Addressing Assumptions for the Use of Non-invasive Cardiac Output Measurement Techniques During Exercise in COPD.

The multifactorial functional limitation of COPD increasingly demonstrates the need for an integrated circulatory assessment. In this study cardiac output (Qc) derived from non-inert (CO2-RB), inert (N2O-RB) gas rebreathing approaches and bioimpedance were compared to examine the limitations of currently available non-invasive techniques for exercise Qc determination in patients with chronic lung disease. Thirteen COPD patients (GOLD II-III) completed three constant cycling bouts at 20, 35, and 50% of peak work on two occasions to assess Qc with bioimpedance as well as using CO2-RB and N2O-RB for all exercise tests. Results showed significantly lower Qc using the N2O-RB or end-tidal CO2-derived Qc compared to the PaCO2-derived CO2-RB or the bioimpedance at rest and for all exercise intensities. End-tidal CO2-derived values are however not statistically different from those obtained using inert-gas rebreathing. This study show that in COPD patients, CO2-rebreathing Qc values obtained using PaCO2 contents which account for any gas exchange impairment or inadequate gas mixing are similar to those obtained using thoracic bioimpedance. Alternately, the lower values for N2O rebreathing derived Qc indicates the inability of this technique to account for gas exchange impairment in the computation of Qc. These findings indicate that the choice of a gas rebreathing technique to measure Qc in patients must be dictated by the ability to include in the derived computations a correction for either gas exchange inadequacies and/or a vascular shunt.

Haemodynamic compensations for exercise tissue oxygenation in early stages of COPD: an integrated cardiorespiratory assessment study.

BACKGROUND: Cardiovascular comorbidities are increasingly being recognised in early stages of chronic obstructive pulmonary disease (COPD) yet complete cardiorespiratory functional assessments of individuals with mild COPD or presenting with COPD risk factors are lacking. This paper reports on the effectiveness of the cardiocirculatory-limb muscles oxygen delivery and utilisation axis in smokers exhibiting no, or mild to moderate degrees of airflow obstruction using standardised cardiopulmonary exercise testing (CPET). METHODS: Post-bronchodilator spirometry was used to classify participants as 'ever smokers without' (n=88), with 'mild' (n=63) or 'mild-moderate' COPD (n=56). All underwent CPET with continuous concurrent monitoring of oxygen uptake (V'O2) and of bioimpedance cardiac output (Qc) enabling computation of arteriovenous differences (a-vO2). Mean values of Qc and a-vO2 were mapped across set ranges of V'O2 and Qc isolines to allow for meaningful group comparisons, at same metabolic and circulatory requirements. RESULTS: Peak exercise capacity was significantly reduced in the 'mild-moderate COPD' as compared with the two other groups who showed similar pulmonary function and exercise capacity. Self-reported cardiovascular and skeletal muscle comorbidities were not different between groups, yet disease impact and exercise intolerance scores were three times higher in the 'mild-moderate COPD' compared with the other groups. Mapping of exercise Qc and a-vO2 also showed a leftward shift of values in this group, indicative of a deficit in peripheral O2 extraction even for submaximal exercise demands. Concurrent with lung hyperinflation, a distinctive blunting of exercise stroke volume expansion was also observed in this group. CONCLUSION: Contrary to the traditional view that cardiovascular complications were the hallmark of advanced disease, this study of early COPD spectrum showed a reduced exercise O2 delivery and utilisation in individuals meeting spirometry criteria for stage II COPD. These findings reinforce the preventive clinical management approach to preserve peripheral muscle circulatory and oxidative capacities.

Eccentric and concentric exercises induce different adaptions in adipose tissue biology.

Alterations in adipose tissue (AT) metabolism related to inflammation and adipokine's production lead to perturbations in its capacity to store lipids and release fatty acids (FA) during feeding/fasting transition or during exercise. Exercise has a beneficial effect on AT metabolism, but conventional trainings are not always suitable for patients with functional limitations. Dynamic eccentric (ECC) exercise prevents the accumulation of AT and may then overcome those limitations. Consequently, this study aimed at investigating AT's adaptations after ECC training. Nine-week-old male rats were randomly assigned to a control sedentary or three-trained groups for which treadmill slopes modulated exercise oxygen consumption (VO2) and mechanical work (n = 15 per group): (1) + 15% uphill-concentric group (CONC), (2) - 15% downhill group (ECC15, same mechanical work as CONC) and (3) - 30% downhill group (ECC30, same VO2, or oxygen cost as CONC). Body composition and energy expenditure (EE) were measured before and after 8 weeks of training. Subcutaneous AT was collected to study total FA profile and gene expression. Higher total EE was driven by lean mass gain in trained animals. In AT, there was a decrease in arachidonic acid with CONC or ECC15 training. Increased adiponectin, leptin, lipases, Glut4 and Igf1 mRNA levels in ECC15 group suggested major metabolic adaption in AT. In conclusion, ECC could induce beneficial modifications in AT fatty acid profile and the expression of key genes related to metabolism and insulin sensitivity.

Detecting improvements in dyspnea in COPD using a three-minute constant rate shuttle walking protocol.

RATIONALE: We examined the responsiveness of a 3-minute constant rate shuttle walking protocol to detect improvements in exertional dyspnea following acute bronchodilation in COPD. Our hypothesis was that the 3-minute constant rate shuttle walking protocol would be able to adequately put forth improvements in exertional dyspnea following acute bronchodilation in this population. METHODS: Using a placebo controlled, double-blind cross-over design, 39 patients with moderate to severe COPD performed a 3-min constant rate shuttle walking test during which they were asked to walk on a flat corridor at a speed that was externally imposed by an audio signal. During the test, dyspnea was graded using the 10-point modified Borg scale. The test was performed twice, following the administration of saline placebo or of 500 µg nebulized ipratropium bromide. RESULTS: Improvements of respiratory pattern (respiratory rate and tidal volume) and statistically and clinically significant reductions in Borg dyspnea scores (∆ dyspnea score = 1.0 ± 0.2, p < 0.01) were seen during the 3-min shuttle walking protocol with ipratropium bromide compared to placebo. CONCLUSION: This 3-minute shuttle walking protocol adequately detected dyspnea and breathing pattern improvements following acute bronchodilation in COPD.

Effects of exercise-induced metabolic and mechanical loading on skeletal muscle mitochondrial function in male rats.

Over the past decades, a growing interest in eccentric (ECC) exercise has emerged, but mitochondrial adaptations to ECC training remain poorly documented. Using an approach for manipulating mechanical and metabolic exercise power, we positioned that for the same metabolic power, training using concentric (CON) or ECC contractions would induce similar skeletal muscle mitochondrial adaptations. Sixty adult rats were randomly assigned to a control (CTRL) or three treadmill training groups running at 15 m·min-1 for 45 min, 5 days weekly for 8 wk at targeted upward or downward slopes. Animals from the CON (+15%) and ECC30 (-30%) groups were trained at iso-metabolic power, whereas CON and ECC15 (-15%) exercised at iso-mechanical power. Assessments were made of vastus intermedius mitochondrial respiration (oxygraphy), enzymatic activities (spectrophotometry), and real-time qPCR for mRNA transcripts. Maximal rates of mitochondrial respiration were 14%-15% higher in CON and ECC30 compared with CTRL and ECC15. Apparent Km for ADP for trained groups was 40%-66% higher than CTRL, with statistical significance reached for CON and ECC30. Complex I and citrate synthase activities were 1.6 (ECC15) to 1.8 (ECC30 and CON) times values of CTRL. Complex IV activity was higher than CTRL (P < 0.05) only for CON and ECC30. mRNA transcripts analyses showed higher TFAM, SLC25A4, CKMT2, and PPID in the ECC30 compared with CTRL. Findings confirm that training-induced skeletal muscle mitochondrial function adaptations are governed by the extent of metabolic overload irrespective of exercise modality. The distinctive ECC30 mRNA transcript pattern may reflect a cytoskeleton damage-repair or ECC adaptive cycle that differs from that of biogenesis.NEW & NOTEWORTHY Anticipating outcomes of eccentric versus concentric training is confounded by differences in mechanical efficiency. Our observations in groups of rats submitted to uphill and downhill running regimens inducing similar levels of metabolic demands or same external power outputs reaffirm that independent of modality, oxygen requirements and not external work governs skeletal muscle mitochondrial function adaptations.

Eccentric cycle exercise in severe COPD: feasibility of application.

Eccentric cycling may present an interesting alternative to traditional exercise rehabilitation for patients with advanced COPD, because of the low ventilatory cost associated with lengthening muscle actions. However, due to muscle damage and soreness typically associated with eccentric exercise, there has been reluctance in using this modality in clinical populations. This study assessed the feasibility of applying an eccentric cycling protocol, based on progressive muscle overload, in six severe COPD patients with the aim of minimizing side effects and maximizing compliance. Over 5 weeks, eccentric cycling power was progressively increased in all patients from a minimal 10-Watt workload to a target intensity of 60% peak oxygen consumption (attained in a concentric modality). By 5 weeks, patients were able to cycle on average at a 7-fold higher power output relative to baseline, with heart rate being maintained at ∼85% of peak. All patients complied with the protocol and presented tolerable dyspnea and leg fatigue throughout the study; muscle soreness was minimal and did not compromise increases in power; creatine kinase remained within normal range or was slightly elevated; and most patients showed a breathing reserve > 15 L.min(-1). At the target intensity, ventilation and breathing frequency during eccentric cycling were similar to concentric cycling while power was approximately five times higher (p = 0.02). This study showed that an eccentric cycling protocol based on progressive increases in workload is feasible in severe COPD, with no side effects and high compliance, thus warranting further study into its efficacy as a training intervention.

Aerobic Metabolic Adaptations in Endurance Eccentric Exercise and Training: From Whole Body to Mitochondria.

A characteristic feature of eccentric as compared with concentric exercise is the ability to generate greater mechanical loads for lower cardiopulmonary demands. Current evidence concurs to show that eccentric training translates into considerable gains in muscle mass and strength. Less is known, however, regarding its impact on oxygen transport and on factors to be considered for optimizing its prescription and monitoring. This article reviews the existing evidence for endurance eccentric exercise effects on the components of the oxygen transport system from systemic to mitochondria in both humans and animals. In the studies reviewed, specially designed cycle-ergometers or downhill treadmill running were used to generate eccentric contractions. Observations to date indicate that overall, the aerobic demand associated with the eccentric training load was too low to significantly increase peak maximal oxygen consumption. By extension, it can be inferred that the very high eccentric power output that would have been required to solicit a metabolic demand sufficient to enhance peak aerobic power could not be tolerated or sustained by participants. The impact of endurance eccentric training on peripheral flow distribution remains largely undocumented. Given the high damage susceptibility of eccentric exercise, the extent to which skeletal muscle oxygen utilization adaptations would be seen depends on the balance of adverse and positive signals on mitochondrial integrity. The article examines the protection provided by repeated bouts of acute eccentric exercise and reports on the impact of eccentric cycling and downhill running training programs on markers of mitochondrial function and of mitochondrial biogenesis using mostly from animal studies. The summary of findings does not reveal an impact of training on skeletal muscle mitochondrial respiration nor on selected mitochondrial messenger RNA transcripts. The implications of observations to date are discussed within future perspectives for advancing research on endurance eccentric exercise physiological impacts and using a combined eccentric and concentric exercise approach to optimize functional capacity.

Eccentric versus conventional cycle training to improve muscle strength in advanced COPD: A randomized clinical trial.

OBJECTIVES: To compare eccentric (ECC) and conventional concentric (CON) cycle training on quadriceps muscle strength in advanced COPD. Secondary objective was to assess functional capacity. METHODS: A parallel-group, assessor-blind, randomized trial was conducted. Severe COPD patients were randomized to either an ECC (n = 13) or CON (n = 11) cycling program for 30-min, 3 times/week for 10 weeks. ECC group trained at ∼4-fold higher power than the CON group at similar relative heart rate intensity. RESULTS: Isometric and isokinetic quadriceps peak torque improved after ECC but not CON; between group difference was significant for isometric peak muscle force (p < 0.05). Peak cycling power and endurance time increased in both groups (p < 0.05). Dyspnea at peak cycling power improved only after ECC training (p < 0.05). Sensory intensity ratings of dyspnea and leg fatigue were significantly lower (p < 0.05) during ECC compared with CON at equivalent relative heart rate intensities. CONCLUSIONS: ECC could be an effective alternative and/or adjunct modality to pulmonary rehabilitation in severely ventilatory limited COPD patients.

The mitochondrial phenotype of peripheral muscle in chronic obstructive pulmonary disease: disuse or dysfunction?

RATIONALE: Peripheral muscle alterations have been recognized to contribute to disability in chronic obstructive pulmonary disease (COPD). OBJECTIVES: To describe the mitochondrial phenotype in a moderate to severe COPD population and age-matched controls. METHODS: Three primary aspects of mitochondrial function were assessed in permeabilized locomotor muscle fibers. MEASUREMENTS AND MAIN RESULTS: Respiration rates per milligram of fiber weight were significantly lower in COPD muscle compared with healthy age-matched control muscle under various respiratory states. However, when variations in mitochondrial volume were taken into account by normalizing respiration per unit of citrate synthase activity, differences between the two groups were abolished, suggesting the absence of specific mitochondrial respiratory impairment in COPD. H(2)O(2) production per mitochondrion was higher both under basal and ADP-stimulated states, suggesting that mitochondria from COPD muscle have properties that potentiate H(2)O(2) release. Direct assessment of mitochondrial sensitivity to Ca(2+)-induced opening of the permeability transition pore (PTP) indicated that mitochondria from patients with COPD were more resistant to PTP opening than their counterparts in control subjects. CONCLUSIONS: Comparison of these results with those of studies comparing healthy glycolytic with oxidative muscle suggests that these differences may be attributable to greater type II fiber expression in COPD muscle, as mitochondria within this fiber type have respiratory function similar to that of mitochondria from type I fibers, and yet are intrinsically prone to greater release of H(2)O(2) and more resistant to PTP opening. These results thus argue against the presence of pathological mitochondrial alterations in this category of patients with COPD.

Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial.

BACKGROUND: Home-based rehabilitation is a promising approach to improve access to pulmonary rehabilitation. OBJECTIVE: To assess whether self-monitored, home-based rehabilitation is as effective as outpatient, hospital-based rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Randomized, multicenter, noninferiority trial. SETTING: 10 academic and community medical centers in Canada. PATIENTS: 252 patients with moderate to severe COPD. INTERVENTION: After a 4-week education program, patients took part in home-based rehabilitation or outpatient, hospital-based rehabilitation for 8 weeks. They were followed for 40 weeks to complete the 1-year study. MEASUREMENTS: The primary outcome was the change in Chronic Respiratory Questionnaire dyspnea subscale score at 1 year. The primary analysis took a modified intention-to-treat approach by using all patients who provided data at the specified follow-up time, regardless of their level of adherence. The analysis used regression modeling that adjusted for the effects of center, sex, and baseline level. All differences were computed as home intervention minus outpatient intervention. RESULTS: Both interventions produced similar improvements in the Chronic Respiratory Questionnaire dyspnea subscale at 1 year: improvement in dyspnea of 0.62 (95% CI, 0.43 to 0.80) units in the home intervention (n = 107) and 0.46 (CI, 0.28 to 0.64) units in the outpatient intervention (n = 109). The difference between the 2 treatments at 1 year was small and clinically unimportant. The 95% CI of the difference did not exceed the prespecified noninferiority margin of 0.5: difference in dyspnea score of 0.16 (CI, -0.08 to 0.40). Most adverse events were related to COPD exacerbations. No serious adverse event was considered to be related to the study intervention. LIMITATION: The contribution of the educational program to the improvement in health status and exercise tolerance cannot be ascertained. CONCLUSION: Home rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients with COPD.

Paced-walk and step tests to assess exertional dyspnea in COPD.

This study reports on the development and test-retest reproducibility of a modified shuttle walking and step testing protocols to assess exertional dyspnea in patients with COPD. Patients with COPD randomly performed four externally paced 3-min bouts of shuttle walking at 1.5, 2.5, 4.0 and 6.0 km x h(- 1) or stepping at constant rate of 18, 22, 26 and 32 steps x min(- 1). Walking and stepping procedures were repeated once, on a separate occasion. Ventilation, heart rate, gas exchange parameters and dyspnea Borg scores were obtained at the end of each exercise bout. Most patients completed walking or stepping at the slow and middle speed cadences but only 33% completed walking at 6.0 km x h(- 1) and 40% completed stepping at 32 steps x min(- 1). Walking and stepping at progressively faster pace caused a progressive increase in ventilation and dyspnea. Test-retest Pearson correlation coefficients for ventilation, heart rate, gas exchange parameters and dyspnea scores over the four exercise bouts, all exceeded 0.80. Intra-class correlation coefficients were at least as strong as Pearson coefficients. Bland & Altman representation showed that for repeated Borg scores, 92 and 96% of points lied within 2 SD of the mean difference between test-retest values for walking and stepping. The majority of moderate and severe COPD patients completed the 3-min shuttle waking testing at 1.5 to 4.0 km x h(- 1) and the 3-min of step testing at rates between 18 and 26 steps x min(- 1). Both field tests were highly reproducible in patients with COPD.

Validation of intracardiac shunt using thoracic bioimpedance and inert gas rebreathing in adults before and after percutaneous closure of atrial septal defect in a cardiology research unit: study protocol.

INTRODUCTION: Intrathoracic shunt quantification is a major factor for appropriate clinical management of heart and pulmonary diseases. Intracardiac shunts quantified by pulmonary to systemic output ratio (Qp/Qs) are generally assessed by Doppler echocardiography, MRI or catheterisation. Recently, some authors have suggested the concomitant use of thoracic bioimpedance (TB) and inert gas rebreathing (IGR) techniques for shunt quantification. The purpose of this study is to validate the use of this approach under conditions where shunt fraction is directly quantified such as in patients with isolated atrial septal defect (ASD). METHODS AND ANALYSIS: This trial is a prospective, observational single-centre, non-blinded study of adults seen for percutaneous closure of ASD. Qp/Qs ratio will be directly measured by Doppler echocardiography and direct Fick. IGR and TB will be used simultaneously to measure the cardiac output before and after closure: the ratio of outputs measured by IGR and TB reflecting the shunt fraction. The primary outcome will be the comparison of shunt values measured by TB-IGR and Doppler echocardiography. ETHICS AND DISSEMINATION: The study has been approved by an independent Research Ethics Committee (2017-A03149-44 Fr) and registered as an official clinical trial. The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03437148; Pre-results.

Effectiveness of combined eccentric and concentric exercise over traditional cardiac exercise rehabilitation programme in patients with chronic heart failure: protocol for a randomised controlled study.

INTRODUCTION: Exercise-based rehabilitation is a standard feature of chronic heart failure management. The effectiveness of eccentric exercise could offer new opportunities for better tailoring rehabilitation programme to patients' limitations. The goal of the study is to contrast the impact of a mixed eccentric and concentric cycling training programme, to that of conventional concentric cycling rehabilitation in patients with chronic heart failure (peak oxygen consumption (VO2Peak) < 15 mL⋅kg-1⋅min-1, ejection fraction <40%). METHODS AND ANALYSIS: It is a prospective, open, controlled and randomised study (2×25 subjects) carried out in a single centre. Subjects will perform five exercise sessions per week per the randomisation outcome, with the intervention group performing eccentric in three of the five weekly sessions while the control group will perform the five sessions of concentric exercise. Cycling intensity will be the same in both groups and fixed to the power associated with the first ventilatory threshold. Self-management education programme, callisthenics sessions and muscle strength trainings will also be carried out as for any heart failure patient normally included in the rehabilitation programme. The primary outcome will be the change in distance covered during the 6 min walk test. Secondary outcomes will include other physical mobility parameters, functional exercise capacities, quality of life and body composition as well as skeletal muscle properties including mitochondrial function parameters. ETHICS AND DISSEMINATION: The study has been approved by the institutional ethics review board (17.079) and the French regulatory authority for research (2017-A00969-44). Adverse events that could occur during the protocol will be reported to the principal investigator. The results will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03716778.

Impact of Eccentric or Concentric Training on Body Composition and Energy Expenditure.

PURPOSE: To compare the effects of 8-wk eccentric (ECC) versus concentric (CON) training using downhill and uphill running in rats on whole body composition, bone mineral density (BMD), and energy expenditure. METHODS: Animals were randomly assigned to one of the following groups: 1) control (CTRL), 2) +15% uphill-running slope (CON), 3) -15% downhill-running slope (ECC15), and 4) -30% downhill-running slope (ECC30). Those programs enabled to achieve conditions of isopower output for CON and ECC15 and of iso-oxygen uptake (V˙O2) for CON and ECC30. Trained rats ran 45 min at 15 m·min five times per week. Total body mass, fat body mass, and lean body mass (LBM) measured through EchoMRI™, and 24-h energy expenditure including basal metabolic rate (BMR) assessed using PhenoMaster/LabMaster™ cage system were obtained before and after training. At sacrifice, the right femur was collected for bone parameters analysis. RESULTS: Although total body mass increased in all groups over the 8-wk period, almost no change occurred for fat body mass in exercised groups (CON, -4.8 ± 6.18 g; ECC15, 0.6 ± 3.32 g; ECC30, 2.6 ± 6.01 g). The gain in LBM was mainly seen for ECC15 (88.9 ± 6.85 g) and ECC30 (101.6 ± 11.07 g). ECC was also seen to positively affect BMD. An increase in BMR from baseline was seen in exercise groups (CON, 13.9 ± 4.13 kJ·d; ECC15, 11.6 ± 5.10 kJ·d; ECC30, 18.3 ± 4.33 kJ·d) but not in CTRL one. This difference disappeared when BMR was normalized for LBM. CONCLUSIONS: Results indicate that for iso-V˙O2 training, the impact on LBM and BMD is enhanced with ECC as compared with CON, and that for isopower but lower V˙O2 ECC, an important stimulus for adaptation is still observed. This provides further insights for the use of ECC in populations with cardiorespiratory exercise limitations.

Orthostatic symptoms, blood pressure and working postures of factory and service workers over an observed workday.

North American workers usually stand while working, and prolonged standing is associated with discomfort and cardiovascular problems. Moving may alleviate the problems, but optimum mobility is unknown. The effects of variations in mobility were explored among (1) 34 health care workers whose symptoms of orthostatic intolerance (OI) were recorded after work; (2) 45 factory and laundry workers. Postures were observed over a workday and blood pressure (BP) and heart rate (HR) of both groups were recorded before and after work. Among health care workers, 65% manifested OI symptoms. In a multiple logistic regression, presence of >or= 1 symptom of OI was associated with static postures and being female (p=0.001). More static standing was associated with a larger drop in BP (p=0.04) in both populations. The results suggest that more static standing postures are associated with OI and musculoskeletal symptoms and with a subclinical drop in BP.

Eccentric Training Improves Body Composition by Inducing Mechanical and Metabolic Adaptations: A Promising Approach for Overweight and Obese Individuals.

Skeletal muscle generates force by either shortening (concentrically) or lengthening (eccentrically). Eccentric (ECC) exercise is characterized by a lower metabolic demand and requires less muscle activity than concentric (CON) exercise at the same level of exerted force. However, the specific effect of ECC training vs. CON training on lean and fat mass remains underexplored. The first aim of this paper was to review the available evidence regarding the effects of ECC training on whole body and segmental lean and fat mass and, when possible, compare these with the effects of CON training. The second aim was to provide some insights into the main mechanical, physiological, and metabolic adaptations of ECC training that contribute to its effects on body composition. The third aim was to determine the beneficial effects of ECC exercise on health-related parameters in overweight and obese patients. ECC training is an effective modality to improve lean mass, but when matched for load or work, the difference between ECC and CON trainings seems unclear. A few studies reported that ECC training is also efficient at reducing fat mass. By increasing post-exercise resting energy expenditure, modifying metabolic substrate, and improving both blood lipid profile and insulin resistance, ECC training is a potential exercise modality for individuals with chronic conditions such as those who are overweight and obese. Further investigations using standardized experimental conditions, examining not only segmental but also whole body composition, are required to compare ECC and CON trainings.

Cycling efficiency is not compromised for moderate exercise in moderately severe COPD.

INTRODUCTION/PURPOSE: Hyperpnea and hyperinflation have been proposed as contributors to exaggerated energy demands in chronic obstructive pulmonary disease (COPD), yet there are incomplete data on exercise requirements. This study compared total-body energy demands of the internal (unloaded) and external work of cycling and delta mechanical efficiency in 40 patients (FEV1: 36+/-14% predicted) with COPD and 28 healthy age-matched controls while characterizing dynamic hyperinflation. METHODS: Steady-state V O2 was obtained at rest, during unloaded and 20-W cycling, and at 20, 50, and 65% peak cycling power. Delta mechanical efficiency was calculated between constant-load cycling at 65 and 20% peak power. Dynamic hyperinflation was assessed from inspiratory capacity maneuvers. RESULTS: Oxygen demands (L.min) at rest, for internal work (0.47+/-0.14 vs 0.45+/-0.11) or external work at 20 W (0.62+/-0.20 vs 0.57+/-0.13), were not different between patients and controls, although ventilation was elevated in COPD. Cycling at 65% of peak power induced dynamic hyperinflation in COPD, which indices were not related to cycling efficiency. Delta efficiency (%) was not different between patients (26.3+/-8.1) and controls (24.8+/-4.0). CONCLUSION: Findings suggest that bioenergetics of submaximal cycling is not compromised in moderately severe COPD despite tachypnea and dynamic hyperinflation.

Eccentric Ergometer Training Promotes Locomotor Muscle Strength but Not Mitochondrial Adaptation in Patients with Severe Chronic Obstructive Pulmonary Disease.

Eccentric ergometer training (EET) is increasingly being proposed as a therapeutic strategy to improve skeletal muscle strength in various cardiorespiratory diseases, due to the principle that lengthening muscle actions lead to high force-generating capacity at low cardiopulmonary load. One clinical population that may particularly benefit from this strategy is chronic obstructive pulmonary disease (COPD), as ventilatory constraints and locomotor muscle dysfunction often limit efficacy of conventional exercise rehabilitation in patients with severe disease. While the feasibility of EET for COPD has been established, the nature and extent of adaptation within COPD muscle is unknown. The aim of this study was therefore to characterize the locomotor muscle adaptations to EET in patients with severe COPD, and compare them with adaptations gained through conventional concentric ergometer training (CET). Male patients were randomized to either EET (n = 8) or CET (n = 7) for 10 weeks and matched for heart rate intensity. EET patients trained on average at a workload that was three times that of CET, at a lower perception of leg fatigue and dyspnea. EET led to increases in isometric peak strength and relative thigh mass (p < 0.01) whereas CET had no such effect. However, EET did not result in fiber hypertrophy, as morphometric analysis of muscle biopsies showed no increase in mean fiber cross-sectional area (p = 0.82), with variability in the direction and magnitude of fiber-type responses (20% increase in Type 1, p = 0.18; 4% decrease in Type 2a, p = 0.37) compared to CET (26% increase in Type 1, p = 0.04; 15% increase in Type 2a, p = 0.09). EET had no impact on mitochondrial adaptation, as revealed by lack of change in markers of mitochondrial biogenesis, content and respiration, which contrasted to improvements (p < 0.05) within CET muscle. While future study is needed to more definitively determine the effects of EET on fiber hypertrophy and associated underlying molecular signaling pathways in COPD locomotor muscle, our findings promote the implementation of this strategy to improve muscle strength. Furthermore, contrasting mitochondrial adaptations suggest evaluation of a sequential paradigm of eccentric followed by concentric cycling as a means of augmenting the training response and attenuating skeletal muscle dysfunction in patients with advanced COPD.

Three-minute constant rate step test for detecting exertional dyspnea relief after bronchodilation in COPD.

BACKGROUND: The aim of this study was to evaluate the responsiveness of the 3-minute constant rate step test (3-MST) to detect the relief of exertional dyspnea (respiratory discomfort) after acute bronchodilation in COPD patients. PATIENTS AND METHODS: A total of 40 patients with moderate-to-severe COPD (mean forced expiratory volume in 1 second: 45.7 (±14.7), % predicted) performed four 3-MSTs at randomly assigned stepping rates of 14, 16, 20 and 24 steps/min after inhalation of nebulized ipratropium bromide (500 µg)/salbutamol (2.5 mg) and saline placebo, which were randomized to order. Patients rated their intensity of perceived dyspnea at the end of each 3-MST using Borg 0-10 category ratio scale. RESULTS: A total of 37 (92.5%), 36 (90%), 34 (85%) and 27 (67.5%) patients completed all 3 minutes of exercise at 14, 16, 20 and 24 steps/min under both treatment conditions, respectively. Compared with placebo, ipratropium bromide/salbutamol significantly decreased dyspnea at the end of the third minute of exercise at 14 steps/min (by 0.6±1.0 Borg 0-10 scale units, P<0.01) and 16 steps/min (by 0.7±1.3 Borg 0-10 scale units, P<0.01); however, no statically significant differences were observed between treatments at 20 and 24 steps/min (both P>0.05). CONCLUSION: The 3-MST, when performed at 14 and 16 steps/min, was responsive to detect the relief of exertional dyspnea after acute bronchodilation in patients with moderate-to-severe COPD.

A Canadian, multicentre, randomized clinical trial of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease: rationale and methods.

BACKGROUND: Pulmonary rehabilitation remains largely underused. Self-monitored, home-based rehabilitation is a promising approach to improving the availability of pulmonary rehabilitation. OBJECTIVE: To report the rationale and methods of a trial comparing the effectiveness of self-monitored, home-based rehabilitation with hospital-based, outpatient rehabilitation in patients with chronic obstructive pulmonary disease (COPD). STUDY DESIGN: A parallel-group, randomized, noninferiority, multicentre trial will be performed with 240 patients with moderate to severe COPD. INTERVENTION: Patients will be randomly assigned to conventional, supervised, hospital-based outpatient rehabilitation or self-monitored, home-based rehabilitation. Both interventions will include a standardized, comprehensive self-management program, in addition to the hospital-based outpatient or home-based exercise program. After the three-month intervention, patients in both groups will be encouraged to continue exercising at home. Patients will be assessed monthly with telephone interviews and in person at enrollment, three months and 12 months. OUTCOMES: The dyspnea domain of the Chronic Respiratory Questionnaire (CRQ) at 12 months is the primary outcome variable. Secondary outcome variables include total and domain-specific CRQ scores; exercise tolerance and activity of daily living; health service use over the one-year study period; and direct and indirect costs of COPD treatment. ANALYSIS: An intent-to-treat approach will be used as the primary analysis. The primary analysis will focus on the change in the CRQ dyspnea score using a two-sided t distribution based on 95% CIs. The same approach will be used for secondary continuous outcome variables. CONCLUSION: The present trial will address two unresolved issues in pulmonary rehabilitation for patients with COPD: the short-term and long-term effectiveness of home-based pulmonary rehabilitation strategies. The authors will also determine if home-based pulmonary rehabilitation can reduce health service use (eg, hospitalizations and emergency visits) and if it can be done at a lower cost than the traditional hospital-based outpatient pulmonary rehabilitation.