STRUCTURAL AND FUNCTIONAL CORRELATES OF EXERCISE VENTILATORY INEFFICIENCY IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS WITH MILD-TO-MODERATE SPIROMETRIC ABNORMALITIES

Background: Individuals with chronic obstructive pulmonary disease (COPD) have higher than normal ventilatory equivalents for carbon dioxide (VE/VCO2) during exercise. There is growing evidence that emphysema on thoracic computed tomography (CT) scans is associated with poor exercise capacity in COPD patients with only mild-to-moderate airflow obstruction. We hypothesized that emphysema is an underlying cause of microvascular dysfunction and ventilatory inefficiency, which in turn contributes to reduced exercise capacity. We expected ventilatory inefficiency to be associated with a) the extent of emphysema; b) lower diffusing capacity for carbon monoxide; c) a reduced pulmonary blood flow response to exercise; and d) reduced exercise capacity. Methods: In a cross-sectional study, 19 subjects with mild-to-moderate COPD (mean ± SD FEV1= 82 ± 13% predicted, 12 GOLD grade 1) and 26 age-, sex-, and activity-matched controls underwent a ramp-incremental symptom-limited exercise test on a cycle ergometer. Ventilatory inefficiency was assessed by the minimum VE/VCO2 value (nadir). A subset of subjects also completed repeated constant work rate exercise bouts with non-invasive measurements of pulmonary blood flow. Emphysema was quantified as the percentage of attenuation areas below -950 Housefield Units on CT scans. An electronic scoresheet was used to keep track of emphysema sub-types. Results: COPD subjects typically had centrilobular emphysema (76.8 ± 10.1% of total emphysema) in the upper lobes (upper/lower lobe ratio= 0.82 ± 0.04). They had lower peak oxygen uptake (VO2), higher VE/VCO2 nadir and greater dyspnea scores than controls (p<0.05). Lower peak O2 and worse dyspnea were found in COPD subjects with VE/VCO2 nadirs ≥ 30. COPD subjects had blunted increases in pulmonary blood flow from rest to iso-VO2 exercise (p<0.05). Higher VE/VCO2 nadir in COPD subjects correlated with emphysema severity (r= 0.63), which in turn correlated with reduced lung diffusing capacity (r= -0.72) and blunted changes in pulmonary blood flow from rest to exercise (r= -0.69) (p<0.01). Conclusions: Ventilation “wasted” in emphysematous areas is associated with reduced exercise ventilatory efficiency in mild-to-moderate COPD. Exercise ventilatory inefficiency links structure (emphysema) and function (gas transfer) to a key clinical outcome (reduced exercise capacity) in COPD patients with modest spirometric abnormalities.

Effect of continuous and interval exercise training on the PETCO2 response during a graded exercise test in patients with coronary artery disease

OBJECTIVE: The purpose of this study was to evaluate the following: 1) the effects of continuous exercise training and interval exercise training on the end-tidal carbon dioxide pressure (PETCO2) response during a graded exercise test in patients with coronary artery disease; and 2) the effects of exercise training modalities on the association between PETCO2 at the ventilatory anaerobic threshold (VAT) and indicators of ventilatory efficiency and cardiorespiratory fitness in patients with coronary artery disease. METHODS: Thirty-seven patients (59.7 +/- 1.7 years) with coronary artery disease were randomly divided into two groups: continuous exercise training (n = 20) and interval exercise training (n = 17). All patients performed a graded exercise test with respiratory gas analysis before and after three months of the exercise training program to determine the VAT, respiratory compensation point (RCP) and peak oxygen consumption. RESULTS: After the interventions, both groups exhibited increased cardiorespiratory fitness. Indeed, the continuous exercise and interval exercise training groups demonstrated increases in both ventilatory efficiency and PETCO2 values at VAT, RCP, and peak of exercise. Significant associations were observed in both groups: 1) continuous exercise training (PETCO(2)VAT and cardiorespiratory fitness r = 0.49; PETCO(2)VAT and ventilatory efficiency r = -0.80) and 2) interval exercise training (PETCO(2)VAT and cardiorespiratory fitness r = 0.39; PETCO(2)VAT and ventilatory efficiency r = -0.45). CONCLUSIONS: Both exercise training modalities showed similar increases in PETCO2 levels during a graded exercise test in patients with coronary artery disease, which may be associated with an improvement in ventilatory efficiency and cardiorespiratory fitness.

Inspiratory Muscle Training Reduces Sympathetic Nervous Activity and Improves Inspiratory Muscle Weakness and Quality of Life in Patients With Chronic Heart Failure A CLINICAL TRIAL

PURPOSE: To evaluate the effect of inspiratory muscle training (IMT) on cardiac autonomic modulation and on peripheral nerve sympathetic activity in patients with chronic heart failure (CHF). METHODS: Functional capacity, low-frequency (LF) and high-frequency (HF) components of heart rate variability, muscle sympathetic nerve activity inferred by microneurography, and quality of life were determined in 27 patients with CHF who had been sequentially allocated to 1 of 2 groups: (1) control group (with no intervention) and (2) IMT group. Inspiratory muscle training consisted of respiratory exercises, with inspiratory threshold loading of seven 30-minute sessions per week for a period of 12 weeks, with a monthly increase of 30% in maximal inspiratory pressure (PImax) at rest. Multivariate analysis was applied to detect differences between baseline and followup period. RESULTS: Inspiratory muscle training significantly increased PImax (59.2 +/- 4.9 vs 87.5 +/- 6.5 cmH(2)O, P = .001) and peak oxygen uptake (14.4 +/- 0.7 vs 18.9 +/- 0.8 mL.kg(-1).min(-1), P = .002); decreased the peak ventilation (V. E) +/- carbon dioxide production (V-CO2) ratio (35.8 +/- 0.8 vs 32.5 +/- 0.4, P = .001) and the (V) over dotE +/-(V) over dotCO(2) slope (37.3 +/- 1.1 vs 31.3 +/- 1.1, P = .004); increased the HF component (49.3 +/- 4.1 vs 58.4 +/- 4.2 normalized units, P = .004) and decreased the LF component (50.7 +/- 4.1 vs 41.6 +/- 4.2 normalized units, P = .001) of heart rate variability; decreased muscle sympathetic nerve activity (37.1 +/- 3 vs 29.5 +/- 2.3 bursts per minute, P = .001); and improved quality of life. No significant changes were observed in the control group. CONCLUSION: Home-based IMT represents an important strategy to improve cardiac and peripheral autonomic controls, functional capacity, and quality of life in patients with CHF.

Exercise training reverses exertional oscillatory ventilation in heart failure patients

Exertional oscillatory ventilation (EOV) is an ominous prognostic sign in chronic heart failure (CHF), but little is known about the success of specific therapeutic interventions. Our aim was to study the impact of an exercise training on exercise capacity and cardiopulmonary adaptation in stable CHF patients with left ventricular systolic dysfunction and EOV. 96 stable CHF patients with EOV were included in a retrospective analysis (52 training versus 44 controls). EOV was defined as follows: 1) three or more oscillatory fluctuations in minute ventilation (V'(E)) during exercise; 2) regular oscillations; and 3) minimal average ventilation amplitude ≥5 L. EOV disappeared in 37 (71.2%) out of 52 patients after training, but only in one (2.3%) out of 44 without training (p<0.001). The decrease of EOV amplitude correlated with changes in end-tidal carbon dioxide tension (r= -0.60, p<0.001) at the respiratory compensation point and V'(E)/carbon dioxide production (V'(CO(2))) slope (r=0.50, p<0.001). Training significantly improved resting values of respiratory frequency (f(R)), V'(E), tidal volume (V(T)) and V'(E)/V'(CO(2)) ratio. During exercise, V'(E) and V(T) reached significantly higher values at the peak, while f(R) and V'(E)/V'(CO(2)) ratio were significantly lower at submaximal exercise. No change was noted in the control group. Exercise training leads to a significant decrease of EOV and improves ventilatory efficiency in patients with stable CHF.

Effects of inspiratory muscle training in patients with heart failure with preserved ejection fraction

BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is remarkably common in elderly people with highly prevalent comorbid conditions. Despite its increasing in prevalence, there is no evidence-based effective therapy for HFpEF. We sought to evaluate whether inspiratory muscle training (IMT) improves exercise capacity, as well as left ventricular diastolic function, biomarker profile and quality of life (QoL) in patients with advanced HFpEF and nonreduced maximal inspiratory pressure (MIP). DESIGN AND METHODS A total of 26 patients with HFpEF (median (interquartile range) age, peak exercise oxygen uptake (peak VO2) and left ventricular ejection fraction of 73 years (66-76), 10 ml/min/kg (7.6-10.5) and 72% (65-77), respectively) were randomized to receive a 12-week programme of IMT plus standard care vs. standard care alone. The primary endpoint of the study was evaluated by positive changes in cardiopulmonary exercise parameters and distance walked in 6 minutes (6MWT). Secondary endpoints were changes in QoL, echocardiogram parameters of diastolic function, and prognostic biomarkers. RESULTS The IMT group improved significantly their MIP (p < 0.001), peak VO2 (p < 0.001), exercise oxygen uptake at anaerobic threshold (p = 0.001), ventilatory efficiency (p = 0.007), metabolic equivalents (p < 0,001), 6MWT (p < 0.001), and QoL (p = 0.037) as compared to the control group. No changes on diastolic function parameters or biomarkers levels were observed between both groups. CONCLUSIONS In HFpEF patients with low aerobic capacity and non-reduced MIP, IMT was associated with marked improvement in exercise capacity and QoL.

Physiologic response to changing positive end-expiratory pressure during neurally adjusted ventilatory assist in sedated, critically ill adults

Neurally adjusted ventilatory assist (NAVA) delivers airway pressure (Paw) in proportion to neural inspiratory drive as reflected by electrical activity of the diaphragm (EAdi). Changing positive end-expiratory pressure (PEEP) impacts respiratory muscle load and function and, hence, EAdi. We aimed to evaluate how PEEP affects the breathing pattern and neuroventilatory efficiency during NAVA.

Ventilatory response to nitrogen multiple-breath washout in infants

BACKGROUND Nitrogen multiple-breath washout (N2 MBW) using 100% oxygen (O2 ) has regained interest to assess efficiency of tracer gas clearance in, for example, children with Cystic Fibrosis (CF). However, the influence of hyperoxia on the infants' respiratory control is unclear. We assessed safety and impact on breathing pattern from hyperoxia, and if exposure to 40% O2 first induces tolerance to subsequent 100% O2 for N2 MBW. METHODS We prospectively enrolled 39 infants aged 3-57 weeks: 15 infants with CF (8 sedated for testing) and 24 healthy controls. Infants were consecutively allocated to the protocols comprising of 100% O2 or 40/100% O2 administered for 30 breaths. Lung function was measured using an ultrasonic flowmeter setup. Primary outcome was tidal volume (VT ). RESULTS None of the infants experienced apnea, desaturation, or bradycardia. Both protocols initially induced hypoventilation. VT temporarily declined in 33/39 infants across 10-25 breaths. Hypoventilation occurred independent of age, disease, and sedation. In the new 40/100% O2 protocol, VT returned to baseline during 40% O2 and remained stable during 100% O2 exposure. End-tidal carbon dioxide monitored online did not change. CONCLUSION The classical N2 MBW protocol with 100% O2 may change breathing patterns of the infants. The new protocol with 40% O2 induces hyperoxia-tolerance and does not lead to changes in breathing patterns during later N2 washout using 100% O2 . Both protocols are safe, the new protocol seems an attractive option for N2 MBW in infants. Pediatr Pulmonol. © 2013 Wiley Periodicals, Inc.

On the efficiency of impingers with fritted nozzle tip for collection of ultrafine particles

The aim of this study was to determine the collection efficiency of ultrafine particles into an impinger fitted with a fritted nozzle tip as a means to increase contact surface area between the aerosol and the liquid. The influence of liquid sampling volume, frit porosity and the nature of the sampling liquid was explored and it was shown that all impact on the collection efficiency of particles smaller than 220 nm. Obtained values for overall collection efficiency were substantially higher (~30–95%) than have been previously reported, mainly due to the high deposition of particles in the fritted nozzle tip, especially in case of finer porosity frits and smaller particles. Values for the capture efficiency of the solvent alone ranged from 20 to 45%, depending on the type and the volume of solvent. Additionally, our results show that airstream dispersion into bubbles improves particle trapping by the liquid and that there is a difference in collection efficiencies based on the nature and volume of the solvent used.

Final report : tasks 1 and 4: eco-efficiency assessment of building refurbishment

The main objective was to compare the environmental impacts of a building undergoing refurbishment both before and after the refurbishment and to assist in the design of the refurbishment with what is learned.

Re-life of buildings - decision support tools for maximising project efficiency

This paper describes the process adopted in developing an integrated decision support framework for planning of office building refurbishment projects, with specific emphasize on optimising rentable floor space, structural strengthening, residual life and sustainability. Expert opinion on the issues to be considered in a tool is being captured through the DELPHI process, which is currently ongoing. The methodology for development of the integrated tool will be validated through decisions taken during a case study project: refurbishment of CH1 building of Melbourne City Council, which will be followed through to completion by the research team. Current status of the CH1 planning will be presented in the context of the research project.

Sustainable construction for the future - the role of government in energy efficiency and sustainability in buildings

This paper will summarise the findings from a study that explored the link between dwelling design, or type, and energy efficiencies in sub-tropical climates. An increasing number of government and private sector development companies are initiating projects that aim to deliver enhanced environmental outcomes at both sub-divisional and dwelling levels. The study used AccuRate, a new thermal modelling tool developed by CSIRO that responds to the need to improve ventilation modelling. The study found that dwellings developed in conjunction with the Departments of Housing and Public Works have set the benchmark. It provides a snapshot of the energy efficiency of a range of dwelling types found in recent subdivisions. However, the trend toward increasing urban densities may reduce the likelihood that cooling breezes will be available to cool dwellings. The findings are relevant to regulators, designers and industry in all states interested in reducing the energy used to cool dwellings in summer.

Integrating eco-efficiency assessment of commercial buildings into the design process : LCADesign

The ability to assess a commercial building for its impact on the environment at the earliest stage of design is a goal which is achievable by integrating several approaches into a single procedure directly from the 3D CAD representation. Such an approach enables building design professionals to make informed decisions on the environmental impact of building and its alternatives during the design development stage instead of at the post-design stage where options become limited. The indicators of interest are those which relate to consumption of resources and energy, contributions to pollution of air, water and soil, and impacts on the health and wellbeing of people in the built environment as a result of constructing and operating buildings. 3D object-oriented CAD files contain a wealth of building information which can be interrogated for details required for analysis of the performance of a design. The quantities of all components in the building can be automatically obtained from the 3D CAD objects and their constituent materials identified to calculate a complete list of the amounts of all building products such as concrete, steel, timber, plastic etc. When this information is combined with a life cycle inventory database, key internationally recognised environmental indicators can be estimated. Such a fully integrated tool known as LCADesign has been created for automated ecoefficiency assessment of commercial buildings direct from 3D CAD. This paper outlines the key features of LCADesign and its application to environmental assessment of commercial buildings.