-i ventilator. Tests were performed in randomized order and at least 48 hours apart. The WLmax, breathing pattern, metabolic parameters, and mouth pressure (Pmo) were compared using repeated measures analysis of variance. Mean PSV during titration was 8.2 ± 4.5 cm H2O. There was no difference in the WLmax achieved during the three tests. At rest, PSV increased the tidal volume, minute ventilation, and mean inspiratory flow with a lower end-tidal CO2; this was not sustained at peak exercise. Pmo decreased progressively (decreased unloading) with PSV at workloads close to peak, suggesting the ventilator was unable to keep up with the increased ventilatory demand at high workloads. In conclusion, with a Servo-i ventilator, 10 cm H2O of PSV and a fixed level of PSV established by titration to comfort at rest, is ineffective for the purpose of achieving higher exercise workloads as the acute physiological effects may not be sustained at peak exercise.
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Affiliation(s)
- David Anekwe
- a School of Physical and Occupational Therapy , McGill University , Montreal , Quebec , Canada.,b Research Center , Sacré-Coeur Hospital , Montreal , Quebec , Canada.,c Center for Interdisciplinary Research in Rehabilitation in Montreal , Jewish Rehabilitation Hospital , Laval , Quebec , Canada
| | - Michel de Marchie
- d Department of Adult Critical Care , Jewish General Hospital , Montreal , Quebec , Canada
| | - Jadranka Spahija
- a School of Physical and Occupational Therapy , McGill University , Montreal , Quebec , Canada.,b Research Center , Sacré-Coeur Hospital , Montreal , Quebec , Canada.,c Center for Interdisciplinary Research in Rehabilitation in Montreal , Jewish Rehabilitation Hospital , Laval , Quebec , Canada
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O'Donnell DE, Elbehairy AF, Berton DC, Domnik NJ, Neder JA. Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases. Front Physiol 2017; 8:82. [PMID: 28275353 PMCID: PMC5319975 DOI: 10.3389/fphys.2017.00082] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 11/13/2022] Open
Abstract
Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.
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Affiliation(s)
- Denis E. O'Donnell
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Amany F. Elbehairy
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
- Department of Chest Diseases, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
| | - Danilo C. Berton
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Nicolle J. Domnik
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - J. Alberto Neder
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
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15
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Ou YE, Lin ZM, Wu WL, Luo Q, Chen RC. Efficacy of non-invasive ventilation as a rescue therapy for relieving dyspnea in patients with stable severe COPD. Respir Med 2016; 121:74-80. [DOI: 10.1016/j.rmed.2016.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 10/14/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
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Dennis C, Menadue C, Harmer A, Barnes D, Alison J. Effect of non-invasive ventilation on the measurement of ventilatory and metabolic variables. Respir Physiol Neurobiol 2016; 228:76-82. [DOI: 10.1016/j.resp.2016.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/25/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
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17
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Faisal A, Alghamdi BJ, Ciavaglia CE, Elbehairy AF, Webb KA, Ora J, Neder JA, O'Donnell DE. Common Mechanisms of Dyspnea in Chronic Interstitial and Obstructive Lung Disorders. Am J Respir Crit Care Med 2016; 193:299-309. [PMID: 26407036 DOI: 10.1164/rccm.201504-0841oc] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The mechanisms underlying dyspnea in interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) are unknown. OBJECTIVES To examine whether the relationship between inspiratory neural drive to the diaphragm and exertional dyspnea intensity is different in ILD and COPD, given the marked differences in static respiratory mechanics between these conditions. METHODS We compared sensory-mechanical relationships in patients with ILD, patients with COPD, and healthy control subjects (n = 16 each) during incremental cycle exercise with diaphragmatic electromyography (EMGdi) and respiratory pressure measurements. MEASUREMENTS AND MAIN RESULTS In patients with mild to moderate ILD or COPD with similarly reduced inspiratory capacity, the peak oxygen uptake, work rate, and ventilation were lower (P < 0.05) than in healthy control subjects. EMGdi expressed as a percentage of the maximum (EMGdi/EMGdi,max), respiratory effort (esophageal pressure expressed as percentage of the maximum), and ventilation were higher (P < 0.05) at rest and during exercise in both patients with ILD and patients with COPD than in control subjects. Each of these measurements was similar in the ILD and COPD groups. A Vt inflection and critically reduced inspiratory reserve volume occurred at a lower (P < 0.05) ventilation in the ILD and COPD groups than in control subjects. Patients with ILD had greater diaphragmatic activity, whereas patients with COPD had greater expiratory muscle activity. The relationship between dyspnea intensity and EMGdi/EMGdi,max during exercise was similar in all three groups. In ILD and COPD, descriptors alluding to inspiratory difficulty were selected more frequently, with a greater disparity between EMGdi/EMGdi,max and Vt. CONCLUSIONS Disease-specific differences in mechanics and respiratory muscle activity did not influence the key association between dyspnea intensity and inspiratory neural drive to the diaphragm.
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Affiliation(s)
- Azmy Faisal
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,2 Faculty of Physical Education for Men and
| | - Bader J Alghamdi
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,3 King Saud Bin Abdulaziz University for Health Science, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Casey E Ciavaglia
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Amany F Elbehairy
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,4 Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt; and
| | - Katherine A Webb
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Josuel Ora
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - J Alberto Neder
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
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Gravier FÉ, Bonnevie T, Medrinal C, Debeaumont D, Dupuis J, Viacroze C, Muir JF, Tardif C. Ventilation non invasive au cours de la réhabilitation respiratoire des patients atteints de BPCO. Rev Mal Respir 2016; 33:422-30. [DOI: 10.1016/j.rmr.2015.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 10/22/2022]
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Wysham NG, Nipp RD, LeBlanc TW, Wolf SP, Ekstrom MP, Currow DC. A practical measurement of thoracic sarcopenia: correlation with clinical parameters and outcomes in advanced lung cancer. ERJ Open Res 2016; 2:00085-2015. [PMID: 27730193 PMCID: PMC5005176 DOI: 10.1183/23120541.00085-2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/19/2016] [Indexed: 01/06/2023] Open
Abstract
Sarcopenia, the loss of skeletal muscle mass, is common in chronic disease, and has been hypothesised to contribute to fatigue and breathlessness [1, 2]. The research gold standard for assessing sarcopenia relies on whole-body, cross-sectional imaging, an impractical approach in routine care [3]. A more practical alternative measures lumbar skeletal muscle density at L3 using computed tomography (CT) normalised for height, termed the skeletal muscle index (SMI) [4]. While evidence suggests that reduced lumbar SMI correlates with adverse clinical outcomes, such as mortality in lung or colorectal cancers [5], little research has explored how this measure of sarcopenia relates to breathlessness or exercise tolerance. Thoracic sarcopenia can feasibly be measured from routine CT scans but does not correlate to patient-centred outcomeshttp://ow.ly/102UkQ
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Affiliation(s)
- Nicholas G Wysham
- Dept of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Ryan D Nipp
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas W LeBlanc
- Duke Clinical Research Institute, Durham, NC, USA; Dept of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Steven P Wolf
- Dept of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Magnus P Ekstrom
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden; Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
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Rossi A, Aisanov Z, Avdeev S, Di Maria G, Donner CF, Izquierdo JL, Roche N, Similowski T, Watz H, Worth H, Miravitlles M. Mechanisms, assessment and therapeutic implications of lung hyperinflation in COPD. Respir Med 2015; 109:785-802. [DOI: 10.1016/j.rmed.2015.03.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/04/2015] [Accepted: 03/23/2015] [Indexed: 02/05/2023]
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21
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Murphy PB, Arbane G, Ramsay M, Suh ES, Mandal S, Jayaram D, Leaver S, Polkey MI, Hart N. Safety and efficacy of auto-titrating noninvasive ventilation in COPD and obstructive sleep apnoea overlap syndrome. Eur Respir J 2015; 46:548-51. [DOI: 10.1183/09031936.00205714] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 04/15/2015] [Indexed: 11/05/2022]
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Ambrosino N, Cigni P. Non invasive ventilation as an additional tool for exercise training. Multidiscip Respir Med 2015; 10:14. [PMID: 25874110 PMCID: PMC4396167 DOI: 10.1186/s40248-015-0008-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 02/23/2015] [Indexed: 11/10/2022] Open
Abstract
Recently, there has been increasing interest in the use of non invasive ventilation (NIV) to increase exercise capacity. In individuals with COPD, NIV during exercise reduces dyspnoea and increases exercise tolerance. Different modalities of mechanical ventilation have been used non-invasively as a tool to increase exercise tolerance in COPD, heart failure and lung and thoracic restrictive diseases. Inspiratory support provides symptomatic benefit by unloading the ventilatory muscles, whereas Continuous Positive Airway Pressure (CPAP) counterbalances the intrinsic positive end-expiratory pressure in COPD patients. Severe stable COPD patients undergoing home nocturnal NIV and daytime exercise training showed some benefits. Furthermore, it has been reported that in chronic hypercapnic COPD under long-term ventilatory support, NIV can also be administered during walking. Despite these results, the role of NIV as a routine component of pulmonary rehabilitation is still to be defined.
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Affiliation(s)
- Nicolino Ambrosino
- Pulmonary Rehabilitation and Weaning Center, Auxilium Vitae, Borgo S.Lazzaro 5, Volterra, PI Italy
| | - Paolo Cigni
- Pulmonary Rehabilitation and Weaning Center, Auxilium Vitae, Borgo S.Lazzaro 5, Volterra, PI Italy
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23
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Baz M, Haji GS, Menzies-Gow A, Tanner RJ, Hopkinson NS, Polkey MI, Hull JH. Dynamic laryngeal narrowing during exercise: a mechanism for generating intrinsic PEEP in COPD? Thorax 2015; 70:251-7. [PMID: 25586938 PMCID: PMC4345987 DOI: 10.1136/thoraxjnl-2014-205940] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with COPD commonly exhibit pursed-lip breathing during exercise, a strategy that, by increasing intrinsic positive end-expiratory pressure, may optimise lung mechanics and exercise tolerance. A similar role for laryngeal narrowing in modulating exercise airways resistance and the respiratory cycle volume-time course is postulated, yet remains unstudied in COPD. The aim of this study was to assess the characteristics of laryngeal narrowing and its role in exercise intolerance and dynamic hyperinflation in COPD. METHODS We studied 19 patients (n=8 mild-moderate; n=11 severe COPD) and healthy age and sex matched controls (n=11). Baseline physiological characteristics and clinical status were assessed prior to an incremental maximal cardiopulmonary exercise test with continuous laryngoscopy. Laryngeal narrowing measures were calculated at the glottic and supra-glottic aperture at rest and peak exercise. RESULTS At rest, expiratory laryngeal narrowing was pronounced at the glottic level in patients and related to FEV1 in the whole cohort (r=-0.71, p<0.001) and patients alone (r=-0.53, p=0.018). During exercise, glottic narrowing was inversely related to peak ventilation in all subjects (r=-0.55, p=0.0015) and patients (r=-0.71, p<0.001) and peak exercise tidal volume (r=-0.58, p=0.0062 and r=-0.55, p=0.0076, respectively). Exercise glottic narrowing was also inversely related to peak oxygen uptake (% predicted) in all subjects (r=-0.65, p<0.001) and patients considered alone (r=-0.58, p=0.014). Exercise inspiratory duty cycle was related to exercise glottic narrowing for all subjects (r=-0.69, p<0.001) and patients (r=-0.62, p<0.001). CONCLUSIONS Dynamic laryngeal narrowing during expiration is prevalent in patients with COPD and is related to disease severity, respiratory duty cycle and exercise capacity.
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Affiliation(s)
- M Baz
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK Departamento Clinico de Medicina, Hospital de Clinicas, Facultad de Medicina, Universidad de la Republica, Montevideo, Uruguay
| | - G S Haji
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - A Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - R J Tanner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - N S Hopkinson
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - M I Polkey
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - J H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
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Effects of an additional pressure support level on exercise duration in patients on prolonged mechanical ventilation. J Formos Med Assoc 2014; 114:1204-10. [PMID: 25304086 DOI: 10.1016/j.jfma.2014.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 09/01/2014] [Accepted: 09/02/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND/PURPOSE Noninvasive positive pressure ventilation has been regarded as a strategy for improving exercise performance. Whether an increase in the ventilatory support level improves exercise performance in patients who have received invasive ventilation is unknown. The purpose of this study is to examine the effects of an additional level of pressure support (PS) ventilation on exercise tolerance in patients undergoing prolonged mechanical ventilation (PMV). METHODS This study examined 15 patients who were undergoing PMV. All patients performed an upper-arm exercise test at three PS levels: the baseline PS level (PS), a level 2 cmH2O higher than the baseline level (PS+2), and a level 4 cmH2O higher than the baseline level (PS+4). The physiological response, reasons for discontinuing the exercise test, and exercise duration were recorded and analyzed. RESULTS The tidal volume increased significantly from 271.7 ± 54.7 mL to 398.3 ± 88.7 mL at the PS+4 level (p = 0.01). Significant differences in exercise duration were observed at different PS levels. The exercise duration was significantly longer at the PS+4 level than at the PS and PS+2 levels (146.3 ± 139.9 seconds vs. 108.5 ± 85.9 seconds vs. 72.8 ± 43.9 seconds, p = 0.038) as their corresponding order. There were significant relationships between resting respiratory rate and exercise duration at the PS (r = -0.639, p = 0.034) and PS+2 levels (r = -0.668, p = 0.025). CONCLUSION In patients undergoing PMV, an additional PS level of up to 4 cmH2O compared with the baseline setting may help to improve exercise tolerance by prolonging exercise duration.
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Martolini D, Tanner R, Davey C, Patel MS, Elia D, Purcell H, Palange P, Hopkinson NS, Polkey MI. Significance of Patent Foramen Ovale in Patients with GOLD Stage II Chronic Obstructive Pulmonary Disease (COPD). CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2014; 1:185-192. [PMID: 28848820 DOI: 10.15326/jcopdf.1.2.2013.0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Patent foramen ovale (PFO) is a common finding in adults. A PFO is associated with right to left shunting but its importance in the aetiology of hypoxia in early COPD remains uncertain, although it has not proved possible to demonstrate a role for PFOs in the aetiology of hypoxia in patients with Global Initiative for chronic Obstructive Lung Disease (GOLD) stage III/IV disease. We compared the characteristics of GOLD stage II patients with or without a PFO and assessed its impact on exercise performance. Methods: In 22 GOLD stage II COPD patients we measured exercise performance, arterial oxygen tension and lung function and used contrast transcranial Doppler ultrasonography (TCD) to assess the presence of a PFO. Patients (n=20) underwent TCD measurements during incremental cycle ergometry with respiratory pressures measured using an esophageal balloon catheter (n=13). Results:Twelve individuals (54%) had a PFO. Patients with a PFO were more hypoxic; mean(SD) partial pressure of oxygen in arterial blood (PaO2)10.2(1.1) kilopascals (kPa) vs. 11.7(0.9)kPa (p<0.01), but the presence of a PFO was not associated with reduced exercise performance either on cycle ergometry or a 6 Minute Walk Test (6MWT). A strong relationship was noted between the esophageal pressure swing (PSwingEs) and the degree of shunting observed during exercise (r=0.7; p<0.001). Conclusions:The presence of a PFO in GOLD stage II COPD patients does not appear to influence exercise performance despite increased right-to-left shunting.
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Affiliation(s)
- Dario Martolini
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom.,Laboratory of Respiratory Pathophysiology, Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Rebecca Tanner
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Claire Davey
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Mehul S Patel
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Davide Elia
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Helen Purcell
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Paolo Palange
- Laboratory of Respiratory Pathophysiology, Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Nicholas S Hopkinson
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
| | - Michael I Polkey
- National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College, London, United Kingdom
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Does expiratory muscle activity influence dynamic hyperinflation and exertional dyspnea in COPD? Respir Physiol Neurobiol 2014; 199:24-33. [DOI: 10.1016/j.resp.2014.04.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 04/15/2014] [Accepted: 04/18/2014] [Indexed: 11/24/2022]
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Louvaris Z, Vogiatzis I, Aliverti A, Habazettl H, Wagner H, Wagner P, Zakynthinos S. Blood flow does not redistribute from respiratory to leg muscles during exercise breathing heliox or oxygen in COPD. J Appl Physiol (1985) 2014; 117:267-76. [PMID: 24903919 DOI: 10.1152/japplphysiol.00490.2014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In patients with chronic obstructive pulmonary disease (COPD), one of the proposed mechanisms for improving exercise tolerance, when work of breathing is experimentally reduced, is redistribution of blood flow from the respiratory to locomotor muscles. Accordingly, we investigated whether exercise capacity is improved on the basis of blood flow redistribution during exercise while subjects are breathing heliox (designed to primarily reduce the mechanical work of breathing) and during exercise with oxygen supplementation (designed to primarily enhance systemic oxygen delivery but also to reduce mechanical work of breathing). Intercostal, abdominal, and vastus lateralis muscle perfusion were simultaneously measured in 10 patients with COPD (forced expiratory volume in 1 s: 46 ± 12% predicted) by near-infrared spectroscopy using indocyanine green dye. Measurements were performed during constant-load exercise at 75% of peak capacity to exhaustion while subjects breathed room air and, then at the same workload, breathed either normoxic heliox (helium 79% and oxygen 21%) or 100% oxygen, the latter two in balanced order. Times to exhaustion while breathing heliox and oxygen did not differ (659 ± 42 s with heliox and 696 ± 48 s with 100% O2), but both exceeded that on room air (406 ± 36 s, P < 0.001). At exhaustion, intercostal and abdominal muscle blood flow during heliox (9.5 ± 0.6 and 8.0 ± 0.7 ml · min(-1)·100 g(-1), respectively) was greater compared with room air (6.8 ± 0.5 and 6.0 ± 0.5 ml·min(-1)·100 g·, respectively; P < 0.05), whereas neither intercostal nor abdominal muscle blood flow differed between oxygen and air breathing. Quadriceps muscle blood flow was also greater with heliox compared with room air (30.2 ± 4.1 vs. 25.4 ± 2.9 ml·min(-1)·100 g(-1); P < 0.01) but did not differ between air and oxygen breathing. Although our findings confirm that reducing the burden on respiration by heliox or oxygen breathing prolongs time to exhaustion (at 75% of maximal capacity) in patients with COPD, they do not support the hypothesis that redistribution of blood flow from the respiratory to locomotor muscles is the explanation.
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Affiliation(s)
- Zafeiris Louvaris
- First Department of Critical Care Medicine and Pulmonary Services, GP Livanos and M Simou Laboratories, Medical School of Athens University, Evangelismos Hospital, Athens, Greece; National and Kapodistrian University of Athens, Department of Physical Education and Sports Sciences, Athens, Greece
| | - Ioannis Vogiatzis
- First Department of Critical Care Medicine and Pulmonary Services, GP Livanos and M Simou Laboratories, Medical School of Athens University, Evangelismos Hospital, Athens, Greece; National and Kapodistrian University of Athens, Department of Physical Education and Sports Sciences, Athens, Greece; University of the West of Scotland, Institute of Clinical Exercise and Health Sciences, Hamilton, United Kingdom
| | - Andrea Aliverti
- Dipartimento di Biongegneria, Politecnico di Milano, Milano Italy
| | - Helmut Habazettl
- Institute of Physiology, Charite Campus Benjamin Franklin, Berlin, Germany; Institute of Anesthesiology, German Heart Institute, Berlin, Germany
| | - Harrieth Wagner
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Peter Wagner
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Spyros Zakynthinos
- First Department of Critical Care Medicine and Pulmonary Services, GP Livanos and M Simou Laboratories, Medical School of Athens University, Evangelismos Hospital, Athens, Greece;
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Menadue C, Piper AJ, van 't Hul AJ, Wong KK. Non-invasive ventilation during exercise training for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; 2014:CD007714. [PMID: 24823712 PMCID: PMC10984247 DOI: 10.1002/14651858.cd007714.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Exercise training as a component of pulmonary rehabilitation improves health-related quality of life (HRQL) and exercise capacity in people with chronic obstructive pulmonary disease (COPD). However, some individuals may have difficulty performing exercise at an adequate intensity. Non-invasive ventilation (NIV) during exercise improves exercise capacity and dyspnoea during a single exercise session. Consequently, NIV during exercise training may allow individuals to exercise at a higher intensity, which could lead to greater improvement in exercise capacity, HRQL and physical activity. OBJECTIVES To determine whether NIV during exercise training (as part of pulmonary rehabilitation) affects exercise capacity, HRQL and physical activity in people with COPD compared with exercise training alone or exercise training with sham NIV. SEARCH METHODS We searched the following databases between January 1987 and November 2013 inclusive: The Cochrane Airways Group specialised register of trials, AMED, CENTRAL, CINAHL, EMBASE, LILACS, MEDLINE, PEDro, PsycINFO and PubMed. SELECTION CRITERIA Randomised controlled trials that compared NIV during exercise training versus exercise training alone or exercise training with sham NIV in people with COPD were considered for inclusion in this review. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion in the review, extracted data and assessed risk of bias. Primary outcomes were exercise capacity, HRQL and physical activity; secondary outcomes were training intensity, physiological changes related to exercise training, dyspnoea, dropouts, adverse events and cost. MAIN RESULTS Six studies involving 126 participants who completed the study protocols were included. Most studies recruited participants with severe to very severe COPD (mean forced expiratory volume in one second (FEV1) ranged from 26% to 48% predicted). There was an increase in percentage change peak and endurance exercise capacity with NIV during training (mean difference in peak exercise capacity 17%, 95% confidence interval (CI) 7% to 27%, 60 participants, low-quality evidence; mean difference in endurance exercise capacity 59%, 95% CI 4% to 114%, 48 participants, low-quality evidence). However, there was no clear evidence of a difference between interventions for all other measures of exercise capacity. The results for HRQL assessed using the St George's Respiratory Questionnaire do not rule out an effect of NIV (total score mean 2.5 points, 95% CI -2.3 to 7.2, 48 participants, moderate-quality evidence). Physical activity was not assessed in any study. There was an increase in training intensity with NIV during training of 13% (95% CI 1% to 27%, 67 participants, moderate-quality evidence), and isoload lactate was lower with NIV (mean difference -0.97 mmol/L, 95% CI -1.58mmol/L to -0.36 mmol/L, 37 participants, moderate-quality evidence). The effect of NIV on dyspnoea or the number of dropouts between interventions was uncertain, although again results were imprecise. No adverse events and no information regarding cost were reported. Only one study blinded participants, whereas three studies used blinded assessors. Adequate allocation concealment was reported in four studies. AUTHORS' CONCLUSIONS The small number of included studies with small numbers of participants, as well as the high risk of bias within some of the included studies, limited our ability to draw strong evidence-based conclusions. Although NIV during lower limb exercise training may allow people with COPD to exercise at a higher training intensity and to achieve a greater physiological training effect compared with exercise training alone or exercise training with sham NIV, the effect on exercise capacity is unclear. Some evidence suggests that NIV during exercise training improves the percentage change in peak and endurance exercise capacity; however, these findings are not consistent across other measures of exercise capacity. There is no clear evidence that HRQL is better or worse with NIV during training. It is currently unknown whether the demonstrated benefits of NIV during exercise training are clinically worthwhile or cost-effective.
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Affiliation(s)
- Collette Menadue
- Royal Prince Alfred HospitalDepartment of Respiratory and Sleep MedicineMissenden RoadCamperdownNSWAustralia2050
| | - Amanda J Piper
- Royal Prince Alfred HospitalDepartment of Respiratory and Sleep MedicineMissenden RoadCamperdownNSWAustralia2050
- Woolcock Institute of Medical Research431 Glebe Point RoadGlebeNSWAustralia2037
| | | | - Keith K Wong
- Royal Prince Alfred HospitalDepartment of Respiratory and Sleep MedicineMissenden RoadCamperdownNSWAustralia2050
- Woolcock Institute of Medical Research431 Glebe Point RoadGlebeNSWAustralia2037
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Shaikh ZF, Kelly JL, Shrikrishna D, de Villa M, Mullen MJ, Hopkinson NS, Morrell MJ, Polkey MI. Patent foramen ovale is not associated with hypoxemia in severe chronic obstructive pulmonary disease and does not impair exercise performance. Am J Respir Crit Care Med 2014; 189:540-7. [PMID: 24450410 DOI: 10.1164/rccm.201309-1618oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance. OBJECTIVES To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance. METHODS Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters. MEASUREMENTS AND MAIN RESULTS PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns). CONCLUSIONS Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.
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Affiliation(s)
- Zarrin F Shaikh
- 1 Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, and
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Hill K, Holland AE. Strategies to enhance the benefits of exercise training in the respiratory patient. Clin Chest Med 2014; 35:323-36. [PMID: 24874128 DOI: 10.1016/j.ccm.2014.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Despite the well-established benefits of exercise training in people with chronic respiratory disease, there are a group of people in whom it confers minimal gains. Furthermore, there is increasing recognition of the prevalence of comorbid conditions among people with chronic obstructive pulmonary disease and other respiratory diseases, such as musculoskeletal disorders, which make participation in traditional exercise training programs challenging. This article focuses on several adjuncts or strategies that may be implemented by clinicians during exercise training, with the goal of optimizing the proportion of pulmonary rehabilitation participants who achieve significant and meaningful gains on program completion.
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Affiliation(s)
- Kylie Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia; Lung Institute of Western Australia, Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Hospital Avenue, Nedlands, Western Australia 6009, Australia; Physiotherapy Department, Royal Perth Hospital, Wellington Street, Perth, Western Australia 6000, Australia.
| | - Anne E Holland
- Department of Physiotherapy, La Trobe University, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Department of Physiotherapy, Alfred Health, Commercial Road, Melbourne, Victoria 3004, Australia; Institute for Breathing and Sleep, Studley Road, Heidelberg, Victoria 3084, Australia
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Thomas M, Decramer M, O'Donnell DE. No room to breathe: the importance of lung hyperinflation in COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:101-11. [PMID: 23429861 PMCID: PMC6442765 DOI: 10.4104/pcrj.2013.00025] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are progressively limited in their ability to undertake normal everyday activities by a combination of exertional dyspnoea and peripheral muscle weakness. COPD is characterised by expiratory flow limitation, resulting in air trapping and lung hyperinflation. Hyperinflation increases acutely under conditions such as exercise or exacerbations, with an accompanying sharp increase in the intensity of dyspnoea to distressing and intolerable levels. Air trapping, causing increased lung hyperinflation, can be present even in milder COPD during everyday activities. The resulting activity-related dyspnoea leads to a vicious spiral of activity avoidance, physical deconditioning, and reduced quality of life, and has implications for the early development of comorbidities such as cardiovascular disease. Various strategies exist to reduce hyperinflation, notably long-acting bronchodilator treatment (via reduction in flow limitation and improved lung emptying) and an exercise programme (via decreased respiratory rate, reducing ventilatory demand), or their combination. Optimal bronchodilation can reduce exertional dyspnoea and increase a patient's ability to exercise, and improves the chance of successful outcome of a pulmonary rehabilitation programme. There should be a lower threshold for initiating treatments appropriate to the stage of the disease, such as long-acting bronchodilators and an exercise programme for patients with mild-to-moderate disease who experience persistent dyspnoea.
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Affiliation(s)
- Mike Thomas
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Nicolini A, Merliak F, Barlascini C. Use of positive expiratory pressure during six minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease. Multidiscip Respir Med 2013; 8:19. [PMID: 23497658 PMCID: PMC3637106 DOI: 10.1186/2049-6958-8-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 01/17/2013] [Indexed: 11/20/2022] Open
Abstract
Background The six-minute walk test (6MWT) is widely used because it is both simple and reliable as a measure of exercise capacity. Individuals with chronic obstructive pulmonary disease (COPD) usually show a limited capacity to perform exercise. Methods Our study is a prospective, randomized controlled trial which uses the 6MWT in one hundred consecutive in and out- patients with moderate to severe COPD to assess the benefit of a simple positive expiratory pressure (PEP) device. PEP device consisted of a PEP valve 5 cmH2O connected to 1-meter tube and a mouthpiece. All the enrolled patients performed a 6MWT before randomization. The following day PEP group patients performed the 6MWT using PEP device. Control group patients performed the 6MWT without this device. The primary outcome was the difference in distance (meters) walked. Results Functional capacity assessed by the distance covered during 6MWT improved in the PEP group more than in the control group. The difference was statistically significant (p < 0.001).Oxygen saturation improved to a statistically significant level during 6MWT (p < 0.01). Heart rate was also reduced (p < 0.03). Conclusions There are few studies demonstrating that PEP devices enhance exercise capacity in COPD patients. Our results has been obtained using only a low positive expiratory pressure (5 cmH2O). In our opinion the strength of this study is the simplicity and the lower cost when compared to other devices and approaches. The study was registered as Chi CTR-ORC-12002173 at http://www.chictr.org.
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Affiliation(s)
- Antonello Nicolini
- Respiratory Diseases Unit,Hospital of Sestri Levante, Via Terzi 43-16039, SestriLevante, Italy.
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Takara LS, Cunha TM, Barbosa P, Rodrigues MK, Oliveira MF, Nery LE, Neder JA. Dynamics of chest wall volume regulation during constant work rate exercise in patients with chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2012; 45:1276-83. [PMID: 23250012 PMCID: PMC3854210 DOI: 10.1590/s0100-879x2012007500162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/27/2012] [Indexed: 11/22/2022]
Abstract
This study evaluated the dynamic behavior of total and compartmental chest wall volumes [(V CW) = rib cage (V RC) + abdomen (V AB)] as measured breath-by-breath by optoelectronic plethysmography during constant-load exercise in patients with stable chronic obstructive pulmonary disease. Thirty males (GOLD stages II-III) underwent a cardiopulmonary exercise test to the limit of tolerance (Tlim) at 75% of peak work rate on an electronically braked cycle ergometer. Exercise-induced dynamic hyperinflation was considered to be present when end-expiratory (EE) V CW increased in relation to resting values. There was a noticeable heterogeneity in the patterns of V CW regulation as EEV CW increased non-linearly in 17/30 "hyperinflators" and decreased in 13/30 "non-hyperinflators" (P < 0.05). EEV AB decreased slightly in 8 of the "hyperinflators", thereby reducing and slowing the rate of increase in end-inspiratory (EI) V CW (P < 0.05). In contrast, decreases in EEV CW in the "non-hyperinflators" were due to the combination of stable EEV RC with marked reductions in EEV AB. These patients showed lower EIV CW and end-exercise dyspnea scores but longer Tlim than their counterparts (P < 0.05). Dyspnea increased and Tlim decreased non-linearly with a faster rate of increase in EIV CW regardless of the presence or absence of dynamic hyperinflation (P < 0.001). However, no significant between-group differences were observed in metabolic, pulmonary gas exchange and cardiovascular responses to exercise. Chest wall volumes are continuously regulated during exercise in order to postpone (or even avoid) their migration to higher operating volumes in patients with COPD, a dynamic process that is strongly dependent on the behavior of the abdominal compartment.
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Affiliation(s)
- L S Takara
- Setor de Função Pulmonar e Fisiologia Clínica do Exercício, Disciplina de Pneumologia, Departamento de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Takara L, Cunha T, Barbosa P, Rodrigues M, Oliveira M, Nery L, Neder J. Dynamics of chest wall volume regulation during constant work rate exercise in patients with chronic obstructive pulmonary disease. Braz J Med Biol Res 2012. [DOI: 10.1590/s0100-879x2012001200024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - T.M. Cunha
- Universidade Federal de São Paulo, Brasil
| | - P. Barbosa
- Universidade Federal de São Paulo, Brasil
| | | | | | - L.E. Nery
- Universidade Federal de São Paulo, Brasil
| | - J.A. Neder
- Universidade Federal de São Paulo, Brasil; Queen’s University, Canada
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Patel MS, Hart N, Polkey MI. Rebuttal from Mehul S. Patel, Nicholas Hart and Michael I. Polkey. J Physiol 2012. [DOI: 10.1113/jphysiol.2012.236364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Elia D, Kelly JL, Martolini D, Renzoni EA, Boutou AK, Chetta A, Polkey MI, Hopkinson NS. Respiratory muscle fatigue following exercise in patients with interstitial lung disease. ACTA ACUST UNITED AC 2012; 85:220-7. [PMID: 22813885 DOI: 10.1159/000338787] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 03/26/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is not known whether respiratory muscle fatigue occurs as a consequence of exercise in patients with interstitial lung disease (ILD) and, if so, to what extent it is related to changes in dynamic lung volumes. OBJECTIVES To assess the development of respiratory muscle fatigue in patients with ILD and relate it to the respiratory pattern during exercise. METHODS Sixteen ILD patients (11 women) performed incremental, symptom-limited cycle ergometry with inspiratory capacity manoeuvres used to measure changes in end-expiratory lung volume (EELV). Twitch transdia-phragmatic pressure (TwPdi) and twitch gastric pressure (TwT10Pga), in response to magnetic stimulation, were used to assess the development of fatigue. RESULTS TwPdi did not differ significantly before and after exercise (21.8 ± 8 vs. 20.2 ± 8 cm H2O; p = 0.10), while TwT10Pga fell from 28.6 ± 18 to 25.2 ± 14 cm H2O (p = 0.02). EELV fell from 2.18 ± 0.65 to 1.91 ± 0.59 liters following exercise (p = 0.04). The fall in TwT10Pga correlated with peak oxygen uptake at peak of exercise (r = -0.52, p = 0.041), increase in heart rate (r = 0.53, p = 0.032) and with the decrease of EELV during exercise (r = 0.57, p = 0.021). Abdominal muscle fatiguers (n = 9, 56%), defined as having a ≥10% fall in TwT10Pga, had a fall in EELV of 22 ± 22% compared to 0.7 ± 8% in non-fatiguers (p = 0.016). CONCLUSION Abdominal muscle fatigue develops during exercise in some ILD patients in association with increased expiratory muscle activity manifested by reduced EELV.
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Affiliation(s)
- Davide Elia
- NIHR Respiratory Biomedical Research Unit at Royal Brompton and Harefield NHS Foundation Trust and Imperial College, Royal Brompton Hospital, London, UK
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Reilly CC, Ward K, Jolley CJ, Frank LA, Elston C, Moxham J, Rafferty GF. Effect of endurance exercise on respiratory muscle function in patients with cystic fibrosis. Respir Physiol Neurobiol 2012; 180:316-22. [DOI: 10.1016/j.resp.2011.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 12/15/2011] [Accepted: 12/20/2011] [Indexed: 11/17/2022]
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Moga AM, de Marchie M, Saey D, Spahija J. Mechanisms of non-pharmacologic adjunct therapies used during exercise in COPD. Respir Med 2012; 106:614-26. [PMID: 22341681 DOI: 10.1016/j.rmed.2012.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 01/04/2012] [Accepted: 01/12/2012] [Indexed: 11/16/2022]
Abstract
Individuals with chronic obstructive pulmonary disease (COPD) are often limited in their ability to perform exercise due to a heightened sense of dyspnea and/or the occurrence of leg fatigue associated with a reduced ventilatory capacity and peripheral skeletal muscle dysfunction, respectively. Pulmonary rehabilitation programs have been shown to improve exercise tolerance and health related quality of life. Additional therapeutic approaches such as non-invasive ventilatory support (NIVS), heliox (He-O(2)) and supplemental oxygen have been used as non-pharmacologic adjuncts to exercise to enhance the ability of patients with COPD to exercise at a higher exercise-intensity and thus improve the physiological benefits of exercise. The purpose of the current review is to examine the pathophysiology of exercise limitation in COPD and to explore the physiological mechanisms underlying the effect of the adjunct therapies on exercise in patients with COPD. This review indicates that strategies that aim to unload the respiratory muscles and enhance oxygen saturation during exercise alleviate exercise limiting factors and improve exercise performance in patients with COPD. However, available data shows significant variability in the effectiveness across patients. Further research is needed to identify the most appropriate candidates for these forms of therapies.
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Affiliation(s)
- A M Moga
- School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir William Osler, Montreal, Quebec H3G 1Y5, Canada
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Vogiatzis I, Habazettl H, Aliverti A, Athanasopoulos D, Louvaris Z, LoMauro A, Wagner H, Roussos C, Wagner PD, Zakynthinos S. Effect of helium breathing on intercostal and quadriceps muscle blood flow during exercise in COPD patients. Am J Physiol Regul Integr Comp Physiol 2011; 300:R1549-59. [PMID: 21411767 DOI: 10.1152/ajpregu.00671.2010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emerging evidence indicates that, besides dyspnea relief, an improvement in locomotor muscle oxygen delivery may also contribute to enhanced exercise tolerance following normoxic heliox (replacement of inspired nitrogen by helium) administration in patients with chronic obstructive pulmonary disease (COPD). Whether blood flow redistribution from intercostal to locomotor muscles contributes to this improvement currently remains unknown. Accordingly, the objective of this study was to investigate whether such redistribution plays a role in improving locomotor muscle oxygen delivery while breathing heliox at near-maximal [75% peak work rate (WR(peak))], maximal (100%WR(peak)), and supramaximal (115%WR(peak)) exercise in COPD. Intercostal and vastus lateralis muscle perfusion was measured in 10 COPD patients (FEV(1) = 50.5 ± 5.5% predicted) by near-infrared spectroscopy using indocyanine green dye. Patients undertook exercise tests at 75 and 100%WR(peak) breathing either air or heliox and at 115%WR(peak) breathing heliox only. Patients did not exhibit exercise-induced hyperinflation. Normoxic heliox reduced respiratory muscle work and relieved dyspnea across all exercise intensities. During near-maximal exercise, quadriceps and intercostal muscle blood flows were greater, while breathing normoxic heliox compared with air (35.8 ± 7.0 vs. 29.0 ± 6.5 and 6.0 ± 1.3 vs. 4.9 ± 1.2 ml·min(-1)·100 g(-1), respectively; P < 0.05; mean ± SE). In addition, compared with air, normoxic heliox administration increased arterial oxygen content, as well as oxygen delivery to quadriceps and intercostal muscles (from 47 ± 9 to 60 ± 12, and from 8 ± 1 to 13 ± 3 mlO(2)·min(-1)·100 g(-1), respectively; P < 0.05). In contrast, normoxic heliox had neither an effect on systemic nor an effect on quadriceps or intercostal muscle blood flow and oxygen delivery during maximal or supramaximal exercise. Since intercostal muscle blood flow did not decrease by normoxic heliox administration, blood flow redistribution from intercostal to locomotor muscles does not represent a likely mechanism of improvement in locomotor muscle oxygen delivery. Our findings might not be applicable to patients who hyperinflate during exercise.
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Affiliation(s)
- Ioannis Vogiatzis
- Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, “M. Simou, and G.P. Livanos Laboratories,” National and Kapodistrian University of Athens, Greece
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Luo Y, Li R, Jolley C, Wu H, Steier J, Moxham J, Zhong N. Neural Respiratory Drive in Patients with COPD during Exercise Tests. Respiration 2011; 81:294-301. [DOI: 10.1159/000317136] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/05/2010] [Indexed: 11/19/2022] Open
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De Backer LA, Ides K, Daems D, Dieriks B, De Backer WA, Germonpre P. Pulmonary rehabilitation and non-invasive ventilation in COPD. Acta Clin Belg 2010; 65:330-5. [PMID: 21128560 DOI: 10.1179/acb.2010.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A multidisciplinary pulmonary rehabilitation program has become an important part of the treatment of chronic obstructive pulmonary disease. It can improve both exercise tolerance and health related quality of life in these patients. Exercise training has to be included for the program to be successful. The intensity of the training is of great importance: there is more physiological benefit in high-intensity training, compared to moderate-intensity training. High-intensity training results in reduced levels of blood lactate and pulmonary ventilation at a given heavy work rate. High-intensity training is limited in COPD patients because of exercise-induced dyspnoea. Flow limitation, as a consequence of increased ventilatory demands of exercise, causes a breathing pattern with greater demands on their inspiratory muscles: this results in a pattern of low tidal volume and high-frequency breathing. Increased inspiratory muscle work causes dyspnoea and limitation in exercise intensity. Artificial ventilatory assistance could improve exercise tolerance and hence help severe COPD patients to achieve a higher level of training. It could help to unload and assist the overburdened ventilatory muscles and give a possibility for higher levels of exercise intensity. In this review article we will discuss the effectiveness and feasibility of training with ventilatory aids.
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Affiliation(s)
- L A De Backer
- Department of Respiratory Medicine, Antwerp University Hospital, Antwerp, Belgium.
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Taylor BJ, West CR, Romer LM. No effect of arm-crank exercise on diaphragmatic fatigue or ventilatory constraint in Paralympic athletes with cervical spinal cord injury. J Appl Physiol (1985) 2010; 109:358-66. [DOI: 10.1152/japplphysiol.00227.2010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cervical spinal cord injury (CSCI) results in a decrease in the capacity of the lungs and chest wall for pressure, volume, and airflow generation. We asked whether such impairments might increase the potential for exercise-induced diaphragmatic fatigue and mechanical ventilatory constraint in this population. Seven Paralympic wheelchair rugby players (mean ± SD peak oxygen uptake = 16.9 ± 4.9 ml·kg−1·min−1) with traumatic CSCI (C5–C7) performed arm-crank exercise to the limit of tolerance at 90% of their predetermined peak work rate. Diaphragm function was assessed before and 15 and 30 min after exercise by measuring the twitch transdiaphragmatic pressure (Pdi,tw) response to bilateral anterolateral magnetic stimulation of the phrenic nerves. Ventilatory constraint was assessed by measuring the tidal flow volume responses to exercise in relation to the maximal flow volume envelope. Pdi,tw was not different from baseline at any time after exercise (unpotentiated Pdi,tw = 19.3 ± 5.6 cmH2O at baseline, 19.8 ± 5.0 cmH2O at 15 min after exercise, and 19.4 ± 5.7 cmH2O at 30 min after exercise; P = 0.16). During exercise, there was a sudden, sustained rise in operating lung volumes and an eightfold increase in the work of breathing. However, only two subjects showed expiratory flow limitation, and there was substantial capacity to increase both flow and volume (<50% of maximal breathing reserve). In conclusion, highly trained athletes with CSCI do not develop exercise-induced diaphragmatic fatigue and rarely reach mechanical ventilatory constraint.
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Affiliation(s)
- Bryan J. Taylor
- Centre for Sports Medicine and Human Performance, Brunel University, Uxbridge, United Kingdom
| | - Christopher R. West
- Centre for Sports Medicine and Human Performance, Brunel University, Uxbridge, United Kingdom
| | - Lee M. Romer
- Centre for Sports Medicine and Human Performance, Brunel University, Uxbridge, United Kingdom
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Amann M, Regan MS, Kobitary M, Eldridge MW, Boutellier U, Pegelow DF, Dempsey JA. Impact of pulmonary system limitations on locomotor muscle fatigue in patients with COPD. Am J Physiol Regul Integr Comp Physiol 2010; 299:R314-24. [PMID: 20445160 DOI: 10.1152/ajpregu.00183.2010] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We examined the effects of respiratory muscle work [inspiratory (W(r-insp)); expiratory (W(r-exp))] and arterial oxygenation (Sp(O(2))) on exercise-induced locomotor muscle fatigue in patients with chronic obstructive pulmonary disease (COPD). Eight patients (FEV, 48 +/- 4%) performed constant-load cycling to exhaustion (Ctrl; 9.8 +/- 1.2 min). In subsequent trials, the identical exercise was repeated with 1) proportional assist ventilation + heliox (PAV); 2) heliox (He:21% O(2)); 3) 60% O(2) inspirate (hyperoxia); or 4) hyperoxic heliox mixture (He:40% O(2)). Five age-matched healthy control subjects performed Ctrl exercise at the same relative workload but for 14.7 min ( approximately best COPD performance). Exercise-induced quadriceps fatigue was assessed via changes in quadriceps twitch force (Q(tw,pot)) from before to 10 min after exercise in response to supramaximal femoral nerve stimulation. During Ctrl, absolute workload (124 +/- 6 vs. 62 +/- 7 W), W(r-insp) (207 +/- 18 vs. 301 +/- 37 cmH(2)O x s x min(-1)), W(r-exp) (172 +/- 15 vs. 635 +/- 58 cmH(2)O x s x min(-1)), and Sp(O(2)) (96 +/- 1% vs. 87 +/- 3%) differed between control subjects and patients. Various interventions altered W(r-insp), W(r-exp), and Sp(O(2)) from Ctrl (PAV: -55 +/- 5%, -21 +/- 7%, +6 +/- 2%; He:21% O(2): -16 +/- 2%, -25 +/- 5%, +4 +/- 1%; hyperoxia: -11 +/- 2%, -17 +/- 4%, +16 +/- 4%; He:40% O(2): -22 +/- 2%, -27 +/- 6%, +15 +/- 4%). Ten minutes after Ctrl exercise, Q(tw,pot) was reduced by 25 +/- 2% (P < 0.01) in all COPD and 2 +/- 1% (P = 0.07) in healthy control subjects. In COPD, DeltaQ(tw,pot) was attenuated by one-third after each interventional trial; however, most of the exercise-induced reductions in Q(tw,pot) remained. Our findings suggest that the high susceptibility to locomotor muscle fatigue in patients with COPD is in part attributable to insufficient O(2) transport as a consequence of exaggerated arterial hypoxemia and/or excessive respiratory muscle work but also support a critical role for the well-known altered intrinsic muscle characteristics in these patients.
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Affiliation(s)
- Markus Amann
- John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison Medical School, Madison, Wisconsin, USA.
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Oliveira CC, Carrascosa CR, Borghi-Silva A, Berton DC, Queiroga F, Ferreira EMV, Nery LE, Alberto Neder J. Influence of respiratory pressure support on hemodynamics and exercise tolerance in patients with COPD. Eur J Appl Physiol 2010; 109:681-9. [DOI: 10.1007/s00421-010-1408-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2010] [Indexed: 11/27/2022]
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Hopkinson NS, Dayer MJ, Moxham J, Polkey MI. Abdominal muscle fatigue following exercise in chronic obstructive pulmonary disease. Respir Res 2010; 11:15. [PMID: 20132549 PMCID: PMC2824704 DOI: 10.1186/1465-9921-11-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 02/04/2010] [Indexed: 11/16/2022] Open
Abstract
Background In patients with chronic obstructive pulmonary disease, a restriction on maximum ventilatory capacity contributes to exercise limitation. It has been demonstrated that the diaphragm in COPD is relatively protected from fatigue during exercise. Because of expiratory flow limitation the abdominal muscles are activated early during exercise in COPD. This adds significantly to the work of breathing and may therefore contribute to exercise limitation. In healthy subjects, prior expiratory muscle fatigue has been shown itself to contribute to the development of quadriceps fatigue. It is not known whether fatigue of the abdominal muscles occurs during exercise in COPD. Methods Twitch gastric pressure (TwT10Pga), elicited by magnetic stimulation over the 10th thoracic vertebra and twitch transdiaphragmatic pressure (TwPdi), elicited by bilateral anterolateral magnetic phrenic nerve stimulation were measured before and after symptom-limited, incremental cycle ergometry in patients with COPD. Results Twenty-three COPD patients, with a mean (SD) FEV1 40.8(23.1)% predicted, achieved a mean peak workload of 53.5(15.9) W. Following exercise, TwT10Pga fell from 51.3(27.1) cmH2O to 47.4(25.2) cmH2O (p = 0.011). TwPdi did not change significantly; pre 17.0(6.4) cmH2O post 17.5(5.9) cmH2O (p = 0.7). Fatiguers, defined as having a fall TwT10Pga ≥ 10% had significantly worse lung gas transfer, but did not differ in other exercise parameters. Conclusions In patients with COPD, abdominal muscle but not diaphragm fatigue develops following symptom limited incremental cycle ergometry. Further work is needed to establish whether abdominal muscle fatigue is relevant to exercise limitation in COPD, perhaps indirectly through an effect on quadriceps fatigability.
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Affiliation(s)
- Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, Fulham Rd, London SW3 6NP, UK.
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Fulton I, McEvoy M, Pieterse J, Williams M, Thoirs K, Petkov J. Transversus abdominis: changes in thickness during the unsupported upper limb exercise test in older adults. Physiother Theory Pract 2009; 25:523-32. [PMID: 19925260 DOI: 10.3109/09593980802665023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Novel, short-lived upper limb tasks performed by young adults have been used to investigate the role of transversus abdominis (TrA) in maintaining postural stability. Little information exists concerning the behaviour of TrA in older adults during protracted postural challenges. The primary aim of this study was to describe the change in thickness of TrA during an incremental upper limb exercise test in older adults. A secondary analysis was undertaken to compare the results between younger and older subjects. Healthy subjects aged between 40 and 70 years performed the Unsupported Upper Limb Exercise Test (UULEX) while activity of TrA was continuously monitored by using rehabilitative ultrasound imaging. Changes in muscle dimensions were measured every minute during the test. The thickness of TrA increased significantly and exponentially between minutes 8 and 13 of the UULEX. Although there was a significant difference between older and younger subjects in absolute measures of TrA thickness, the change in TrA thickness as a percentage of resting thickness during the UULEX demonstrated an identical pattern between younger and older subjects. This study suggests that TrA is continually and increasingly active during an upper limb task in both younger and older asymptomatic subjects.
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Affiliation(s)
- Ian Fulton
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Menadue C, Alison JA, Piper AJ, Flunt D, Ellis ER. Bilevel ventilation during exercise in acute on chronic respiratory failure: a preliminary study. Respir Med 2009; 104:219-27. [PMID: 19804963 DOI: 10.1016/j.rmed.2009.08.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 08/28/2009] [Accepted: 08/28/2009] [Indexed: 11/19/2022]
Abstract
To determine the immediate effects of bilevel non-invasive ventilation plus oxygen (NIV+O(2)) during exercise compared to exercise with O(2) alone in people recovering from acute on chronic hypercapnic respiratory failure (HRF), a randomised crossover study with repeated measures was performed. Eighteen participants performed six minute walk tests (6MWT) and 16 participants performed unsupported arm exercise (UAE) tests with NIV+O(2) and with O(2) alone in random order. Distance walked increased by a mean of 43.4m (95% CI 14.1 to 72.8, p=0.006) with NIV+O(2) compared to exercise with O(2) alone. In addition, isotime oxygen saturation increased by a mean of 5% (95% CI 2-7, p=0.001) and isotime dyspnoea was reduced [median 2 (interquartile range (IQR) 1-4) versus 4 (3-5), p=0.028] with NIV+O(2). A statistically significant increase was also observed in UAE endurance time with NIV+O(2) [median 201s (IQR 93-414) versus 157 (90-342), p=0.033], and isotime perceived exertion (arm muscle fatigue) was reduced by a mean of 1.0 on the Borg scale (95% CI -1.9 to -0.1, p=0.037) compared with O(2) alone. Non-invasive ventilation plus O(2) during walking resulted in an immediate improvement in distance walked and oxygen saturation, and a reduction in dyspnoea compared to exercise with O(2) alone in people recovering from acute on chronic HRF. The reduction of dyspnoea during walking and arm muscle fatigue during UAE observed with NIV+O(2) may allow patients to better tolerate exercise early in the recovery period.
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Affiliation(s)
- Collette Menadue
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown NSW, Australia.
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Abstract
Respiratory rehabilitation is known to improve outcomes in patients with chronic obstructive pulmonary disease (COPD). The question addressed in the present review is whether these beneficial effects are related to improvements in inspiratory muscle function. Respiratory muscle fatigue often did not occur during exercise in patients with COPD, since exercise limitation usually occurred when significant force reserve in the inspiratory muscles was still present. Notwithstanding, a number of observations may provide indirect evidence that respiratory muscle fatigue may occur during exercise. Some evidence is present that, in normal humans, whole body exercise training improved inspiratory muscle endurance, but no studies are available in patients with COPD. Animal studies invariably demonstrated that exercise training increased the number of oxidative fibers and oxidative enzyme activity in inspiratory muscles. These effects, however, were considerably smaller than the effects found on peripheral muscles with similar fiber composition. Clear evidence indicated that inspiratory muscle training (IMT) improved inspiratory muscle function. Two large meta-analyses indicated that, if the training load was properly controlled, IMT alone or combined with general exercise reconditioning improved inspiratory muscle strength and endurance and dyspnea. The combination did not result in greater improvements in functional exercise capacity. Animal studies and one patient study confirmed the occurrence of structural remodeling of the inspiratory muscles in response to IMT. The final question is whether improvements in inspiratory muscle function produced by IMT lead to improved outcomes in COPD. In all five studies in which training load was adequately controlled, a significant reduction of dyspnea during activities of daily living was found. Eight randomized studies examined the effects of the combination. Greater improvements in exercise capacity were only found in three studies, and none showed a greater reduction in dyspnea.
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Luo Y, Qiu Z, Wu H, Steier J, Jolley C, Zhong N, Moxham J, Polkey M. Neural drive during continuous positive airway pressure (CPAP) and pressure relief CPAP. Sleep Med 2009; 10:731-8. [DOI: 10.1016/j.sleep.2008.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 06/07/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
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Abstract
Dyspnea and activity limitation are the primary symptoms of chronic obstructive pulmonary disease and progress relentlessly as the disease advances. In COPD, dyspnea is multifactorial but abnormal dynamic ventilatory mechanics are believed to be important. Dynamic lung hyperinflation occurs during exercise in the majority of flow-limited patients with chronic obstructive pulmonary disease and may have serious sensory and mechanical consequences. This proposition is supported by several studies, which have shown a close correlation between indices of dynamic lung hyperinflation and measures of both exertional dyspnea and exercise performance. The strength of this association has been further confirmed by studies that have therapeutically manipulated this dependent variable. Relief of exertional dyspnea and improved exercise endurance following bronchodilator therapy correlate well with reduced lung hyperinflation. The mechanisms by which dynamic lung hyperinflation give rise to exertional dyspnea and exercise intolerance are complex. However, recent mechanistic studies suggest that dynamic lung hyperinflation-induced volume restriction and consequent neuromechanical uncoupling of the respiratory system are key mechanisms. This review examines, in some detail, the derangements of ventilatory mechanics that are peculiar to chronic obstructive pulmonary disease and attempts to provide a mechanistic rationale for the attendant respiratory discomfort and activity limitation.
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Affiliation(s)
- Denis E O'Donnell
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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