Attenuated relationship between cardiac output and oxygen uptake during high-intensity exercise.

AIM: Recent findings have challenged the belief that the cardiac output (CO) and oxygen consumption (VO(2) ) relationship is linear from rest to maximal exercise. The purpose of this study was to determine the CO and stroke volume (SV) response to a range of exercise intensities, 40-100% of VO(2max), during cycling. METHODS: Ten well-trained cyclists performed a series of discontinuous exercise bouts to determine the CO and SV vs. VO(2) responses. RESULTS: The rate of increase in CO, relative to VO(2) , during exercise from 40 to 70% of VO(2max) was 4.4 ± 1.4 L L(-1). During exercise at 70-100% of VO(2max) , the rate of increase in CO was reduced to 2.1 ± 0.9 L L(-1) (P = 0.01). Stroke volume during exercise at 80-100% of VO(2max) was reduced by 7% when compared to exercise at 50-70% of VO(2max) (134 ± 5 vs. 143 ± 5 mL per beat, P = 0.02). Whole body arterial-venous O(2) difference increased significantly as intensity increased. CONCLUSION: The observation that the rate of increase in CO is reduced as exercise intensity increases suggests that cardiovascular performance displays signs of compromised function before maximal VO(2) is reached.

Variability in pulmonary function following rapid altitude ascent to the Amundsen-Scott South Pole station.

The impact of acute altitude exposure on pulmonary function is variable. A large inter-individual variability in the changes in forced expiratory flows (FEFs) is reported with acute exposure to altitude, which is suggested to represent an interaction between several factors influencing bronchial tone such as changes in gas density, catecholamine stimulation, and mild interstitial edema. This study examined the association between FEF variability, acute mountain sickness (AMS) and various blood markers affecting bronchial tone (endothelin-1, vascular endothelial growth factor (VEGF), catecholamines, angiotensin II) in 102 individuals rapidly transported to the South Pole (2835 m). The mean FEF between 25 and 75% (FEF(25-75)) and blood markers were recorded at sea level and after the second night at altitude. AMS was assessed using Lake Louise questionnaires. FEF(25-75) increased by an average of 12% with changes ranging from -26 to +59% from sea level to altitude. On the second day, AMS incidence was 36% and was higher in individuals with increases in FEF(25-75) (41 vs. 22%, P = 0.05). Ascent to altitude induced an increase in endothelin-1 levels, with greater levels observed in individuals with decreased FEF(25-75). Epinephrine levels increased with ascent to altitude and the response was six times larger in individuals with decreased FEF(25-75). Greater levels of endothelin-1 in individuals with decreased FEF(25-75) suggest a response consistent with pulmonary hypertension and/or mild interstitial edema, while epinephrine may be upregulated in these individuals to clear lung fluid through stimulation of ß(2)-adrenergic receptors.

Pulmonary function in patients with reduced left ventricular function: influence of smoking and cardiac surgery.

STUDY OBJECTIVE: The impact of stable, chronic heart failure on baseline pulmonary function remains controversial. Confounding influences include previous coronary artery bypass or valve surgery (CABG), history of obesity, stability of disease, and smoking history. DESIGN: To control for some of the variables affecting pulmonary function in patients with chronic heart failure, we analyzed data in four patient groups, all with left ventricular (LV) dysfunction (LV ejection fraction [LVEF] < or =35%): (1) chronic heart failure, nonsmokers, no CABG (n = 78); (2) chronic heart failure, nonsmokers, CABG (n = 46); (3) chronic heart failure, smokers, no CABG (n = 40); and (4) chronic heart failure, smokers, CABG (n = 48). Comparisons were made with age- and gender-matched patients with a history of coronary disease but no LV dysfunction or smoking history (control subjects, n = 112) and to age-predicted norms. RESULTS: Relative to control subjects and percent-predicted values, all groups with chronic heart failure had reduced lung volumes (total lung capacity [TLC] and vital capacity [VC]) and expiratory flows (p < 0.05). CABG had no influence on lung volumes and expiratory flows in smokers, but resulted in a tendency toward a reduced TLC and VC in nonsmokers. Smokers with chronic heart failure had reduced expiratory flows compared to nonsmokers (p < 0.05), indicating an additive effect of smoking. Diffusion capacity of the lung for carbon monoxide (DLCO) was reduced in smokers and in subjects who underwent CABG, but not in patients with chronic heart failure alone. There was no relationship between LV size and pulmonary function in this population, although LV function (cardiac index and stroke volume) was weakly associated with lung volumes and DLCO. CONCLUSIONS: We conclude that patients with chronic heart failure have primarily restrictive lung changes with smoking causing a further reduction in expiratory flows.

Predictors of oxygen desaturation during submaximal exercise in 8,000 patients.

STUDY OBJECTIVES: To determine predictors of oxygen desaturation during submaximal exercise in patients with various lung diseases. DESIGN AND SETTING: This retrospective case series used pulmonary function laboratory results from all patients referred to a major tertiary-care center. PATIENTS AND MEASUREMENTS: All patients > or = 35 years old who underwent spirometry, diffusing capacity of the lung for carbon monoxide (DLCO), lung volumes, and pulse oximetry during 3-min submaximal step-test exercise during 1996 were included (4,545 men and 3,472 women). Logistic regression models, correcting for gender, age, and weight, determined the odds ratios (ORs) for oxygen desaturation of > or = 4% during exercise for each category of lung function abnormality (compared to those with entirely normal lung function). RESULTS: Approximately 74% of the patients had airways obstruction, while only 5.6% had restriction of lung volumes. One third of those with obstruction had a low DLCO, compared to 56% with restriction, while 2.7% had a low DLCO without obstruction or restriction. The risk of oxygen desaturation during submaximal exercise was very high (OR, 34) in patients with restriction and low DLCO (as in interstitial lung disease) and in patients with obstruction and low DLCO (as in COPD; OR, 18), intermediate (OR, 9) in patients with only a low DLCO, and lowest in those with a normal DLCO (OR, 4 if restricted; OR, 2 if obstructed). A cut point of DLCO < 62% predicted resulted in 75% sensitivity and specificity for exercise desaturation. No untoward cardiac events occurred in any patients during or following the submaximal exercise tests. CONCLUSIONS: The risk of oxygen desaturation during submaximal exercise is very high in patients with a low DLCO. Submaximal exercise tests are safe, even in elderly patients with heart and lung diseases.

Variance of ventilation during exercise.

Expired gas concentrations were measured during a multibreath washin of He in one female and seven male subjects at rest (seated) and during cycle exercise at work rates of 70-210 W. In a computational model, the ventilation distribution was represented as a log-normal distribution with standard deviation (sigmaV); values of sigmaV were obtained by fitting the output of the model to the data. At rest, sigmaV was 0.89 +/- 0.18; during exercise, sigmaV was 0.60 +/- 0.13, independent of the level of exercise. These values for the width of the functional ventilation distribution at the scale of the acinus are approximately two times larger than those obtained from anatomic measurements in animals at a scale of 1 cm3. The values for sigmaV, together with data from the literature on the width of the functional ventilation-perfusion distribution, show that ventilation and perfusion are highly correlated at rest, in agreement with anatomic data. The structural sources of nonuniform ventilation and perfusion and of the correlation between them are unknown.

Role of nitric oxide during hyperventilation-induced bronchoconstriction in the guinea pig.

Airway function is largely preserved during exercise or isocapnic hyperventilation in humans and guinea pigs despite likely changes in airway milieu during hyperpnea. It is only on cessation of a hyperpneic challenge that airway function deteriorates significantly. We tested the hypothesis that nitric oxide, a known bronchodilator that is produced in the lungs and bronchi, might be responsible for the relative bronchodilation observed during hyperventilation (HV) in guinea pigs. Three groups of anesthetized guinea pigs were given saline and three groups given 50 mg/kg N(G)-monomethyl-L-arginine (L-NMMA), a potent nitric oxide synthase inhibitor. Three isocapnic ventilation groups included normal ventilation [40 breaths/min, 6 ml/kg tidal volume (VT)], increased respiratory rate only (150 breaths/min, 6 ml/kg VT), and increased respiratory rate and increased volume (100 breaths/min, 8 ml/kg VT). L-NMMA reduced expired nitric oxide in all groups. Expired nitric oxide was slightly but significantly increased by HV in the saline groups. However, inhibition of nitric oxide production had no significant effect on rate of rise of respiratory system resistance (Rrs) during HV or on the larger rise in Rrs seen 6 min after HV. We conclude that nitric oxide synthase inhibition has no effect on changes in Rrs, either during or after HV in guinea pigs.

Airway function after cyclooxygenase inhibition during hyperpnea-induced bronchoconstriction in guinea pigs.

Airway function deteriorates significantly on cessation of exercise or isocapnic hyperventilation challenges but is largely preserved during the challenge in humans and guinea pigs. PGE(2), an endogenous bronchodilator, might be responsible for the preservation of lung function during hyperventilation (HV). We hypothesized that PGE(2) might have a protective effect during HV, partially explaining the minimal changes in respiratory system resistance (Rrs) usually seen during HV in humans and guinea pigs. Therefore, changes in Rrs were measured during and after HV in anesthetized, mechanically ventilated guinea pigs treated with flurbiprofen (FBN) or placebo. With HV, there was an initial bronchodilation that was unaffected by FBN. Rrs then increased with time during HV, an effect that was blocked by FBN. After HV, Rrs increased further in all groups, but the increase in Rrs was less in the FBN-treated groups. FBN treatment reduced the PGE(2) concentration slightly in lung lavage fluid compared with placebo. We found no enhancement or refractoriness of the Rrs response to repeat bouts of HV and no effect of FBN treatment on the response of Rrs to repeat HV. These results suggest that a constrictor PG is released during and possibly after HV and that the post-HV increase in Rrs is the sum of effects of the PG released during HV and a second constrictor mechanism operating after HV. We found no evidence for bronchodilator PG during or after HV in the guinea pig.

Cardiac output during exercise by the open circuit acetylene washin method: comparison with direct Fick.

An open-circuit (OpCirc) acetylene uptake cardiac output (QT) method was modified for use during exercise. Two computational techniques were used. OpCirc1 was based on the integrated uptake vs. end-tidal change in acetylene, and OpCirc2 was based on an iterative finite difference modeling method. Six subjects [28-44 yr, peak oxygen consumption (VO(2)) = 120% predicted] performed cycle ergometry exercise to compare QT using OpCirc and direct Fick methods. An incremental protocol was repeated twice, separated by a 10-min rest, and subsequently subjects exercised at 85-90% of their peak work rate. Coefficient of variation of the OpCirc methods and Fick were highest at rest (OpCirc1, 7%, OpCirc2, 12%, Fick, 10%) but were lower at moderate to high exercise intensities (OpCirc1, 3%, OpCirc2, 3%, Fick, 5%). OpCirc1 and OpCirc2 QT correlated highly with Fick QT (R(2) = 0.90 and 0.89, respectively). There were minimal differences between OpCirc1 and OpCirc2 compared with Fick up to moderate-intensity exercise (<70% peak VO(2)); however, both techniques tended to underestimate Fick at >70% peak VO(2). These differences became significant for OpCirc1 only. Part of the differences between Fick and OpCirc methods at the higher exercise intensities are likely related to inhomogeneities in ventilation and perfusion matching (R(2) = 0.36 for Fick - OpCirc1 vs. alveolar-to-arterial oxygen tension difference). In conclusion, both OpCirc methods provided reproducible, reliable measurements of QT during mild to moderate exercise. However, only OpCirc2 appeared to approximate Fick QT at the higher work intensities.

Ventilatory constraints during exercise in patients with chronic heart failure.

We examined the degree of ventilatory constraint in patients with a history of chronic heart failure (CHF; n = 11; mean +/- SE age, 62 +/- 4 years; cardiac index [CI], 2.0 +/- 0.1; and ejection fraction [EF], 24 +/- 2%) and in control subjects (CTLS; n = 8; age, 61 +/- 5 years; CI, 2.6 +/- 0.3) by plotting the tidal flow-volume responses to graded exercise in relationship to the maximal flow-volume envelope (MFVL). Inspiratory capacity (IC) maneuvers were performed to follow changes in end-expiratory lung volume (EELV) during exercise, and the degree of expiratory flow limitation was assessed as the percent of the tidal volume (VT) that met or exceeded the expiratory boundary of the MFVL. CHF patients had significantly (p < 0.05) reduced baseline pulmonary function (FVC, 76 +/- 4%; FEV(1), 78 +/- 4% predicted) relative to CTLS (FVC, 99 +/- 4%; FEV(1), 102 +/- 4% predicted). At peak exercise, oxygen consumption (VO(2)) and minute ventilation (V(E)) were lower in CHF patients than in CTLS (VO(2), 17 +/- 2 vs 32 +/- 2 mL/kg/min; VE, 56 +/- 4 vs 82 +/- 6 L/min, respectively), whereas VE/carbon dioxide output was higher (42 +/- 4 vs 29 +/- 5). In CTLS, EELV initially decreased with light exercise, but increased as VE and expiratory flow limitation increased. In contrast, the EELV in patients with CHF remained near residual volume (RV) throughout exercise, despite increasing flow limitation. At peak exercise, IC averaged 91 +/- 3% and 79 +/- 4% (p < 0.05) of the FVC in CHF patients and CTLS, respectively, and flow limitation was present over > 45% of the VT in CHF patients vs < 25% in CTLS (despite the higher VE in CTLS). The least fit and most symptomatic CHF patients demonstrated the lowest EELV, the greatest degree of flow limitation, and a limited response to increased inspired carbon dioxide during exercise, all consistent with VE constraint. We conclude that patients with CHF commonly breathe near RV during exertion and experience expiratory flow limitation. This results in VE constraint and may contribute to exertional intolerance.

Advances in pulmonary laboratory testing.

This review examines emerging technologies that are of potential use in the routine clinical pulmonary laboratory. These technologies include the following: the measurement of exercise tidal flow-volume (FV) loops plotted within the maximal FV envelope for assessment of ventilatory constraint during exercise; the use of negative expiratory pressures to asses expiratory flow limitation in various populations and under various conditions; the potential use of expired nitric oxide for assessing airway inflammation; and the use of forced oscillation for assessment of airway resistance. These methodologies have been used extensively in the research setting and are gaining increasing popularity and clinical application due to the availability of commercially available, simplified, and automated systems. An overview of each technique, its potential advantages and limitations will be discussed, along with suggestions for further investigation that is considered necessary prior to extensive clinical use.

Airway obstruction during exercise and isocapnic hyperventilation in asthmatic subjects.

We compared pulmonary mechanics measured during long-term exercise (LTX = 20 min) with long-term isocapnic hyperventilation (LTIH = 20 min) in the same asthmatic individuals (n = 6). Peak expiratory flow (PEF) and forced expiratory volume in 1 s (FEV(1)) decreased during LTX (-19.7 and -22.0%, respectively) and during LTIH (-6.66 and 10. 9%, respectively). In contrast, inspiratory pulmonary resistance (RL(I)) was elevated during LTX (57.6%) but not during LTIH (9.62%). As expected, airway function deteriorated post-LTX and post-LTIH (FEV(1) = -30.2 and -21.2%; RL(I) = 111.8 and 86.5%, respectively). We conclude that the degree of airway obstruction observed during LTX is of a greater magnitude than that observed during LTIH. Both modes of hyperpnea induced similar levels of airway obstruction in the posthyperpnea period. However, the greater airway obstruction during LTX suggests that a different process may be responsible for the changes in airway function during and after the two modes of hyperpnea. This finding raises questions about the equivalency of LTIH and LTX in the study of airway function during exercise-induced asthma.

Emerging concepts in the evaluation of ventilatory limitation during exercise: the exercise tidal flow-volume loop.

Traditionally, ventilatory limitation (constraint) during exercise has been determined by measuring the ventilatory reserve or how close the minute ventilation (VE) achieved during exercise (i.e., ventilatory demand) approaches the maximal voluntary ventilation (MVV) or some estimate of the MVV (i.e., ventilatory capacity). More recently, it has become clear that rarely is the MVV breathing pattern adopted during exercise and that the VE/MVV relationship tells little about the specific reason(s) for ventilatory constraint. Although it is not a new concept, by measuring the tidal exercise flow-volume (FV) loops (extFVLs) obtained during exercise and plotting them according to a measured end-expiratory lung volume (EELV) within the maximal FV envelope (MFVL), more specific information is provided on the sources (and degree) of ventilatory constraint. This includes the extent of expiratory flow limitation, inspiratory flow reserve, alterations in the regulation of EELV (dynamic hyperinflation), end-inspiratory lung volume relative to total lung capacity (or tidal volume/inspiratory capacity), and a proposed estimate of ventilatory capacity based on the shape of the MFVL and the breathing pattern adopted during exercise. By assessing these types of changes, the degree of ventilatory constraint can be quantified and a more thorough interpretation of the cardiopulmonary exercise response is possible. This review will focus on the potential role of plotting the extFVL within the MFVL for determination of ventilatory constraint during exercise in the clinical setting. Important physiologic concepts, measurements, and limitations obtained from this type of analysis will be defined and discussed.

Evaluation of pulmonary resistance and maximal expiratory flow measurements during exercise in humans.

To evaluate methods used to document changes in airway function during and after exercise, we studied nine subjects with exercise-induced asthma and five subjects without asthma. Airway function was assessed from measurements of pulmonary resistance (RL) and forced expiratory vital capacity maneuvers. In the asthmatic subjects, forced expiratory volume in 1 s (FEV1) fell 24 +/- 14% and RL increased 176 +/- 153% after exercise, whereas normal subjects experienced no change in airway function (RL -3 +/- 8% and FEV1 -4 +/- 5%). During exercise, there was a tendency for FEV1 to increase in the asthmatic subjects but not in the normal subjects. RL, however, showed a slight increase during exercise in both groups. Changes in lung volumes encountered during exercise were small and had no consistent effect on RL. The small increases in RL during exercise could be explained by the nonlinearity of the pressure-flow relationship and the increased tidal breathing flows associated with exercise. In the asthmatic subjects, a deep inspiration (DI) caused a small, significant, transient decrease in RL 15 min after exercise. There was no change in RL in response to DI during exercise in either asthmatic or nonasthmatic subjects. When percent changes in RL and FEV1 during and after exercise were compared, there was close agreement between the two measurements of change in airway function. In the groups of normal and mildly asthmatic subjects, we conclude that changes in lung volume and DIs had no influence on RL during exercise. Increases in tidal breathing flows had only minor influence on measurements of RL during exercise. Furthermore, changes in RL and in FEV1 produce equivalent indexes of the variations in airway function during and after exercise.

Control of airway function during and after exercise in asthmatics.

Control of airway function during and after exercise in asthmatics. Med. Sci. Sports Exerc., Vol. 31, No. 1 (Suppl.), pp. S4-S11, 1999. In asthmatics, airway function can be quite variable during exercise depending on the level of exercise intensity, the duration of exercise, and whether the exercise is at constant load or variable in intensity. Airway diameter can be affected by activity of parasympathetic and sympathetic nerves, by systemic mediators such as catecholamines, and by local mediators such as histamine or leukotrienes. Asthmatic airways are populated with more inflammatory cells than normal airways, and bronchoconstrictor mediator release from these cells is probably caused by drying of the mucosa during and after periods of increased ventilation. There are a few bronchodilating mediators present in both asthmatic and normal airways that could protect against this bronchoconstriction, including prostaglandin PGE2 and nitric oxide. Although it is clear that many of the inflammatory mediators play a role in causing bronchoconstriction after exercise, the role of either bronchoconstrictor or bronchodilator mediators in controlling airway function during exercise has yet to be resolved. In addition, the mechanical interaction between lung parenchyma and airways may provide a bronchodilating influence. In conclusion, the variability in airway function during exercise in asthmatics could be caused by balance among various bronchodilator and bronchoconstrictor mediators, but it may also reflect a mechanical effect of varying levels of ventilation.

Lung volumes in 4,774 patients with obstructive lung disease.

STUDY OBJECTIVES: To determine the correlates of static lung volumes in patients with airways obstruction, and to determine if static lung volumes differ between asthma and COPD. PATIENTS AND METHODS: We examined the data from all of the adult patients (mean age of 69) who were referred to a pulmonary function laboratory from January 1990 through July 1994 with an FEV1/FVC ratio of < 0.70 and tested using a body plethysmograph. Correlates were determined using regression analysis. MEASUREMENTS AND RESULTS: Of the 4,774 patients observed with evidence of airways obstruction, 61% were men. Self-reported diagnoses included asthma, 19%; emphysema or COPD, 23%; chronic bronchitis, 1.5%; and alpha1-antiprotease deficiency, 0.6%. Fifty-six percent of the patients did not report a respiratory disease. The degree of hyperinflation, as determined by the residual volume (RV)/total lung capacity (TLC) ratio, or the RV % predicted (but not the TLC % predicted), was strongly associated with the degree of airways obstruction (the FEV1 % predicted). Patients with moderate to severe airways obstruction and high RV and TLC levels were more likely to have COPD than asthma. Of the 1,872 patients with a reduced vital capacity determined by spirometry testing, 87% had hyperinflation as defined by the RV/TLC, and 9.5% had a low TLC (with less severe airways obstruction). CONCLUSION: In patients found to have airways obstruction by spirometry, the additional measurement of static lung volumes added little to the clinical interpretation.

Influence of age and gender on cardiac output-VO2 relationships during submaximal cycle ergometry.

It is presently unclear how gender, aging, and physical activity status interact to determine the magnitude of the rise in cardiac output (Qc) during dynamic exercise. To clarify this issue, the present study examined the Qc-O2 uptake (Vo2) relationship during graded leg cycle ergometry in 30 chronically endurance-trained subjects from four groups (n = 6-8/group): younger men (20-30 yr), older men (56-72 yr), younger women (24-31 yr), and older women (51-72 yr). Qc (acetylene rebreathing), stroke volume (Qc/heart rate), and whole body Vo2 were measured at rest and during submaximal exercise intensities (40, 70, and approximately 90% of peak Vo2). Baseline resting levels of Qc were 0.6-1.2 l/min less in the older groups. However, the slopes of the Qc-Vo2 relationship across submaximal levels of cycling were similar among all four groups (5.4-5.9 l/l). The absolute Qc associated with a given Vo2 (1.0-2.0 l/min) was also similar among groups. Resting and exercise stroke volumes (ml/beat) were lower in women than in men but did not differ among age groups. However, older men and women showed a reduced ability, relative to their younger counterparts, to maintain stroke volume at exercise intensities above 70% of peak Vo2. This latter effect was most prominent in the oldest women. These findings suggest that neither age nor gender has a significant impact on the Qc-Vo2 relationships during submaximal cycle ergometry among chronically endurance-trained individuals.

Posttransplantation physiologic features of the lung and obliterative bronchiolitis.

Obliterative bronchiolitis remains the major obstacle to long-term survival after lung transplantation. Herein we provide a brief review of the key literature as well as our own experience with this condition. Obliterative bronchiolitis has occurred in up to two-thirds of all lung transplant recipients. The characteristic physiologic changes include declines in (1) forced expiratory volume in 1 second, (2) forced vital capacity, and (3) diffusing capacity of the lungs for carbon monoxide. Lung biopsy in patients with obliterative bronchiolitis reveals occlusion of bronchioles in a patchy but extensive distribution. Mucous plugging and bronchiectasis may also be seen. Furthermore, intimal thickening of pulmonary vessels together with mild arteriosclerotic changes of the muscular and elastic pulmonary arterioles may be observed. To date, the main risk factor for the development of obliterative bronchiolitis is recurrent, severe, and persistent acute lung rejection. The recommended management is prevention because the established fibrotic condition may necessitate retransplantation.

Delay time adjustments to minimize errors in breath-by-breath measurement of Vo2 during exercise.

If the delay time between gas concentration and flow signals is not adequately corrected during breath-by-breath analysis of expired gas, an error in calculation of oxygen consumption (Vo2) will result. To examine the frequency and delay time dependences of errors in Vo2 measurement, six healthy men exercised at 100, 200, and 250 W on a cycle ergometer while breath-by-breath assessment of Vo2 was made simultaneously with collection of expired air. Subjects breathed first at normal rates (15-30 breaths/min) and then at 70 breaths/min. Each subject performed each level of exercise twice by using erroneous values for the delay time between gas concentration and flow signals. At normal breathing frequencies, errors in Vo2 measurement were +/- 10% over the full range of delay times used, and the errors were not tightly correlated with variations in delay times from optimum. However, at 70 breaths/min, errors approached +/- 30% as the variations in delay times deviated +/- 0.1 s from the optimal, and the errors were highly correlated with the variations in delay times. We conclude that there is greater potential for errors in Vo2 measurement with incorrect delay time at higher breathing frequencies. These findings suggest that the optimal delay time for breath-by-breath systems should be adjusted by using high breathing frequencies.

Frequency and clinical implications of increased pulmonary artery pressures in liver transplant patients.

OBJECTIVE: To characterize the pulmonary hemodynamics and identify predictors of pulmonary hypertension in a group of patients before liver transplantation and to determine whether pulmonary hypertension in these patients is related to survival. MATERIAL AND METHODS: In 362 patients before their first liver transplantation (between 1985 and 1993), the clinical history, laboratory data, and results of pulmonary function tests were recorded. Pulmonary artery (PA) catheterization was performed after induction of anesthesia at the time of transplantation. Monthly follow-up was maintained. RESULTS: A hyperdynamic circulation was often present -- an increased mean cardiac output (7.6 L/min), increased mean PA pressure (20.9 mm Hg), correlation of mean PA pressure with cardiac output (r = 0.25; P<0.001), and decreased mean pulmonary vascular resistance (60 dynes times s/cm5). Mean PA pressures were more than 25 mm Hg in 72 patients (20%). Pulmonary hypertension (defined as mean PA pressure of more than 25 mm Hg and pulmonary vascular resistance in excess of 120 dynes times s/cm5) occurred in 15 patients (4%). Pulmonary function tests revealed obstruction in 7%, restriction in 18%, and low diffusing capacity in 46%. By univariate analysis, lower forced expiratory volume in 1 second, forced vital capacity, and total lung capacity were the only preoperative factors associated with pulmonary hypertension (P<0.05). Survival was significantly lower in patients with acute fulminant hepatitis (P<0.001), the group with the highest mean PA pressure, than in those with other diagnoses. Increased PA pressures or mild to moderate pulmonary hypertension was not found to be associated with a worse survival by univariate or multivariate analysis. CONCLUSION: Increased PA pressure is common in liver transplant patients (20%). "True" pulmonary hypertension occurred in only 4% of our patients and was not associated with an adverse outcome.