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In 2020, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States excluding COVID-19, and its mortality burden has been rising since the 1980s. Smoking cessation, long-term oxygen therapy, noninvasive ventilation, and lung volume reduction surgery have had a beneficial effect on mortality; however, until recently, the effects of pharmacologic therapies on all-cause mortality have been unclear. Inhaled pharmacologic treatments for patients with COPD include combinations of long-acting muscarinic receptor antagonists (LAMAs), long-acting-β2-agonists (LABAs), and inhaled corticosteroids (ICS). The recent IMPACT and ETHOS clinical trials reported mortality benefits with ICS/LAMA/LABA triple therapy compared with LAMA/LABA dual therapy. In IMPACT, fluticasone furoate/umeclidinium/vilanterol therapy significantly reduced the risk of on-/off-treatment all-cause mortality vs umeclidinium/vilanterol (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=.042). The ETHOS trial found a reduction in the risk of on-/off-treatment all-cause mortality in patients treated with budesonide/glycopyrrolate/formoterol vs glycopyrrolate/formoterol (hazard ratio, 0.51 [0.33 to 0.80]; nominal P=.0035). Both trials included populations of patients with symptomatic COPD at high risk of future exacerbations, and a post hoc analysis of the final retrieved vital status data suggested that the observed mortality benefits are conferred by the ICS component. In conclusion, triple therapy reduces the risk of mortality in patients with symptomatic COPD characterized by moderate or severe airflow obstruction and a recent history of moderate or severe exacerbations. This benefit is likely to be driven by reductions in exacerbations. Future research efforts should focus on improving the long-term prognosis of patients living with COPD.

Biomarkers in COPD may be clinical (prior exacerbation history), physiologic (FEV1), or blood based (eosinophil count or fibrinogen level). Recent interest in using biomarkers to predict response to therapy in clinical practice has emerged. The benefits of inhaled therapy depend on the correct use of the inhaler, including an appropriate inspiratory flow. Of the available delivery systems, dry powder inhalers are unique because they have an internal resistance, are breath actuated, and are flow dependent. Ideally, the user inhales “forcefully” to generate turbulent energy (determined by an individual’s inspiratory flow and the resistance of the device) within the device that disaggregates the powder so that the individual inhales the medication particles into the lower respiratory tract. Because of specific features of dry powder inhalers and the required optimal inspiratory flow, an unmet need exists to identify individuals who are likely or unlikely to benefit from dry powder medications. Peak inspiratory flow, defined as the maximum airflow generated during inhalation against the simulated resistance of a dry powder inhaler, is a physiologic measure that has biological plausibility, has good test characteristics (repeatability and reliability), and is generalizable. Current evidence supports peak inspiratory flow as a predictive therapeutic biomarker to optimize therapy in both outpatients with COPD as well as those hospitalized for an exacerbation before discharge. This approach is consistent with the precepts of precision medicine, which considers differences in a person’s biological features, exposure, and lifestyle to prevent and treat disease.

Introduction. Many patients with chronic obstructive pulmonary disease (COPD) may derive inadequate benefit from dry powder inhalers (DPIs) because of suboptimal peak inspiratory flow (sPIF). Objectives. To assess the clinical burden of COPD by characterizing the clinical characteristics of participants with sPIF against medium-low resistance DPIs versus those with optimal PIF (oPIF) from two phase 3 clinical trials. Methods. Baseline data were collected from two randomized, controlled, phase 3 trials (NCT03095456; NCT02518139) in participants with moderate-to-severe COPD. oPIF (60 L/min) against the medium-low resistance DPIs was used as the threshold for defining the PIF subgroups (<60 L/min (sPIF) vs ≥60 L/min (oPIF)). Results. Most participants included in this analysis were White (92%) and male (63%); the mean (range) age was 65 (43–87) years. Participants with sPIF had significantly greater dyspnea than those with oPIF as measured using the modified Medical Research Council scoring (mean (95% CI): 2.1 (2.0–2.2) vs 1.6 (1.4–1.7); P <0.001) and baseline dyspnea index (mean (95% CI): 5.1 (4.9–5.4) vs 6.1 (5.8–6.3); P <0.001). Based on COPD Assessment Test scores, participants with sPIF had a higher COPD symptom burden than those with oPIF (mean (95% CI): 21.5 (19.7–23.3) vs 19.5 (18.6–20.4); P=0.05). Conclusion. In these trials, participants with COPD who had sPIF against the medium-low resistance DPIs had more dyspnea and worse health status than those with oPIF. These results demonstrate that sPIF is associated with a higher clinical burden as measured by patient-reported outcomes.

Peak inspiratory flow (PIF) has been proposed as a measure to assess a patient’s ability to use dry powder inhalers (DPIs). However, robust quality criteria to determine a repeatability limit for measuring PIF are lacking.

Dyspnea is due to an imbalance between the demand to breatheand the ability to breathe. The prevalence is ∼30% for those 65 years or older with walking on a level surface or up an incline. Dyspnea is a strong predictor of mortality in elderly individuals. Anemia, cardiovascular disease, deconditioning, psychological disorders, and respiratory diseases are common causes of dyspnea. Initial treatments to relieve breathing discomfort should be directed toward improving the pathophysiology of the underlying disease. Simple and inexpensive strategies to relieve dyspnea are available. This article provides an update on the evaluation of chronic dyspnea in elderly individuals.

Nebulizers are commonly employed for inhaled drug delivery. As they deliver medication through aerosol generation, clarification is needed on what constitutes safe aerosol delivery in infectious respiratory disease settings. The coronavirus disease 2019 pandemic highlighted the importance of understanding the safety and potential risks of aerosol-generating procedures. However, evidence supporting the increased risk of disease transmission with nebulized treatments is inconclusive, and inconsistent guidelines and differing opinions have left uncertainty regarding their use. Many clinicians opt for alternative devices, but this practice could negatively impact outcomes, especially for patients who may not derive full treatment benefit from hand-held inhalers. Therefore, it is prudent to develop strategies that can be used during nebulized treatment to minimize the emission of fugitive aerosols, these comprising bioaerosols exhaled by infected individuals and medical aerosols generated by the device that may also be contaminated. This is particularly relevant for patient care in the context of a highly transmissible virus. The COPD Foundation Nebulizer Consortium (CNC) was formed in 2020 to address uncertainties surrounding administration of nebulized medication. The CNC is an international, multidisciplinary collaboration of patient advocates, pulmonary physicians, critical care physicians, respiratory therapists, clinical scientists, and pharmacists from research centers, medical centers, professional societies, industry, and government agencies. The CNC developed this Expert Guidance to inform the safe use of nebulized therapies for patients and providers and to answer key questions surrounding medication delivery with nebulizers during pandemics or when exposure to common respiratory pathogens is anticipated. CNC members reviewed literature and guidelines regarding nebulization and developed two sets of guidance statements: one for the health care setting, and one for the home environment. Future studies need to explore the risk of disease transmission with fugitive aerosols associated with different nebulizer types in real patient-care situations and to evaluate the effectiveness of mitigation strategies.

As guidelines and strategies for pharmacologic treatment of COPD focus on specific classes of inhaled medications, there is an unmet need for information to guide health care professionals (HCPs) for selecting an inhaled medication delivery system that matches the unique characteristics of individual patients. In this Special Feature article, we provide guidance for selecting an inhaled medication delivery system based on three “key” patient factors – cognitive function, manual dexterity/strength, and peak inspiratory flow (PIF). Additionally, information is provided about specific tests to assess these patient factors. Cognitive impairment with an estimated prevalence of 25% among patients with COPD adversely affects patients’ ability to use a handheld device correctly. To our knowledge, the prevalence of impaired manual dexterity/strength has not been reported in those with COPD. However, 79% of patients with COPD have reported one or more physical impediments that could impact their ability to manipulate an inhaler device. The measurement of PIF against the simulated resistance (r) of a dry powder inhaler (DPI) establishes whether the patient has the inhalation ability for creating optimal turbulent energy within the device. A suboptimal PIFr for low to medium-high resistance DPIs has been reported in 19% to 84% of stable out-patients with COPD. HCPs should consider cognitive function, manual dexterity/strength, and PIFr in their patients with COPD when prescribing inhaled pharmacotherapy. Impairments in these patient factors are common among those with COPD and can affect the individual’s competency and effectiveness of using inhaled medications delivered by handheld devices.

AbstractEffective treatment of dyspnea, or breathing difficulty, for patients with chronic obstructive pulmonary disease is a major unmet need. Five of six published randomized controlled trials show that acupuncture and/or applying transcutaneous electrical nerve stimulation over acupuncture points improves breathing difficulty in patients with chronic obstructive pulmonary disease. Acupuncture techniques may relieve the perception of dyspnea by three possible mechanisms: (1) activation of areas in the central nervous system where afferent signals are processed and integrated; (2) relaxation of bronchial smooth muscle; and (3) the release of neurotransmitters, such as endorphins, that modulate breathlessness. Adverse events of acupuncture reported in a national database in the United Kingdom include retained needles, dizziness, loss of consciousness/unresponsiveness, falls, bruising at the needle site, and pneumothorax. Caution is advised before needles are placed into the chest of an individual who has chronic obstructive pulmonary disease because lung hyperinflation and low chest wall fat may increase the risk of a pneumothorax. Transcutaneous electrical nerve stimulation at acupuncture points is an alternative noninvasive approach to insertion of needles into the chest. Clinical uncertainties need to be addressed in prospective clinical trials to further understand the potential role of acupuncture techniques in relieving the distressing symptom of dyspnea.

Although patients may find it difficult to describe their breathing discomfort, most are able to select statements among a list to describe their experience. The primary objective of this study was to examine sensitivity and specificity of descriptors of breathing discomfort prospectively in patients with common respiratory conditions as well as those patients who had refractory dyspnea.

Dyspnea is the most prevalent symptom among patients with cardiac and respiratory diseases. It is an independent predictor of mortality in patients with heart disease, COPD, and the elderly. Studies using naloxone to block opioid-receptor signaling demonstrate that endogenous opioids modulate dyspnea in patients with COPD. Neuroimaging studies support a cortical-limbic network for dyspnea perception. A 2012 American Thoracic Society statement recommended that dyspnea be considered across three different constructs: sensory (intensity), affective (distress), and impact on daily activities. The 2013 GOLD (Global Initiative for Chronic Obstructive Lung Disease) executive summary recommended a treatment paradigm for patients with COPD based on the modified Medical Research Council dyspnea score. The intensity and quality of dyspnea during exercise in patients with COPD is influenced by the time to onset of critical mechanical volume constraints that are ultimately dictated by the magnitude of resting inspiratory capacity. Long-acting bronchodilators, either singly or in combination, provide sustained bronchodilation and lung deflation that contribute to relief of dyspnea in those with COPD. Opioid medications reduce breathing discomfort by decreasing respiratory drive (and associated corollary discharge), altering central perception, and/or decreasing anxiety. For individuals suffering from refractory dyspnea, a low dose of an opioid is recommended initially, and then titrated to achieve the lowest effective dose based on patient ratings. Acupuncture, bronchoscopic volume reduction, and noninvasive open ventilation are experimental approaches shown to ameliorate dyspnea in patients with COPD, but require confirmatory evidence before clinical use.

BACKGROUND:Arformoterol tartrate (arformoterol, 15 μg bid) is a nebulized long-acting β2-agonist approved for maintenance treatment of COPD.

The use of inhaled corticosteroids (ICSs) is associated with an increased risk of pneumonia in patients with COPD. However, the risks of other respiratory infections, such as TB and influenza, remain unclear.

Whether the combination of a once-daily inhaled corticosteroid with a once-daily longacting β2agonist is more protective than a once-daily longacting β2agonist alone against exacerbations of chronic obstructive pulmonary disease (COPD) is unknown. We hypothesised that fluticasone furoate and vilanterol would prevent more exacerbations than would vilanterol alone.

Although opioid receptors are expressed broadly in the CNS and in peripheral sensory nerve endings including bronchioles and alveolar walls of the respiratory tract, it is unknown whether the modulatory effect of endogenous opioids on breathlessness occurs in the CNS or in the peripheral nervous system. The purpose of this investigation was to examine whether increased blood levels of β-endorphin modify breathlessness by a putative effect of binding to peripheral opioid receptors in the respiratory tract.

Patients with COPD exhibit greater oxyhemoglobin desaturation during walking than with cycling. The purpose of this investigation was to investigate differences in ventilatory responses and gas exchange as proposed mechanisms for this observation.

To review the mechanisms for the perception of dyspnea and to consider the plausibility of interventions that palliate dyspnea after optimal treatment of the underlying disease.

This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea.

Although questionnaires are used frequently with patients to self-report the severity of dyspnea as related to activities of daily living, the reliability of these instruments has not been established. The two purposes of this study were to examine the test-retest reliability of three widely used dyspnea instruments and to compare dyspnea scores at different stages of disease.

Although the cycle ergometer is the traditional mode for exercise testing in patients with respiratory disease, this preference over the treadmill does not consider perceptual responses. Our hypotheses were as follows: (1) the regression slope between breathlessness and oxygen consumption (o2) is greater on the treadmill than on the cycle ergometer; and (2) the regression slope between leg discomfort and o2is greater on the cycle ergometer than on the treadmill.

Scales and questionnaires have been used for nearly 50 years in an effort to quantify the severity of dyspnea as experienced by patients with chronic respiratory disease. These instruments have been used for grading the severity of breathlessness (discriminative purpose), predicting outcomes such as survival, and assessing the efficacy of a treatment (evaluative purpose). Two distinct approaches have been used for patients to report the severity of breathlessness. Questionnaires are used in order to grade the impact of activities of daily living on dyspnea; and patients can use the 0 - 10 Category-Ratio scale or a visual analog scale to report the intensity of dsypnea at selected work loads or time periods during an exercise test. Recently, these standard methods have been modified to enhance the quality and utility of patientreported ratings of breathlessness. The Baseline and Transition Dyspnea Indexes have been converted into selfadministered computerized versions; the dyspnea component of the Chronic Respiratory Questionnaire has been converted from an interview-based format into a self-reported version containing individualized activities. In addition, a computerized method has been developed whereby the patient provides continuous ratings of breathlessness throughout exercise using a computer mouse to adjust the length of a bar located next to the 0 -10 Category-Ratio scale. These modifications of traditional instruments have greatly improved the measurement of the intensity of breathlessness in patients with chronic respiratory disease.

Background:Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

Background:The purpose of the study was to examine the responsiveness of a computerized system whereby the patient reports spontaneously any change in the intensity of breathlessness during exercise. The hypotheses were that hypercapnia would increase and hyperoxia would decrease the slope of power production-breathlessness ratings compared with a control condition during cycle ergometry.

To examine the effect of fluticasone propionate, 250 μg/salmeterol, 50 μg combination (FSC 250/50) twice daily on lung hyperinflation and associated measures of exercise performance in patients with COPD.

The Baseline (BDI) and Transition (TDI) Dyspnea Indexes provide interview-based measurements of breathlessness related to activities of daily living. The BDI is a discriminative instrument that includes specific criteria for each of three components at a single point in time.The TDI is an evaluative instrument that includes specific criteria for each of three components to measure changes from a baseline state.Observational studies have shown that patients with COPD generally experience a gradual progression of breathing difficulty as measured by the TDI over time. Randomized controlled trials have demonstrated excellent measurement characteristics of the TDI; these include responsiveness (ability to detect change) and construct validity (a change in the TDI correlates with changes in other variables). Supporting evidence for one unit as the minimal clinically important difference (MCID) of the TDI is based on: expert preference; use of the physician's global evaluation score as an anchor; and distribution estimates (standard error of measurement and 0.5 of the standard deviation). As an alternative to the interview process, self-administered computerized (SAC) versions of the BDI/TDI have been developed to provide direct patient-reported ratings of dyspnea. To further establish the MCID of the interview-administered and/or the SAC TDI, we recommend that a patient's report of global ratings of change by used as an independent standard or anchor.

The major clinical outcomes measured in evaluating the responses to pharmacotherapy in patients with chronic obstructive pulmonary disease (COPD) include the severity of dyspnea, exercise capacity, exacerbations, and health status. Various studies have demonstrated that testing for acute bronchodilator reversibility in the pulmonary function laboratory does not predict the clinical responses to a trial of bronchodilator therapy in patients with COPD. Separate studies have shown that inhaled albuterol, both a single dose (300 μg) and 2 weeks of therapy (200 μg/4×/day), reduces dyspnea. There is more published information available about the effects of long-acting (≥12 hours' duration of action) inhaled β2-agonists because of greater interest in considering clinical outcomes at the time of drug testing. In one randomized clinical trial, formoterol reduced symptoms (as recorded in a home diary) and improved health status. Nine clinical studies have examined the effects of salmeterol on clinical outcomes. Salmeterol reduced the perception of breathlessness (in 6 of 9 studies) and improved health status (in 3 of 4 studies). These results collectively demonstrate that long-acting inhaled β2-agonists not only relax bronchial smooth muscle but also provide important clinical benefits in symptomatic patients with COPD. (J Allergy Clin Immunol 2002;110:S298-303.)

Chronic lung disease (CLD) and any consequent disease-related muscle myopathy along with deconditioning can cause both dyspnea and/or leg discomfort during exertion. These unpleasant experiences frequently lead an individual to reduce or even eliminate daily tasks which adversely impacts quality of life for the individual. The primary goal of exercise training is to restore the individual patient to the highest possible level of independent function. Improvements in exertional breathlessness observed following an exercise training program may be due to a physiologic training effect, enhanced mechanical efficiency, and/or psychologic desensitization. Any symptomatic patient with CLD who is motivated to participate should be referred to a pulmonary rehabilitation program. Exercise prescription is based on the principle of “overload” training. Although there is no optimal or best training regimen established for patients with CLD, we provide general guidelines for the mode, frequency, intensity, and duration of exercise training. The recommended minimalintensity of exercise training is 50 of peak work rate, although exercise at “maximal limits tolerated by symptoms” may also be prescribed. The recommended minimalduration of training is 20 to 30 minutes of continuous exertion. Resistance training should be incorporated into a comprehensive exercise program. One approach for patients with CLD to monitor their training intensity is to use a “dyspnea target” as a guide for intensity of training effort.

Patients with COPD often require multiple therapies to improve lung function and decrease symptoms and exacerbations. Salmeterol and theophylline are indicated for the treatment of COPD, but the use of these agents in combination has not been extensively studied.

A continuous method for recording changes in breathlessness (dyspnea) during exercise is introduced and compared with the traditional discrete method. Instudy 1, a category-rating scale was presented on a computer screen, and 14 healthy, young female subjects exercised on a cycle ergometer until exhaustion. Two approaches were used to obtain ratings of breathlessness: a discrete method, in which subjects gave single judgments every minute, and a continuous method, in which subjects throughout exercise moved the mouse so that a bar on the screen extended to the desired location along the scale. Psychophysical results relating measures of breathlessness and the variables of work, oxygen consumption, and minute ventilation were statistically indistinguishable with the two methods, and both methods were highly reliable across test sessions. In study 2, both measurement methods were employed, and the subjects were 14 healthy, young males. In each of two sessions (discrete or continuous method), subjects first rated their breathlessness during an incremental test in which the workload was increased over time and levels of work, and minute ventilation were recorded. Subjects then exercised for 10 min at 60% of the maximal oxygen consumption achieved during the incremental test. At two points during steady-state exercise, a respiratory load was introduced that lasted for 1 min. It was possible to determine the responsiveness of subjects to onset and offset of the respiratory load for the continuous method but not for the discrete method. Instudy 3, patients with chronic obstuctive pulmonary disease employed both methods, and it was found that the continuous method was better at determining whether subjects showed a significant positive slope of the regression line between breathlessness ratings and physiological variables.

The traditional approach of caring for patients with chronic respiratory disease has been to rely on pulmonary function tests to quantify the severity and to assess response to therapy. However, patients with respiratory conditions seek medical attention because of symptoms, particularly dyspnea, and impaired ability to function, which clearly impact on an individual's health-related quality of life (HRQOL). Accordingly, instruments have been developed to provide a standardized method to measure health status and levels of impairment. One of the major reasons for measuring HRQOL is to detect how much HRQOL has changed in response to therapy (an evaluative instrument). A minimum clinically significant change has been established for some HRQOL instruments in order to indicate the relative value of any measured change and to guide the interpretation as to whether the change is “clinically meaningful.” Selected studies using disease-specific instruments have demonstrated that β2-agonist, anticholinergic, and theophylline medications can improve HRQOL, as compared with placebo therapy.

To examine and compare the efficacy and safety of salmeterol xinafoate, a long-acting inhaledβ 2-adrenergic agonist, with inhaled ipratropium bromide and inhaled placebo in patients with COPD.

We studied the acute effects of one hour of passive cigarette smoking on the lung function and airway reactivity of nine young adult asthmatic volunteers. At the time of this study, the subjects were asymptomatic and had normal or nearly normal lung function. Passive smoking produced no change in expiratory flow rates. However, there was a small decreasein nonspecific bronchial reactivity, as assessed by methacholine inhalation challenge testing (p=0.022). Pharmacologically active substances present in cigarette smoke, such as nicotine, may explain the observed change in airway reactivity. Although the finding of decreased airway reactivity might suggest that passive smoking produces a “protective” effect on the underlying asthma, the observed change in reactivity was slight and of uncertain clinical significance. We conclude that passive smoking presents no acute respiratory risk to young asymptomatic asthmatic patients.

MAHLER, DONALD A., ERNEST D. MORITZ, and JACOB LOKE. Exercise performance in marathon runners with airway obstruction. Med. Sci. Sports Exercise,Vol. 13, No. 5, pp. 284–289. 1981. While evaluating lung function prior to four longdistance races (20–100 km), we found that nine of 127 marathon runners (7. 1) had airway obstruction (mean FEV1/EVC, FVC 63.3). Since obstruction to air flow may limit exercise performance, we compared selected cardiorespiratory parameters during exercise on a cycle ergometer in runners with airway obstruction (RAO), nine non-athletic control subjects (CON), and nine marathon runners with normal lung function (RNL). As the chemical drive to breathe affects exercise byperpnea, the ventilatory responses to hypercapnia and hypoxia were measured. All HAO were males with a mean age of 35.6 yr (range of 20–44 yr). Eight of nine RAO had a significant increase in flow rates after inhalation of isoproterenol. In the HAO and CON groups exercise ventilation was similar when oxygen consumption (Vo2) was less than 2.0 1/ min; as Vo2exceeded this level, significantly greater ventilation was required by the HAO, Carbon dioxide production was highest in RAO, intermediate in CON. and lowest in HNL. There was no significant difference in the mean ventilatory responses among CON, HAO, and HNL. Despite pulmonary dysfunction, the HAO achieved moderate-to-high levels of exercise performance

To investigate the ability of patients with COPD to reproduce an exercise intensity accurately on the treadmill using dyspnea ratings obtained during incremental exercise on the cycle ergometer (cross-modal exercise prescription).

Exertional dyspnea is an very common problem and contributes to a sedentary life style. The history should focus on descriptive characteristics of dyspnea (onset, frequency, intensity, duration, triggers, or provoking activities, and what, if anything, relieves breathing difficulty), positional influences, other respiratory symptoms, as well as information on cigarette smoking and occupation. The physical examination is most helpful in excluding certain diagnoses (negative predictive value) rather than predicting a specific condition. Laboratory testing is essential to establish a diagnosis for chronic dyspnea. Specific tests should be ordered in a logical sequence based on whether the health-care provider suspects respiratory or cardiac disease. If the patient's history and physical examination do not provide any clues to the probable etiology for breathlessness, spirometry, chest radiograph, electrocardiogram, and oximetry are recommended as initial screening tests. Cardiopulmonary exercise testing can be performed to simulate activities that cause dyspnea in order to differentiate respiratory and cardiac limitation, to evaluate de-conditioning, to determine exercise-induced oxygen desaturation, and to diagnose psychogenic breathlessness. Specific examples of various causes of chronic dyspnea are presented to illustrate approaches for diagnostic testing.

The purpose of this study was to determine whether dyspnea ratings would be similar during submaximal (as used for training) and incremental (as used in testing) exercise at specific intensities in patients with chronic obstructive pulmonary disease (COPD).

To investigate the short-term effects of inhaled salmeterol on the perception of dyspnea and lung function in patients with COPD

MAHLER, DONALD A., BRUCE E. ANDREA, and DONALD C. ANDRESEN. Comparison of 6-min “all-out” and incremental exercise tests in elite oarsmen. Med, Sci. Sports Exerc., Vol. 16, No. 6, pp. 567–571, 1984. A high aerobic capacity is an important criterion for rowing success. Two exercise protocols, the 6-min “all-out” (6M-AO) and progressive incremental (PI) tests, have been used to evaluate physiological performance in rowers and to select team members. We measured heart rate (HR), minute ventilation (VE), oxygen consumption (VO2), and carbon dioxide production (VCO2) every 30 s, and obtained ratings of perceived exertion (RPE) from 12 candidates for the 1983 United States Men's Lightweight Rowing Team. Testing was randomized and each oarsman performed a different test on the rowing ergometer on consecutive days. For the group, age was 23 ± 2 yr (mean ± SD), height was 183 ± 3 cm, and weight was 72.2 ± 1.4 kg. Peak physiological values were achieved in the first 2 min of exercise for the 6M-AO test, but in the last 2 min for the PI test. There were no statistically significant differences among peak values for HR, VE, VO2, VCO2, and RPE with each test. The peak ventilatory equivalent for oxygen (VE/VO2) was also similar. The onset of anaerobic metabolism was observed at 83 ± 4 of peak VO2during the PI test, while anaerobic metabolism has been shown to occur within the first minute of the 6M-AO test. We conclude that physiological values at peak exercise were similar for the 6M-AO and PI tests. Because the onset of anaerobic metabolism can only be determined by noninvasive means using the PI test, this method of testing is preferable for the physiological assessment of rowing performance. The results can be used to assist the coach in selecting team members and in establishing an individual training program.

MAHLER, D. A. and A. HARVER. Prediction of peak oxygen consumption in obstructive airway disease. Med. Sci. Sports Exerc., Vol. 20, No. 6, pp. 574–578, 1988. The hypothesis of this study was that non-exercise variables can be used to reliably predict peak oxygen consumption (O2) in patients with obstructive airway disease (OAD). We also evaluated the impact of symptoms on exercise capacity. Selected predictor variables included age, lung function, respiratory muscle strength, gas exchange, and the Baseline Dyspnea Index (BDI). In 40 patients peak O2was 19.9 ± 8.7 (mean ± SD) ml·kg-1min-1during progressive, incremental exercise until limited by symptoms on a cycle ergometer. Multiple regression analysis yielded three significant predictors: forced expiratory volume in one second (FEV1), age, and BDI. Peak O2(ml·kg-1·min-1) = 5.5 (FEV1)-0.3 (age) 0.8 (BDI) 19.3 (R2= 0.79; SEE: 4.2 ml·kg-1min-1). Comparisons between patients who stopped exercise because of breathlessness (N= 14) and those who stopped because of leg fatigue (N= 18) showed that lung function, inspiratory muscle strength, and peak O2were significantly reduced in the former group compared to the latter. Peak exercise ventilation (E)/MW ratio was similar in the breathless (95.3 ± 23.8) and leg fatigue (86.8 ± 20.3) groups, but peak heart rate (HR)/pred. HRmaxratio was significantly higher in the leg fatigue group (86.8 ± 12.6) than in the breathless group (75.1 ± 8.6) (P= 0.006). We conclude that lung function, age, and the clinical rating of breathlessness reliably predict peak O2in patients with symptomatic OAD. Moreover, peak exercise performance in OAD appears to be affected by different physiological factors which may be distinguished by the major symptom limiting exercise.

The purpose of this investigation was to evaluate the cardiovascular responses to rowing. In the first part of the study, heart rate (HR) and cardiac output (Q) were measured at rest and at three steady-state exercise levels on the variable-resistance rowing ergometer in 10 female and 11 male subjects. was determined non-invasively by the equilibration method of CO2re-breathing, and stroke volume (SV) was calculated. Subjects varied in rowing ability from healthy, inexperienced rowers to competitive athletes. The linear relationships between and oxygen consumption for the women (r = 0.57; P< 0.001; slope = 5.2 ± 1.1) (mean ± SD) and the men (r = 0.58; P< 0.001; slope = 6.1 ± 1.4) were similar to published values for other types of upright exercises. For both men and women, SV increased from rest to the first level of exercise, and then reached a plateau at or before the second exercise intensity. Between the second and third levels of exercise, SV decreased significantly in the female subjects (107 ± 18 vs 94 ± 16 ml; P< 0.05), but not in the male subjects (128 ± 1 I vs 126 ± 15 ml; P= not statistically significant). In the second part of the study, HR, , and SV were compared on the cycle and rowing ergometers on successive days in eight additional subjects. At similar levels of oxygen consumption and , HR was significantly higher, and SV was significantly lower during rowing exercise than with cycle exercise. These results demonstrate that the cardiovascular responses to rowing are different from upright cycle exercise. There was a greater reliance upon the increase in HR than the SV response to increase during rowing than during cycling.

We describe the scientific basis for evaluating the biomechanics and associated physiological requirements of exercise performance in elite national rowers. Computer-assisted analysis of high-speed cinematography has demonstrated that efficiency in rowing is related to the relative proximity between peak force and the perpendicular position of the oar. Physiological testing has indicated that near maximal levels of oxygen consumption are required during "all out" rowing, involving both aerobic and anaerobic metabolism. Serial testing has been performed on elite oarsmen throughout the year in order to evaluate the individual benefits of a training program and to establish guidelines for future training. Successful application of the scientific analysis of rowing performance requires that the athlete, coach, and investigator work closely together in an effort to increase the average velocity of the boat.(JAMA 1984;252:496-499)