Exercise Dyspnea Research Articles

A Silent Patent Ductus Arteriosus

A 4-mm patent ductus arteriosus (PDA) was serendipitously diagnosed during intraoperative transesophageal echocardiography for a noncardiac procedure in an obese adult patient with a history of decreased exercise tolerance and dyspnea, despite a negative preoperative transthoracic examination. This uncommon event poses questions regarding the relevance of this finding to the differential diagnosis of dyspnea in an obese adult with a negative transthoracic echocardiography study, given the unknown prevalence of this pathology and the absence of consensus regarding the clinical management.

Cardiopulmonary Exercise Testing: Relevant but Underused

Cardiopulmonary exercise testing (CPX) is a relatively old technology, but has sustained relevance for many primary care clinical scenarios in which it is, ironically, rarely considered. Advancing computer technology has made CPX easier to administer and interpret at a time when our aging population is more prone to comorbidities and higher prevalence of nonspecific symptoms of exercise intolerance and dyspnea, for which CPX is particularly useful diagnostically and prognostically. These discrepancies in application are compounded by patterns in which CPX is often administered and interpreted by cardiology, pulmonary, or exercise specialists who limit their assessments to the priorities of their own discipline, thereby missing opportunities to distinguish symptom origins. When used properly, CPX enables the physician to assess fitness and uncover cardiopulmonary issues at earlier phases of work-up, which would therefore be especially useful for primary care physicians. In this article, we provide an overview of CPX principles and testing logistics, as well as some of the clinical contexts in which it can enhance patient care.

Cardiac autonomic responses to exercise testing in patients with chronic obstructive pulmonary disease

Incremental exercise testing is used to evaluate exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). The purpose of this cross-sectional, observational study was to compare cardiac autonomic responses of patients to exercise testing with healthy subjects and to investigate their determinants. Twenty-five COPD patients and 20 healthy subjects participated in the study. Pulmonary function test, arterial blood gas analysis and exercise test were performed. Heart rate, blood pressure and dyspnea were measured before and after the test. Peak oxygen uptake, chronotropic index and heart rate recovery were recorded. Dyspnea perception during daily activities was measured using the modified Medical Research Council dyspnea scale. Student t test, Mann Whitney u test, Spearman correlation coefficients and multiple linear regression analysis were used for statistical analysis. Peak heart rate, chronotropic index and peak oxygen uptake were significantly lower and exercise dyspnea perception was significantly higher in COPD patients than those of healthy subjects (p<0.05). Forty-eight percent of patients had chronotropic incompetence. Body weight and body mass index of these patients were significantly higher than in those with normal chronotropic response (p<0.05). Baseline, peak and recovery heart rate were significantly lower in patients with chronotropic incompetence (p<0.05). Modified Medical Research Council dyspnea score explained 44% of the variance in chronotropic index (r=0.66; r2=0.44, F (1, 16) =12.46, p=0.003). Chronic obstructive pulmonary disease patients had chronotropic incompetence to maximal volitional exercise. Dyspnea perception during daily activities is an important determinant of chronotropic incompetence. Effects of desensitization of dyspnea on sympathetic system activation in COPD should be investigated.

Systolic Anterior Motion of the Mitral Valve in the Absence Left Ventricular Hypertrophy: Role of Mitral Leaflet Elongation and Papillary Muscle Displacement

We report a 15-year-old patient who presented with exercise dyspnea and limitation of physical activity. Echocardiography revealed significant left ventricular outflow tract obstruction caused by systolic anterior motion (SAM) of the mitral valve. The wall thickness of the left ventricle was within normal limits. Elongation of the mitral leaflets and anterior displacement of the posteromedial papillary muscle were apparent in the echocardiographic examination. These two factors have been previously demonstrated to play a central role in the occurrence of SAM in patients with hypertrophic cardiomyopathy. The present case validates that such intrinsic abnormalities of the mitral valve can cause significant SAM even in the absence of left ventricular hypertrophy.

Dyspnea and ventilatory muscle function during exercise on air and oxygen breathing in patients with chronic obstructive pulmonary disease (COPD)

Exercise performance and dyspnea in COPD patients have been shown to be improved with supplemental oxygen, although the exact mechanisms resulting in the improvement are still unclear. The purpose of the present study was to investigate a possible relationship between ventilatory muscle function and sensation of dyspnea (modified Borg Scale) during exercise on 20% O2 and 30% O2. Eight patients with COPD (FEV1 1.06 L +/- 0.30 L) exercised on a treadmill two times breathing compressed air or 30% oxygen with a one hour rest in between. The electrical activity of the diaphragm (EMGdi) was recorded with esophageal electrodes, and that of the sternomastoid muscle (EMGsm) was recorded from the fine wire electrodes. The ratio of high frequency (150 to 350 Hz) to low frequency (20 to 47 Hz) power (H/L) of EMGdi was analyzed to assess diaphragmatic fatigue, which was defined as a 20% fall of H/L ratio from the control value. Flow, volume, O2 Saturation (SaO2), esophageal pressure (Pes) and transdiaphragmatic pressure (Pdi) were measured. Tension time index (TTdi) was calculated from Pdi and the ratio of inspiratory time to total time for one cycle (Ti/Ttot). At rest, we measured maximal esophageal pressure (Pesmax), maximal transdiaphragmatic pressure (Pdimax), maximal integrated EMGdi (EMGdimax) and EMGsm (EMGsmmax). Incremental exercise was discontinued by dyspnea. The walking distance achieved was increased in all patients on 30% O2. Dyspnea and desaturation were significantly improved on 30% O2 breathing, and the onset of diaphragmatic fatigue was delayed.(ABSTRACT TRUNCATED AT 250 WORDS)

Differenzialdiagnostik restriktiver Ventilationsstörungen: Stellenwert der Spiroergometrie

Exercise dyspnea is a common symptom of restrictive lung diseases. Not only from the clinical perspective but also from the pathophysiological point of view, restrictive lung disorders represent a very heterogeneous group of diseases. Exercise testing is mandatory because pulmonary function tests at rest are not reliable for the diagnostic evaluation and functional characterisation of these patients. Cardiopulmonary exercise testing (CPET) with measurement of gas exchange is the favoured tool. It is an excellent method to investigate exercise dyspnea, describe altered physiological response to exercise and characterise the involved organ systems heart, lung and muscle. This paper addresses the pathophysiology of restrictive lung diseases and the principles of cardiopulmonary exercise testing, discusses case reports and assesses the clinical value of CPET in patients with restrictive lung disease.

Expiratory flow-limitation and heliox breathing in resting and exercising COPD patients

In 26 stable patients with chronic obstructive pulmonary disease, tidal expiratory flow-limitation (TEFL), inspiratory capacity, breathing pattern and dyspnea sensation were assessed during air and heliox (20% O(2) in He) breathing at rest and during exercise up to 2/3 maximal work rate. Breathing air, the 13 patients with TEFL at rest remained flow-limited also during exercise, while 7 of the non-flow-limited patients became flow-limited; tidal volume increased more in non-flow-limited patients, whereas inspiratory capacity decreased in flow-limited and increased in the non-flow-limited patients. Heliox did not abolish flow-limitation, had no effect on breathing pattern, reduced exercise dynamic hyperinflation in 25% of the flow-limited patients, depending on the degree of the dynamic hyperinflation on air, and lessened dyspnea sensation in all patients. Hence, the presence of TEFL has no systematic effects on the respiratory response to heliox, and the heliox-induced decrease of exercise dyspnea is not mainly due to changes in dynamic hyperinflation or TEFL.

Acidosis and raised norepinephrine levels are associated with exercise dyspnoea in idiopathic pulmonary fibrosis

Exertional dyspnoea limits patients with IPF in their activities of daily living. The mechanism, however, has not been elucidated. This study tested the hypothesis in IPF that exertional dyspnoea correlates with cardiopulmonary exercise responses, specifically changes in arterial blood pH and plasma norepinephrine (NE). Cardiopulmonary exercise testing with measurements of dyspnoea (Borg scale), plasma NE, plasma lactate and arterial blood gases were performed in 29 patients with IPF and in nine controls. Both groups showed obvious break points in dyspnoea changes during exercise. In IPF, an abrupt change in the Borg scale, pH, PaCO(2) and plasma NE occurred in the late exercise phase after the 'break point'. Compared with controls, patients with IPF had significantly higher HCO(3)(-) levels and physiologic dead space/tidal volume during exercise. In IPF, during both exercise phases, the dyspnoea slope (DeltaBorg scale/Deltaminute ventilation) correlated with the pH slope (DeltapH/Deltaoxygen uptake) (before the break point: r = -0.537, P = 0.0022; r = -0.886, P < 0.0001, after the break point) and the NE slope (DeltaNE/Deltaoxygen uptake) (before the break point: r = 0.481, P = 0.0075; R = 0.784, P < 0.0001, after the break point). In patients with IPF, exercise-induced acidosis and increases in circulating NE levels were associated with intensity of exertional dyspnoea.

Five-chambered heart: a 20-year story of left atrial appendage aneurysm

Left atrial aneurysm (LAAn) is a rare congenital pathology described by Semans and Taussig in 1938. Most commonly, clinical presentation includes exercise dyspnoea, palpitations, or angina. The condition may be complicated by atrial ectopy or fibrillation, embolism, mitral regurgitation, and, rarely, cardiac tamponade or infarction. To date, approximately 80 case reports on LAAn have been published. This case represents the sole occurrence of the entity in >300 000 echocardiographic examinations performed over 20 years in the laboratories of the authors. A 25-year-old male was admitted to hospital for the first time in 1988 due to exercise intolerance [New York Heart Association (NYHA) functional class II/III]. Chest X-ray suggested cardiac enlargement. Echocardiogram revealed an additional echo-free cavity adjacent to the left ventricle. Preliminary echocardiographic diagnosis was pericardial cyst. Surgery was advised but rejected by the patient. Ten years later, he was reassessed and echocardiography demonstrated a 2 cm wide communication between the left atrium …

The effects of oxygen supplementation during exercise in patients with non-hypoxemic chronic obstructive pulmonary disease

Introduction: Oxygen therapy consists in a modality of treatment in patients with chronic obstructive pulmonary disease (COPD) for the mainteance of oxygen arterial saturation (SpO2) above 90%. In patients with a reduction in SpO2 during exercise, oxygen supplementation during the effort improves exercise tolerance. Objective: The purpose of this study is to evaluate, through a literature review, the effects of oxygen supplementation in patients with non-hypoxemic COPD during rest on exercise tolerance, SpO2 and dyspnea. Materials and Methods: We have searched the data bank Medline/Pubmed and Scielo and selected randomized, controlled trials, from 1996 to 2007, written in Portuguese or English. All papers where the keywords COPD, oxygen, exercise and rehabilitation were present in the title or the abstract were selected. Results: From 10 studies that have used oxygen during effort in non-hypoxemic patients in rest situation, 7 papers showed beneficial effects, which indicates that oxygen during exercise can help patients with COPD in improving their performance during exercise and contribute to the maintenance or improvement of the SpO2. There was no significant improvement when dyspnea was analyzed. The use of O2 after and/or before exercise or during a pulmonary rehabilitation program seems not to cause any additional effescts. Conclusions: Oxygen supplementation during exercise in rest non-hypoxemic COPD patients promotes the maintenance or improvement of SpO2, as well as improves performance during exercise.

The evaluation of exercise dyspnoea by Cardio-Pulmonary Exercise Test (CPET) in patients with WPW pattern in ECG

The evaluation of exercise dyspnoea by Cardio-Pulmonary Exercise Test (CPET) in patients with WPW pattern in ECG

Respiratory failure with diffuse bronchiectases and cryoglobulinaemia

A 48-yr-old nonsmoking female presented with a 5-yr history of recurrent bronchitis with progressive exercise dyspnoea. She had been diagnosed with a small monoclonal gammopathy of undermined significance (MGUS) 6 yrs previously. Inspiratory vital capacity was 4.7 L (125% predicted) and forced expiratory volume in one second/forced vital capacity (FVC) ratio was 79%. Carbon monoxide transfer factor was markedly impaired (35% pred), and arterial oxygen tension ( P a,O2) decreased from 9.2 to 6.0 kPa at exercise (40 W, 10 min). A thoracic computed tomography (CT) scan was performed (fig. 1⇓). Fibreoptic bronchoscopy found inflammation of the bronchial mucosa with candle stain-like deposits on the trachea and large bronchi, without any purulent secretion within the respiratory tract (fig. 2⇓). The histopathological aspect of bronchial biopsies is shown in figure 3⇓. Blood tests disclosed type I cryoglobulinaemia composed of a 32 g·L−1 monoclonal immunoglobulin (Ig)Mκ serum component (at 37°C). Blood cell count was normal. Bone marrow examination showed malignant lymphoplasmacytic cells representing 30% of total cells, with a monotypic surface expression of IgMκ. The C-reactive protein level was 21 mg·L−1. Extensive renal, cardiac and hepatic evaluations were normal. As severe hypoxaemia and reduction of carbon monoxide transfer factor were unexplained, the patient underwent videothoracoscopic lung biopsies. Fig. 1— Thoracic computed tomography scan. Fig. 2— Fibreoptic bronchoscopy. Arrow shows candle stain-like deposits. Fig. 3— a) Bronchial biopsy of candle-stain like lesions stained by haematoxylin-eosin-saffron. Submucosal abnormal deposits with concentric pattern around the vessels (black arrow), arranging in cords or ribbon-like structures in the interstitium (black dashed arrow) or in an organoid, raspberry-like fashion in smooth muscle fascicles (black arrowhead). b) Bronchial biopsy; perivascular deposits with negative Congo red dye staining. c) Direct anti-κ-light chain immunofluorescence in bronchial biopsy showing positivity of perivascular (white arrow) and interstitial (white dashed arrow) deposits, and epithelial …

Lung disease after long-term inhalation of organic dusts in employees of a drug firm (author's transl)

Nine patients, as employees of a drug firm exposed to pancreatin and other organic substances in dust form for long periods of time, complained of non-specific breathing disorders and exercise dyspnoea. Investigation revealed predominantly restrictive-obstructive disorders of ventilation with diffuse emphysema and evidence of abnormal oxygen diffusion. In two patients the chest X-ray revealed signs of acute alveolitis, in a third a marked pulmonary fibrosis after exposure for several years. Six of seven patients reacted positively to a prick test with pancreatin. Precipitating antibodies were demonstrated in only one patient. Immunopathological and chemical-toxic effects of pancreatin dust may be causes of the described pulmonary disease.

Intérêt de l’épreuve fonctionnelle d’exercice au cours des myopathies inflammatoires avec atteinte pulmonaire

Dyspnoea occurring during inflammatory myopathy associated with interstitial lung disease (ILD) can be ascribed to several physiopathological pathways. The purpose of this study was to analyse cardiopulmonary exercise testing (CPET) abnormalities in these patients in order to precise mechanisms responsible for decreased aerobic capacity.Ten patients (52 +/- 12 years) were diagnosed as having inflammatory myopathy with interstitial lung disease. Exercise dyspnoea was found in 9 patients. All of them had a restrictive pattern associated to and impairment of the transfer factor for carbon monoxide. CPET was performed with a bicycle ergometer using a standard protocol of incremental increasing work load.Two patients had a normal exercise capacity while eight patients had abnormal VO2 associated with hyperventilation, abnormal gas exchange, as well as and abnormal dead space. Five patients also exhibited decreased oxygen pulse (<80% expected value) at peak exercise; 4 out of 5 had persistence of ventilatory reserve. In addition DeltaFC/DeltaVO2 was increased (>50) in 7 cases.CPET provides useful information in the understanding of mechanisms of dyspnoea and might be an effective tool in treatment decision making: in patients with inflammatory myopathy and associated ILD abnormal oxygen pulse may reflect cardiac disorder or muscular abnormalities (inflammatory or steroid myopathy).

Step-test 3-minutes : étude de faisabilité chez l’enfant transplanté médullaire

Bronchiolitis obliterans following a bone marrow transplantation needs an early diagnosis for a better evolution. First signs are exercise dyspnea and hypoxemia. A walking test evaluating the tolerance for effort could have an interest in detecting such symptoms. We report a preliminary study of feasibility of the 3-minute step-test in children with a bone marrow transplantation. Ten patients (5 boys, median 11.7 years, range 5.1-15.5 years) were included within at least 3 months away from a bone marrow transplantation. After clinical examination and realisation of pulmonary function tests, the test was to step up and down a single step which is 15 cm high, rhythmically (30 per minute) during 3 minutes. Heart rate and pulsed oxygen saturation were registered, dyspnea being assessed before and after the test by means of a visual analogue score and the fifteen-count breathlessness score. All the children realised the 3-minute step-test successfully and with excellent tolerance. Only 1 child made an effort judged maximum. No hypoxemia caused by the effort was highlighted. The 3-minute step-test is easy to achieve in a population of paediatric patients who have undergone a bone marrow transplantation. It could be a valuable tool in the respiratory follow up of these children.

Effects of formoterol on exercise tolerance in severely disabled patients with COPD

We wished to evaluate the effects of inhaled formoterol, a long-acting beta(2)-adrenergic agonist, on exercise tolerance and dynamic hyperinflation (DH) in severely disabled chronic obstructive pulmonary disease (COPD) patients. In a two-period, crossover study, 21 patients with advanced COPD (FEV(1)=38.8+/-11.7% predicted, 16 patients GOLD stages III-IV) were randomly allocated to receive inhaled formoterol fumarate 12 microg twice daily for 14 days followed by placebo for 14 days, or vice versa. Patients performed constant work-rate cardiopulmonary exercise tests to the limit of tolerance (Tlim) on a cycle ergometer: inspiratory capacity (IC) was obtained at rest and each minute during exercise. Baseline and transitional dyspnoea indices (BDI and TDI) were also recorded. Eighteen patients completed both treatment periods. Formoterol treatment was associated with an estimated increase of 130 s in Tlim compared with placebo (P=0.052): this corresponded to a 37.8% improvement over placebo (P=0.012). Enhanced exercise tolerance after bronchodilator was associated with diminished DH marked by higher inspiratory reserve and tidal volumes at isotime and exercise cessation (P<0.05). There was no significant difference between formoterol and placebo on exercise dyspnoea ratings; however, all domains of the TDI improved (P<or=0.02) following formoterol, compared with placebo. Inhaled formoterol 12 microg twice daily is effective in ameliorating DH, daily dyspnoea and exercise intolerance even in patients with advanced COPD.

743 64-row Multi-Detector Computed Tomography (MDCT) as a useful tool in morphologic and functional measurements of left ventricle (LV) in patients with exercise dyspnea

743 64-row Multi-Detector Computed Tomography (MDCT) as a useful tool in morphologic and functional measurements of left ventricle (LV) in patients with exercise dyspnea

Research in Exercise Physiology and Dyspnea at McMaster University

Dr EJ Moran Campbell arrived in Hamilton, Ontario, in September 1968, as the founding chairman of the Department of Medicine at McMaster University Medical Centre (Hamilton, Ontario). He had asked me to be the Head of the Regional Respiratory Program, and I followed him two weeks later. We had worked together at the Royal Postgraduate Medical School, Hammersmith Hospital, for several years to develop a system of exercise testing that could be routinely applied to any clinical problem associated with effort intolerance. We also each had our own separate obsessions; Moran’s obsession was in dyspnea, and mine was in exercise metabolism. The three research streams – exercise testing, metabolism and dyspnea – gradually gained momentum, largely due to the hard work of graduate students and fellows. In the present brief overview, I hope to acknowledge their contribution as much as the progress we made in these topics.

COPD and Exercise: What's Really Important? A Nursing Perspective

Numerous studies demonstrate the importance of exercise training to improve endurance in patients with chronic obstructive pulmonary disease (COPD) and its positive effect on activities of daily living and quality of life. However, successful care of the individual with COPD also relies on recognizing that this person requires individualized care and non-pharmacologic modalities specific to their needs in order to cope with the various aspects of their disease. It is also important to note that improvement in quality of life is not necessarily related to improvement in exercise endurance alone. Comprehensive and effective pulmonary rehabilitation for the COPD patient needs to encompass several components to provide benefit for the spectrum of symptoms of COPD beyond exercise tolerance and dyspnea to ultimately improve quality of life.

Respiratory symptoms and smoking behaviour in Swiss conscripts.

Smoking is a major health hazard in young adults. Reducing smoking is the only well established effective primary prevention of chronic obstructive pulmonary disease. We undertook a prospective cross sectional study to determine the prevalence of respiratory symptoms, smoking behaviour and willingness to participate in a smoking cessation program in Swiss conscripts. Conscripts completed a standardized questionnaire on respiratory symptoms, asthma and smoking behaviour and underwent spirometry measurement. 2604 conscripts were included. 1252 (48%) were current smokers, 144 (6%) were former smokers, 111 (4%) were recent beginners or low intensity smokers and 1097 (42%) were never smokers. Respiratory symptoms were significantly higher in smokers compared to never smokers (wheezing 16% vs. 7%, wheezing without cold 9% vs. 4%, exercise dyspnoea 15% vs. 10%, regular cough 35% vs. 10% and regular phlegm 15% vs. 2%). The mean score of the Fagerstrom Test for Nicotine Dependency (FTND) was 2.6 (+/-2.1). According to the transtheoretical model of stage of change 50% were in the precontemplation, 34% in the contemplation, 5% in the preparation, 5% in the action and 6% in the maintenance stage. Amongst the current smokers 33% were willing to participate in a smoking cessation program. Those willing to participate in a smoking cessation program included 17% precontemplators and 53% contemplators. There is a high prevalence of respiratory symptoms in young current smokers. The Fagerstrom Test for Nicotine Dependence score in conscripts is low thus favouring a potentially successful outcome of a smoking cessation intervention. Using motivational stages to tailor smoking cessation aids might preclude adequate interventions in individuals belonging to the precontemplation stage.