Breathing Kinetics: FVL Analysis

CPET in Athletes:
Observations from Minnesota
Paul D. Scanlon, M.D.
Professor of Medicine
Medical Director, Pulmonary Function
Laboratories, Mayo Clinic Rochester
November 28, 2014
Paul D. Scanlon, MD
Disclosures
• Research: Boehringer Ingelheim, Forest
Pharmaceuticals, GlaxoSmithKline, Novartis,
Pfizer, National Heart, Lung & Blood Institute
• Consulting: GlaxoSmithKline, Merck, Libby
Medical Program, University of Minnesota
• Royalties: Lippincott Williams & Wilkins
• Employed by Mayo Clinic
Mayo Clinic Pulmonary Function Labs
Largest single center PF Lab in North America:
• 10,000 square feet in Gonda Building
• Staff – 39.4 FTE allied health staff, 11 MD’s in rotation
• Routine Lab performs spirometry, lung volumes, Raw,
DLCO, oximetry, respiratory pressures, methacholine
challenge, IOS
• Special Pulmonary Evaluation Lab performs ABG’s,
Exercise studies, eNO, Oxygen titration, overnight
oximetry, REE, hypopharyngeal pH (reflux)
• Up to 125 patients/day in Routine PF Lab, 225 total
including all procedures in outpatient lab
• 16,400 Spirometry, 15,366 DLCO in 2013
• Full service PF labs in St. Marys Campus (Rochester
inpatient facility), Phoenix and Scottsdale AZ,
Jacksonville FL, various levels of service in Mayo
Clinic Health System
Outline
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Example exercise case from our lab
Linkages of exercise physiology
Flow limitation
Upper airway problems, e.g. vocal cord
dysfunction
• Asthma/Exercise-induced bronchoconstriction
• Definitions of lactate/anaerobic threshold,
isocapnic buffering, respiratory compensation
point, maximal lactate steady-state
• Training and other factors to consider - which
parameters can be improved with physical
training
33 yo M referred to evaluate CV fitness
• Concern after recent athletic
competition re CV fitness
• BMI 27.4
• Excellent workload – 360 watts
• Low normal VO2 for elite athlete – 35 ml/kg/min
• Exercise continued 7 minutes past anaerobic
threshold
• Heart rate recovery slow compared with other
elite athletes (>100 5’ post)
Normal Limits of Exercise in Athletes
• Respiration
• Ventilation
• Gas Exchange
• Cardiac Function
• Rate
• Systolic Function
• Diastolic Function
• Vascular System
• Arteriolar distribution of resistance
• Capillary distribution
• O2 extraction
Figure 1. Derangements of gas exchange in disease.
Milani R V et al. Circulation. 2004;110:e27-e31
Copyright © American Heart Association, Inc. All rights reserved.
Cardiopulmonary Exercise Testing
• Oxygen consumption
(VO2max)
•Index of cardiopulmonary
fitness (gold standard)
• Cardiovascular response
• Ventilatory limitation and
breathing strategies
• Gas Exchange
• Metabolic calculations
and derivatives
Cardiopulmonary Exercise Testing
Metabolic Response
• Fick Equation
• Reductions in
VO2max can be
from a single
entity or
multifactorial
Oded Bar-Or Pediatric Exercise
Medicine Human Kinetics 2004
Exercise Testing Methods
• Simple tests to evaluate possible exerciseinduced bronchospasm
• methacholine, mannitol, eNO, cold air
• Limited exercise capacity – 6 minute
walk
• Desaturation – submaximal versus
maximal tests
• Complex cardiopulmonary assessment test
– complexity, cost
CPET Abnormalities in Athletes
• Ventilatory Limitation
• Exercise-induced bronchospasm
• Upper airway dysfunction
• Fixed Obstruction – less common in
athletes
• Gas exchange abnormalities
• Cardiac abnormalities less common in
our practice – Chronotropic
insufficiency (incl. excess beta blocker),
LVF, RVF, PHTN, arrhythmia
• Deconditioning - injury or training gap
Flow Volume Loop Dynamic Profiles
10
Exercise
Rest
8
Flow (L/sec)
6
4
Ex
2
0
2
Ex
1
2
3
4
Rest
5
1
2
3
4
5
Rest
4
6
8
Normal
Severe COPD
Mottram CD, Manual of Pulmonary Function Testing 2012
Breathing Kinetics: FVL Analysis
Normal
Breathing Kinetics: FVL Analysis
Flow limitation
Breathing Kinetics: FVL Analysis
Inappropriate Shift
Breathing Kinetics: FVL Analysis
Vocal Cord Dysfunction
Breathing Kinetics: FVL Analysis
Pseudo – Asthma “type 2”
Upper Airway Problems Identifiable
with Exercise Laryngoscopy
VIDEO EXAMPLES:
• VCD
• Laryngomalacia – arytenoid rotation
Asthma in Athletes
• EIA occurs in 40-90% of asthmatics
• Prevalence of asthma among elite
athletes is same as in general population
• Most, but not all, EIA is mild
• Management principals are mostly the
same
• Postulated Mechanisms of EIA
• Drying & osmotic stress - SD Anderson
• Respiratory heat loss – ER McFadden
24
Bronchospasm during Exercise?
Beck, Med Sci Spts Exc 1999;31:S4-S11
25
Asthma in Cold Weather Athletes
• Cold weather athletes
have greatly increased
incidence of asthma
sxs or BHR, up to 80%
of elite XC ski racers.
Why?
Larsson BMJ 1993;
307:1326
26
Does Cold Air Exercise Cause Asthma?
Cold and dry air exposure causes
bronchoconstriction during
exercise
Beck, Offord, Scanlon. AJRCCM 1994;
149:352-7
Cause of asthma & BHR in cold
weather athletes unknown - thermal
injury to epithelium 
inflammation?
Racing sled-dogs have bronchial
debris & exudate
Davis AJRCCM 166:878-82; 2002
Previous opinion that exercise does
not cause delayed response or
inflammation is likely incorrect
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Methods for Determining
Anaerobic Threshold/Ventilatory Threshold
• Rise in lactate, followed by fall in HCO3
• Ventilatory equivalents
• Initial rise in VE/VO2, earliest
• Nadirs or crossover of VE/VO2 and
VE/VCO2
• Change in R < 1.0
• V-slope – Can be curvilinear, particularly in
unfit individuals
• In a single well-mixed compartment, all
methods give same result. Reality diverges
because of complexity, non-uniformity,
measurement error
• Hyperventilation confounds all methods
Adapted from Mottram CD. Manual of Pulmonary Function Testing 2012
Methods for Determining
Anaerobic Threshold/Ventilatory Threshold
• Rise in lactate, followed by fall in HCO3
• Ventilatory equivalents
• Initial rise in VE/VO2, earliest
• Nadirs or crossover of VE/VO2 and
VE/VCO2
• Change in R < 1.0
• V-slope – Can be curvilinear, particularly in
unfit individuals
• In a single well-mixed compartment, all
methods give same result. Reality diverges
because of complexity, non-uniformity,
measurement error
• Hyperventilation confounds all methods
Adapted from Mottram CD. Manual of Pulmonary Function Testing 2012
Anaerobic Threshold Methods
H. Stegmann, W. Kindermann, A. Schnabel. Lactate Kinetics and
Individual Anaerobic Threshold. Int J Sports Med 1981; 2(3):160165
Multisession Maximal Lactate Steady-State (MLSS) test is “gold
standard” for Anaerobic threshold estimation. VL Billat. Sports
Med 2003; 33 (6): 407-426.
Reverse Lactate Threshold Test – approaches AT from higher
workload intensities. R Dotan. Int J Sports Physiol Perform 2012;
7(2):141-51.
Respiratory Compensation Point, RCP
(or Ventilatory Compensation Point, VCP)
• VCP = The point above which VE increases more rapidly
than VCO2 (Wasserman)
• The respiratory compensation point (RCP) is the moment
during a cardiopulmonary exercise test where minute
ventilation starts becoming excessive with respect to
carbon dioxide output. The RCP is an important concept in
exercise physiology as it forms the boundary between the
heavy and severe exercise intensity domains. There are
currently several methods for identifying the RCP, but these
are not very robust due to the noise in the data used for its
identification. (http://www.edgehill.ac.uk/sport/mresprojects-rcp/ - 11/19/2014)
• Correlates with hypoxic ventilatory drive and lactate
sensitivity (Takano, Jap J Physiol 2000; 50:449-55)
Metabolic Response
Anaerobic Threshold/Ventilatory Threshold
Isocapnic buffering
Ventilatory Equivalents
40
35
Ratio
30
25
VE/VO2
20
AT
15
VE/VCO2
Isocapnic buffering
zone
10
5
0
0
50
100
150
200
Workload (watts)
H+ + HCO3  H2CO3-  H2O + CO2
250
300
Metabolic Response
Anaerobic Threshold/Ventilatory Threshold
• Lactate kinetics
•Data from Kanaley JA. Mottram CD.
et. al Fatty acid kinetic responses to
running above or below lactate
threshold. Journal of Applied
Physiology. 79(2):439-47, 1995 Aug.
• End-exercise > 6 mM/L
Oxygen Uptake and
Exercise Domains
IN CREMENTAL
VO2 (L/min)
LT
CONSTA NT LOAD
MLSS
Severe
4
4
Heavy
Severe
2
2
Moderate
Heavy
Moderate
0
150
Work Rate (Watts)
300
0
12
Time (minutes)
24
Tip from Tom Allison re
Exercise Testing at Altitude
• Jaeger/CareFusion (and others?)
“corrects” some but not all gas
volumes to STPD vs. BTPS.
• VE is “corrected”, whereas VCO2 is
not.
• At altitude, this results in a spurious
elevation of VE/VCO2
Basic Principal of Lactate Steady
State (or any measure during exercise)
• 1 min ≠ 3 min ≠ 10 min ≠ 30 min ≠ 90 min
• E.G. Exercise-induced bronchospasm does
not occur during exercise.
Basic Principal of Lactate Steady
State (or any measure during exercise)
• 1 min ≠ 3 min ≠ 10 min ≠ 30 min ≠ 90 min
• E.G. Exercise-induced bronchospasm does
not occur during 10 minutes of steady state
exercise.
Anaerobic Threshold, VO2max,
Training Type and Age
• Cross-sectional study of 87 endurance runners
(ER), 51 speed-power athletes (SP, Polish
national team and international competitors),
61 untrained (UT, ≤ 150 min mod to vigorous
activity/week) individuals
• VO2max
• ER 58 (36-74), SP 47 (30-61), UT 41 (28-54)
• AT varies with training methods
• Endurance vs. speed-power vs. untrained
• Both total and % of VO2max
• AT declines with advancing age
• Both total and % of VO2max
Kusy K, Krol-Zielibska M, Domaszewska K, et. al.
Gas Exchange Threshold in Male Speed–Power
versus Endurance Athletes Ages 20–90 Years. Med
& Sci Sports & Exerc. 2012; 44(12):2415–2422.
Effects of training - what can be
improved with training
• Lungs are treatable, but not trainable
• Human heart/lung vs. horse
• Ventilatory limitation
• Gas Exchange abnormalities
• Cardiovascular performance
• Cardiac – Stroke volume, CO
• Aerobic fitness
• Anaerobic power, anaerobic tolerance
• Peripheral vascular
• Musculature – fiber type, endurance, output,
efficiency
Longitudinal monitoring of power output and heart rate
profiles in elite cyclists. Nimmerichter A1, Eston RG, Bachl N,
Williams C. J Sports Sci. 2011 May; 29(8):831-40. School of
Sport and Health Sciences, University of Exeter, UK
• Power output and heart rate monitored, 11 months in 11 elite cyclists.
1802 workout data sets divided into type categories per training goals.
• Power output and heart rate intensity zones calculated.
• Intensity Factor = ratio of mean power output to respiratory compensation point
power output .
• Variability of power output was calculated as a coefficient of variation.
• Mean VO2max > 65 mL · kg⁻¹ · min⁻¹.
• No difference in distribution of power output and heart rate for the season (P =
0.15). But significant differences were observed during high-intensity workouts (P
< 0.001).
• Better performance by cyclists was characterized by lower variability in power
output, higher exercise intensities during intervals, and low cadence power.
• The variability in power output was inversely associated with performance
(P < 0.01).
• The intensity factor for intervals was related to performance (P < 0.01).
• Performance improvements across the season were related to low -cadence
strength workouts (P < 0.05).
Excellent review of physiological parameters
and athletic (cycling) performance
“Despite its general use, VO2max has not been shown to be reliable in
predicting endurance performance, as witnessed by the lack of difference
between professional and amateur cyclists.
“…other parameters seem to be highly beneficial in assessing and predicting
cycling endurance performance…power output (W), breathing pattern (minute
ventilation, VE; breathing frequency; tidal volume, Vt), ventilatory equivalent
(eqVO2), delta VO2 versus delta workload ratio (dVO2/dW), blood lactate
levels, gross efficiency (GE), delta efficiency (DE), cycling economy (CE), and
the intensity where the highest absolute fat oxidation occurs (Fatmax).”
Comment: Comparison of professional vs. amateur cyclist notes superior
performance of pros in most measures, attributed to greater mileage and thus
predominance of Type I muscle fibers and greater aerobic capacity. Should not
ignore innate talent.
Physiological parameters in professional and elite amateur road cyclists.
Master’s Thesis HKG Schmitz, Faculty of Health Sciences, Maastricht
University, 2007
Event Specific Athletic Performance Depends
on Many Factors in Addition to CV Fitness
• Genetic Determinants - Raw Talent/Speed/Power
• Task Specific training, e.g. sprinting, climbing
• Athletic Equipment, Team Support
• Food/Fuel Mix and Schedule
• Experience, Technical Skill
• Familiarity with course
• Altitude adaptation
• Work Efficiency
• Aerodynamics
• Endurance
• “Peaking”
Tips from an Asthmatic
Pulmonologist Athletic Wannabe
1) “Well controlled” asthmatics (i.e. negative methacholine
challenge) can still develop EIA with high level exercise in
cold air.
2) Cold weather athletes don’t usually tolerate masks or scarves
for warming air.
3) Short courses of oral steroids are often necessary to achieve
control quickly.
4) Retraining after intercurrent illness is difficult. I recommend
HR monitor, avoid overtraining. Some athletes do not regain
former level of performance.
5) Vocal Cord dysfunction may be over- or under-diagnosed,
can be documented.
6) I find eNO helpful to fine tune anti-inflammatory therapy (or
point to alternate diagnosis).
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#1 Overall
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Summary
Issue #1
Issue #2
• asdf
• Lung
Indications for CPET in athletes
Heart Rate During Graded Exercise
Change in Ventricular Volumes during Exercis
Training Stroke Volume
Summary
Test deletions
Test additions
• Lung volumes if Nl •
or low O2
•
• Bronchodilator if
restricted and prev
•
normal
•
• DLCO if low O2
•
• Oximetry
Lung volumes if low VC
Maximal Respiratory
Pressures
FIVC if suspected UAO
Raw for Nonspecific
ABG
Gas Exchange
• PaO2 is relatively
stable with the (A-a)
gradient < 20
• PaO2 may fall in
highly trained
subjects
Rest
Max Ex
Gas Exchange
• VD/VT
•Rest: 30 - 40%,
Maximal exercise:
near 20%
•Elderly normals:
Values higher,
but kinetics same

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