Fixed maximal stroke index in patients after pneumonectomy

Biology of VO2 max: looking under the physiology lamp

In this review, we argue that several key features of maximal oxygen uptake (VO₂ max) should underpin discussions about the biological and reductionist determinants of its interindividual variability: (i) training-induced increases in VO₂ max are largely facilitated by expansion of red blood cell volume and an associated improvement in stroke volume, which also adapts independent of changes in red blood cell volume. These general concepts are also informed by cross-sectional studies in athletes that have very high values for VO₂ max. Therefore, (ii) variations in VO₂ max improvements with exercise training are also likely related to variations in these physiological determinants. (iii) All previously untrained individuals will respond to endurance exercise training in terms of improvements in VO₂ max provided the stimulus exceeds a certain volume and/or intensity. Thus, genetic analysis and/or reductionist studies performed to understand or predict such variations might focus specifically on DNA variants or other molecular phenomena of relevance to these physiological pathways.

Comparative analysis of the mechanical signals in lung development and compensatory growth

This review compares the manner in which physical stress imposed on the parenchyma, vasculature and thorax and the thoraco-pulmonary interactions, drive both developmental and compensatory lung growth. Re-initiation of anatomical lung growth in the mature lung is possible when the loss of functioning lung units renders the existing physiologic-structural reserves insufficient for maintaining adequate function and physical stress on the remaining units exceeds a critical threshold. The appropriate spatial and temporal mechanical interrelationships and the availability of intra-thoracic space, are crucial to growth initiation, follow-on remodeling and physiological outcome. While the endogenous potential for compensatory lung growth is retained and may be pharmacologically augmented, supra-optimal mechanical stimulation, unbalanced structural growth, or inadequate remodeling may limit functional gain. Finding ways to optimize the signal-response relationships and resolve structure-function discrepancies are major challenges that must be overcome before the innate compensatory ability could be fully realized. Partial pneumonectomy reproducibly removes a known fraction of functioning lung units and remains the most robust model for examining the adaptive mechanisms, structure-function consequences and plasticity of the remaining functioning lung units capable of regeneration. Fundamental mechanical stimulus-response relationships established in the pneumonectomy model directly inform the exploration of effective approaches to maximize compensatory growth and function in chronic destructive lung diseases, transplantation and bioengineered lungs.

Endurance training and maximal oxygen consumption with ageing: Role of maximal cardiac output and oxygen extraction

BACKGROUND

The increase in maximal oxygen consumption (VO2max) with endurance training is associated with that of maximal cardiac output (Qmax), but not oxygen extraction, in young individuals. Whether such a relationship is altered with ageing remains unclear. Therefore, we sought systematically to review and determine the effect of endurance training on and the associations among VO2max, Qmax and arteriovenous oxygen difference at maximal exercise (Ca-vO2max) in healthy aged individuals.

DESIGN AND METHODS

We conducted a systematic search of MEDLINE, Scopus and Web of Science, from their inceptions until May 2015 for articles assessing the effect of endurance training lasting 3 weeks or longer on VO2max and Qmax and/or Ca-vO2max in healthy middle-aged and/or older individuals (mean age ≥40 years). Meta-analyses were performed to determine the standardised mean difference (SMD) in VO2max, Qmax and Ca-vO2max between post and pre-training measurements. Subgroup and meta-regression analyses were used to evaluate the associations among SMDs and potential moderating factors.

RESULTS

Sixteen studies were included after systematic review, comprising a total of 153 primarily untrained healthy middle-aged and older subjects (mean age 42-71 years). Endurance training programmes ranged from 8 to 52 weeks of duration. After data pooling, VO2max (SMD 0.89; P < 0.0001) and Qmax (SMD 0.61; P < 0.0001) were increased after endurance training; no heterogeneity among studies was detected. Ca-vO2max was only increased with endurance training interventions lasting more than 12 weeks (SMD 0.62; P = 0.001). In meta-regression, the SMD in Qmax was positively associated with the SMD in VO2max (B = 0.79, P = 0.04). The SMD in Ca-vO2max was not associated with the SMD in VO2max (B = 0.09, P = 0.84).

CONCLUSIONS

The improvement in VO2max following endurance training is a linear function of Qmax, but not Ca-vO2max, through healthy ageing.

Respiratory measurements of cardiac output: from elegant idea to useful test

The measurement of cardiac output was first proposed by Fick, who published his equation in 1870. Fick's calculation called for the measurement of the contents of oxygen or CO2 in pulmonary arterial and systemic arterial blood. These values could not be determined directly in human subjects until the acceptance of cardiac catheterization as a clinical procedure in 1940. In the meanwhile, several attempts were made to perfect respiratory methods for the indirect determination of blood-gas contents by respiratory techniques that yielded estimates of the mixed venous and pulmonary capillary gas pressures. The immediate uptake of nonresident gases can be used in a similar way to calculate cardiac output, with the added advantage that they are absent from the mixed venous blood. The fact that these procedures are safe and relatively nonintrusive makes them attractive to physiologists, pharmacologists, and sports scientists as well as to clinicians concerned with the physiopathology of the heart and lung. This paper outlines the development of these techniques, with a discussion of some of the ways in which they stimulated research into the transport of gases in the body through the alveolar membrane.

Lessons from a canine model of compensatory lung growth

For over a century, canines have been used to study adaptation to surgical lung resection or pneumonectomy (PNX) that results in a quantifiable and reproducible loss of lung units. As reviewed by Schilling (1965), the first successful experimental pneumonectomies were performed in dogs and rabbits in 1881. By the early 1920s, it was appreciated that dogs can function normally with one remaining lung that increases in volume to fill the thoracic cavity (Andrus, 1923; Heuer and Andrus, 1922; Heuer and Dunn, 1920); these pioneering observations paved the way for surgeons to perform major lung resection in patients. Reports in the 1950s (Schilling et al., 1956) detail surprisingly well-preserved work performance in dogs following staged resection of up to 70% of lung mass. Since then, the bulk of the literature on post-PNX adaptation has shifted to rodents, especially for defining molecular mediators of compensatory lung growth. Because rodents are smaller and easier to handle, more animals can be studied over a shorter duration, resulting in time and cost savings. On the other hand, key aspects of lung anatomy, development, and time course of response in the rodent do not mimic those in the human subject, and few rodent studies have related structural adaptation to functional consequences. In larger mammals, anatomical lung development more closely resembles that in humans, and physiological function can be readily measured. Because dogs are natural athletes, functional limits of compensation can be characterized relatively easily by stressing oxygen transport at peak exercise. Thus, the canine model remains useful for relating structure to function, defining sources and limits of adaptation as well as evaluating therapeutic manipulation. This chapter summarizes key concepts of compensatory lung growth that have been consolidated from canine studies: (i) structure-function relationships during adaptation, (ii) dysanaptic (unequal) nature of compensation, and (iii) signals for initiation of cellular growth.

Estimate of pulmonary diffusing capacity for oxygen during exercise in humans from routine O2 and CO2 measurements

A method to estimate pulmonary diffusing capacity for O(2) (D(LO2)) during exercise based on routine O(2) and CO(2) transport variables is presented. It is based on the fitting of a mathematical model to gas exchange data. The model includes heterogeneity (described as two exchanging compartments), diffusion limitation and right-to-left shunt. Mass conservation equations and Bohr integration were solved to calculate partial pressures in each compartment. Diffusion was distributed with perfusion. Two-compartment ventilation and perfusion distributions were estimated at rest during conditions of negligible diffusion limitation. These distributions were used during hypoxic and normoxic exercise to obtain the D(LO2) from the model computations (D(LO2)2C) compatible with experimental data. Three normals, four sarcoid patients and four patients after lung resection were studied. An independent technique for carbon monoxide was used to provide experimental estimates of DLo2 (D(LO2)EXP, rebreathing technique for sarcoid patients and single breath for lung resection). D(LO2)2C was highly correlated with D(LO2)EXP (r2 = 0.95, P<0.001) and the slope of the regression line was not statistically different from 1. The mean (D(LO2)EXP - D(LO2)2C) difference was -1.0 +/- 7.4 ml min-1 mmHg-1. The results suggest that use of a refined analytical procedure allows for assessment of D(LO2) from routine O(2) and CO(2) measurements comparable with those obtained from independent carbon monoxide techniques. The method may be an alternative for estimates of D(LO2) during exercise.

Cardiovascular limitations in chronic pulmonary disease

Chronic lung disease has significant impact on cardiovascular function. Much of this effect is because of increased right ventricular afterload caused by increased pulmonary vascular resistance resulting from structural changes in the pulmonary circulation, and because of hypoxic pulmonary vasoconstriction. In the case of chronic obstructive diseases, there may be additional increases in afterload resulting from dynamic hyperinflation. These processes can lead to structural changes in the heart (cor pulmonale), including right ventricular dilatation and hypertrophy, to maintain right ventricular output. In most ambulatory patients with chronic obstructive disease, it appears that cardiac output may be maintained at levels that are similar to normal both at rest and during exercise, with no consistent improvement in maximal exercise function afforded by interventions that increase blood flow. In contrast, diseases characterized by fibrosis or infiltration of the lung parenchyma may be associated with a disproportionate increase in pulmonary vascular resistance and more pronounced cardiovascular impairment, particularly with exercise.

Cardiopulmonary limitations to exercise in restrictive lung disease

Cardiopulmonary limitations to exercise in restrictive lung disease. Med. Sci. Sports Exerc., Vol. 31, No. 1 (Suppl.), pp. S28-S32, 1999. Restrictive lung disease encompasses a large and diverse group of disorders characterized by a diminished lung volume. These disorders exhibit common pathophysiologic features including abnormal gas exchange caused by loss of functioning alveolar-capillary unit, abnormal respiratory muscle energetics caused by altered mechanical ventilatory function, and secondary hemodynamic and cardiac dysfunction. Impaired gas exchange is the most prominent exercise abnormality in interstitial lung disease and eventually develops in other causes of lung restriction as well. Measurements of diffusing capacity (DLCO) and alveolar-arterial oxygen tension gradient during exercise are more sensitive detectors of disease than measurements at rest. Excessive dead space ventilation is common in pulmonary parenchymal, pleural, and thoracic diseases, leading to a higher minute ventilation and ventilatory work during exercise. The associated increase in the metabolic energy requirement of respiratory muscles may exceed 50% of available total body oxygen delivery and result in insufficient energy delivery to nonrespiratory muscles that sustain locomotion. Pulmonary arterial hypertension develops secondarily to an increased pulmonary vascular resistance. In addition, diastolic filling of the ventricles during exercise may be restricted by pulmonary fibrosis or anatomical restriction of the pleura and thorax, contributing to secondary cardiac dysfunction. Examples of heart-lung interaction are illustrated by the patient after unilateral pneumonectomy. These pathophysiologic changes help explain why functional disability in these patients is often out proportion to the impairment in lung function.