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Bronchodilators Accelerate the Dynamics of Muscle O2 Delivery

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Bronchodilators Accelerate the Dynamics of Muscle O2 Delivery Chronic obstructive pulmonary disease Bronchodilators accelerate the dynamics of muscle Thorax: first published as 10.1136/thx.2009.120857 on 13 July 2010. Downloaded from O2 delivery and utilisation during exercise in COPD Danilo C Berton,1 Priscila B Barbosa,1 Luciana S Takara,1 Gaspar R Chiappa,1 Ana Cristina B Siqueira,1 Daniela M Bravo,1 Leonardo F Ferreira,2 J Alberto Neder1 See Editorial, p 573 ABSTRACT (QT), suggesting an important role for the central Background Expiratory flow limitation and lung cardiovascular adjustments in setting the limits of < Supplementary methods are hyperinflation promote cardiocirculatory perturbations increase in peripheral QO at the onset of exercise. published online only. To view 2 these files please visit the that might impair O2 delivery to locomotor muscles in Further experimental evidence for this contention journal online (http://thorax.bmj. patients with chronic obstructive pulmonary disease was obtained in a subsequent study in which com). (COPD). The hypothesis that decreases in lung hyperinflation a strategy aimed to reduce the resistive work of 1Pulmonary Function and Clinical after the inhalation of bronchodilators would improve breathing and dynamic hyperinflation (heliox) Exercise Physiology Unit skeletal muscle oxygenation during exercise was tested. simultaneously accelerated the dynamics of QTand (SEFICE), Division of Respiratory 5 Methods Twelve non- or mildly hypoxaemic males QO2 in patients with moderate to severe COPD. Diseases, Department of (forced expiratory volume in 1 s (FEV1)¼38.5612.9% These data prompted the hypothesis that similar Medicine, Federal University of > fi Sao Paulo (UNIFESP), Sa˜o predicted; PaO2 60 mm Hg) underwent constant work ndings would be observed in response to the most Paulo, Brazil rate cycle ergometer exercise tests (70e80% peak) to effective and clinically feasible intervention avail- 2Department of Physiology, the limit of tolerance (Tlim) after inhaled bronchodilators able to alleviate lung hyperinflation and improve University of Kentucky, (salbutamol plus ipratropium) or placebo. Muscle (de) exercise tolerance in these patientsdthat is, inhaled Lexington, Kentucky, USA 167 oxygenation (wfractional O2 extraction) was determined bronchodilators. Correspondence to in the vastus lateralis by changes (D) in the In the present study, therefore, we aimed to Professor J A Neder, Pulmonary deoxyhaemoglobin/myoglobin signal ([HHb]) from near- investigate the effects of acute inhalation of Function and Clinical Exercise b infrared spectroscopy, and cardiac output (QT) was a combination of a short-acting 2-adrenoceptor Physiology Unit (SEFICE), monitored by impedance cardiography. agonist (salbutamol sulfate) and a short-acting Respiratory Division, Department of Medicine, Results Bronchodilators reduced lung hyperinflation and anticholinergic (ipratropium bromide) on key 6 _ Federal University of Sa˜o Paulo increased Tlim compared with placebo (454 131 s vs determinants of QO2 and Vo2 during high-inten- (UNIFESP), Rua Professor 3216140 s, respectively; p<0.05). On-exercise kinetics sity, constant work rate cycling exercise in patients Francisco de Castro 54, Vila _ of QT and pulmonary O2 uptake ðVo2Þ were accelerated with moderate to severe COPD. Confirmation of Clementino, Sa˜o Paulo CEP: D 04020-050, Brazil; with active treatment; [HHb] dynamics, however, were the hypothesis that bronchodilators would slow http://thorax.bmj.com/ [email protected] delayed by w78% and the signal amplitude diminished the dynamics and decrease the amplitude of leg by w21% (p<0.01). Consequently, the ratio between muscle deoxygenation would provide novel _ Received 1 June 2009 Vo2 and D[HHb] dynamics decreased, suggesting evidence that amelioration of the mechanical Accepted 12 January 2010 _ improved microvascular O2 delivery (s-Vo2/MRT-D burden of breathing might positively impact upon ¼ 6 6 < [HHb] 4.48 1.57 s vs 2.08 1.15 s, p 0.05). Of note, the provision of O2 to the working peripheral reductions in lung hyperinflation were related to faster muscles during exercise in patients with COPD. _ QT kinetics and larger decrements in s-Vo2/MRT-D[HHb] < on September 25, 2021 by guest. Protected copyright. (p 0.01). METHODS Decreases in operating lung volumes after Conclusions Subjects the inhalation of bronchodilators are associated with faster Twelve males with moderate to severe, stable ‘central’ cardiovascular adjustments to high-intensity COPD (forced expiratory volume in 1 s (FEV )/ exercise with beneficial consequences on muscle 1 forced vital capacity (FVC) <0.7 and post- oxygenation in patients with moderate to severe COPD. < bronchodilator FEV1 60% predicted), and resting > PaO2 60 mm Hg, volunteered to participate in the study. Patients were recruited from the COPD INTRODUCTION Outpatients Clinic of the Sao Paulo Hospital Exercise intolerance is a multifactorial construct in (Brazil), a University-based teaching hospital. patients with chronic obstructive pulmonary Subjects were free of echo Doppler cardiographic e disease (COPD).1 3 In fact, recent studies from our evidence of severe pulmonary hypertension and left laboratory suggest that expiratory flow limitation ventricular dysfunction. No patient has ever been and lung hyperinflation are related to sluggish enrolled in a pulmonary rehabilitation programme. central cardiovascular adjustments at the onset of All participants signed a written informed consent exercise which might impair the balance between form. The study protocol was approved by the ð _ Þ O2 delivery (QO2) and uptake Vo2 in the exer- Institutional Medical Ethics Committee. cising muscles of patients with COPD.45The result, then, is faster and heightened muscle deox- Study protocol ygenation measured by near-infrared spectroscopy This was a double-blinded, placebo-controlled _ (NIRS) in patients compared with age-matched crossover study. After determination of peak ðVo2Þ controls.4 Interestingly, these abnormalities were on a maximal incremental cycle ergometer exercise closely related to slower kinetics of cardiac output test, subjects were randomly assigned to inhale 588 Thorax 2010;65:588e593. doi:10.1136/thx.2009.120857 Chronic obstructive pulmonary disease m m fi salbutamol sulfate 120 g plus ipratropium bromide 20 g per 180 s of exercise, metabolic and NIRS data were tted by the Thorax: first published as 10.1136/thx.2009.120857 on 13 July 2010. Downloaded from actuation, via a metered dose inhaler (MDI; Combivent, Boeh- following monoexponential equation from the start of exercise ringer Ingelheim, Germany) or Combivent placebo via an MDI to the third minute16: each on a different day. At these visits, patients performed À ðtÀTDpÞ ½Y ¼½Y þ Ap À e sp a total of four transitions from baseline pedalling to 70e80% ðtÞ ðbÞ 1 peak work rate. The initial test was performed to the limit of b p tolerance (Tlim, min) 20 min after the inhalation of broncho- where and refer to baseline unloaded cycling and primary component, respectively; A, TD and s are the amplitude, time dilators or placebo. Patients rested for 1 h before performing an _ additional 4 min exercise test. Thus, there were two on-exercise delay and time constant of the exponential response. For Vo2 fi repetitions per day. Data from same-day transitions were aver- analysis we deleted the data relative to the rst 20 s after exer- d s _ aged to reduce data noise for the kinetic analyses (see details cise onset that is, the cardiodynamic phase. Therefore, Vo2 represents the time course of the primary componentdan below). Additional details are described in the supplement _ 17 available online. estimate of the muscle Vo2 kinetics. The overall kinetics of [HHb] were determined by the mean response time ¼s s _ Measurements (MRT +TD). The ratio -Vo2/MRT-[HHb] was used as Pulmonary function tests a semiquantitative index of microvascular QO2 kinetics, with 45 Spirometry, single-breath lung diffusing capacity, static lung higher values indicating slower QO2. Based on our experience with NIRS in patients with COPD,4518and previous findings volumes by body plethysmography and arterial blood gases were 19 measured at baseline. Recorded values were compared with with other disease populations, we systematically examined ‘ ’ D those predicted for the adult Brazilian population.8 9 whether there was an overshoot in [HHb] after the initial fast response (see the Results section). In the case of a discernible ‘ ’ Exercise tests overshoot in the two interventions, we used the area under the ‘overshoot’ as an additional index of impaired microvascular Standard metabolic and ventilatory responses were measured 12 breath-by-breath using a calibrated, computer-based system QO2. Additional information on kinetic analyses are detailed in the supplement online. (CardiO2 System, Medical Graphics, St Paul, Minnesota, USA). A period of 3 min unloaded exercise preceded the imposition of the selected work rate. Serial inspiratory capacity (IC, litres) Statistical analysis manoeuvres were performed during the test. Assuming that total Statistical analysis was performed using SPSS 15.0. We planned lung capacity (TLC) remains constant during exercise, IC to evaluate 12 patients based on our previous results in a similar manoeuvres provide an estimate of end-expiratory lung volume.10 transversal and crossover study with heliox in patients with COPD.5 Paired t test was used to contrast within-subject exer- Skeletal muscle oxygenation cise responses with the exception of symptom scores (Wilcoxon fi signed-rank
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