The Effects of Oxitropium Bromide on Exercise Performance in Patients with Stable Chronic Obstructive Pulmonary Disease

562

390

Evidence-based recommendations on the clinical use of cardiopulmonary exercise testing (CPET) in lung and heart disease are presented, with reference to the assessment of exercise intolerance, prognostic assessment and the evaluation of therapeutic interventions (e.g. drugs, supplemental oxygen, exercise training). A commonly used grading system for recommendations in evidence-based guidelines was applied, with the grade of recommendation ranging from A, the highest, to D, the lowest.For symptom-limited incremental exercise, CPET indices, such as peak O 2 uptake (V9O 2 ), V9O 2 at lactate threshold, the slope of the ventilation-CO 2 output relationship and the presence of arterial O 2 desaturation, have all been shown to have power in prognostic evaluation. In addition, for assessment of interventions, the tolerable duration of symptom-limited high-intensity constant-load exercise often provides greater sensitivity to discriminate change than the classical incremental test. Field-testing paradigms (e.g. timed and shuttle walking tests) also prove valuable.In turn, these considerations allow the resolution of practical questions that often confront the clinician, such as: 1) ''When should an evaluation of exercise intolerance be sought?''; 2) ''Which particular form of test should be asked for?''; and 3) ''What cluster of variables should be selected when evaluating prognosis for a particular disease or the effect of a particular intervention?''

Section: Utility Of Exercise Testing In Defining Responses To Intervementioning

confidence: 94%

“…Recent data from the literature support the notion that in COPD patients, endurance tests are more sensitive than other exercise protocols in detecting exercise-related physiological changes induced by interventions, and are thus very useful in clinical practice ( fig. 4) [242].…”

Section: Symptom-limited Incremental Testmentioning

confidence: 99%

Recommendations on the use of exercise testing in clinical practice

Palange¹,

Ward²,

Carlsen³

et al. 2006

562

390

“…This is the first study to show consistent increases in exercise endurance of this magnitude after salmeterol. Inconsistent effects on exercise endurance seen in previous studies probably reflect differences in study design (parallel versus crossover) and exercise test modality used [25,[31][32][33]. The constant-load cycle exercise endurance test has been shown to be more responsive than the 6-min walk test for the purpose of bronchodilator evaluation [33].…”

Section: Effect Of Salmeterol On Ventilationmentioning

confidence: 99%

“…Inconsistent effects on exercise endurance seen in previous studies probably reflect differences in study design (parallel versus crossover) and exercise test modality used [25,[31][32][33]. The constant-load cycle exercise endurance test has been shown to be more responsive than the 6-min walk test for the purpose of bronchodilator evaluation [33]. The contention that improved ventilatory capacity and exercise performance is explained, at least in part, by reduced lung hyperinflation is supported by the finding of close statistical inter-relationships between the increases in resting IC, peak VT, peak V9E and peak symptom-limited V9O 2 during the constant-load exercise.…”

Section: Effect Of Salmeterol On Ventilationmentioning

confidence: 99%

Effect of salmeterol on the ventilatory response to exercise in chronic obstructive pulmonary disease

O’Donnell¹,

Voduc²,

Fitzpatrick³

et al. 2004

331

273

This study examined the effects of bronchodilator-induced reductions in lung hyperinflation on breathing pattern, ventilation and dyspnoea during exercise in chronic obstructive pulmonary disease (COPD). Quantitative tidal flow/volume loop analysis was used to evaluate abnormalities in dynamic ventilatory mechanics and their manipulation by a bronchodilator.In a randomised double-blind crossover study, 23 patients with COPD (mean¡SEM forced expiratory volume in one second 42¡3% of the predicted value) inhaled salmeterol 50 mg or placebo twice daily for 2 weeks each. After each treatment period, 2 h after dose, patients performed pulmonary function tests and symptom-limited cycle exercise at 75% of their maximal work-rate.After salmeterol versus placebo at rest, volume-corrected maximal expiratory flow rates increased by 175¡52%, inspiratory capacity (IC) increased by 11¡2% pred and functional residual capacity decreased by 11¡3% pred. At a standardised time during exercise, salmeterol increased IC, tidal volume (VT), mean inspiratory and expiratory flows, ventilation, oxygen uptake (V9O 2 ) and carbon dioxide output. Salmeterol increased peak exercise endurance, V9O 2 and ventilation by 58¡19, 8¡3 and 12¡3%, respectively. Improvements in peak V9O 2 correlated best with increases in peak VT; increases in peak VT and resting IC were interrelated. The reduction in dyspnoea ratings at a standardised time correlated with the increased VT.Mechanical factors play an important role in shaping the ventilatory response to exercise in chronic obstructive pulmonary disease. Bronchodilator-induced lung deflation reduced mechanical restriction, increased ventilatory capacity and decreased respiratory discomfort, thereby increasing exercise endurance. Several recent studies have shown that improvements in exertional dyspnoea following bronchodilator therapy in chronic obstructive pulmonary disease (COPD) correlate well with reductions in lung hyperinflation, as indicated by increases in inspiratory capacity (IC) [1][2][3][4][5]. However, the relationship between bronchodilator-induced increases in IC and improvements in symptoms and exercise performance is complex and poorly understood. Given the multifactorial nature of dyspnoea and exercise limitation in COPD, it remains unclear why small increases in resting IC (in the order of 0.3 L) appear to be clinically important. The current study extends previous studies conducted in the present authors9 laboratory using ipratropium bromide by, in addition, examining the effect of a bronchodilator (salmeterol) on plethysmographic lung volume components at rest and on breathing pattern and ventilatory capacity during exercise. Moreover, the study was designed to advance understanding of the mechanisms of bronchodilatorinduced dyspnoea relief, especially the role of reduced mechanical restriction.It has previously been shown that acute-on-chronic hyperinflation during exercise severely constrains tidal volume (VT) expansion, and that this dynamic mechanical restriction makes ...

“…Recently, the current authors have used constant-load cycle endurance testing, at a fixed fraction of the patient9s pre-determined peak work rate (Wmax) to evaluate bronchodilator efficacy [5,6]. This approach appears to be more responsive than other tests, as it allows for placebo-controlled comparisons of symptoms and physiological parameters, including exercise endurance time (ET), at a standardised work rate or power output [5,7]. Cycle exercise endurance testing, combined with measurements of exertional dyspnoea, ventilation and dynamic operating lung volumes, has been shown to be reliable (reproducible and responsive) [5,6].…”

mentioning

confidence: 99%

Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD

O’Donnell¹,

Flüge²,

Gerken³

et al. 2004

764

581

The aim of this study was to test the hypothesis that use of tiotropium, a new long-acting anticholinergic bronchodilator, would be associated with sustained reduction in lung hyperinflation and, thereby, would improve exertional dyspnoea and exercise performance in patients with chronic obstructive pulmonary disease.A randomised, double-blind, placebo-controlled, parallel-group study was conducted in 187 patients (forced expiratory volume in one second 44 ¡ 13% pred): 96 patients received 18 mg tiotropium and 91 patients received placebo once daily for 42 days. Spirometry, plethysmographic lung volumes, cycle exercise endurance and exertional dyspnoea intensity at 75% of each patient9s maximal work capacity were compared.On day 42, the use of tiotropium was associated with the following effects at pre-dose and post-dose measurements as compared to placebo: vital capacity and inspiratory capacity (IC) increased, with inverse decreases in residual volume and functional residual capacity. Tiotropium increased post-dose exercise endurance time by 105¡40 s (21%) as compared to placebo on day 42. At a standardised time near end-exercise (isotime), IC, tidal volume and minute ventilation all increased, whilst dyspnoea decreased by 0.9¡0.3 Borg scale units.In conclusion, the use of tiotropium was associated with sustained reductions of lung hyperinflation at rest and during exercise. Resultant increases in inspiratory capacity permitted greater expansion of tidal volume and contributed to improvements in both exertional dyspnoea and exercise endurance.