Mechanisms of exercise limitation in patients with chronic hypersensitivity pneumonitis

Olívia Meira Dias, Bruno Guedes Baldi, Jeferson George Ferreira, Letícia Zumpano Cardenas, Francesca Pennati, Caterina Salito, Carlos Roberto Ribeiro Carvalho, Andrea Aliverti, André Luis Pereira de Albuquerque, Olívia Meira Dias, Bruno Guedes Baldi, Jeferson George Ferreira, Letícia Zumpano Cardenas, Francesca Pennati, Caterina Salito, Carlos Roberto Ribeiro Carvalho, Andrea Aliverti, André Luis Pereira de Albuquerque

Abstract

Small airway and interstitial pulmonary involvements are prominent in chronic hypersensitivity pneumonitis (cHP). However, their roles on exercise limitation and the relationship with functional lung tests have not been studied in detail. Our aim was to evaluate exercise performance and its determinants in cHP. We evaluated maximal cardiopulmonary exercise testing performance in 28 cHP patients (forced vital capacity 57±17% pred) and 18 healthy controls during cycling. Patients had reduced exercise performance with lower peak oxygen production (16.6 (12.3-19.98) mL·kg-1·min-1versus 25.1 (16.9-32.0), p=0.003), diminished breathing reserve (% maximal voluntary ventilation) (12 (6.4-34.8)% versus 41 (32.7-50.8)%, p<0.001) and hyperventilation (minute ventilation/carbon dioxide production slope 37±5 versus 31±4, p<0.001). All patients presented oxygen desaturation and augmented Borg dyspnoea scores (8 (5-10) versus 4 (1-7), p=0.004). The prevalence of dynamic hyperinflation was found in only 18% of patients. When comparing cHP patients with normal and low peak oxygen production (<84% pred, lower limit of normal), the latter exhibited a higher minute ventilation/carbon dioxide production slope (39±5.0 versus 34±3.6, p=0.004), lower tidal volume (0.84 (0.78-0.90) L versus 1.15 (0.97-1.67) L, p=0.002), and poorer physical functioning score on the Short form-36 health survey. Receiver operating characteristic curve analysis showed that reduced lung volumes (forced vital capacity %, total lung capacity % and diffusing capacity of the lung for carbon dioxide %) were high predictors of poor exercise capacity. Reduced exercise capacity was prevalent in patients because of ventilatory limitation and not due to dynamic hyperinflation. Reduced lung volumes were reliable predictors of lower performance during exercise.

Conflict of interest statement

Conflict of interest: Carlos Roberto Ribeiro Carvalho reports personal fees from Boehringer Ingelheim, outside the submitted work.

Figures

FIGURE 1
FIGURE 1
Study recruitment protocol. cHP: chronic hypersensitivity pneumonitis; DLCO: diffusing capacity of the lung for carbon monoxide; FVC: forced vital capacity.
FIGURE 2
FIGURE 2
a) Minute ventilation (V′E), b) tidal volume (VT) and c) dyspnoea (Borg score) paired to workload during an incremental cycle exercise test in patients with chronic hypersensitivity pneumonitis (cHP) compared to age-matched healthy controls. V′E and dyspnoea intensity were higher in cHP patients at any given work rate, whereas VT was higher in controls at free wheel (FW), 40 W and peak exercise. Dyspnoea scores were higher in cHP patients, although this difference was not significant. Data are presented as mean±sem. *: p<0.05, **: p<0.005 for cHP patients versus controls.
FIGURE 3
FIGURE 3
Receiver operating characteristic curve for a) forced vital capacity (% predicted), b) total lung capacity (% predicted) and c) diffusing capacity of the lung for carbon dioxide (% predicted) for predicting normal exercise capacity in chronic hypersensitivity patients. AUC: area under the curve.

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