Nicholas A. Cassuto

Glycemic Status Affects Cardiopulmonary Exercise Response in Athletes with Type I Diabetes

PURPOSE This study aimed to (a) examine the influence of type I diabetes on the cardiopulmonary exercise response in trained subjects and (b) determine whether glycemic control affects these responses. METHODS The cardiopulmonary responses to maximal incremental cycle ergometry were compared in 12 Ironman triathletes with type I diabetes and 10 age- and sex-matched control subjects without diabetes. Athletes with type I diabetes were then stratified into low- (glycosylated hemoglobin (HbA1c) < 7%, n = 5) and high-HbA1c (HbA1c > 7%, n = 7) groups for comparison. Cardiac output, stroke volume, arterial blood pressure, and calculated systemic vascular resistance along with airway function were measured at rest and during steady-state exercise. RESULTS During peak exercise HR, stroke volume and cardiac output were not different between the groups with and without diabetes; however, forced expiratory flow at 50% of the forced vital capacity was lower in subjects with diabetes (P < 0.05). Within the group with diabetes, HbA1c was lower in the low-HbA1c versus high-HbA1c group (6.5 +/- 0.3 vs 7.8 +/- 0.4, respectively; P < 0.05), but training volume was not different. At rest, the low-HbA1c group had greater cardiac output and lower systemic vascular resistance than the high-HbA1c group, and all pulmonary function measurements were greater in the low-HbA1c group (P < 0.05). During peak exercise, the VO2, workload, HR, stroke volume, and cardiac output were greater in the low-HbA1c versus the high-HbA1c group (P < 0.05). In addition, all indices of pulmonary function were higher in the low-HbA1c group (P < 0.05). Finally, within the subjects with diabetes, there was a weak inverse correlation between HbA1c and exercise training volume (r2 = -0.352) and stroke volume (r2 = -0.339). These data suggest that highly trained individuals with type I diabetes can achieve the same cardiopulmonary exercise responses as trained subjects without diabetes, but these responses are reduced by poor glycemic control.

Impaired lung diffusing capacity for nitric oxide and alveolar-capillary membrane conductance results in oxygen desaturation during exercise in patients with cystic fibrosis.

BACKGROUND Exercise has been shown to be beneficial for patients with cystic fibrosis (CF), but for some CF patients there is a risk of desaturation, although the predicting factors are not conclusive or reliable. We sought to determine the relationship between the diffusion capacity of the lungs for nitric oxide and carbon monoxide (DLNO and DLCO) and the components of DLCO: alveolar-capillary membrane conductance (D(M)), and pulmonary capillary blood volume (V(C)) on peripheral oxygen saturation (SaO(2)) at rest and during exercise in CF. METHODS 17 mild/moderate CF patients and 17 healthy subjects were recruited (age=26±7 vs. 23±8 years, ht=169±8 vs. 166±8 cm, wt=65±9 vs. 59±8 kg, BMI=23±3 vs. 22±3 kg/m(2), VO(2PEAK)=101±36 vs. 55±25%pred., FEV(1)=92±22 vs. 68±25%pred., for healthy and CF, respectively, mean±SD, VO(2PEAK) and FEV(1) p<0.001). Subjects performed incremental cycle ergometry to exhaustion with continuous monitoring of SaO(2) and measures of DLNO, DLCO, D(M) and V(C) at each stage. RESULTS CF patients had a lower SaO(2) at rest and peak exercise (rest=98±1 vs. 96±1%, peak=97±2 vs. 93±5%, for healthy and CF, respectively, p<0.01). At rest, DLNO, DLCO, D(M) were significantly lower in the CF group (p<0.01). The difference between groups was augmented with exercise (DLNO=117±4 vs. 73±3ml/min/mmHg; DLCO=34±8 vs. 23±8ml/min/mmHg; D(M)=50±1 vs. 34±1, p<0.001, for healthy and CF respectively). Peak SaO(2) was related to resting DLNO in CF patients (r=0.65, p=0.003). CONCLUSIONS These results suggest a limitation in exercise-mediated increases in membrane conductance in CF which may contribute to a drop in SaO(2) and that resting DLNO can account for a large portion of the variability in SaO(2).

Effects of an inhaled β2-agonist on cardiovascular function and sympathetic activity in healthy subjects.

Study Objective. To determine the effect of a short‐acting, inhaled β2‐adrenergic receptor agonist, albuterol sulfate, administered by nebulization, on cardiovascular function and sympathetic activity in healthy individuals.

Genetic variation of αENaC influences lung diffusion during exercise in humans.

Exercise, decompensated heart failure, and exposure to high altitude have been shown to cause symptoms of pulmonary edema in some, but not all, subjects, suggesting a genetic component to this response. Epithelial Na(+) Channels (ENaC) regulate Na(+) and fluid reabsorption in the alveolar airspace in the lung. An increase in number and/or activity of ENaC has been shown to increase lung fluid clearance. Previous work has demonstrated common functional genetic variants of the α-subunit of ENaC, including an A→T substitution at amino acid 663 (αA663T). We sought to determine the influence of the T663 variant of αENaC on lung diffusion at rest and at peak exercise in healthy humans. Thirty healthy subjects were recruited for study and grouped according to their SCNN1A genotype [n=17 vs. 13, age=25±7 years vs. 30±10 years, BMI=23±4 kg/m(2) vs. 25±4 kg/m(2), V(O2 peak) = 95±30%pred. vs. 100±31%pred., mean±SD, for AA (homozygous for αA663) vs. AT/TT groups (at least one αT663), respectively]. Measures of the diffusing capacity of the lungs for carbon monoxide (DL(CO)), the diffusing capacity of the lungs for nitric oxide (DL(NO)), alveolar volume (V(A)), and alveolar-capillary membrane conductance (D(M)) were taken at rest and at peak exercise. Subjects expressing the AA polymorphism of ENaC showed a significantly greater percent increase in DL(CO) and DL(NO), and a significantly greater decrease in systemic vascular resistance from rest to peak exercise than those with the AT/TT variant (DL(CO)=51±12% vs. 36±17%, DL(NO)=51±24% vs. 32±25%, SVR=-67±3 vs. -50±8%, p<0.05). The AA ENaC group also tended to have a greater percent increase in DL(CO)/VA from rest to peak exercise, although this did not reach statistical significance (49±26% vs. 33±26%, p=0.08). These results demonstrate that genetic variation of the α-subunit of ENaC at amino acid 663 influences lung diffusion at peak exercise in healthy humans, suggesting differences in alveolar Na(+) and, therefore, fluid handling. These findings could be important in determining who may be susceptible to pulmonary edema in response to various clinical or environmental conditions.

Genetic variation of the alpha subunit of the epithelial Na + channel influences exhaled Na + in healthy humans

Epithelial Na(+) channels (ENaC) are located in alveolar cells and are important in β(2)-adrenergic receptor-mediated lung fluid clearance through the removal of Na(+) from the alveolar airspace. Previous work has demonstrated that genetic variation of the alpha subunit of ENaC at amino acid 663 is important in channel function: cells with the genotype resulting in alanine at amino acid 663 (A663) demonstrate attenuated function when compared to genotypes with at least one allele encoding threonine (T663, AT/TT). We sought to determine the influence of genetic variation at position 663 of ENaC on exhaled Na(+) in healthy humans. Exhaled Na(+) was measured in 18 AA and 13 AT/TT subjects (age=27±8 years vs. 30±10 years; ht.=174±12 cm vs. 171±10 cm; wt.=68±12 kg vs. 73±14 kg; BMI=22±3 kg/m(2) vs. 25±4 kg/m(2), mean±SD, for AA and AT/TT, respectively). Measurements were made at baseline and at 30, 60 and 90 min following the administration of a nebulized β(2)-agonist (albuterol sulfate, 2.5 mg diluted in 3 ml normal saline). The AA group had a higher baseline level of exhaled Na(+) and a greater response to β(2)-agonist stimulation (baseline=3.1±1.8 mmol/l vs. 2.3±1.5 mmol/l; 30 min-post=2.1±0.7 mmol/l vs. 2.2±0.8 mmol/l; 60 min-post=2.0±0.5 mmol/l vs. 2.3±1.0 mmol/l; 90 min-post=1.8±0.8 mmol/l vs. 2.6±1.5 mmol/l, mean±SD, for AA and AT/TT, respectively, p<0.05). The results are consistent with the notion that genetic variation of ENaC influences β(2)-adrenergic receptor stimulated Na(+) clearance in the lungs, as there was a significant reduction in exhaled Na(+) over time in the AA group.

Variability in Measures of Exhaled Breath Na + , Influence of Pulmonary Blood Flow and Salivary Na +

The assessment of inflammatory markers and ions in exhaled breath condensate (EBC) is being utilized more frequently in diseases such as asthma and cystic fibrosis with marked variability in EBC measures, including those of exhaled Na+. We sought to determine if variability in exhaled Na+ was due to differences in pulmonary blood flow (PBF) or Na+ in the mouth (salivary Na+). We measured exhaled Na+ three times with coinciding sampling of salivary Na+ and assessment of PBF (using acetylene rebreathing) in 13 healthy subjects (54% female, age = 27 ± 7 yrs., ht. = 172 ± 10 cm, wt. = 70 ± 21 kg, BMI = 22 ± 7 kg/m2 mean ± SD). Exhaled Na+ averaged 2.7 ± 1.2 mmol/l, and salivary Na+ averaged 5.51 ± 4.58 mmol/l. The coefficients of variation across all three measures in all 13 subjects averaged 30% for exhaled Na+ and 83% for salivary Na+, within subjects the variability across the three measures averaged 30% for exhaled Na+ and 38% for salivary Na+. Across all three measures in all 13 subjects the relationship between PBF and exhaled Na+ averaged 0.027 (P = 0.87), and the relationship between salivary Na+ and exhaled Na+ concentrations averaged 0.59 (P = 0.001). Also, we sought to determine the relationship between exhaled Na+ and serum Na+ in an addition 20 subjects. There was a moderate and significant relationship between serum Na+ and exhaled Na+ (r = 0.37, P = 0.04). These findings suggest there that the variability in exhaled Na+ is caused, at least in part, by droplet formation from within the mouth as turbulent air passes through and that there is a flux of ions from the pulmonary blood into the airways.

Exhaled Breath Condensate Detects Baseline Reductions in Chloride and Increases in Response to Albuterol in Cystic Fibrosis Patients

Impaired ion regulation and dehydration is the primary pathophysiology in cystic fibrosis (CF) lung disease. A potential application of exhaled breath condensate (EBC) collection is to assess airway surface liquid ionic composition at baseline and in response to pharmacological therapy in CF. Our aims were to determine if EBC could detect differences in ion regulation between CF and healthy and measure the effect of the albuterol on EBC ions in these populations. Baseline EBC Cl−, DLCO and SpO2 were lower in CF (n = 16) compared to healthy participants (n = 16). EBC Cl− increased in CF subjects, while there was no change in DLCO or membrane conductance, but a decrease in pulmonary-capillary blood volume in both groups following albuterol. This resulted in an improvement in diffusion at the alveolar-capillary unit, and removal of the baseline difference in SpO2 by 90-minutes in CF subjects. These results demonstrate that EBC detects differences in ion regulation between healthy and CF individuals, and that albuterol mediates increases in Cl− in CF, suggesting that the benefits of albuterol extend beyond simple bronchodilation.