Principi Fisiopatologici Paolo Palange FERS Sapienza University Rome

Principi Fisiopatologici Paolo Palange, FERS Sapienza University Rome, Italy

N Engl J Med 2002

Gulati M, N Engl J Med 2005

V’O 2 at rest and during exercise CO 2

Fctors limiting exercise tolerange Depletion of energy stores (Glycogen, CP) Accumulation of fatigue metabolites (H+, H 2 PO 4 -) Perception of symptoms limitation (Dyspnoea, Muscle)

Cardio-pulmonary Exercise Testing (CPET)

CPET: history

V’O 2 = (FIO 2 x V’I) – (FEO 2 x V’ E) V’CO 2 = (FECO 2 x V’ E) – (FICO 2 x V’ I)

V’E, RR, Vt, V’O 2, V’CO 2, Pet. CO 2, HR, ECG WATT BP Sp. O 2 BR, V’E/MVV, IC, V’O 2/Kg, V’O 2@AT, METS, V’E/V’CO 2, V’E/V’O 2, V’O 2/HR, HRR,

Eur Respir J 1997

Eur Respir J 1997

O 2 CO 2 MUSCOLO ADP ATP Polmone V’O 2=VE*(FIO 2 -FEO 2) CO 2 V’O 2=DO 2 (Pc. O 2 –Pmit. O 2) Cuore V’O 2=Q*(Ca. O 2 -Cv. O 2)

Metabolic Pathways for Energy Production

V’O 2–W relationship V’O 2 peak * 10 ml V’O 2/min/watt

V’O 2 kinetics during moderate CWR exercise Training Aging

Maximal Incremental Test LT VCP

Linearity of Oxygen Uptake with Work Rate Increases

Aerobic Anaerobic C 6 H 10 O 5 + H 2 O 12, 3*(C 6 H 10 O 5 + H 2 O) 37 ATP 6 O 2 37 ATP ØO 2 W 24, 6 La- 6 CO 2 16 CO 2 anaerobic: aerobic > 2, 5: 1

Alveolar ventilation and Pa. CO 2 = Set Point 863 * V’CO 2 V’A Metabolic demand 863 * V’CO 2 V’E * (1 -VD/VT) Gas exchange efficiency

“CO 2 output” CO 2 V’E CO 2 V’A Lung gas exchange efficiency (VD/VT) O 2 V’CO 2 Q’CO 2 transport + CO 2 stores Muscle energetics + Buffers

Ventilatory demand (V’E/V’CO 2) Sun XG, AJRCCM 2002

Ventilatory efficiency (V’E/VCO 2)

The Fick Principle Mass conservation (O 2) in a closed circuit . . “O 2 extraction” VO 2 = QT x C(a-v)O 2 (SV x HR) “O 2 delivery”

. VO 2= QT (SV X HR) x C(a-v)O 2 m 5 5 L/min EXERCISE INTENSITY OXYGEN PULSE Cardiovascular Adjustments CARDIAC OUTPUT EXERCISE INTENSITY OXYGEN UPTAKE m . VO 2/HR

Dyspnea and Exercise limitation in COPD K. Wasserman Lung Diseases V/Q mismatch VD/VT PAO 2 p. H ventilatory requirement Work of breathing ß ATP ß Lactate Ý V’CO 2 Muscle Fatigue airflow obstruction elastic recoil ventilatory capacity Dyspnea and Exercise Limitation V’E max = FEV 1 x 40

Dyspnea and Exercise limitation in COPD K. Wasserman Lung Diseases V/Q mismatch VD/VT PAO 2 p. H ventilatory requirement Work of breathing ß ATP ß Lactate Ý V’CO 2 Muscle Fatigue airflow obstruction elastic recoil ventilatory capacity Dyspnea and Exercise Limitation

Dyspnea and Exercise limitation in COPD K. Wasserman Lung Diseases V/Q mismatch VD/VT PAO 2 p. H ventilatory requirement Work of breathing ß ATP ß Lactate Ý V’CO 2 Muscle Fatigue airflow obstruction elastic recoil ventilatory capacity Dyspnea and Exercise Limitation

COPD FEV 1 = 0. 75 L

Exercise in patients with primary pulmonary hypertension (PPH) Sun XG, Circulation 2001

CPET in patients with primary pulmonary hypertension (IPH) Sun XG, Circulation 2001

Eur Respir J 2007

Eur Respir J 2007 HI CWR endurance TLIM

Eur Respir J 2007

Thanks P. Palange