Paired phrenic nerve stimuli for the detection of diaphragm fatigue in humans

A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management)

Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO₂, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.

Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength

OBJECTIVE

Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength.

DESIGN

Secondary analysis of prospectively collected data.

SETTING

Tertiary care PICU.

PATIENTS

Four hundred nine mechanically ventilated children.

INTERVENTIONS

Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made preextubation during airway occlusion and on continuous positive airway pressure of 5 and pressure support of 10 above positive end-expiratory pressure 5 cm H2O, as well as 5 and 60 minutes postextubation.

MEASUREMENTS AND MAIN RESULTS

Thirty-four patients (8.3%) were reintubated within 48 hours of extubation. Reintubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax) preextubation, longer length of ventilation, postextubation upper airway obstruction, high respiratory effort postextubation (pressure rate product, pressure time product, tension time index), and high postextubation phase angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). Reintubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (pressure rate product > 500), whereas children with preserved aPiMax had reintubation rates greater than 20% only when postextubation effort was very high (pressure rate product > 1,000). When children developed postextubation upper airway obstruction, reintubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p = 0.02). Multivariable risk factors for reintubation included acute neurologic disease, lower aPiMax, postextubation upper airway obstruction, higher preextubation positive end-expiratory pressure, higher postextubation pressure rate product, and lower height.

CONCLUSIONS

Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when postextubation effort was high.

Changes of Respiratory Mechanics in COPD Patients from Stable State to Acute Exacerbations with Respiratory Failure

Symptoms, clinical course, functional and biological data during an exacerbation of chronic obstructive pulmonary disease (EXCOPD) have been investigated, but data on physiological changes of respiratory mechanics during a severe exacerbation with respiratory acidosis requiring noninvasive mechanical ventilation (NIMV) are scant. The aim of this study was to evaluate changes of respiratory mechanics in COPD patients comparing data observed during EXCOPD with those observed during stable state in the recovery phase. In 18 COPD patients having severe EXCOPD requiring NIMV for global respiratory failure, we measured respiratory mechanics during both EXCOPD (T0) and once the patients achieved a stable state (T1). The diaphragm and inspiratory muscles effort was significantly increased under relapse, as well as the pressure-time product of the diaphragm and the inspiratory muscle (PTPdi and PTPes). The resistive loads to breathe (i.e., PEEPi,dyn, compliance and inspiratory resistances) were also markedly increased, while the maximal pressures generated by the diaphragm and the inspiratory muscles, together with forced expired volumes were decreased. All these indices statistically improved but with a great intrasubject variability in stable condition. Moreover, tension-time index (TTdi) significantly improved from the EXCOPD state to the condition of clinical stability (0.156 ± 0.04 at T0 vs. 0.082 ± 0.02 at T1 p < 0.001). During an EXCOPD, the load/capacity of the respiratory pump is impaired, and although the patients exhibit a rapid shallow breathing pattern, this does not necessarily correlate with a TTdi ≥ 0.15. These changes are reverted once they recover from the EXCOPD, despite a large variability between patients.

Ventilation and respiratory mechanics

During dynamic exercise, the healthy pulmonary system faces several major challenges, including decreases in mixed venous oxygen content and increases in mixed venous carbon dioxide. As such, the ventilatory demand is increased, while the rising cardiac output means that blood will have considerably less time in the pulmonary capillaries to accomplish gas exchange. Blood gas homeostasis must be accomplished by precise regulation of alveolar ventilation via medullary neural networks and sensory reflex mechanisms. It is equally important that cardiovascular and pulmonary system responses to exercise be precisely matched to the increase in metabolic requirements, and that the substantial gas transport needs of both respiratory and locomotor muscles be considered. Our article addresses each of these topics with emphasis on the healthy, young adult exercising in normoxia. We review recent evidence concerning how exercise hyperpnea influences sympathetic vasoconstrictor outflow and the effect this might have on the ability to perform muscular work. We also review sex-based differences in lung mechanics.

Central and peripheral quadriceps fatigue in congestive heart failure

AIMS

The clinical syndrome of heart failure includes exercise limitation that is not directly linked to measures of cardiac function. Quadriceps fatigability may be an important component of this and this may arise from peripheral or central factors.

METHODS AND RESULTS

We studied 10 men with CHF and 10 healthy age-matched controls. Compared with a rest condition, 10 min after incremental maximal cycle exercise, twitch quadriceps force in response to supramaximal magnetic femoral nerve stimulation fell in both groups (CHF 14.1% ± 18.1%, p=0.037;

CONTROL

20.8 ± 11.0%, p<0.001; no significant difference between groups). There was no significant change in quadriceps maximum voluntary contraction voluntary force. The difference in the motor evoked potential (MEP) response to transcranial magnetic stimulation of the motor cortex between rest and exercise conditions at 10 min, normalised to the peripheral action potential, also fell significantly in both groups (CHF: 27.3 ± 38.7%, p=0.037;

CONTROL

41.1 ± 47.7%, p=0.024). However, the fall in MEP was sustained for a longer period in controls than in patients (p=0.048).

CONCLUSIONS

The quadriceps is more susceptible to fatigue, with a similar fall in TwQ occurring in CHF patients at lower levels of exercise. This is associated with no change in voluntary activation but a lesser degree of depression of quadriceps motor evoked potential.

Impact of preinduced quadriceps fatigue on exercise response in chronic obstructive pulmonary disease and healthy subjects

Exercise intolerance in chronic obstructive pulmonary disease (COPD) results from a complex interaction between central (ventilatory) and peripheral (limb muscles) components of exercise limitation. The purpose of this study was to evaluate the influence of quadriceps muscle fatigue on exercise tolerance and ventilatory response during constant-workrate cycling exercise testing (CWT) in patients with COPD and healthy subjects. Fifteen patients with COPD and nine age-matched healthy subjects performed, 7 days apart, two CWTs up to exhaustion at 80% of their predetermined maximal work capacity. In a randomized order, one test was performed with preinduced quadriceps fatigue and the other in a fresh state. Quadriceps fatigue was produced by electrostimulation-induced contractions and quantified by maximal voluntary contraction and potentiated twitch force (TwQpot). Endurance time and ventilatory response during CWT were compared between fatigued and fresh state. Endurance time significantly decreased in the fatigued state compared with the fresh condition in COPD (356 ± 69 s vs. 294 ± 45 s, P < 0.05) and controls (450 ± 74 s vs. 340 ± 45 s, P < 0.05). Controls showed significantly higher ventilation and end-exercise dyspnea scores in the fatigued condition, whereas, in COPD, fatigue did not influence ventilation or dyspnea during exercise. The degree of ventilatory limitation, as expressed by the V̇e/maximum voluntary ventilation ratio, was similar in both conditions in patients with COPD. We conclude that it is possible to induce quadriceps fatigue by local electrostimulation-induced contractions. Our findings demonstrate that peripheral muscle fatigue is an additional important factor, besides intense dyspnea, that limits exercise tolerance in COPD.

Comparison of electrical and magnetic stimulations to assess quadriceps muscle function

This study aimed to 1) compare electrical and magnetic stimulations for quadriceps muscle function assessment, and 2) ascertain whether the ratios of the second twitch elicited by supramaximal electrical and magnetic femoral nerve stimulation at 10 and 100 Hz (T210:100) and the total twitch force elicited by the same types of stimulations (Fpaired10:100) are equivalent to the standard low- to high-frequency force ratio associated with submaximal electrical tetanic stimulations (Ftet10:100). Quadriceps force and vastus lateralis EMG were recorded at rest ( n = 21 subjects), immediately after, and 30 min after a 30-min downhill run ( n = 10) when 1) supramaximal electrical nerve stimulation (ENS), 2) magnetic nerve stimulation (MNS) and 3) submaximal electrical muscle stimulation (EMS) were delivered in random order at 1 (single stimulation), 10, and 100 Hz (paired stimulations). Ten- and 100-Hz 500-ms tetani were also evoked with EMS to determine Ftet10:100. Before exercise, contractile properties with single and paired stimulations were similar for ENS and MNS (all intraclass correlation coefficients k > 0.90), but smaller for EMS ( P < 0.001). M-wave characteristics were also similar for ENS and MNS (all k > 0.90). After exercise, changes in all parameters did not differ between methods. With fatigue, the changes in Ftet10:100 were inconsistently correlated with the changes in T210:100 ( r2 = 0.24–0.73, P = 0.002–0.15) but better correlated with the changes in Fpaired10:100 (immediately after exercise: r2 = 0.80–0.83, P < 0.001; 30 min after exercise: r2 = 0.46–0.82, P = 0.001–0.03). We conclude that ENS and MNS provide similar quadriceps muscle function assessment, while Fpaired10:100 is a better index than T210:100 of low- to high-frequency fatigue of the quadriceps in vivo.

Physiological properties of human diaphragm muscle fibres and the effect of chronic obstructive pulmonary disease

The contractile and actomyosin ATPase properties of single fibres were examined in human diaphragm muscle obtained from patients with and without chronic obstructive pulmonary disease (COPD). Costal diaphragm biopsies were taken from five patients without evidence of COPD and from 11 age-matched individuals with varying degrees of the disease. Our aim was to establish whether changes in contractile properties of COPD diaphragm could be fully explained by the previously documented shift towards a greater proportion of type I myosin heavy chain isoform in COPD. The relative proportion of type I diaphragm fibres from non-COPD and COPD patients was measured by gel electrophoresis, and was negatively correlated with FEV(1) over the full range of values investigated. There was also significant atrophy of the type I fibre population in COPD diaphragms. Isometric tension was similar among the fibre types and between the COPD and non-COPD patients. The intrinsic energetic properties of diaphragm fibres were examined by monitoring the time-resolved actomyosin ATPase activity in COPD and non-COPD fibres that produced similar isometric forces. The isometric ATPase rate in COPD fibres was reduced to 50% of the rate in non-COPD fibres; hence, the cost of isometric contraction in type I and type IIA COPD fibres was reduced to between one-third and one-half of the tension cost calculated for non-COPD fibres. The rate of force development in type I COPD fibres was reduced to 50% of the rate seen in non-COPD type-I fibres. No difference in the rate of ATP consumption between COPD and non-COPD fibres was evident during isovelocity shortening. These data extend previous findings showing that aspects of breathing mechanics during progressive COPD are associated with remodelling of the diaphragm fibre-type distribution; on top of the increase in type I fibres there are fibre-specific reductions in force development rate (type I fibres) and ATPase rate that are consistent with the impairment of cross-bridge cycling kinetics.

Inspiratory muscles do not limit maximal incremental exercise performance in healthy subjects

We investigated whether the inspiratory muscles affect maximal incremental exercise performance using a placebo-controlled, crossover design. Six cyclists each performed six incremental exercise tests. For three trials, subjects exercised with proportional assist ventilation (PAV). For the remaining three trials, subjects underwent sham respiratory muscle unloading (placebo). Inspiratory muscle pressure (P(mus)) was reduced with PAV (-35.9+/-2.3% versus placebo; P<0.05). Furthermore, V(O2) and perceptions of dyspnea and limb discomfort at submaximal exercise intensities were significantly reduced with PAV. Peak power output, however, was not different between placebo and PAV (324+/-4W versus 326+/-4W; P>0.05). Diaphragm fatigue (bilateral phrenic nerve stimulation) did not occur in placebo. In conclusion, substantially unloading the inspiratory muscles did not affect maximal incremental exercise performance. Therefore, our data do not support a role for either inspiratory muscle work or fatigue per se in the limitation of maximal incremental exercise.

Effect of acute severe hypoxia on peripheral fatigue and endurance capacity in healthy humans

We hypothesized that severe hypoxia limits exercise performance via decreased contractility of limb locomotor muscles. Nine male subjects [mean ± SE maximum O2 uptake (V̇o2 max) = 56.5 ± 2.7 ml·kg−1·min−1] cycled at ≥90% V̇o2 max to exhaustion in normoxia [NORM-EXH; inspired O2 fraction (FiO2) = 0.21, arterial O2 saturation (SpO2) = 93 ± 1%] and hypoxia (HYPOX-EXH; FiO2 = 0.13, SpO2 = 76 ± 1%). The subjects also exercised in normoxia for a time equal to that achieved in hypoxia (NORM-CTRL; SpO2 = 96 ± 1%). Quadriceps twitch force, in response to supramaximal single (nonpotentiated and potentiated 1 Hz) and paired magnetic stimuli of the femoral nerve (10–100 Hz), was assessed pre- and at 2.5, 35, and 70 min postexercise. Hypoxia exacerbated exercise-induced peripheral fatigue, as evidenced by a greater decrease in potentiated twitch force in HYPOX-EXH vs. NORM-CTRL (−39 ± 4 vs. −24 ± 3%, P < 0.01). Time to exhaustion was reduced by more than two-thirds in HYPOX-EXH vs. NORM-EXH (4.2 ± 0.5 vs. 13.4 ± 0.8 min, P < 0.01); however, peripheral fatigue was not different in HYPOX-EXH vs. NORM-EXH (−34 ± 4 vs. −39 ± 4%, P > 0.05). Blood lactate concentration and perceptions of limb discomfort were higher throughout HYPOX-EXH vs. NORM-CTRL but were not different at end-exercise in HYPOX-EXH vs. NORM-EXH. We conclude that severe hypoxia exacerbates peripheral fatigue of limb locomotor muscles and that this effect may contribute, in part, to the early termination of exercise.

Effect of Home Mechanical Ventilation on Inspiratory Muscle Strength in COPD

BACKGROUND

The mechanism responsible for chronic hypercapnic respiratory failure (HRF) in patients with COPD remains unclear. In this study, we tested the hypothesis that chronic HRF in patients with COPD is associated with low-frequency fatigue (LFF) of the diaphragm.

METHODS

To test this hypothesis, we measured the twitch transdiaphragmatic pressure (Tw Pdi) elicited by stimulation of the phrenic nerves in 25 patients with chronic HRF (mean [+/- SD] Paco(2), 55.2 +/- 5.2 mm Hg) due to COPD before and 2 months after the initiation of noninvasive mechanical ventilation (NIV) [pressure-cycled ventilation with inspiratory positive airway pressure of 19.0 +/- 2.5 cm H(2)O]. We reasoned that had LFF been present, Tw Pdi should rise after effective NIV.

RESULTS

The treatment compliance with NIV was good (median of machine usage was 7.1 h per night). Paco(2) decreased from 55.2 +/- 5.2 to 48.8 +/- 5.9 mm Hg (p < 0.001), and Pao(2) increased from 53.1 +/- 5.9 to 57.7 +/- 7.0 mm Hg (p = 0.007). Mean Tw Pdi at baseline was 11.1 +/- 6.6 cm H(2)O and after treatment was 11.7 +/- 7.2 cm H(2)O (not significant). Also, maximal static inspiratory mouth pressure did not change significantly (44.3 +/- 15.9 cm H(2)O vs 46.5 +/- 19.7 cm H(2)O).

CONCLUSION

LFF of the diaphragm does not accompany chronic HRF in patients with COPD.

Effects of arterial oxygen content on peripheral locomotor muscle fatigue

The effect of arterial O2 content (CaO2) on quadriceps fatigue was assessed in healthy, trained male athletes. On separate days, eight participants completed three constant-workload trials on a bicycle ergometer at fixed workloads (314 ± 13 W). The first trial was performed while the subjects breathed a hypoxic gas mixture [inspired O2 fraction (FiO2) = 0.15, Hb saturation = 81.6%, CaO2 = 18.2 ml O2/dl blood; Hypo] until exhaustion (4.5 ± 0.4 min). The remaining two trials were randomized and time matched with Hypo. The second and third trials were performed while the subjects breathed a normoxic (FiO2 = 0.21, Hb saturation = 95.0%, CaO2 = 21.3 ml O2/dl blood; Norm) and a hyperoxic (FiO2 = 1.0, Hb saturation = 100%, CaO2 = 23.8 ml O2/dl blood; Hyper) gas mixture, respectively. Quadriceps muscle fatigue was assessed via magnetic femoral nerve stimulation (1–100 Hz) before and 2.5 min after exercise. Myoelectrical activity of the vastus lateralis was obtained from surface electrodes throughout exercise. Immediately after exercise, the mean force response across 1–100 Hz decreased from preexercise values ( P < 0.01) by −26 ± 2, −17 ± 2, and −13 ± 2% for Hypo, Norm, and Hyper, respectively; each of the decrements differed significantly ( P < 0.05). Integrated electromyogram increased significantly throughout exercise ( P < 0.01) by 23 ± 3, 10 ± 1, and 6 ± 1% for Hypo, Norm, and Hyper, respectively; each of the increments differed significantly ( P < 0.05). Mean power frequency fell more ( P < 0.05) during Hypo (−15 ± 2%); the difference between Norm (−7 ± 1%) and Hyper (−6 ± 1%) was not significant ( P = 0.32). We conclude that ΔCaO2 during strenuous systemic exercise at equal workloads and durations affects the rate of locomotor muscle fatigue development.

Arterial oxygenation influences central motor output and exercise performance via effects on peripheral locomotor muscle fatigue in humans

Changing arterial oxygen content (C(aO(2))) has a highly sensitive influence on the rate of peripheral locomotor muscle fatigue development. We examined the effects of C(aO(2)) on exercise performance and its interaction with peripheral quadriceps fatigue. Eight trained males performed four 5 km cycling time trials (power output voluntarily adjustable) at four levels of C(aO(2)) (17.6-24.4 ml O(2) dl(-1)), induced by variations in inspired O(2) fraction (0.15-1.0). Peripheral quadriceps fatigue was assessed via changes in force output pre- versus post-exercise in response to supra-maximal magnetic femoral nerve stimulation (DeltaQ(tw); 1-100 Hz). Central neural drive during the time trials was estimated via quadriceps electromyogram. Increased C(aO(2)) from hypoxia to hyperoxia resulted in parallel increases in central neural output (43%) and power output (30%) during cycling and improved time trial performance (12%); however, the magnitude of DeltaQ(tw) (-33 to -35%) induced by the exercise was not different among the four time trials (P > 0.2). These effects of C(aO(2)) on time trial performance and DeltaQ(tw) were reproducible (coefficient of variation = 1-6%) over repeated trials at each F(IO(2)) on separate days. In the same subjects, changing C(aO(2)) also affected performance time to exhaustion at a fixed work rate, but similarly there was no effect of Delta C(aO(2)) on peripheral fatigue. Based on these results, we hypothesize that the effect of C(aO(2)) on locomotor muscle power output and exercise performance time is determined to a significant extent by the regulation of central motor output to the working muscle in order that peripheral muscle fatigue does not exceed a critical threshold.

Effect of inspiratory muscle work on peripheral fatigue of locomotor muscles in healthy humans

The work of breathing required during maximal exercise compromises blood flow to limb locomotor muscles and reduces exercise performance. We asked if force output of the inspiratory muscles affected exercise-induced peripheral fatigue of locomotor muscles. Eight male cyclists exercised at > or = 90% peak O2 uptake to exhaustion (CTRL). On a separate occasion, subjects exercised for the same duration and power output as CTRL (13.2 +/- 0.9 min, 292 W), but force output of the inspiratory muscles was reduced (-56% versus CTRL) using a proportional assist ventilator (PAV). Subjects also exercised to exhaustion (7.9 +/- 0.6 min, 292 W) while force output of the inspiratory muscles was increased (+80%versus CTRL) via inspiratory resistive loads (IRLs), and again for the same duration and power output with breathing unimpeded (IRL-CTRL). Quadriceps twitch force (Q(tw)), in response to supramaximal paired magnetic stimuli of the femoral nerve (1-100 Hz), was assessed pre- and at 2.5 through to 70 min postexercise. Immediately after CTRL exercise, Q(tw) was reduced -28 +/- 5% below pre-exercise baseline and this reduction was attenuated following PAV exercise (-20 +/- 5%; P < 0.05). Conversely, increasing the force output of the inspiratory muscles (IRL) exacerbated exercise-induced quadriceps muscle fatigue (Q(tw) = -12 +/- 8% IRL-CTRL versus-20 +/- 7% IRL; P < 0.05). Repeat studies between days showed that the effects of exercise per se, and of superimposed inspiratory muscle loading on quadriceps fatigue were highly reproducible. In conclusion, peripheral fatigue of locomotor muscles resulting from high-intensity sustained exercise is, in part, due to the accompanying high levels of respiratory muscle work.

Effect of exercise-induced arterial hypoxemia on quadriceps muscle fatigue in healthy humans

The effect of exercise-induced arterial hypoxemia (EIAH) on quadriceps muscle fatigue was assessed in 11 male endurance-trained subjects [peak O2 uptake (V̇o2 peak) = 56.4 ± 2.8 ml·kg−1·min−1; mean ± SE]. Subjects exercised on a cycle ergometer at ≥90% V̇o2 peak to exhaustion (13.2 ± 0.8 min), during which time arterial O2 saturation (SaO2) fell from 97.7 ± 0.1% at rest to 91.9 ± 0.9% (range 84–94%) at end exercise, primarily because of changes in blood pH (7.183 ± 0.017) and body temperature (38.9 ± 0.2°C). On a separate occasion, subjects repeated the exercise, for the same duration and at the same power output as before, but breathed gas mixtures [inspired O2 fraction (FiO2) = 0.25–0.31] that prevented EIAH (SaO2 = 97–99%). Quadriceps muscle fatigue was assessed via supramaximal paired magnetic stimuli of the femoral nerve (1–100 Hz). Immediately after exercise at FiO2 0.21, the mean force response across 1–100 Hz decreased 33 ± 5% compared with only 15 ± 5% when EIAH was prevented ( P < 0.05). In a subgroup of four less fit subjects, who showed minimal EIAH at FiO2 0.21 (SaO2 = 95.3 ± 0.7%), the decrease in evoked force was exacerbated by 35% ( P < 0.05) in response to further desaturation induced via FiO2 0.17 (SaO2 = 87.8 ± 0.5%) for the same duration and intensity of exercise. We conclude that the arterial O2 desaturation that occurs in fit subjects during high-intensity exercise in normoxia (−6 ± 1% ΔSaO2 from rest) contributes significantly toward quadriceps muscle fatigue via a peripheral mechanism.

The effect of treatment on diaphragm contractility in obstructive sleep apnea syndrome

In untreated obstructive sleep apnea syndrome (OSAS) inspiratory efforts are made against an occluded airway and diaphragm fatigue might therefore complicate OSAS. To test this hypothesis we measured twitch transdiaphragmatic pressure (Tw Pdi) in response to bilateral cervical magnetic stimulation of the phrenic nerve roots in nine patients with OSAS before and one month after successful therapy with nasal continuous positive airways pressure (nCPAP). The mean Tw Pdi before therapy was 23.2cm H2O and after therapy was 22.8cm H2O (P = 0.59); the mean change after initiation of nCPAP was 0.4cm H2O with 95% confidence intervals of -1.3cm H2O and +2.1 cm H2O. We conclude that low frequency diaphragm fatigue does not complicate untreated OSAS.

Evaluation of an inspiratory muscle trainer in healthy humans

The Powerbreathe is an inspiratory muscle trainer promoted as improving inspiratory muscle strength (and consequently exercise performance) in athletes and patients with respiratory disease. No published evidence supports its efficacy. We performed a prospective randomized controlled study in which 12 normal subjects received either Powerbreathe training or sham training for a 6-week period. The primary outcome measure was diaphragm strength evaluated as twitch transdiaphragmatic pressure (Tw Pdi) but secondary outcome measures were provided by full respiratory muscle assessment and cardiopulmonary exercise testing. An advantage to training was observed when outcome was assessed by maximal static inspiratory mouth pressure (mean advantage 14.5 cm H2O, 95% CI 2.2-26.9 cm H2O, P=0.025). However. no significant difference was observed between the groups in any other parameter. In particular the deltaTw Pdi was not different between groups (mean 'advantage' 0.7 cmH2O, 95% CI- 7.0+/-5.5 cmH2O, P=0.8). The continued sale and use of the Powerbreathe device is not justified by our data. A sample size calculation showed that 234 subjects would need to be randomized to definitively refute the hypothesis that Powerbreathe improves Tw Pdi and we argue that such a study is required.

Sensation of inspiratory difficulty during inspiratory threshold and hyperinflationary loadings. Effect of inspiratory muscle strength

Dynamic hyperinflation loads the inspiratory muscles by increasing end-expiratory lung volume (EELV) and imposing intrinsic positive end-expiratory pressure (PEEPi), the latter behaving as an inspiratory threshold load (ITL). The aim of the current study was to examine how induced-inspiratory muscle fatigue affects the independent effects of the imposed ITL and increasing operating lung volume on the perceived inspiratory difficulty. Dynamic hyperinflation in healthy subjects was induced by positive end-expiratory pressure (PEEP). Increasing operating lung volume alone (without PEEPi) and increasing ITL alone (without change in EELV) were induced by continuous positive airway pressure (CPAP) and external ITL, respectively. Inspiratory difficulty was quantified by the modified Borg scale and analyzed by step forward multiple regression, using the imposed ITL, EELV, and end-inspiratory lung volume (EILV) as independent variables. When fresh, the first entered variable was the imposed ITL (r(2), 0.38). Adding EILV into the model increased r(2) to 0.67. After fatigue, the first entered variable became EILV (r(2), 0.50) and the second selected variable was the imposed ITL, which increased r(2) to 0.66. EELV was insignificant under both conditions. The coefficient of EILV increased significantly from 0.039 +/- 0.005 to 0.092 +/- 0.012 (% inspiratory capacity(-)(1)) after fatigue run (p < 0.001), whereas that of the imposed ITL did not change. It is concluded that in the experimental conditions studied, inspiratory muscle fatigue increased the importance of lung volume over that of inspiratory threshold load in determining the perceived inspiratory difficulty.

Effect of hypercapnia on maximal voluntary ventilation and diaphragm fatigue in normal humans

Relatively little is known about the combined effects of hypercapnia and fatigue on the human diaphragm. We examined the effects of acute hypercapnia and fatigue in seven subjects by measuring changes in transdiaphragmatic pressure (Pdi) elicited by cervical magnetic stimulation after 2 min maximal voluntary ventilation (MVV) while breathing air and also with the inspired PCO(2) increased to 8% for 12 min before and during the MVV. Diaphragm strength was assessed before and at 0, 20, 40, 60, and 90 min after the MVV in both studies with the subjects breathing air. There was no difference in the level of ventilation for each run. Mean (+/- SD) twitch Pdi (TwPdi) fell significantly (p < 0.01) at 20 min after the control and hypercapnic MVV; (30.4 [7.8] to 27.0 [8.1] cm H(2)O control and 30.3 [4.1] to 27.3 [5.0] cm H(2)O CO(2)) and remained significantly (p < 0.01) below baseline. The changes in TwPdi at 20 to 90 min were not significantly different between the control and CO(2) runs. The decrease in TwPdi at 0 min after MVV, however, was greater (15%) in the hypercapnic run than in the control run (8.1%) (p < 0.05) when compared with baseline valves. Hypercapnia does not intensify long lasting fatigue but may reduce diaphragm contractility immediately after MVV.

Diaphragm strength in chronic heart failure

Reduced respiratory muscle strength has been reported in chronic heart failure (CHF) in several studies. The data supporting this conclusion come almost exclusively from static inspiratory and expiratory mouth pressure maneuvers (MIP, MEP), which many subjects find difficult to perform. We therefore performed a study using measurements that are less dependent on patient aptitude and also provide specific data on diaphragm strength. In 20 male patients and 15 control subjects we measured MIP and MEP as well as esophageal and transdiaphragmatic pressure during maximal sniffs (Sn Pes, Sn Pdi) and cervical magnetic phrenic nerve stimulation (Tw Pdi). In a subgroup the response to paired phrenic nerve stimulation (pTw Pdi) at interpulse intervals from 10 to 200 ms (5 to 100 Hz) was also determined. As expected, MIP was significantly reduced in the CHF group (CHF, 69.5 cm H(2)O; control, 96.7 cm H(2)O; p = 0.01), but differences were much less marked for Sn Pes (CHF, 95.2 cm H(2)O; control, 104.8 cm H(2)O; p = 0.20) and MEP (CHF, 109.1 cm H(2)O; control, 135.7 cm H(2)O; p = 0.09). Diaphragm strength was significantly reduced (Sn Pdi: CHF, 123.8 cm H(2)O; control 143.5 cm H(2)O; p = 0.04. Tw Pdi: CHF, 21.4 cm H(2)O; control, 28.5 cm H(2)O; p = 0.0005). Paired phrenic nerve stimulation suggested a trend to increased twitch summation at 5 to 20 Hz in CHF, although this did not reach significance. We conclude that mild reduction in diaphragm strength occurs in CHF, possibly because of an increased proportion of slow fibers, but overall strength of the respiratory muscles remains well preserved.

Influence of acute lung volume change on contractile properties of human diaphragm

The effect of stimulus frequency on the in vivo pressure generating capacity of the human diaphragm is unknown at lung volumes other than functional residual capacity. The transdiaphragmatic pressure (Pdi) produced by a pair of phrenic nerve stimuli may be viewed as the sum of the Pdi elicited by the first (T1 Pdi) and second (T2 Pdi) stimuli. We used bilateral anterior supramaximal magnetic phrenic nerve stimulation and a digital subtraction technique to obtain the T2 Pdi at interstimulus intervals of 999, 100, 50, 33, and 10 ms in eight normal subjects at lung volumes between residual volume and total lung capacity. The reduction in T2 Pdi that we observed as lung volume increased was greatest at long interstimulus intervals, whereas the T2 Pdi obtained with short interstimulus intervals remained relatively stable over the 50% of vital capacity around functional residual capacity. For all interstimulus intervals, the total pressure produced by the pair decreased as a function of increasing lung volume. These data demonstrate that, in the human diaphragm, hyperinflation has a disproportionately severe effect on the summation of pressure responses elicited by low-frequency stimulations; this effect is distinct from and additional to the known length-tension relationship.