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Tidal Flow-Volume Analysis of Ventilation During Exercise : A Useful Approach for Diagnosing the Mechanism of Ventilatory Limitation to Exercise During Cardiopulmonary Exercise Testing

Sanford Levine, MD, FCCP (Philadelphia, PA)
Author and Funding Information

Dr. Levine is Professor of Medicine, at MCP Hahneman University, Adjunct Professor of Medicine at the University of Pennsylvania School of Medicine, and Attending Physician in medicine at the Philadelphia VA Medical Center.

Correspondence to: Sanford Levine, MD, FCCP, Professor of Medicine, Department of Veterans Affairs Medical Center, University and Woodland Aves, Philadelphia, PA 19104; e-mail: sdlevine@mail.med.upenn.edu



Chest. 1999;116(2):277-278. doi:10.1378/chest.116.2.277
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At the present time, the diagnosis of a ventilatory limitation to exercise is based on the breathing reserve concept, ie, how close the peak exercise ventilation (Ve) approaches the maximum voluntary ventilation (MVV) or some estimate of the MVV (typically the FEV1 multiplied by 35 or 40). Therefore, a small or no breathing reserve indicates a Ve limitation to muscular exercise (Ve limit), whereas a large breathing reserve rules out a Ve limit. At a given intensity of external work, the four major causes of an increased Ve—and therefore, a decreased breathing reserve—are some combination of the following: (1) arterial hypoxemia; (2) arterial acidosis effected by increases in lactate concentration; (3) anxiety and phobias regarding exercise and/or sensations related to it; and (4) inefficiency in performing a particular type of exercise.1 Many investigators have demonstrated that the administration of supplemental oxygen during exercise will decrease Ve at a given exercise intensity and thereby increase the breathing reserve. Similarly, comprehensive pulmonary rehabilitation programs containing an exercise training component will decrease the arterial lactate concentration, anxiety, and inefficient limb muscle use at any given intensity of exercise, and thereby decrease the Ve and increase the breathing reserve at that exercise intensity. In summary, the major strength of the breathing reserve concept is its direct therapeutic applications, whereas a problem is that this analysis provides us no mechanistic insight into the physiologic mechanisms underlying a Ve limit.


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