Professional Documents
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pulmonary disease
DENIS E. ODONNELL
Departments of Medicine and Physiology, Division of Respiratory and Critical Care Medicine, Queens University,
Kingston, Ontario, CANADA
ABSTRACT
ODONNELL, E. D. Ventilatory limitations in chronic obstructive pulmonary disease. Med. Sci. Sports Exerc., Vol. 33, No. 7, Suppl.,
pp. S647S655, 2001. Chronic obstructive pulmonary disease (COPD) is a heterogeneous disorder characterized by dysfunction of the
small and large airways, as well as by destruction of the lung parenchyma and vasculature, in highly variable combinations.
Breathlessness and exercise intolerance are the most common symptoms in COPD and progress relentlessly as the disease advances.
Exercise intolerance is multifactorial, but in more severe disease, ventilatory limitation is often the proximate exercise-limiting event.
Multiple factors determine ventilatory limitation and include integrated abnormalities in ventilatory mechanics and ventilatory muscle
function as well as increased ventilatory demands (as a result of gas exchange abnormalities) and alterations in the neuroregulatory
control of breathing. Despite its heterogeneity, the pathophysiological hallmark of COPD is expiratory flow limitation. When
ventilation increases in flow-limited patients during exercise, air trapping is inevitable and causes further dynamic lung hyperinflation
(DH) above the already increased resting volumes. DH causes elastic and inspiratory threshold loading of inspiratory muscles already
burdened with increased resistive work. It seriously constrains tidal volume expansion during exercise. DH compromises the ability
of the inspiratory muscles to generate pressure, and the positive intrathoracic pressures likely contribute to cardiac impairment during
exercise. Progressive DH hastens the development of critical ventilatory constraints that limit exercise and, by causing serious
neuromechanical uncoupling, contributes importantly to the quality and intensity of breathlessness. The corollary of this is that
therapeutic interventions that reduce operational lung volumes during exercise, by improving lung emptying or by reducing ventilatory
demand (which delays the rate of DH), result in clinically meaningful improvement of exercise endurance and symptoms in disabled
COPD patients. Key Words: DYSPNEA, DYNAMIC HYPERINFLATION, MECHANICS, FLOWVOLUME LOOPS
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3) alteration of afferent inputs from peripheral chemoreceptors, and 4) altered perception of dyspnea and leg discomfort. The relative importance of these factors likely varies
between individuals. Although gas exchange abnormalities,
such as severe hypoxemia, are inextricably linked to ventilatory limitation in COPD, the effects of correction of arterial hypoxemia on exercise performance are quite variable
and unpredictable in a given subject (6,24,60). However, in
general, patients with the most severe mechanical and gas
exchange abnormalities benefit most in terms of improved
dyspnea and exercise endurance (36,45).
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FIGURE 5Responses to bronchodilator therapy (nebulized ipratropium bromide, 500 g) are shown. As maximal expiratory flow
volume relationships improved after dose, tidal flowvolume curves at
rest can shift to the right, i.e., lung hyperinflation is reduced as
reflected by an increased IC (top panel). Exertional dyspnea decreases
significantly (*P < 0.05) in response to bronchodilator therapy (middle
panel). Operational lung volumes improve in response to bronchodilator therapy, i.e., mechanical constraints on VT expansion are reduced
as IC and IRV are increased significantly (*P < 0.05) (lower panel).
Adapted from ODonnell et al. (38) with permission.
SUMMARY
On the basis of extensive studies in COPD patients, we
can conclude that ventilatory limitation contributes importantly, and often predominantly, to exercise limitation. Expiratory flow limitation is the hallmark of this heterogeneous condition, and its most important consequence during
exercise is dynamic lung hyperinflation, which accelerates
ventilatory limitation and exercise termination. The recognition that dynamic hyperinflation is one factor contributing
Medicine & Science in Sports & Exercise
S653
to reduced ventilatory capacity is potentially clinically important, since lung hyperinflation is at least partially reversible and can, therefore, be manipulated for the patients
benefit. Interventions that improve airway function and lung
emptying will reduce operational lung volumes during exercise, and delay the occurrence of critical ventilatory constraints, thus improving exercise endurance and symptoms.
An integrative approach that maximizes lung emptying
(combined bronchodilators) and further reduces the rate of
gas accumulation by reducing ventilatory demand during
exercise (i.e., oxygen therapy and exercise training) can
result in clinically meaningful benefits for the patient with
advanced symptomatic COPD.
Although much of the scientific evidence currently available refers to COPD patients, certain of the principles of
exercise limitation described above also apply to patients
with other types of chronic pulmonary disease. The reduced
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