1
|
McNamara RJ, Houben-Wilke S, Franssen FM, Smid DE, Vanfleteren LE, Groenen MT, Uszko-Lencer NH, Wouters EF, Alison JA, Spruit MA. Determinants of functional, peak and endurance exercise capacity in people with chronic obstructive pulmonary disease. Respir Med 2018; 138:81-87. [DOI: 10.1016/j.rmed.2018.03.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/22/2018] [Accepted: 03/28/2018] [Indexed: 11/26/2022]
|
2
|
Bell M, Fotheringham I, Punekar YS, Riley JH, Cockle S, Singh SJ. Systematic Review of the Association Between Laboratory- and Field-Based Exercise Tests and Lung Function in Patients with Chronic Obstructive Pulmonary Disease. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2015; 2:321-342. [PMID: 28848854 DOI: 10.15326/jcopdf.2.4.2014.0157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction: Typical symptoms of chronic obstructive pulmonary disease (COPD) include breathlessness and reduced exercise capacity. Several laboratory- and field-based exercise tests are used to assess the exercise capacity of patients with COPD. It is unclear whether these exercise tests reflect the spirometric measures recommended for diagnosis of COPD. We therefore aimed to systematically assess the correlation between these exercise tests and common measures of lung function. Methods: A search of Embase™, MEDLINE® and The Cochrane Library identified primary publications in English that reported data on the correlations (Pearson's r or Spearman's rho) between the outcomes of exercise tests and the physiological measures of interest: forced expiratory volume in 1 second (FEV1), forced vital capacity, inspiratory capacity and arterial oxygen saturation. We included studies reporting on the following exercise tests: 6- and 12-minute walk tests (6MWT and 12 MWT), incremental and endurance shuttle walk tests, incremental and endurance cycle ergometer tests, and treadmill tests. Results: Of 1781 articles screened, 45 were ultimately deemed eligible for inclusion in this review. The most commonly reported lung function variable was FEV1 (reported by 39 studies); the most commonly reported exercise test was the 6-minute walk test (reported by 24 studies). FEV1 appears to correlate moderately-to-strongly with 6MWT and 12MWT; and moderately-to-very strongly with incremental cycle ergometer tests (ICET); evidence for other exercise tests was limited. Conclusion: There is evidence that 6MWT, 12MWT and ICET correlate with FEV1 to some degree; - evidence for associations of other exercise tests with measures of lung function in patients with COPD is limited. Clinicians must consider this when deciding to use these tests. Further comparisons of these tests must be made in order to assess which physiological and hemodynamic characteristics they reflect in patients with COPD.
Collapse
Affiliation(s)
- Martin Bell
- Value Demonstration Practice, Oxford PharmaGenesis Ltd, Oxford, United Kingdom
| | - Iain Fotheringham
- Value Demonstration Practice, Oxford PharmaGenesis Ltd, Oxford, United Kingdom
| | | | - John H Riley
- Global Clinical Development and Respiratory R and D, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Sarah Cockle
- Value Evidence and Outcomes, GlaxoSmithKline, Brentford, United Kingdon
| | - Sally J Singh
- Global Clinical Development and Respiratory R and D, GlaxoSmithKline, Uxbridge, United Kingdom
| |
Collapse
|
3
|
Chuang ML, Huang SF, Su CH. Cardiovascular and respiratory dysfunction in chronic obstructive pulmonary disease complicated by impaired peripheral oxygenation. Int J Chron Obstruct Pulmon Dis 2015; 10:329-37. [PMID: 25709427 PMCID: PMC4334300 DOI: 10.2147/copd.s76209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Impaired peripheral oxygenation (IPO)-related variables readily achieved with cardiopulmonary exercise testing (CPET) represent cardiovascular dysfunction. These variables include peak oxygen uptake (
(V˙O2)<85% predicted, anaerobic threshold
<40%V˙O2max predicted,
V˙O2-work rate slope <8.6 mL/watt, oxygen pulse <80% predicted, and ventilatory equivalents for O2 and CO2 at nadir of >31 and >34, respectively. Some of these six variables may be normal while the others are abnormal in patients with chronic obstructive pulmonary disease (COPD). This may result in confusion when using the interpretation algorithm for diagnostic purposes. We therefore hypothesized that patients found to have abnormal values for all six variables would have worse cardiovascular function than patients with abnormal values for none or some of these variables. Methods In this cross-sectional comparative study, 58 COPD patients attending a university teaching hospital underwent symptom-limited CPET with multiple lactate measurements. Patients with abnormal values in all six IPO-related variables were assigned to an IPO group while those who did not meet the requirements for the IPO group were assigned to a non-IPO group. Cardiovascular function was measured by two-dimensional echocardiography and
Δlactate/ΔV˙O2, and respiratory dynamics were compared between the two groups. Results Fourteen IPO and 43 non-IPO patients were entered into the study. Both groups were similar with regard to left ventricular ejection fraction and right ventricular morphology (P>0.05 for both). At peak exercise, both groups reached a similar heart rate level and
Δlactate/ΔV˙O2. The IPO patients had an unfavorable dead space to tidal volume ratio, mean inspiratory tidal flow, and shallow breathing (P<0.05–P<0.001). Conclusion Our IPO and non-IPO patients with COPD had similar cardiovascular performance at rest and at peak exercise, indicating that IPO variables are non-specific for cardiovascular function in these patients. COPD patients with full IPO variables have more deranged ventilatory function.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China ; School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Shih-Feng Huang
- Division of Pulmonary Medicine and Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chun-Hung Su
- School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China ; Division of Cardiology and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China
| |
Collapse
|
4
|
Abstract
OBJECTIVES The objective of this review is to present a case-based clinical discussion on this topic. METHODS The article represents part of the proceedings of the Occupational and Environmental Lung Disease conference held by the American College of Chest Physicians at Toronto, Ontario, Canada, in 2013, and is based upon a nonsystematic review of the current literature by the author. RESULTS Although the American Medical Association Guides to the Evaluation of Permanent Impairment is the mainstay for evaluating respiratory impairment, many other impairment schemata are currently available in the United States. Impairment evaluation for a case with chronic respiratory disease and a separate case with asthma is discussed. CONCLUSIONS Pulmonary function tests are the cornerstone for evaluating respiratory impairment. Impairment values differ between various impairment schemata. Impairment evaluation for asthma may be particularly difficult.
Collapse
Affiliation(s)
- Akshay Sood
- From the University of New Mexico Health Sciences Center School of Medicine, Albuquerque, NM
| |
Collapse
|
5
|
Kealy S, Hussey J, Lane SJ. Reasons for Exercise Intolerance in Patients with Chronic Obstructive Pulmonary Disease. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/108331903225001372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
6
|
Maximal oxygen uptake cannot be estimated from resting lung function and submaximal exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev 2012; 32:219-25. [PMID: 22691941 DOI: 10.1097/hcr.0b013e318259b6a5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Maximal oxygen uptake ((V)O(2max)) obtained from incremental exercise testing is a useful indicator of limited exercise capacity. Several prediction equations have been developed to estimate (V)O(2max) in patients with chronic obstructive pulmonary disease (COPD), but agreement studies between estimated and measured (V)O(2max) are lacking. This study aims to assess agreement between the 6 estimated (V)O(2max) evaluated during maximal incremental exercise testing in male COPD patients. METHODS Patients with stable COPD, in accordance with GOLD guidelines, were included in the study. Agreement between (V)O(2max) obtained during incremental exercise testing and (V)O(2max) obtained from 6 prediction equations were studied. To estimate (V)O(2max) from anthropometric prediction equations, lung function variables and submaximal exercise testing were used. RESULTS Of the 60 male patients in the study, 12 were GOLD stage II, 24 GOLD stage III, and 24 GOLD stage IV. Five prediction equations underestimated the value of (V)O(2max) in relation to measured (V)O(2max) : equations 1, 2, 3, 4, and 6, by 14%, 66%, 42.2%, 35%, and 23.3%, respectively. Conversely, prediction equation 5 overestimated measured (V)O(2max) by 76.9%. Agreement between all (V)O(2max) prediction equations and measured (V)O(2max) was poor. Discrepancy between (V)O(2max) prediction equations and measured (V)O(2max) varied from 20.857 to 0.736 L/min. CONCLUSIONS The use of lung function at rest and submaximal exercise testing is inaccurate for determining (V)O(2max) , which cannot be estimated by prediction equations in patients with stable COPD.
Collapse
|
7
|
Han MK, Agusti A, Calverley PM, Celli BR, Criner G, Curtis JL, Fabbri LM, Goldin JG, Jones PW, Macnee W, Make BJ, Rabe KF, Rennard SI, Sciurba FC, Silverman EK, Vestbo J, Washko GR, Wouters EFM, Martinez FJ. Chronic obstructive pulmonary disease phenotypes: the future of COPD. Am J Respir Crit Care Med 2010; 182:598-604. [PMID: 20522794 DOI: 10.1164/rccm.200912-1843cc] [Citation(s) in RCA: 689] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Significant heterogeneity of clinical presentation and disease progression exists within chronic obstructive pulmonary disease (COPD). Although FEV(1) inadequately describes this heterogeneity, a clear alternative has not emerged. The goal of phenotyping is to identify patient groups with unique prognostic or therapeutic characteristics, but significant variation and confusion surrounds use of the term "phenotype" in COPD. Phenotype classically refers to any observable characteristic of an organism, and up until now, multiple disease characteristics have been termed COPD phenotypes. We, however, propose the following variation on this definition: "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death)." This more focused definition allows for classification of patients into distinct prognostic and therapeutic subgroups for both clinical and research purposes. Ideally, individuals sharing a unique phenotype would also ultimately be determined to have a similar underlying biologic or physiologic mechanism(s) to guide the development of therapy where possible. It follows that any proposed phenotype, whether defined by symptoms, radiography, physiology, or cellular or molecular fingerprint will require an iterative validation process in which "candidate" phenotypes are identified before their relevance to clinical outcome is determined. Although this schema represents an ideal construct, we acknowledge any phenotype may be etiologically heterogeneous and that any one individual may manifest multiple phenotypes. We have much yet to learn, but establishing a common language for future research will facilitate our understanding and management of the complexity implicit to this disease.
Collapse
Affiliation(s)
- MeiLan K Han
- University of Michigan-Pulmonary and Critical Care, 1500 E. Medical Center Drive, 3916 Taubman, Ann Arbor, MI 48109, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Efremidis G, Tsiamita M, Manolis A, Spiropoulos K. Accuracy of pulmonary function tests in predicted exercise capacity in COPD patients. Respir Med 2005; 99:609-14. [PMID: 15823459 DOI: 10.1016/j.rmed.2004.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2003] [Revised: 02/10/2004] [Accepted: 08/31/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to examine exercise tolerance in patients with COPD from measurements of resting pulmonary function parameters. METHODS A total of 57 COPD patients were administered the pulmonary function test (PFT) and cardiopulmonary exercise test. The results were analyzed and essentially linear relationships emerged when each subject's VO2 peak was plotted against his individual PFT parameters. Those significant contributors were then introduced in a stepwise multiple regression analysis to determine the best predictor of the VO2 peak. RESULTS Stepwise multiple regressions in variables revealed that peak oxygen consumption (VO2 peak) was predicted best by the following equation: VO2 peak=(maximum voluntary ventilation x 0.024)+(forced mid-expiratory flow x 0.47)+(body surface area x 0.988)-0.913 (r=0.90; r2=0.81 SE=0.29 L/min). CONCLUSION We conclude that exercise capacity was predicted from measurements of resting pulmonary function parameters with excellent accuracy in the COPD patient.
Collapse
Affiliation(s)
- G Efremidis
- Division of Pneumonology, Department of Internal Medicine, University of Patras Medical School, Patras 26500, Greece
| | | | | | | |
Collapse
|
9
|
Antao VCDS, Pinheiro GA, Terra-Filho M, Kavakama J, Müller NL. High-resolution CT in silicosis: correlation with radiographic findings and functional impairment. J Comput Assist Tomogr 2005; 29:350-6. [PMID: 15891506 DOI: 10.1097/01.rct.0000160424.56261.bc] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess high-resolution computed tomography (HRCT) findings in silicosis and to better define the role of HRCT in early detection of parenchymal abnormalities in silica-exposed workers. METHODS Forty-one stone carvers were evaluated with chest radiographs (CR), HRCT, and pulmonary function tests (PFT). Inter-reader agreement was calculated using the kappa statistic (k). Correlation between radiographic and HRCT profusion scores and PFT was assessed using the Spearman correlation coefficient. RESULTS The most common HRCT findings were branching centrilobular structures, seen in 28/41 workers (68.3%). Nodules consistent with silicosis were detected in 53.7% workers on CR and in 56.1% workers on HRCT. Inter-reader agreement for diagnosis of silicosis was better on HRCT (k = 0.84) than on CR (k = 0.54). Small opacity profusion on HRCT correlated inversely with total lung capacity and FVC%. CONCLUSION Profusion of opacities on HRCT correlates with functional impairment. The presence of branching centrilobular structures may be helpful in early recognition of silicosis.
Collapse
|
10
|
Abstract
Patients with COPD suffer from locomotory skeletal muscle contractile dysfunction. This may be due to the disease per se or as a result of some confounding factor. Therefore, the purpose of this investigation was to determine whether emphysema: (1) reduces force production; (2) increases fatigability; and (3) impairs the speed of recovery in locomotory skeletal muscle in an accepted animal model in which many confounding variables can be controlled. To explore this issue, in situ mechanical properties of gastrocnemius were measured in Syrian Golden hamsters 8 months after intratracheal instillation of either saline (control, n = 5) or elastase (emphysema, n = 7). Emphysema increased excised lung volume (80%; P < 0.01), increased fatigability (control, 25% reduction in maximal strength after 4 min of repeated contractions; emphysema, 55% reduction; P < 0.05) and decreased the recovery rate (half-times of recovery: control, 7 +/- 7 s; emphysema, 92 +/- 92 s; P < 0.05) of gastrocnemius muscle. In contrast, emphysema had no effect on maximal force, whether related to body mass or muscle mass, or force-velocity characteristics of gastrocnemius muscle. These data demonstrate that emphysema, independent of physical activity levels, pharmacological intervention, and/or nutritional status, can increase fatigability and impair the speed of recovery of locomotory skeletal muscle contractile function which may contribute to exercise intolerance of COPD patients.
Collapse
Affiliation(s)
- John P Mattson
- Department of Health and Excercise Science, Adolphus College, 212C Lund Center, 800 West College Avenue, Gustavus Adolphus College, St. Peter, MN 56082, USA.
| | | |
Collapse
|
11
|
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. Moderate to severe COPD patients demonstrate severe impairments in exercise performance in daily activities, significantly affecting their quality of life. There are several causes for this limitation found in literature: air-flow limitation, lung hyperinflation, respiratory and peripheral muscles weakness, among others. In this study we intended to identify the potentially relevant factors that influence exercise performance in a group of moderate to severe COPD patients. We studied 24 male patients, 64,13 + 8,46 years old (46-83 years), FEV1: 46,96 + 12,99% predicted, FRC: 144,71 + 26,86% predicted, DLCO: 69,88 + 16,49 % predicted, PaO2: 78,25 + 7,82 mmHg, PaCO2: 40,78 + 4,28 mmHg. Patients performed an incremental symptom-limited cycle exercise. We correlated rest and exercise lung function parameters with peak oxygen uptake, maximal work rate and time span to exertion. The main contributors to exercise limitation were gas exchange abnormalities, ventilatory limitation and smaller values of body mass index. Rest lung hyperinflation didn't correlate with exercise performance. Dynamic exercise hyperinflation contributed greatly to exercise intolerance, through progressive restriction to tidal volume expansion necessary to deal with increasing exercise metabolic demands. Rest lung function parameters didn't correlate with exercise performance, stressing the importance of cardio-pulmonary exercise testing in the detection of exercise limitation factors in each patient. The identification of exercise limitation factors will certainly contribute to towards defining the best therapeutic approach in COPD patients.
Collapse
Affiliation(s)
- Fátima Rodrigues
- Assistente hospitalar de Pneumologia do Hospital de Pulido Valente, SA, Lisboa
| |
Collapse
|
12
|
Yazici M, Arbak P, Balbay O, Maden E, Erbas M, Erbilen E, Albayrak S, Akdemir R, Uyan C. Relationship between arterial blood gas values, pulmonary function tests and treadmill exercise testing parameters in patients with COPD. Respirology 2004; 9:320-5. [PMID: 15363002 DOI: 10.1111/j.1440-1843.2004.00619.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There have been controversial reports regarding the relationship between exercise tolerance and resting pulmonary function in patients with COPD. The aim of this study was to examine the relationship between resting pulmonary function tests (rPFT) and cardiopulmonary exercise testing parameters (CETP) and their value in estimating exercise tolerance of patients. METHODOLOGY In total, 45 patients with COPD (nine females, 36 males; mean age 61.2 +/- 11.2) and 21 healthy subjects (four females, 17 males; mean age 60.3 +/- 9.7) as a control group were studied. COPD patients (group I) were divided into three subgroups according to their FEV(1) (mild/group II: FEV(1) 60-79% of predicted; moderate/group III: FEV(1) 40-59%; severe/group IV: FEV(1) < 40%). In controls FEV(1) was >/= 80%. RESULTS There were significant correlations between FEV(1) and CETP in group III (maximal O(2) consumption (mVO(2)), r= 0.35, P < 0.005; total treadmill time (TTT), r= 0.31, P < 0.01; total metabolic equivalent values (TMET), r= 0.29, P < 0.01)) and in group IV (mVO(2), r= 0.49, P < 0.001; TTT, r= 0.45, P < 0.005; TMET, r= 0.31, P < 0.01; peak heart rate (pHR), r= 0.29, P < 0.02; frequency of ventricular extrasystole (fVES), r=-0.27, P < 0.05). Additionally, in group IV there were significant correlations between PaO(2) and CETP (mVO(2), r= 0.41, P < 0.02; TTT, r= 0.38, P < 0.03; TMET, r= 0.31, P < 0.05; pHR, r= 0.29, P < 0.05; fVES, r=-0.28, P < 0.05). CONCLUSION There are significant correlations of resting FEV(1)% predicted and PaO(2) values with CETP in patients with moderate and severe COPD and these parameters may also have a role as indicators of exercise tolerance in these COPD patients.
Collapse
Affiliation(s)
- Mehmet Yazici
- Department of Cardiology, Duzce Medical Faculty, Abant Izzet Baysal University, Ducze, Turkey.
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Poulain M, Durand F, Palomba B, Ceugniet F, Desplan J, Varray A, Préfaut C. 6-minute walk testing is more sensitive than maximal incremental cycle testing for detecting oxygen desaturation in patients with COPD. Chest 2003; 123:1401-7. [PMID: 12740254 DOI: 10.1378/chest.123.5.1401] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Some respiratory patients exhibit oxygen desaturation during rehabilitative walking but not during maximal cardiopulmonary exercise testing (CPET). We evaluated exercise-induced desaturation during 6-min walk testing (6MWT) in comparison with CPET in patients with COPD and determined the reproducibility of the phenomenon. PATIENTS We tested 80 consecutive patients with COPD (FEV(1), 62.4 +/- 2% predicted) and 10 patients with supplementary COPD (FEV(1), 59.1 +/- 5% predicted) [mean +/- SEM] to determine the reproducibility. MEASUREMENTS AND RESULTS First, patients with COPD performed cycle CPET (first CPET [CPET-1]). Three days later, they performed two 6MWTs (first 6MWT [6MWT-1] and second 6MWT [6MWT-2]). Pulse oximetric saturation (SpO(2)) was recorded every minute in both tests. Three groups emerged: desaturation at 6MWT not observed at CPET (DND) [n = 23], desaturation in both tests (n = 16), and no desaturation in either test (n = 41). Second, to evaluate reproducibility, 10 additional subjects with COPD who exhibited desaturation during two successive 6MWTs but not in CPET performed a second CPET (CPET-2) and a single-bout 6MWT (6MWT-3) in a supplementary trial. When two CPETs were performed, lack of O(2) desaturation was noted in both. O(2) desaturation was confirmed in 6MWT-2 and 6MWT-3 (7.4 +/- 1% and 7.4 +/- 1.5%, respectively). CONCLUSION Twenty-eight percent of patients with COPD presented DND. The phenomenon was reproducible and not protocol dependent, emphasizing the clinical interest of the 6MWT.
Collapse
|
14
|
Hernández N, Orozco-Levi M, Belalcázar V, Pastó M, Minguella J, Broquetas JM, Gea J. Dual morphometrical changes of the deltoid muscle in patients with COPD. Respir Physiol Neurobiol 2003; 134:219-29. [PMID: 12660101 DOI: 10.1016/s1569-9048(03)00015-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The present study was specifically aimed at evaluating if the structure of the deltoid muscles is modified in patients with chronic obstructive pulmonary disease (COPD). Twenty-eight male volunteers (61+/-13 yr) were assigned, according to pulmonary function, to either the COPD (n=14, FEV(1)=22-74%pred) or control group (n=14, FEV(1)=83-121%pred). Biopsies from non-dominant deltoid muscle were obtained and processed for morphometric analysis of the fibre types. Both type I and type II muscle fibres were distributed in the typical mosaic pattern. The mean value of the fibre size was within the normal range. However, three differentiated modes were observed in the deltoid from COPD patients: a central mode of normal sized fibres, a mode of atrophic fibres and a mode of hypertrophic fibres. This observation was evident even within single fascicles and especially prevalent in the most severe COPD patients. We conclude that factors with opposite effect (promotion of either atrophy or hypertrophy) exert relevant roles in the histomorphometrical characteristics of the deltoid muscles in COPD patients.
Collapse
Affiliation(s)
- Nuria Hernández
- Grup de Recerca de Pneumologia, URRA Hospital del Mar-IMIM CEXS, Universitat Pompeu Fabra, Barcelona, Spain
| | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
The mechanisms for exercise intolerance in chronic obstructive pulmonary disease are complex and multifaceted. Although ventilatory limitation caused by abnormal pulmonary function is a major contributor to this phenomenon, other factors may play an important role in limiting exercise. These other factors include depressed cardiac function, respiratory and peripheral muscle weakness, nutritional imbalances, and psychologic factors. The assessment of the pulmonary patient who complains of decreased functional status must include examination and consideration of all these variables. Only by addressing and treating the combination of these variables as they present in an individual patient will clinicians have the potential to impact that individual's functional status and quality of life.
Collapse
Affiliation(s)
- L Nici
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rhode Island Hospital and Brown University, Providence, Rhode Island 02903, USA.
| |
Collapse
|
16
|
Foglio K, Carone M, Pagani M, Bianchi L, Jones PW, Ambrosino N. Physiological and symptom determinants of exercise performance in patients with chronic airway obstruction. Respir Med 2000; 94:256-63. [PMID: 10783937 DOI: 10.1053/rmed.1999.0734] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
To evaluate the physiological and symptom determinants of exercise performance (EP) as measured by a 6-min walking test (6MWD), Watt(max), and peak oxygen consumption (VO2 ml/min/kg), 105 patients with chronic airway obstruction (CAO) [50 chronic obstructive pulmonary disease (COPD): 44 men, aged 63+/-7 years, forced expiratory volume in 1 sec (FEV1) forced vital capacity (FVC)(-1)% 54+/-13; and 55 asthmatic: 23 men, aged 55+/-10 years, FEV1 FVC(-1) % 65+/-10] underwent evaluation of 6MWD, symptom limited cyclo-ergometer exercise test, spirometry, respiratory muscle function, arterial blood gases and sensation of dyspnoea [using the Borg scale, Visual Analogue Scale (VAS) and Baseline Dyspnoea Index (BDI)]. A hierarchical method of analysis identified the residual volume (RV), total lung capacity (TLC)(-1) ratio, BDI and the patient's age as the strongest and most consistent correlates of EP (r2 = 0.14-0.21). The correlation between EP and its various determinants was not influenced by diagnosis. The relationship between breathlessness and EP was different between men and women: at any given level of exercise, women were more breathless than men. In multivariate analyses that contained both RV TLC(-1) and BDI, the RV TLC(-1) ratio was the strongest correlate of EP, although the BDI remained a significant covariate. Overall, age was the major determinant of EP but inclusion of the RV TLC(-1) ratio and the BDI into the model explained a further 9-15% of the variance in EP. These three covariates together explained 26-34% of the variance between patients. We conclude that in stable CAO patients, the prediction of exercise capacity by anthropometric, demographic, clinical and physiological variables is likely to be low. Age, pulmonary hyperinflation and dyspnoea are the strongest and most consistent correlates of impaired exercise performance. Airways obstruction, measured during expiration using FEV1, does not appear to be a predictor of physiological impairment. These results underline the importance of performing exercise evaluation in CAO patients.
Collapse
Affiliation(s)
- K Foglio
- Salvatore Maugeri Foundation, IRCCS, Division of Pulmonary Disease, Medical Centre of Gussago, Italy
| | | | | | | | | | | |
Collapse
|
17
|
Montes de Oca M, Celli BR. Respiratory muscle recruitment and exercise performance in eucapnic and hypercapnic severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 161:880-5. [PMID: 10712337 DOI: 10.1164/ajrccm.161.3.9812102] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
If chronic hypercapnia in patients with severe COPD occurs as a consequence of respiratory muscle (RM) weakness or fatigue, we would expect that ventilatory muscle recruitment (VMR) and exercise performance in stable hypercapnic patients would differ from those in eucapnic patients. We evaluated exercise performance and RM function at rest and during exercise in 19 eucapnic (PCO(2) 40 +/- 3 mm Hg), and 13 hypercapnic (PCO(2) 52 +/- 10 mm Hg) patients with severe COPD. A metabolic cart was used to determine V E, V O(2), V CO(2), and HR. Gastric (Pg) and esophageal (Ppl) balloons were used to measure Pg, Ppl, and Pdi. Ventilatory muscle recruitment pattern (VMR) was partitioned using end-inspiratory and end-expiratory Pg and Ppl. Hypercapnic patients had lower FEV(1) (0.60 +/- 0.24 versus 0.95 +/- 0.31 L, p < 0.001), MVV (28 +/- 11 versus 41 +/- 13 L, p < 0.001), resting PO(2) (61 +/- 11 versus 70 +/- 11 mm Hg, p < 0.001), peak PO(2) (60 +/- 20 versus 75 +/- 22 mm Hg, p < 0.005), and V E(max) (24 +/- 10 versus 32 +/- 12 L/min, p < 0.001). Patients in both groups had similar FRC (5.7 +/- 1.6 versus 5.0 +/- 1.5 L), V O(2)max (0.58 +/- 0.30 versus 0.76 +/- 0.32 L/min), Watts (45 +/- 48 versus 71 +/- 59), V E/MVV (88 +/- 33 versus 79 +/- 14), and HRmax (117 +/- 17 versus 128 +/- 18 beats/min). PI(max) (67 +/- 28 versus 65 +/- 32 cm H(2)O) and PE(max) (98 +/- 34 versus 96 +/- 40 cm H(2)O) were also similar in both groups. VMR (DeltaPg/DeltaPpl) at rest (-0.28 +/- 0.51 versus 0 +/- 0.35) and during exercise (0.4 +/- 0.2 versus 0.39 +/- 0.15) was equally affected in both groups. We conclude that exercise capacity and ventilatory muscle recruitment are similarly impaired in eucapnic and hypercapnic patients with severe COPD. These findings make inability of the lung to increase ventilation and not respiratory muscle dysfunction a more attractive explanation for CO(2) retention in stable hypercapnic patients.
Collapse
Affiliation(s)
- M Montes de Oca
- Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University, Boston, Massachusetts 02135, USA
| | | |
Collapse
|
18
|
Lahrmann H, Wild M, Wanke T, Tschernko E, Wisser W, Klepetko W, Zwick H. Neural drive to the diaphragm after lung volume reduction surgery. Chest 1999; 116:1593-600. [PMID: 10593782 DOI: 10.1378/chest.116.6.1593] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The aim of this study was to investigate prospectively the changes in neural drive to the diaphragm in the first year after lung volume reduction surgery (LVRS) in patients with COPD. PATIENTS AND METHODS In 14 patients with severe emphysema (mean +/- SD; age, 53.7 +/- 8.3 years; FEV(1), 0.64 +/- 0. 18 L; residual volume [RV], 5.33 +/- 1.25 L; PaO(2), 62.3 +/- 9.0 mm Hg; PaCO(2), 39.0 +/- 6.0 mm Hg), we assessed lung function, arterial blood gases, maximal exercise capacity (Wmax), and oxygen uptake (f1.gif" BORDER="0">O(2)max); intrinsic positive end-expiratory pressure (PEEPi); diaphragmatic strength (transdiaphragmatic pressure, Pdisniff) and endurance capacity (tlim); central diaphragmatic drive assessed by root mean square analysis of the esophageal electromyogram (rmsdia); and isotime dyspnea during loaded breathing tests (BS). RESULTS Despite a significant increase (expressed as a percentage of baseline) in FEV(1) (40.6%) and a decrease in RV (30.0%) and PEEPi (75.7%) 1 month after LVRS, the improvements in Wmax (31.2%) and f1.gif" BORDER="0">O(2)max (13.7%); Pdisniff (25.4%) and tlim (64.9%); rmsdia (34.6%); and BS (21.7%) did not reach statistical significance (p < 0.05) until 6 months after LVRS. Arterial blood gases did not change significantly. Significant correlations were found between decrease in rmsdia and changes in PEEPi (r = 0.69), Wmax (r = -0.56), Pdisniff (r = -0.65), tlim (r = -0.59), and BS (r = 0.71) 6 months after LVRS. CONCLUSIONS Our results show that LVRS is able to increase the efficacy of the respiratory pump and by this way reduce ventilatory drive and respiratory effort sensation.
Collapse
Affiliation(s)
- H Lahrmann
- Neurological Department Kaiser Franz Josef Hospital, Vienna, Austria
| | | | | | | | | | | | | |
Collapse
|
19
|
Yoshikawa M, Yoneda T, Kobayashi A, Fu A, Takenaka H, Narita N, Nezu K. Body composition analysis by dual energy X-ray absorptiometry and exercise performance in underweight patients with COPD. Chest 1999; 115:371-5. [PMID: 10027434 DOI: 10.1378/chest.115.2.371] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The aim of this study was to examine the effect of body composition on maximal exercise performance in patients with COPD. METHODS The study was carried out on 27 patients with COPD and was confirmed by pulmonary function testing. Body composition was measured by dual energy x-ray absorptiometry (DXA). Exercise performance was conducted on a cycle ergometer and was measured as maximal work rate (WRmax) and maximal oxygen uptake (VO2max). Bone mineral content (BMC), lean mass (LEAN), and fat mass (FAT) were assessed by DXA and were expressed as a percentage of ideal body weight, BMC, LEAN, and FAT. RESULTS LEAN% correlated significantly with VO2max (r = 0.66, p = 0.0002) and WRmax (r = 0.70, p < 0.0001). No significant correlation was found between FAT% and exercise performance. By stepwise regression analysis, variables significantly contributing to WRmax and VO2max were LEAN% and the maximal voluntary ventilation. Total variance explained in these models was 81% for WRmax aid 82% for VO2max. CONCLUSION Lean mass was an important determinant of maximal exercise performance in patients with COPD.
Collapse
Affiliation(s)
- M Yoshikawa
- Second Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | | | | | | | | | | | | |
Collapse
|
20
|
Serres I, Hayot M, Préfaut C, Mercier J. Skeletal muscle abnormalities in patients with COPD: contribution to exercise intolerance. Med Sci Sports Exerc 1998; 30:1019-27. [PMID: 9662668 DOI: 10.1097/00005768-199807000-00001] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Exercise intolerance in COPD patients appears to be in part because of skeletal muscle dysfunction. Studies using biopsy techniques and magnetic resonance spectroscopy have demonstrated changes in enzyme activities and metabolism that indicate reduced oxidative capacity in the peripheral muscles of these patients. Regarding the respiratory muscles, the biochemical characteristics have been studied in only a few works and the results seem to depend on the specific muscle group studied. Several factors, such as hypoxemia, nutritional status, pharmacological treatment, and deconditioning, may be responsible for these skeletal muscle abnormalities. This brief review describes the changes in peripheral and respiratory muscles in COPD patients based on data from the literature. The causes of these muscle abnormalities, their contribution to exercise intolerance, and the effects of training are then discussed. We conclude with suggested directions for future investigation using contemporary noninvasive technologies.
Collapse
Affiliation(s)
- I Serres
- Laboratoire de Physiologie des Interactions, CHU Arnaud de Villeneuve, Montpellier, France.
| | | | | | | |
Collapse
|
21
|
Serres I, Gautier V, Varray A, Préfaut C. Impaired skeletal muscle endurance related to physical inactivity and altered lung function in COPD patients. Chest 1998; 113:900-5. [PMID: 9554623 DOI: 10.1378/chest.113.4.900] [Citation(s) in RCA: 197] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE The aims of this work were to determine (1) whether patients with COPD have impaired skeletal muscle performance (ie, maximal strength and endurance) compared with healthy subjects, and (2) whether the level of physical activity, body composition, and lung function are related to skeletal muscle performance in COPD patients. METHODS Seventeen COPD patients and eight healthy age-matched control subjects performed maximum voluntary contraction (MVC) of the quadriceps and an endurance test consisting of dynamic contractions of the quadriceps against 20% of MVC at an imposed regular pace until exhaustion. The endurance test duration determined the muscle "limit time" (Tlim). A score of physical activity (PA score) was obtained using an adapted physical activity questionnaire for the elderly, and body composition was measured by the bioelectrical impedance method. Symptom-limited oxygen uptake (VO2 sl) was also assessed in COPD patients using a maximal incremental exercise test. RESULTS The results showed that Tlim and PA score were significantly decreased in COPD patients (p<0.05). Significant positive correlations were found in the COPD group between Tlim and the PA score (r=0.60; p<0.05), FEV1 (r=0.52; p<0.05), and PaO2 (r=0.63; p<0.05). The same results were found between the PA score and VO2 sl (r=0.57; p<0.05) and FEV1 (r=0.63; p<0.05). CONCLUSION These findings indicate impaired skeletal muscle endurance in COPD patients related to altered lung function and associated physical inactivity.
Collapse
Affiliation(s)
- I Serres
- Laboratoire de Physiologie des Interactions, Hôpital Arnaud de Villeneuve, Montpellier, France.
| | | | | | | |
Collapse
|
22
|
Baarends EM, Schols AM, Mostert R, Janssen PP, Wouters EF. Analysis of the metabolic and ventilatory response to self-paced 12-minute treadmill walking in patients with severe chronic obstructive pulmonary disease. JOURNAL OF CARDIOPULMONARY REHABILITATION 1998; 18:23-31. [PMID: 9494879 DOI: 10.1097/00008483-199801000-00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The 12-minute walking test is frequently used to measure exercise capacity in patients with severe chronic obstructive pulmonary disease. However, the physiological response to this test has been the subject of limited investigation. METHODS In this study, the metabolic and ventilatory consequences of a self-paced 12-minute treadmill walking test (WT) were measured in 17 patients with severe chronic obstructive pulmonary disease (FEV1: 40 +/- 9%) and evaluated using the physiological response to symptom-limited cycle ergometry (CE). During exercise testing, heart rate, transcutaneous oxygen saturation, and lactate concentration were measured, and oxygen consumption, carbon dioxide production, tidal volume, and breathing frequency were recorded breath by breath. RESULTS After 4 minutes walking, the peak oxygen consumption (VO2) was already 99 +/- 11% of last-minute walking VO2. Walking speed was chosen within 2 minutes and remained stable throughout the test. The WT and CE showed similar (end-) test results for all measurements, except for a higher carbon dioxide production, venous lactate concentration, and respiratory quotient after CE. However, lactate concentration was also significantly increased after WT. Severe and prolonged desaturation was shown during walking in most patients. CONCLUSIONS The physiological stress evoked during the WT is close to the stress developed at an incremental symptom-limited test and the relatively high metabolic and ventilatory stress is sustained from at least 4 to 12 minutes during the WT. This study has shown that anaerobic metabolism not only occurs during incremental cycle ergometry, but also during the WT.
Collapse
Affiliation(s)
- E M Baarends
- Department of Pulmonology, University of Limburg, Maastricht, The Netherlands
| | | | | | | | | |
Collapse
|
23
|
Bauerle O, Chrusch CA, Younes M. Mechanisms by which COPD affects exercise tolerance. Am J Respir Crit Care Med 1998; 157:57-68. [PMID: 9445279 DOI: 10.1164/ajrccm.157.1.9609126] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In view of the recent advances in our understanding of the pathophysiology of COPD, we felt that it would be appropriate to examine the contribution of several abnormalities, not hitherto examined, to exercise limitation in this disease. These included: (1) The ability to exceed maximum expiratory flow (determined during forced maneuvers from TLC) during partial expiratory maneuvers. This is referred to as deltaFEV1. (2) Shape of the flow-volume curve (Shape). (3) Susceptibility to develop dynamic hyperinflation (dynamic hyperinflation index, DHI). (4) Ventilatory response to exercise (VEmax/VEpred). Twenty-four COPD patients (FEV1 = 42 +/- 13% pred) underwent symptom-limited progressive exercise. DeltaFEV1, shape, DHI and VEmax/VEpred were determined. All values were normalized to eliminate the effects of age, sex, and body size. Shape had no impact on peak VO2 (r = 0.8). DeltaFEV1 (r = 0.50), DHI (r = 0.50) and VEmax/VEpred (r = 0.46) correlated significantly with peak VO2 with all three exceeding FEV1 (r = 0.43). DHI and deltaFEV1 correlated significantly with each other (r = 0.43) suggesting that the latter exerts its beneficial effects by reducing the tendency to develop DH. We conclude that variability among patients in ventilatory response to exercise and in deltaFEV1 (likely an expression of extent of regional mechanical heterogeneity) contribute importantly to variability of exercise tolerance in COPD.
Collapse
Affiliation(s)
- O Bauerle
- Department of Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | | | | |
Collapse
|
24
|
Evans SA, Kinnear WJ, Watson L, Hawkins M, Cowley AJ, Johnston ID. Breathlessness and exercise capacity in heart failure: the role of bronchial obstruction and responsiveness. Int J Cardiol 1996; 57:233-40. [PMID: 9024911 DOI: 10.1016/s0167-5273(96)02802-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The cause of the breathlessness and reduced exercise capacity that occur in patients with chronic heart failure remains obscure. We examined the hypothesis that airway obstruction and bronchial hyper-responsiveness, which are recognised features of chronic heart failure, might contribute to the breathlessness and reduced exercise capacity in this condition. We studied 37 patients (7 female) with chronic heart failure, of mean age 61 years. Each patient underwent: (i) lung function testing with spirometry and expiratory flow volume loops. (ii) Measurement of bronchial responsiveness to methacholine. (iii) Symptom-limited treadmill exercise capacity using both incremental and fixed workload protocols, with measurement of Borg scores for breathlessness. Lung function was not significantly related to either exercise time, or Borg symptom scores in either exercise protocol. Bronchial hyper-responsiveness to methacholine was demonstrated in 12 patients. Exercise time did not correlate with the degree of bronchial hyper-responsiveness in these 12 patients. Group mean exercise time and Borg scores were not significantly different in these 12 patients when compared to the 25 patients in whom bronchial hyper-responsiveness was not found. We conclude that airway obstruction and bronchial hyper-responsiveness are not likely to be important determinants of reduced exercise capacity and breathlessness in chronic heart failure.
Collapse
Affiliation(s)
- S A Evans
- Respiratory Medicine, University Hospital, Nottingham, UK
| | | | | | | | | | | |
Collapse
|
25
|
Fujii T, Kurihara N, Fujimoto S, Hirata K, Yoshikawa J. Role of pulmonary vascular disorder in determining exercise capacity in patients with severe chronic obstructive pulmonary disease. CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 1996; 16:521-33. [PMID: 8889315 DOI: 10.1111/j.1475-097x.1996.tb01017.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In patients with chronic obstructive pulmonary disease (COPD), the primary cardiovascular complication is the development of pulmonary hypertension, especially during exercise. The purpose of this study was to determine whether pulmonary vascular disorder plays an important role in determining exercise capacity in patients with severe COPD. Twenty-one male patients with severe COPD (mean FEV1 = 0.91 +/- 0.26 1) performed a progressive incremental exercise test, until symptom-limited maximum, to determine maximal exercise capacity, and then a constant-load exercise test for 5 min at a workload (20-60 W) corresponding to 60% of maximal workload during right heart catheterization to characterize the haemodynamic behavior of pulmonary circulation during exercise. The severity of the pulmonary vascular disorder was assessed using the slope of the mean pulmonary arterial pressure (PAP) - cardiac index (CI) relationship during constant-load exercise (P-Q slope). A significant inverse correlation was found between the maximal oxygen consumption (VO2max) and P-Q slope (r = -0.669), but not between VO2max and indices of expiratory airflow obstruction. In addition, the P-Q slope was inversely correlated with mixed venous oxygen tension (PvO2) at the end of constant-load exercise (r = -0.679) and with the change in oxygen delivery relative to oxygen consumption (delta DO2/delta VO2) during constant-load exercise (r = -0.671). These findings suggest that in patients with COPD, the functional impairment of the pulmonary vasculature is associated with disturbance in oxygen transport to the peripheral muscle during exercise, resulting in reduction of exercise capacity. We conclude that pulmonary vascular disorder may be an important factor in determining the exercise capacity of patients with severe COPD.
Collapse
Affiliation(s)
- T Fujii
- First Department of Internal Medicine, Osaka City University Medical School, Japan
| | | | | | | | | |
Collapse
|
26
|
Ikeda A, Nishimura K, Koyama H, Tsukino M, Mishima M, Izumi T. Dose response study of ipratropium bromide aerosol on maximum exercise performance in stable patients with chronic obstructive pulmonary disease. Thorax 1996; 51:48-53. [PMID: 8658369 PMCID: PMC472799 DOI: 10.1136/thx.51.1.48] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the bronchodilating effect of inhaled anticholinergics has been established in patients with chronic obstructive pulmonary disease (COPD), their effects on exercise capacity are still controversial. Previous studies have suggested that the standard dosage hardly affects exercise tolerance, whereas higher doses might elicit an improvement. The aim of the present study was to determine the dose of ipratropium bromide aerosol that improves exercise performance using progressive cycle ergometry in patients with stable COPD. METHODS Twenty men with stable COPD of mean (SD) age 69.2 (4.6) years and forced expiratory volume in one second (FEV1) 1.00 (0.37) 1 were studied in a randomised double blind manner. Each patient received ipratropium bromide in doses of 240 micrograms, 160 micrograms, 80 micrograms, 40 micrograms, and placebo from a metered dose inhaler (MDI) with an InspirEase spacer on five separate days. Spirometric parameters were assessed before and at 30, 60, 90, and 120 minutes after each inhalation, and pulse rate and blood pressure were also measured immediately before each spirometric measurement. Symptom limited progressive (20 watts/min) cycle ergometer exercise tests were performed 90 minutes after each inhalation. RESULTS Ipratropium bromide in doses of 160 micrograms and 240 micrograms produced a greater increase in FEV1 than 40 micrograms or 80 micrograms ipratropium bromide at all time points. Doses of 160 micrograms and 240 micrograms ipratropium bromide also produced greater increases in maximal work load and maximal oxygen consumption than placebo, whereas 40 micrograms and 80 micrograms ipratropium bromide did not. There was a weak correlation between the change in FEV1 and the change in maximal work load (r = 0.45). No differences were found in pulse rate or blood pressure between the treatment and placebo groups, and no side effects were noted throughout the study. CONCLUSIONS A dose of at least four times the standard dose of ipratropium bromide from an MDI with a spacer device was necessary to improve maximal cycle exercise capacity in patients with stable COPD. Although the data from cycle ergometry cannot be directly applied to exercise performed during day to day activities, it is conceivable that the recommended doses of ipratropium bromide do not elicit the optimal clinical benefits.
Collapse
Affiliation(s)
- A Ikeda
- Chest Disease Research Institute, Kyoto University, Japan
| | | | | | | | | | | |
Collapse
|
27
|
Predicción de la ventilación máxima alcanzada en el esfuerzo en pacientes con enfermedad pulmonar obstructiva crónica. Arch Bronconeumol 1995. [DOI: 10.1016/s0300-2896(15)30864-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
28
|
|
29
|
Palange P, Forte S, Felli A, Galassetti P, Serra P, Carlone S. Nutritional state and exercise tolerance in patients with COPD. Chest 1995; 107:1206-12. [PMID: 7750307 DOI: 10.1378/chest.107.5.1206] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
We hypothesized that in patients with COPD, poor nutritional status adversely influences exercise tolerance by limiting aerobic capacity of exercising muscles. In 28 patients with stable COPD, we correlated nutritional status with gas exchange indexes obtained during maximal incremental cycle ergometer exercise and with respiratory function parameters. On the basis of percent of ideal body weight (%IBW), patients were divided into three groups (GP): GP1 (n = 8, %IBW < 90); GP2 (n = 13, %IBW > or = 90 < 110); and GP3 (n = 7, %IBW > or = 110). When compared with normally nourished individuals (GPs 2 and 3), malnourished GP1 patients showed greater reduction in maximal workload and in peak O2 uptake (VO2 peak), with earlier onset of metabolic acidosis (anaerobic threshold [AT]); in addition, indexes reflecting O2 cost of ventilation were higher in GP1. Nutritional status could be correlated with exercise tolerance (VO2 peak, r = 0.82, p < 0.0001), with onset of metabolic acidosis (AT, r = 0.69, p < 0.0001) and with dead space/tidal volume ratio (VD/VT, r = -0.59, p < 0.001). Body weight was inversely correlated with indexes that are likely to reflect the increase in O2 cost of ventilation. We conclude that in patients with stable COPD, (1) malnutrition significantly affects muscle aerobic capacity and exercise tolerance, and (2) high wasted ventilation and O2 cost of ventilation may be responsible for the weight loss.
Collapse
Affiliation(s)
- P Palange
- II Patologia Medica, University of Rome La Sapienza Italy
| | | | | | | | | | | |
Collapse
|
30
|
|
31
|
Palange P, Carlone S, Forte S, Galassetti P, Serra P. Cardiopulmonary exercise testing in the evaluation of patients with ventilatory vs circulatory causes of reduced exercise tolerance. Chest 1994; 105:1122-6. [PMID: 8162736 DOI: 10.1378/chest.105.4.1122] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPX) is considered a useful procedure in the evaluation of circulatory, ventilatory, or mixed origin of reduced exercise tolerance. Our study was designed to compare CPX and a standard clinical-instrumental approach in the evaluation of patients with cardiopulmonary disorders. METHODS Fifty-seven patients (31 male, 26 female; mean [+/- SE] age, 60 +/- 2 years) were studied. Each patient was evaluated by two different observers: one used standard clinical criteria, the other used gas exchange indexes, monitored during a maximal incremental CPX, performed on a cycle ergometer. Cardiac output (CO), at rest and at submaximal work level, was also obtained. RESULTS In 46 patients (80.7 percent), a concordant evaluation was reached by the two observers (24 were found to have a predominant ventilatory disorder, 22 to have a circulatory disorder); among these, in subjects considered to have circulatory impairment, the maximal CO/maximal workload ratio was significantly lower than in the ventilatory group; in those with ventilatory impairment, the reduced exercise tolerance correlated with the resting spirometric values. In the remaining 11 patients (19.3 percent), CPX better defined the underlying pathophysiology of exercise limitation: in 10 of them, clinically classified as having a mixed or predominantly ventilatory disorder, a greater importance of the circulatory component was detected; 4 had evidence of pulmonary vascular impairment (high VE/VCO2 at anaerobic threshold). CONCLUSIONS Our study confirmed the sensitivity of CPX in the evaluation of a reduced exercise tolerance in dyspneic patients with cardiopulmonary conditions; when compared with a clinical-laboratory approach, in some patients it allowed the detection of an underestimated circulatory component causing exercise limitation.
Collapse
Affiliation(s)
- P Palange
- II Patologia Medica, University La Sapienza Rome, Italy
| | | | | | | | | |
Collapse
|
32
|
LoRusso TJ, Belman MJ, Elashoff JD, Koerner SK. Prediction of maximal exercise capacity in obstructive and restrictive pulmonary disease. Chest 1993; 104:1748-54. [PMID: 8252956 DOI: 10.1378/chest.104.6.1748] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We evaluated the predictive value of resting pulmonary function tests (PFTs) in the determination of maximal exercise capacity in patients with obstructive and restrictive ventilatory disease. We performed resting PFTs and an incremental exercise study on a bicycle ergometer in 146 patients with chronic obstructive pulmonary disease (COPD) and 68 patients with restrictive disease. The patients with obstructive disease were further subdivided into mild, moderate, and severe based on the severity of their airway obstruction (mean +/- SD:FEV1, 2.78 +/- 0.77, 2.12 +/- 0.74, and 1.06 +/- 0.47, respectively). Correlation coefficients for PFTs vs VO2max and VEmax in restricted patients was generally low (DL = 0.67 and 0.34, IC = 0.58 and 0.35, FVC = 0.57 and 0.35, TLC = 0.35 and 0.18). In patients with COPD, the maximum voluntary ventilation (MVV) was the single best predictor of VO2 in all groups with correlation coefficients of 0.75, 0.69, and 0.89 in the mild, moderate, and severe subgroups, respectively. Similarly, the MVV was the best predictor of VEmax in all groups with correlation coefficients of 0.59, 0.64, and 0.89 in the three subgroups. The correlation with FEV1 was slightly less for both VO2max (0.69, 0.65, and 0.87) and VEmax (0.52, 0.64, 0.64) in the mild, moderate, and severe subgroups, respectively. Our findings show that PFTs are unreliable in predicting VEmax and VO2max in restricted patients. In patients with obstruction, the MVV is the single best predictor of VO2max and VEmax in all three categories, but was not significantly improved by stepwise multiple regression with additional PFT variables. Higher correlations were obtained in the severe group in whom the correlation with VO2max and VEmax was 0.89. However, the 95 percent confidence interval of the estimate for VO2 and VE was relatively large (+/- 0.16 L/min and +/- 6.6 L/min, respectively). We conclude that although several PFTs correlate significantly with maximum exercise, the large variance precludes their use to accurately predict maximum performance in individual patients with COPD.
Collapse
Affiliation(s)
- T J LoRusso
- Division of Pulmonary Medicine, Cedars-Sinai Medical Center, University of California, Los Angeles
| | | | | | | |
Collapse
|
33
|
Dillard TA, Hnatiuk OW, McCumber TR. Maximum voluntary ventilation. Spirometric determinants in chronic obstructive pulmonary disease patients and normal subjects. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1993; 147:870-5. [PMID: 8466122 DOI: 10.1164/ajrccm/147.4.870] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The 12-s maximum voluntary ventilation (MVV) provides an estimate of the ventilatory reserves available to meet the physiologic demands of exercise. Earlier studies established a general relationship between MVV and FEV1. We hypothesized that the resting maximum inspiratory flow rate (MIFR) also serves as a clinically useful predictor of the MVV. A total of 105 subjects, 45 women and 60 men (age 57 +/- 5 yr, mean +/- SD), with expiratory impairment categories of severe (n = 26), moderate (n = 22), mild (n = 18), and normal (n = 39) based on FEV1 (percentage of predicted), comprised the study samples. The ratio MVV/FEV1 averaged 41 +/- 7 overall. The FEV1 correlated with MVV in normal subjects (p < 0.05, r2 = 0.642) and patients (p < 0.05, r2 = 0.787) better than MIFR (p < 0.05, r2 > or = 0.480). MIFR joined with FEV1 in multiple linear regression to significantly improve the description of MVV:MVV L/min = 30.77FEV1 (L) + 5.94MIFR (L/s) - 4.77 (n = 105; p < 0.05, r2 = 0.849). The 95% confidence limits for MVV varied from 90 to 110% of predicted from the equation for this sample. The factors sex and impairment category did not reduce the unexplained variability in MVV after inclusion of FEV1 and MIFR as covariates in ANOVA (p > 0.05). Addition of MIFR to the model with FEV1 produced greater improvement in r2 than PImax. We conclude that MIFR, although secondary in importance to FEV1, is a significant determinant of MVV in patients with COPD and normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- T A Dillard
- Department of Medicine, Walter Reed Army Medical Center, Washington, D.C. 20307-5001
| | | | | |
Collapse
|
34
|
|
35
|
Abstract
Exercise tolerance in patients with COPD is difficult to predict from measurements of lung function. We examined multiple physiologic and psychosocial variables in an attempt to predict exercise performance in a group of patients with COPD enrolled in a clinical trial of pulmonary rehabilitation. A total of 119 patients (FEV1 = 1.41 +/- 0.64 L) were divided randomly into either a study group (group A, n = 58) or validation group (group B, n = 61). Stepwise multiple regression in group A revealed that peak oxygen uptake (peak VO2) was predicted best by the following equation: Peak VO2 (L/min) = (0.0327 x DCO) + (0.0040 x MVV)-(0.0156 x peak-exercise VD/VT) + (0.0259 x resting VE) + 0.848; r = 0.90; SE = 0.233 L/min. This equation was then cross-validated in group B. It demonstrated excellent validity: measured peak VO2 (L/min) = (1.13 x predicted peak VO2)-0.0891; r = 0.90; SE = 0.239 L/min. We conclude that exercise tolerance was predicted reasonably well from measurements of lung function and gas exchange in this group of patients with COPD. However, the variability of the prediction would limit its usefulness in individual patients.
Collapse
Affiliation(s)
- D J Carlson
- Department of Medicine, University of California, San Diego
| | | | | |
Collapse
|
36
|
White NW, Chetty R, Bateman ED. Silicosis among gemstone workers in South Africa: tiger's-eye pneumoconiosis. Am J Ind Med 1991; 19:205-13. [PMID: 1847003 DOI: 10.1002/ajim.4700190208] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Six cases of silicosis in workers involved in the processing of semiprecious gem stones have been seen in our clinic since 1976. They had been employed as stone sculptors in lapidaries where they processed tiger's-eye, rose quartz, amethyst, quartz crystal, and a variety of other locally occurring semiprecious stones. In five of the cases, exposure was in small and poorly regulated lapidaries without specific dust control measures. The sixth was detected during the course of a health and hygiene survey (including dust sampling) that was conducted in one of two lapidaries still operating in our area. Progressive massive fibrosis (PMF) or accelerated silicosis was noted in four of the six cases, three of whom had progression of their disease after cessation of exposure. With the development of PMF, the initial restrictive pulmonary function abnormalities were followed by steadily worsening airflow obstruction. Lung biopsies confirmed silicosis in three cases. Tuberculosis was confirmed in two cases and suspected and treated in a third. Workmen's Compensation was awarded in five cases. The survey confirmed that in semiprecious gem stone processing, the risk of silicosis appears to be confined to stone sculptors. Tried and proven techniques of general and local exhaust ventilation combined with water or oil to control dust at source were capable of effectively reducing dust emission to acceptable levels.
Collapse
Affiliation(s)
- N W White
- Department of Medicine, University of Cape Town, South Africa
| | | | | |
Collapse
|