Fernando Queiroga

CPAP and survival in moderate-to-severe obstructive sleep apnoea syndrome and hypoxaemic COPD

Obstructive sleep apnoea syndrome (OSAS) often coexists in patients with chronic obstructive pulmonary disease (COPD). The present prospective cohort study tested the effect of OSAS treatment with continuous positive airway pressure (CPAP) on the survival of hypoxaemic COPD patients. It was hypothesised that CPAP treatment would be associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving long-term oxygen therapy (LTOT). Prospective study participants attended two outpatient advanced lung disease LTOT clinics in São Paulo, Brazil, between January 1996 and July 2006. Of 603 hypoxaemic COPD patients receiving LTOT, 95 were diagnosed with moderate-to-severe OSAS. Of this OSAS group, 61 (64%) patients accepted and were adherent to CPAP treatment, and 34 did not accept or were not adherent and were considered not treated. The 5-yr survival estimate was 71% (95% confidence interval 53–83%) and 26% (12–43%) in the CPAP-treated and nontreated groups, respectively (p<0.01). After adjusting for several confounders, patients treated with CPAP showed a significantly lower risk of death (hazard ratio of death versus nontreated 0.19 (0.08–0.48)). The present study found that CPAP treatment was associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving LTOT.

Heliox Improves Oxygen Delivery and Utilization during Dynamic Exercise in Patients with Chronic Obstructive Pulmonary Disease

RATIONALE Normoxic heliox (mixture of 79% He and 21% O(2)) may enhance exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). It remains to be determined whether part of these beneficial effects could be ascribed to increased O(2) delivery (O(2)DEL) to locomotor muscles. OBJECTIVES To investigate the effects of heliox on peripheral O(2)DEL and utilization during exercise in moderate to severe COPD. METHODS Twelve mildly hypoxic or nonhypoxemic men (FEV(1) = 45.0 +/- 13.0% predicted) underwent constant-work rate tests (70-80% peak) to the limit of tolerance while receiving heliox or room air. Near-infrared spectroscopy determined changes (Delta) in leg muscle deoxygenation (deoxyhemoglobin concentration [HHb], an index of fractional O(2) extraction), and surface electromyography estimated muscle fiber recruitment (n = 5). Q and Sp(O(2)) were monitored by impedance cardiography and pulse oximetry, respectively. MEASUREMENTS AND MAIN RESULTS Heliox significantly decreased dynamic hyperinflation and increased exercise tolerance compared with room air (640 +/- 95 s vs. 371 +/- 100 s; P < 0.01). Heliox also accelerated on-exercise dynamics of Q, which were accompanied by faster O(2) uptake kinetics and slower Delta[HHb] responses (P < 0.05). During steady-state exercise, Sp(O(2))-corrected Delta[HHb] values decreased with heliox despite no significant changes in cardiac output. Muscle fiber recruitment and leg effort scores were also diminished (P < 0.05). On a multiple regression analysis, reductions in dynamic hyperinflation, dyspnea, and Delta[HHb] were independently related to improvements in exercise tolerance with heliox (R(2) = 0.91; P < 0.01). CONCLUSIONS Heliox increases lower limb O(2)DEL and utilization during dynamic exercise in patients with moderate to severe COPD. These effects enhance exercise tolerance in this patient population.

Kinetics of muscle deoxygenation are accelerated at the onset of heavy-intensity exercise in patients with COPD: relationship to central cardiovascular dynamics

Patients with chronic obstructive pulmonary disease (COPD) have slowed pulmonary O(2) uptake (Vo(2)(p)) kinetics during exercise, which may stem from inadequate muscle O(2) delivery. However, it is currently unknown how COPD impacts the dynamic relationship between systemic and microvascular O(2) delivery to uptake during exercise. We tested the hypothesis that, along with slowed Vo(2)(p) kinetics, COPD patients have faster dynamics of muscle deoxygenation, but slower kinetics of cardiac output (Qt) following the onset of heavy-intensity exercise. We measured Vo(2)(p), Qt (impedance cardiography), and muscle deoxygenation (near-infrared spectroscopy) during heavy-intensity exercise performed to the limit of tolerance by 10 patients with moderate-to-severe COPD and 11 age-matched sedentary controls. Variables were analyzed by standard nonlinear regression equations. Time to exercise intolerance was significantly (P < 0.05) lower in patients and related to the kinetics of Vo(2)(p) (r = -0.70; P < 0.05). Compared with controls, COPD patients displayed slower kinetics of Vo(2)(p) (42 +/- 13 vs. 73 +/- 24 s) and Qt (67 +/- 11 vs. 96 +/- 32 s), and faster overall kinetics of muscle deoxy-Hb (19.9 +/- 2.4 vs. 16.5 +/- 3.4 s). Consequently, the time constant ratio of O(2) uptake to mean response time of deoxy-Hb concentration was significantly greater in patients, suggesting a slower kinetics of microvascular O(2) delivery. In conclusion, our data show that patients with moderate-to-severe COPD have impaired central and peripheral cardiovascular adjustments following the onset of heavy-intensity exercise. These cardiocirculatory disturbances negatively impact the dynamic matching of O(2) delivery and utilization and may contribute to the slower Vo(2)(p) kinetics compared with age-matched controls.

Haemodynamic effects of proportional assist ventilation during high-intensity exercise in patients with chronic obstructive pulmonary disease.

Background and objective:  Proportional assist ventilation (PAV) has been proposed as a more physiological modality of non‐invasive ventilation, thereby reducing the potential for deleterious cardio‐circulatory effects during exercise, in patients with COPD. We therefore evaluated whether PAV modulates the kinetic and ‘steady‐state’ haemodynamic responses to exercise in patients with moderate‐to‐severe COPD.

Exercise tolerance with helium-hyperoxia versus hyperoxia in hypoxaemic patients with COPD

The purpose of this study was to investigate whether helium-hyperoxia (HeHOx) would allow greater tolerance to maximal and submaximal exercise compared to hyperoxia (HOx) on isolation in hypoxaemic chronic obstructive pulmonary disease (COPD) patients under long-term oxygen therapy. In a double-blind study, 24 males in the Global Initiative for Chronic Obstructive Lung Disease functional class IV (forced expiratory volume in 1 s 35.2±10.1% predicted and arterial oxygen tension 56.2±7.5 mmHg) were submitted to incremental and constant load cycling at 70–80% peak work rate while breathing HOx (60% nitrogen and 40% oxygen) or HeHOx (60% helium and 40% oxygen). HeHOx improved resting airflow obstruction and lung hyperinflation in all but two patients (p<0.05). Peak work rate and time to exercise intolerance were higher with HeHOx than HOx in 17 (70.8%) out of 24 patients and 14 (66.6%) out of 21 patients, respectively (p<0.05). End-expiratory lung volumes were lower with HeHOx, despite a higher ventilatory response (p<0.05). HeHOx speeded on-exercise oxygen uptake kinetics by ∼30%, especially in more disabled and hyperinflated patients. Fat-free mass was the only independent predictor of higher peak work rate with HeHOx (r2 = 0.66, p<0.001); in contrast, none of the resting characteristics or exercise responses were related to improvements in time to exercise intolerance (p>0.05). Helium is a valuable ergogenic aid when added to HOx for most long-term oxygen therapy-dependent patients with advanced COPD.