Circulation, Vol 86, 909-918, Copyright © 1992 by American Heart Association
DM Mancini, D Henson, J LaManca and S Levine
BACKGROUND. Patients with heart failure (HF) frequently experience
exertional dyspnea. Using near-infrared spectroscopy, we have previously
demonstrated accessory respiratory muscle deoxygenation during exercise in
these patients by monitoring changes in light absorption at 760-800 nm.
METHODS AND RESULTS. To investigate whether low-frequency respiratory
muscle fatigue occurs, we performed supramaximal bilateral transcutaneous
phrenic nerve stimulation before and after maximal bicycle exercise in 10
patients with HF (age, 62 +/- 10 years; ejection fraction, 18 +/- 7%) and
six normal subjects (age, 50 +/- 8 years). Maximal rates of contraction and
relaxation, peak twitch tension, and maximal transdiaphragmatic pressure
(Pdi) were derived before and after exercise from analysis of six to 12
twitches obtained at functional residual capacity. Pdi, time in inspiration
(Ti), time per breath (TTOT), respiratory gases, ratings of perceived
dyspnea and fatigue, and 760-800 nm near-infrared spectroscopy absorbency
changes of the serratus anterior muscle were measured throughout exercise.
The tension time index (TTdi) of the diaphragm was derived. In both normal
and HF subjects, all parameters of diaphragmatic function (i.e., maximal
rates of contraction and relaxation, peak twitch tension, and maximal Pdi)
were unchanged before and after exercise. Mean Pdi was comparable at rest
(normal, 3.7 +/- 1; HF, 5.8 +/- 2.9 cm H2O; p = NS) but significantly
greater in patients with HF at peak exercise (normal, 12.1 +/- 3; HF, 18.3
+/- 6.6 cm H2O; p less than 0.05). Ti/TTOT of both groups was similar at
rest and throughout exercise. TTdi was significantly greater at rest
(normal, 0.01 +/- 0.01; HF, 0.03 +/- 0.02; p less than 0.05) and at peak
exercise (normal, 0.03 +/- 0.02; HF, 0.10 +/- 0.03; p less than 0.04) in
patients with HF. Significant accessory respiration muscle deoxygenation
was noted only in patients with HF (peak exercise; normal, -1 +/- 13; HF,
28 +/- 15 arbitrary units; p less than 0.01). Linear correlation analysis
was performed between ratings of perceived dyspnea and parameters of
pulmonary and diaphragmatic function. Significant correlations were
observed between ratings of perceived dyspnea and maximal inspiratory and
expiratory pressure, the TTdi of the diaphragm, near-infrared absorption
changes, and forced expiratory volume in 1 second (FEV1) (all r greater
than 0.5; p less than 0.05). Thus, respiratory muscle strength, work, and
oxygenation were significantly correlated with the degree of dyspnea.
CONCLUSIONS. We conclude that low-frequency diaphragmatic muscle fatigue
does not occur despite accessory respiratory muscle deoxygenation during
exercise in patients with HF. However, diaphragmatic work as assessed by
the TTdi is dramatically increased in patients with HF and approaches
levels previously shown to generate fatigue. The sensation of dyspnea
appears closely related to respiratory muscle function.
ARTICLES
Respiratory muscle function and dyspnea in patients with chronic congestive heart failure
Cardiovascular Section, Philadelphia Veterans Administration Medical Center, Pa.
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