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Aging of the Respiratory System: Impact on Pulmonary Function Tests and Adaptation to Exertion Jean-Paul Janssens, MD

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Aging of the Respiratory System: Impact on Pulmonary Function Tests and Adaptation to Exertion Jean-Paul Janssens, MD Clin Chest Med 26 (2005) 469 – 484 Aging of the Respiratory System: Impact on Pulmonary Function Tests and Adaptation to Exertion Jean-Paul Janssens, MD Outpatient Section of the Division of Pulmonary Diseases, Geneva University Hospital, 1211 Geneva 14, Switzerland Life expectancy has risen sharply during the past chest wall, in static elastic recoil of the lung (Fig. 1), century and is expected to continue to rise in virtually and in strength of respiratory muscles. all populations throughout the world. In the United States population, life expectancy has risen from Age-associated changes in the chest wall 47 years in 1900 to 77 in 2001 (74.4 for the male and 79.8 for the female population) [1]. The proportion of Estenne and colleagues measured age-related the population over 65 years of age currently is more changes in chest wall compliance in 50 healthy than 15% in most developed countries and is ex- subjects ages 24 to 75: aging was associated with a pected to reach 20% by the year 2020. Healthy life significant decrease (À31%) in chest wall compli- expectancy, at the age of 60, is at present 15.3 years ance, involving rib cage (upper thorax) compliance for the male population and 17.9 years for the female and compliance of the diaphragm-abdomen compart- population [2]. These demographic changes have a ment (lower thorax) [5]. Calcifications of the costal major impact on health care, financially and clini- cartilages and chondrosternal junctions and degenera- cally. Awareness of the basic changes in respiratory tive joint disease of the dorsal spine are common physiology associated with aging and their clinical radiologic observations in older subjects and contrib- implication is important for clinicians. Indeed, age- ute to chest wall stiffening [6]. Changes in the shape associated alterations of the respiratory system tend of the thorax modify chest wall mechanics; age- to diminish subjects’ reserve in cases of common related osteoporosis results in partial (wedge) or clinical diseases, such as lower respiratory tract in- complete (crush) vertebral fractures, leading to fection or heart failure [3,4]. increased dorsal kyphosis and anteroposteriordi- This review explores age-related physiologic ameter (barrel chest). Indeed, prevalence of vertebral changes in the respiratory system and their conse- fractures in the elderly population is high and quences in respiratory mechanics, gas exchange, and increases with age; in Europe, in female subjects respiratory adaptation to exertion. over 60, the prevalence of vertebral fractures is 16.8% in the 60 to 64 age group, increasing to 34.8% in the 75 to 79 age group [7]. Men also show an Structural changes in the respiratory system increase in vertebral fractures with age, but rates are related to aging approximately half those of the female population [8]. A study of 100 chest radiographs of subjects ages Most of the age-related functional changes in the 75 to 93 years, without cardiac or pulmonary dis- respiratory system result from three physiologic orders, illustrates the frequency of dorsal kyphosis events: progressive decrease in compliance of the in this age group: 25% had severe kyphosis as a consequence of vertebral wedge or crush fractures (>50°), 43% had moderate kyphosis (35°–50°), and E-mail address: [email protected] only 23% had a normal curvature of the spine [6]. 0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccm.2005.05.004 chestmed.theclinics.com 470 janssens A 100 100 80 Chest wall rs 80 60 lung 60 FRC % TLC 40 40 RV 20 20 0 0 -40 -30 -20 -10 010203040 Pressure (cm H2O) B 100 100 80 rs 80 Chest wall 60 FRC 60 lung % TLC 40 40 RV 20 20 0 0 -40 -30 -20 -10 010203040 Pressure (cm H2O) Fig. 1. Static pressure-volume curves showing changes in the compliance of the chest wall, the lung, and the respiratory system between an ‘‘ideal’’ 20-year-old (A) and a 60-year-old subject (B). Note increase in RV and FRC and decrease in slope of pressure-volume curve for the respiratory system (rs) in the older subject, illustrating decreased compliance of the respiratory system. (Data from Turner J, Mead J, Wohl M. Elasticity of human lungs in relation to age. J Appl Physiol 1968;25:664–71.) Respiratory muscle function Fig. 1) [9]. As such, during normal resting tidal breathing, the increase in breathing-related energy Respiratory muscle performance is impaired con- expenditure (elastic work) in a 60-year-old man is comitantly by the age-related geometric modi- estimated at 20% compared with that of a 20-year- fications of the rib cage, decreased chest-wall old, placing an additional burden on the respiratory compliance, and increase in functional residual muscles [8]. capacity (FRC) resulting from decreased elastic recoil Respiratory muscle strength decreases with age of the lung (Fig. 2) [9]. The kyphotic curvature of the (Table 1). Polkey and colleagues report a significant, spine and the anteroposterior diameter of the chest although modest, decrease in the strength of the increase with aging, thereby decreasing the curvature diaphragm in elderly subjects (n = 15; mean age 73, of the diaphragm and thus its force-generating range 67–81 years) compared with a younger control capacity [6]. Changes in chest wall compliance lead group (n = 15; mean age 29, range 21–40 years): to a greater contribution to breathing from the dia- À13% for transdiaphragmatic pressure during a phragm and abdominal muscles and a lesser contri- maximal sniff (sniff transdiaphragmatic pressure bution from thoracic muscles. The age-related [Pdi]: 119 versus 136 cm H2O) and À23% during cer- reduction in chest-wall compliance is somewhat vical magnetic stimulation (twitch Pdi: 26.8 versus greater than the increase in lung compliance; thus, 35.2 cm H2O) [10]. There was, however, a consid- compliance of the respiratory system is 20% less in a erable overlap between groups, and the magnitude 60-year-old subject compared with a 20-year-old (see of the difference in this study was relatively small. aging of the respiratory system 471 70 grip) [13]. Peripheral muscle strength declines with aging. Bassey and Harries report a 2% annual 60 FRC decrease in handgrip strength in 620 healthy subjects 50 over age 65 [20]. Decrease in muscle strength results from a decrease in cross-sectional muscle fiber area 40 (process referred to as sarcopenia), a decrease in the RV number of muscle fibers (especially type II fast- 30 % TLC twitch fibers and motor units), alterations in neuro- muscular junctions, and loss of peripheral motor 20 neurons with selective denervation of type II muscle fibers [21–26]. Other proposed mechanisms of age- 10 related muscular dysfunction include impairment of ++ 0 the sarcoplasmic reticulum Ca pump resulting from 10 20 30 40 50 60 70 uncoupling of ATP hydrolysis from Ca++ transport Age (years) (which may reduce maximal shortening velocity and relaxation), loss of muscle proteins resulting from Fig. 2. Progressive and linear increase in RVand FRC decreased synthesis (ie, decreased ‘‘repair’’ ability between the ages of 20 and 60 years. Gray zones represent and protein turnover), and a decline in mitochondrial ± 1 SD. (Data from Turner J, Mead J, Wohl M. Elasticity of oxidative capacity [27–31]. human lungs in relation to age. J Appl Physiol 1968;25: Respiratory muscle function also is dependent on 664–71.) energy availability (ie, blood flow, oxygen content, and carbohydrate or lipid levels) [32]. Decreased Similarly, Tolep and coworkers report maximal respiratory muscle strength is described in patients Pdi values in healthy elderly subjects (n = 10; ages who have chronic heart failure (CHF). Mancini and 65–75, 128 ± 9 cm H2O), which were 25% lower colleagues show that CHF has a highly significant than values obtained in young adults (n = 9; ages impact on respiratory muscle strength and on the 19–28, 171 ± 8 cm H2O) [11]. Although one cross- tension-time index [33]. The tension-time index de- sectional study fails to demonstrate any relationship scribes the relationship between force of contraction between age and maximal static respiratory pressures (Pdi/Pdimax) and duration of contraction (ratio of in 104 subjects over 55 [12], larger studies—also inspiratory time to total respiratory cycle duration based on noninvasive measurements (maximal inspir- [TI/TTOT]) and is related inversely to respiratory atory and expiratory pressures [MIP and MEP] at the muscle endurance. In elderly subjects who have heart mouth and sniff nasal inspiratory pressure [SNIP])— document an age-related decrease in respiratory muscle performance [13–16]. Table 1 Respiratory muscle strength is related to nutri- Maximal inspiratory and expiratory pressures measured at tional status, often deficient in the elderly. Enright the mouth in older subjects, by age group and sex and colleagues demonstrate significant correlations MIP (cm H2O) MEP (cm H2O) between MIP or MEP pressures and lean body mass Age group (y) n = 5201 n = 756 (measured by bioelectric impedance), body weight, or Women body mass index [14]. Arora and Rochester show the 65–69 59 125 deleterious impact of undernourishment on respira- 70–74 56 121 tory muscle strength or maximal voluntary ventila- 75–79 49 102 tion: the decrease in respiratory muscle strength and 80–84 45 84 maximal voluntary ventilation was highly significant >85 40 94 Men in undernourished subjects (71 ± 6% of ideal body 65–69 84 188 weight) compared with control subjects (104 ± 10% 70–74 81 179 of ideal body weight) [17]. Necropsy studies confirm 75–79 74 161 the correlation between body weight and diaphragm 80–84 64 142 muscle mass further [18]. >85 56 131 Age-associated alterations in skeletal muscles also Data from Enright PL, Kronmal RA, Manolio TA, et al.
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