Effect of weight loss via bariatric surgery for class III obesity on exertional breathlessness

Mainra, Amar; Abdallah, Sara J.; Reid, Ryan E.R.; Andersen, Ross E.; Jensen, Dennis

doi:10.1016/j.resp.2019.05.007

Cited by 10 publications

(8 citation statements)

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“…However, the ventilatory response could also be affected by pathophysiological adaptations during exercise, which may depend on chemoreception and metabolic setpoints. Indeed, increased Vʹ E /Vʹ CO 2 at peak exercise was associated with reduced arterial carbon dioxide tension (P aCO 2 ) and/or end-tidal carbon dioxide tension (P ETCO 2 ) after bariatric surgery [5,6]. Although this metabolic adaptation to resting P ETCO 2 has been confirmed in our study after sleeve gastrectomy, we would like to emphasise that a significant decrease in the submaximal Vʹ E /Vʹ CO 2 slope has been shown [3].…”

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confidence: 55%

“…These adaptations led to an increased breathing reserve and thus less ventilatory limitation at peak exercise in patients who demonstrated improved exercise capacity and tolerance [3].Although the pathophysiological adaptations to physical exercise are positively affected by weight loss and fewer mechanical ventilatory constraints, the mechanisms related to the ventilatory response at maximal exercise intensities are still poorly investigated. Only a few studies have specifically addressed this issue in obesity without considering the possible impact of other frequently associated comorbidities [5][6][7][8].…”

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Correspondence regarding “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

et al. 2022

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1] discussed the pathophysiological mechanisms and clinical relevance of ventilatory efficiency in athletes, asthma and obesity in their interesting review article entitled "Ventilatory efficiency in athletes, asthma and obesity". Patients with obesity can display an altered ventilatory response to exercise, which may contribute to functional limitations in this population. We aim to provide a supplementary contribution to the clinical evaluation and pathophysiological interpretation of the ventilatory response to exercise in patients with obesity. This contribution resulted from two papers recently published by our research group. COLLINS et al.[1] described how patients with obesity have higher ventilation at rest and any given work rate due to increased metabolic costs and work of breathing. Reduced chest wall compliance leads to a shallow breathing pattern, which, however, does not seem to significantly affect the ventilatory efficiency of patients, commonly measured by minute ventilation relative to carbon dioxide production (Vʹ E /Vʹ CO 2 ), at submaximal exercise intensities [1]. Nonetheless, related scientific knowledge is less clear for severe and morbid obesity patients, particularly at elevated exercise intensities. Indeed, inadequate compensatory hyperventilation at maximal physical exertion has been described due to mechanical ventilatory constraints [2].The Vʹ E /Vʹ CO 2 at peak exercise has thus been proposed as a clinical marker to evaluate the respiratory response to exercise, since it can provide important information regarding the underlying mechanisms of exercise intolerance [1].In our recently published paper, entitled "Ventilatory response at rest and during maximal exercise testing in patients with severe obesity before and after sleeve gastrectomy", 46 patients with severe obesity (mean body mass index (BMI) 43.59±5.30 kg•m −2 ) were evaluated 1 month before and 6 months after sleeve gastrectomy. Ventilatory response and efficiency were analysed by incremental, maximal cardiopulmonary exercise testing on a treadmill [3]. It has been shown that patients affected by severe obesity have a shallow breathing pattern but a resulting ventilatory efficiency (i.e. Vʹ E /Vʹ CO 2 slope) within the normal range of predicted [3,4]. Interestingly, after surgery and significant weight loss (BMI 32.27±4.84 kg•m −2 ), reduced ventilation at rest, during submaximal and maximal exercise was revealed by data and an improvement of breathing pattern and Vʹ E /Vʹ CO 2 slope. This might be a suggestion that a significant weight loss can increase ventilatory efficiency, likely because of adaptations in ventilatory mechanics and constraints. A less shallow breathing pattern, enhanced lung expansion and the associated relatively lower dead space ventilation could indeed lead to increased alveolar ventilation and better ventilatory efficiency. These adaptations led to an increased breathing reserve and thus less ventilatory limitation at peak exercise in patients who demonstrated improved exercise capacity and tolera...

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Correspondence regarding “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

et al. 2022

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“…The net effect is: 1) an inability to increase alveolar ventilation sufficiently to compensate for the increased metabolic acidosis at heavy exercise and, 2) premature exercise termination. This conclusion is supported by multiple studies demonstrating an increase in peak V′ E /V′ CO 2 and reduced P aCO 2 and/or P ETCO 2 following bariatric surgery in patients with morbid obesity[124,130]. As such, the change in V′ E /V′ CO 2 observed at peak exercise may be a useful clinical tool when evaluating responses following interventions such as bariatric surgery.Due to the increasing prevalence of obesity, and the multi-comorbid nature of the disease[131], the authors stress the importance of careful interpretation of ventilatory responses to submaximal exercise in these patients.…”

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confidence: 61%

“…Further, individuals with obesity generally adopt a rapid and shallow breathing pattern to minimise the work of breathing, especially at higher ventilatory rates[108]. Despite the rapid and shallow breathing pattern, both arterial P CO 2 (or P ETCO 2 ) and V D /V T are generally within normal ranges during submaximal exercise[23, 108, 113,119,124]. Further, multiple studies have reported a normal V′ E -V′ CO 2 slope, even in morbid obesity, when compared to either non-obese control groups or normative values (table 1 and figure1)[6, 108,[125][126][127].…”

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Ventilatory efficiency in athletes, asthma and obesity

et al. 2021

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During submaximal exercise, minute ventilation (V′E) increases in proportion to metabolic rate (i.e. carbon dioxide production (V′CO2)) to maintain arterial blood gas homeostasis. The ratio V′E/V′CO2, commonly termed ventilatory efficiency, is a useful tool to evaluate exercise responses in healthy individuals and patients with chronic disease. Emerging research has shown abnormal ventilatory responses to exercise (either elevated or blunted V′E/V′CO2) in some chronic respiratory and cardiovascular conditions. This review will briefly provide an overview of the physiology of ventilatory efficiency, before describing the ventilatory responses to exercise in healthy trained endurance athletes, patients with asthma, and patients with obesity. During submaximal exercise, the V′E/V′CO2 response is generally normal in endurance-trained individuals, patients with asthma and patients with obesity. However, in endurance-trained individuals, asthmatics who demonstrate exercise induced-bronchoconstriction, and morbidly obese individuals, the V′E/V′CO2 can be blunted at maximal exercise, likely because of mechanical ventilatory constraint.

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“…Regarding the respiratory system, surgical treatment of obesity was associated with a significant improvement in pulmonary function and the associated respiratory complications [13][14][15][16]. However, there is limited evidence on the effect of massive weight loss on ventilatory response during maximal exercise, while most studies have mainly focused on resting lung volumes and capacity [17][18][19][20]. Moreover, no data on the specific impact of SG on ventilation are currently available, particularly during incremental exercise testing.…”

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Ventilatory Response at Rest and During Maximal Exercise Testing in Patients with Severe Obesity Before and After Sleeve Gastrectomy

et al. 2020

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Introduction Sleeve gastrectomy (SG) has become a widespread treatment option in patients affected by severe obesity. However, studies investigating the impact of the subsequent weight loss on the ventilatory response at rest and during physical exercise are lacking. Methods This is an observational study on 46 patients with severe obesity (76% females), comparing parameters of ventilatory function 1 month before and 6 months after SG. Patients were first evaluated by resting spirometry and subsequently with an incremental, maximal cardiopulmonary exercise test (CPET) on treadmill. Results The important weight loss of 26.35 ± 6.17% of body weight (BMI from 43.59 ± 5.30 to 32.27 ± 4.84 kg/m2) after SG was associated with a significant improvement in lung volumes and flows during forced expiration at rest, while resting ventilation and tidal volume were reduced (all p ≤ 0.001). CPET revealed decreased ventilation during incremental exercise (p < 0.001), with a less shallow ventilatory pattern shown by a lower increase of breathing frequency (∆BFrest to ATp = 0.028) and a larger response of tidal volume (∆TVAT to Peakp < 0.001). Furthermore, a concomitant improvement of the calculated dead space ventilation, VE/VCO2 slope and peripheral oxygen saturation was shown (all p ≤ 0.002). Additionally, the increased breathing reserve at peak exercise was associated with a lower absolute oxygen consumption but improved exercise capacity and tolerance (all p < 0.001). Conclusion The weight loss induced by SG led to less burdensome restrictive limitations of the respiratory system and to a reduction of ventilation at rest and during exercise, possibly explained by an increased ventilatory efficiency and a decrease in oxygen demands.

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Effect of weight loss via bariatric surgery for class III obesity on exertional breathlessness

Cited by 10 publications

References 39 publications

Correspondence regarding “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

Correspondence regarding “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

Ventilatory efficiency in athletes, asthma and obesity

Ventilatory Response at Rest and During Maximal Exercise Testing in Patients with Severe Obesity Before and After Sleeve Gastrectomy

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