Prediction of heart rate and oxygen uptake during incremental and maximal exercise in healthy adults.

Measurement of heart rate and oxygen uptake during incremental exercise and at maximal exercise is useful in evaluating mechanisms responsible for exercise limitation in patients with cardiopulmonary disease. Presently used prediction equations are based on relatively small groups of subjects in whom there was an uneven distribution of subjects with regard to age and sex or based on equations that were from extrapolated data. Our prediction equations are based on data from 231 men and women equally divided within decades between 20 and 80 years. Patients exercised to a symptom-limited maximum on a cycle ergometer while measurements of heart rate and oxygen uptake were recorded. The relationship between heart rate and oxygen uptake throughout exercise (HR:VO2) was determined using a statistical technique that included each data point from each subject. The HR:VO2 throughout incremental exercise was best described by separate equations for women younger than 50 years and older than 50 years and for men younger than 70 years and older than 70 years. Prediction equations for maximal heart rate (HRmax) and maximal oxygen uptake (VO2max) were developed by linear regression and were selected from all possible combinations of parameters. The HRmax was most accurately predicted by age alone for both sexes. Unlike the HR:VO2 relationship, the slope of the line relating heart rate to age was not different for the older women compared with the younger women so that a single equation was derived to predict HRmax. A single equation for the men was also sufficient since the slope of heart rate to age was the same for all ages. To most accurately predict VO2max, a separate equation was required for both the women and men that included age, height, and weight.

Comparison of effects of exercise and hyperventilation on leukocyte kinetics in humans.

The circulating leukocyte (WBC) count increases with exercise, because WBCs enter the circulation from the marginated pool. The lung is a major source of the demarginating cells, but it is unclear whether this occurs because of increased ventilatory movements, increased cardiac output, or both. The present study examined the mechanical effect of ventilation (VE) in six healthy men with three different protocols on three separate occasions. First, the subjects cycled for 5-min intervals at 50, 100, 150, and 200 W, and we measured heart rate (HR), minute ventilation (VE), tidal volume (VT), respiratory rate, and end-tidal CO2. Second, each subject reproduced his exercise VE by matching VT, respiratory rate, and end-tidal CO2 on a circuit designed for isocapnic hyperpnea (matched VE). The subjects then performed a hyperventilation (hyper-VE) protocol with a minimum VT of 1.5 liters and a respiratory rate of 20 breaths/min. Blood samples were drawn at rest and throughout each protocol for measurement of WBCs, hematocrit, and band cells. During cycling, VE increased (9 +/- 1 to 66 +/- 7 l/min), HR increased (71 +/- 7 to 172 +/- 10 beats/min), and WBCs increased (5.5 +/- 0.9 to 7.8 +/- 1.3 x 10(9)/l). During matched VE, VE increased (11 +/- 2 to 69 +/- 11 l/min), but neither HR nor WBCs increased (67 +/- 13 to 78 +/- 12 beats/min and 5.3 +/- 1.6 to 5.7 +/- 1.5 x 10(9)/l, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Normal values and ranges for ventilation and breathing pattern at maximal exercise.

Assessment of the breathing pattern at maximal exercise in patients is limited because the range of ventilatory responses (minute ventilation; tidal volume; respiratory rate) at maximal exercise in normal humans is unknown. We studied 231 normal subjects (120 women; 111 men) equally distributed according to age from 20 to 80 years. Each subject performed a progressive incremental cycle ergometer exercise test to their symptom-limited maximum. Mean ventilation at the end of exercise (Vemax) was significantly higher in men (mean +/- SD, 97 +/- 25 L/min) than in women (69 +/- 22 L/min) (p less than 0.001). Minute ventilation at the end of exercise as a fraction of predicted maximal voluntary ventilation (Vemax/MVV) for all subjects was 0.61 +/- 0.14 (range, 0.28 to 1.02). There was no difference in Vemax/MVV between men (0.62 +/- 0.14) and women (0.59 +/- 0.14). Tidal volume at the end of exercise (Vtmax) was higher in men (2.70 +/- 0.48 L) than in women (1.92 +/- 0.41 L) (p less than 0.001). Any differences in Vtmax between men and women disappeared when Vtmax was corrected for baseline FVC. Respiratory rate at the end of exercise (RRmax) was 36.1 +/- 9.2 breaths per minute for all subjects. There was no difference in RRmax between men and women. The Vemax correlated best with carbon dioxide output at the end of exercise (r = 0.91; p less than 0.001) and with maximal oxygen uptake (r = 0.90; p less than 0.001) for all subjects. This study of a large group of subjects has demonstrated the wide range of possible breathing patterns which are adopted during exercise and has provided a wide range of "normal" responses which must be taken into consideration when maximal ventilatory data from exercise tests are analyzed.

The time course of bronchoconstriction in asthmatics during and after isocapnic hyperventilation.

We studied the effect of changing the duration of isocapnic hyperventilation on the time course of bronchoconstriction in five subjects with asthma. Each subject performed hyperventilation challenges of 4, 8, and 16 min. No significant bronchoconstriction occurred until the hyperventilation was stopped, regardless of its duration. We found increased bronchoconstriction as the duration of hyperventilation increased. The declines in FEV1 (mean +/- SD) from baseline were 13 +/- 10%, 22 +/- 7%, and 29 +/- 12% for 4, 8, and 16 min of hyperventilation, respectively (1 versus 3, p less than 0.01). Mean times after hyperventilation until maximal bronchoconstriction were 12 +/- 4 min, 9 +/- 6 min, and 6 +/- 4 min. We also found slight bronchodilation during the first 4 min of hyperventilation. After 2 and 4 min of hyperventilation, the FEV1 was 103 +/- 5% and 103 +/- 3% of baseline, respectively (both p less than 0.05, compared to baseline). We conclude that increasing the duration of hyperventilation delays the onset of bronchoconstriction but causes greater bronchoconstriction once the hyperventilation is stopped. These results suggest that either hyperventilation itself inhibits bronchoconstriction or that the mechanisms that induce bronchoconstriction in response to hyperventilation operate after, rather than during, hyperventilation.

Changes in total lung capacity during acute spontaneous asthma.

An increased TLC has been reported during exacerbations of asthma, but the methods used (helium, dilution, plethysmography) have been subsequently found unreliable in the assessment of lung volumes in patients with obstructive lung disease. To address this problem, we measured TLC (TLC-XR) from posteroanterior and lateral chest roentgenograms obtained during exacerbations (E) of asthma and after recovery (R) using planimetry in 12 asthmatic subjects. At recovery, TLC was also measured by plethysmography or by helium dilution for comparison with the radiographic measurement. The plethysmographic measurements were made with a panting frequency less than 1 Hz to allow for airway obstruction. A chest radiologist also used independent radiologic measurements of hyperinflation (lung height, diaphragmatic arc height, rib counts) to assess lung volumes. Mean FEV1 during E was 1.43 +/- 0.38 L, and significant improvement occurred at R (FEV1 = 2.81 +/- 0.58 L, p less than 0.05). Of the independent radiologic variables measured, only an increase in lung height distinguished the two sets of radiographs. Mean TLC-XR (E) (6.01 +/- 1.62 L) was significantly greater than mean TLC-XR (R) (5.44 +/- 1.17 L, p less than 0.05). TLC measured radiographically at recovery was strongly correlated (r = 0.94) with TLC measured by plethysmography or helium dilution. We conclude that acute reversible increases in TLC do occur during exacerbations of asthma and that these changes are only readily detected by formal planimetry.

Exercise testing in the assessment of pulmonary disease.

In this chapter, the different types of exercise tests and the indications for requesting a particular type of test have been discussed. The normal physiological responses to exercise have been reviewed and examples of the abnormal responses seen in a variety of disease states that have been discussed. The relatively small number of these responses limits the specificity of exercise tests in actually establishing a diagnosis, but can be helpful in narrowing the differential diagnosis. Perhaps exercise tests are most valuable in cases where the patient's symptoms are mainly limited to exercise and where investigations done at rest have failed to resolve a diagnostic question. When exercise testing is used under these circumstances, it serves a unique function in the diagnosis and management of pulmonary disease.

Granulomatous Pneumocystis carinii pneumonia mimicking tuberculosis.

A 62-year-old man with untreated, well-differentiated lymphocytic lymphoma, presenting with progressive dyspnea, was found on open lung biopsy to have multiple necrotizing granulomas that on frozen section were initially called tuberculosis. Routine Grocott methenamine-silver stain showed these to contain Pneumocystis carinii organisms. A review of the literature shows that this is an unusual histologic presentation that can occur in a wide variety of immunosuppressed states, including the acquired immunodeficiency syndrome. The histologic similarities to tuberculous infection are stressed to increase the awareness of possible misdiagnosis that could result in delayed or inappropriate therapy.

Cardiac output at rest and in exercise in elderly subjects.

We measured cardiac output (Q), at rest and during graded exercise, in 68 women and 41 men over the age of 55 yr, using a CO2 rebreathing method. Mean (+/- SD) age was 66 +/- 5 yr in women and 66 +/- 6 yr in men. Only subjects with no history or physical examination findings of pulmonary, cardiac, neuromuscular, or endocrine disease and normal electrocardiography and spirometry were studied. We found a linear relationship between Q and oxygen uptake (VO2) in males and females. The regression equation expressing this relationship in males was Q = 2.9 + 5 VO2 1.min-1 (SEE 2.8) and, in females, Q = 2.9 + 4.6 VO2 1.min-1 (SEE 2.8). This is similar to the relationship previously estimated for elderly males using the direct Fick method and concurs with other reports in the literature which show that, while the Q-VO2 relationship in the elderly has a slope similar to that in younger groups, the Q-VO2 intercept is lower. This means that the absolute level of cardiac output for a given level of work is lower in the elderly than in younger populations. This may reflect an age-related decrease in active metabolic tissue in the elderly and/or altered metabolic regulation with increased oxygen extraction from blood.

Prediction of maximal oxygen uptake and power during cycle ergometry in subjects older than 55 years of age.

One hundred twenty-eight healthy volunteers (81 women, 47 men) older than 55 yr of age were studied with an incremental progressive cycle ergometer test to a symptom-limited, maximal tolerable work load. Mean (+/- SD) age was 66 +/- 6 yr in women and 66 +/- 5 years in men. Subjects with a history of ischemic heart disease, diabetes, pulmonary disease, or neuromuscular disease were excluded. Smokers were included, but all subjects had normal FEV1 and FVC. The objective of the study was to compare measured values of VO2max and Wmax in this older population with previously published predicted values based on subjects of all ages. We found that Wmax observed exceeded Wmax predicted by 9.5 +/- 22% (mean +/- SD) and that VO2max observed exceeded VO2max predicted by 17.5 +/- 22%. Because of this systematic underestimate of VO2max and Wmax by the previous prediction equations, we constructed new prediction equations for use in subjects older than 55 yr of age using height, weight, age, and sex as variables. We conclude that these new prediction equations more accurately predict Wmax and VO2max in subjects older than 55 yr of age because they are based solely on subjects in this age group.