慢性阻塞性肺疾病患者通气有效性与运动后心脏功能的关系

doi:10.3969/j.issn.1006-9771.2021.07.013

摘要/Abstract

摘要：

目的观察通气有效性对慢性阻塞性肺疾病(COPD)患者运动后心脏功能的影响。

方法 2019年1月至2020年12月,广东省人民医院门诊COPD患者190例行症状限制性递增功率踏车运动测试,记录患者一般情况、既往病史和用药史、肺通气功能与心肺运动测试参数,根据踏车运动后第1分钟心率下降是否> 12次,将患者分为正常组和延迟组。

结果延迟组共89例(46.84%)。与正常组相比,延迟组年龄更高(Z = 2.282, P < 0.05),第一秒用力呼气容积占预测值百分比(Z = 3.626, P < 0.001)、最大功率(t = 5.547, P < 0.001)、剩余呼吸储备(t = 2.122, P < 0.05)下降,通气有效性曲线最低值(VE/VCO_2nadir)明显升高(Z = 3.296, P = 0.001)。Logistic回归分析显示,气道阻塞严重程度分级、VE/VCO_2nadir、剩余呼吸储备与心率恢复延迟相关;校正性别、年龄、体质量指数和气道阻塞严重程度分级后,VE/VCO_2nadir是心率恢复延迟的独立危险因素(OR = 1.203, 95%CI 1.032~1.873, P < 0.01),最佳预测界值为33.15 (AUC = 0.6387, 95%CI 0.5595~0.7178, P = 0.001)。

结论 COPD患者通气有效性障碍增加运动后心率恢复延迟的风险。

关键词: 慢性阻塞性肺疾病, 心肺运动测试, 心率恢复, 通气有效性

Abstract:

Objective To observe the relationship of ventilatory efficiency to cardiac function, especially heart rate recovery after exercise for patients with chronic obstructive pulmonary disease (COPD).

Methods From January, 2019 to December, 2020, 190 patients with COPD were recruited for Cardiopulmonary Exercise Testing. The general condition, medical history and medication history, lung function test and parameters of Cardiopulmonary Exercise Testing were recorded. They were divided into normal group and delay group according to whether the heart rate decline more than twelve beats within a minute after Cardiopulmonary Exercise Testing.

Results There were 89 patients (46.84%) in the delay group. Compared with the normal group, the delay group were older (Z = 2.282, P < 0.05), with less ratio of force exiratory volume in the first second in prediction (FEV_1.0%) (Z = 3.626, P < 0.001), maximum power (t = 5.547, P < 0.001), breath reserve (BR) (t = 2.122, P < 0.05) and higher minimum ventilation equivalent of carbon dioxide (VE/VCO_2nadir) (Z = 3.296, P = 0.001). Logistic regression showed that the COPD severity, VE/VCO_2nadir and BR correlated with heart rate recovery. After adjusting for gender, age, body mass index and COPD severity, VE/VCO_2nadir was an independent risk factor for delayed heart rate recovery (OR = 1.203, 95%CI 1.032 to 1.873, P = 0.004), and the best cut-off point was 33.15 (AUC = 0.6387, 95%CI 0.5595 to 0.7178, P = 0.001).

Conclusion The ventilatory inefficiency may increase the risk of abnormal heart rate recovery after exercise in COPD patients.

Key words: chronic obstructive pulmonary disease, Cardiopulmonary Exercise Testing, heart rate recovery, ventilatory efficiency

中图分类号:

R562.2

曾斌,刘亚康,王龙平,张鸣生. 慢性阻塞性肺疾病患者通气有效性与运动后心脏功能的关系[J]. 《中国康复理论与实践》, 2021, 27(7): 812-818.

ZENG Bin,LIU Ya-kang,WANG Long-ping,ZHANG Ming-sheng. Relationship of Ventilatory Efficiency to Cardiac Function after Exercise in Patients with Chronic Obstructive Pulmonary Disease[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2021, 27(7): 812-818.

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参考文献 32

[1]	JOLLY M A, BRENNAN D M, CHO L, et al. Impact of exercise on heart rate recovery[J]. Circulation, 2011, 124(14):1520-1526. doi: 10.1161/CIRCULATIONAHA.110.005009
[2]	王磊, 高真真, 潘化平, 等. 个体化有氧运动对冠心病患者心率恢复及运动能力的影响[J]. 中国康复医学杂志, 2015, 30(3):242-246.
	WANG L, GAO Z Z, PAN H P, et al. Effects of individual aerobic exercise on heart rate recovery and exercise capacity in patients with coronary heart disease[J]. Chin J Rehabil Med, 2015, 30(3):242-246.
[3]	VAN DE VEGTE Y J, TEGEGNE B S, VERWEIJ N, et al. Genetics and the heart rate response to exercise[J]. Cell Molecul Life Sci, 2019, 76(12):2391-2409.
[4]	CRISAFULLI E, VIGNA M, IELPO A, et al. Heart rate recovery is associated with ventilatory constraints and excess ventilation during exercise in patients with chronic obstructive pulmonary disease[J]. Eur J Prev Cardiol, 2018, 25(15):1667-1674. doi: 10.1177/2047487318789756
[5]	LIU H J, GUO J, ZHAO Q H, et al. Chronotropic incompetence and its relation to exercise intolerance in chronic obstructive pulmonary disease[J]. Am J Med Sci, 2017, 353(3):216-223. doi: 10.1016/j.amjms.2016.12.015
[6]	DA SILVA GONCALVES BOS D, VAN DER BRUGGEN C E E, KURAKULA K, et al. Contribution of impaired parasympathetic activity to right ventricular dysfunction and pulmonary vascular remodeling in pulmonary arterial hypertension[J]. Circulation, 2018, 137(9):910-924. doi: 10.1161/CIRCULATIONAHA.117.027451
[7]	ELBEHAIRY A F, CIAVAGLIA C E, WEBB K A, et al. Pulmonary gas exchange abnormalities in mild chronic obstructive pulmonary disease. Implications for dyspnea and exercise intolerance[J]. Am J Respir Crit Care Med, 2015, 191(12):1384-1394. doi: 10.1164/rccm.201501-0157OC
[8]	中国康复医学会循证康复医学工作委员会, 中国康复研究中心/中国康复科学所康复信息研究所, 兰州大学循证医学中心, 等. 慢性阻塞性肺疾病临床康复循证实践指南[J]. 中国康复理论与实践, 2021, 27(1):15-26.
	Evidence-based Rehabilitation Committee, Chinese Association of Rehabilitation Medicine; Research Institute of Rehabilitation Information, China Rehabilitation Research Center/China Rehabilitation Sciences Institute; Evidence-based Medicine Center, Lanzhou University; et al. Evidence-based Practice Guidelines for Clinical Rehabilitation of Chronic Obstructive Pulmonary Disease[J]. Chin J Rehabil Theory Pract, 2021, 27(1):15-26.
[9]	邱卓英, 张爱民. «国际功能、残疾和健康分类»应用指导(一)[J]. 中国康复理论与实践, 2003, 9(1):20-34.
	QIU Z Y, ZHANG A M. Chin J Rehabil Theory Pract, 2003, 9(01):20-34.
[10]	林小锋, 刘泽, 董凤英, 等. 心率恢复在心血管疾病康复中的应用及研究进展[J]. 中华物理医学与康复杂志. 2013, 35(6):498-500.
	LIN X F, LIU Z, DONG F Y, et al. Application and research progress of heart rate recovery in cardiovascular disease rehabilitation[J]. Chin J Phys Med Rehabil, 2013, 35(6):498-500.
[11]	LAUER M S. Heart rate recovery: coming back full-circle to the baroreceptor reflex[J]. Circ Res, 2016, 119(5):582-583. doi: 10.1161/CIRCRESAHA.116.309392
[12]	袁玮, 聂姗, 贾楠, 等. 运动康复对经皮冠状动脉介入术后急性冠状动脉综合征患者的效果[J]. 中国康复理论与实践, 2021, 27(2):208-215.
	YUAN W, NIE S, JIA N, et al. Effect of exercise-based cardiac rehabilitation on patients with acute coronary syndrome after percutaneous coronary intervention[J]. Chin J Rehabil Theory Pract, 2021, 27(2):208-215.
[13]	CARNETHON M R, STERNFELD B, LIU K, et al. Correlates of heart rate recovery over 20 years in a healthy population sample[J]. Med Sci Sport Exerc, 2012, 44(2):273-279. doi: 10.1249/MSS.0b013e31822cb190
[14]	张红霞, 原杰, 柳洁, 等. 代谢综合征患者运动试验后心率恢复异常与心外膜脂肪体积的相关性[J]. 中华糖尿病杂志, 2012, 4(11):666-670.
	ZHANG H X, YUAN J, LIU J, et al. Association of blunted heart rate recovery with epicardial fat volume in patients with metabolic syndrome[J]. Chin J Diabet Mellit, 2012, 4(11):666-670.
[15]	ABBOTT T E F, MINTO G, LEE A M, et al. Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients[J]. Br J Anaesth, 2017, 119(1):87-94. doi: 10.1093/bja/aex164
[16]	CAHALIN L P, ARENA R, LABATE V, et al. Predictors of abnormal heart rate recovery in patients with heart failure reduced and preserved ejection fraction[J]. Eur J Prev Cardiol, 2014, 21(7):906-914. doi: 10.1177/2047487313475892
[17]	李艳芳, 牛青英, 王俊莉. 个体化有氧运动对高龄冠心病患者心功能、心率恢复及生活质量的影响[J]. 中华物理医学与康复杂志, 2016, 38(1):39-42.
	LI Y F, NIU Q Y, WANG J L, et al. Aerobic exercise, cardiac function, heart rate recovery and the quality of life of elderly heart disease patients[J]. Chin J Phys Med Rehabil, 2016, 38(1):39-42.
[18]	CRISAFULLI E, SCELFO C, TZANI P, et al. Asymptomatic peripheral artery disease can limit maximal exercise capacity in chronic obstructive pulmonary disease patients regardless of airflow obstruction and lung hyperinflation[J]. Eur J Prev Cardiol, 2017, 24(9):990-999. doi: 10.1177/2047487317695629
[19]	DELGADO-ORTIZ L, ARBILLAGA-ETXARRI A, RODRIGUEZ-CHIARADIA D A, et al. Physical activity and cardiac autonomic dysfunction in patients with chronic obstructive pulmonary disease: a cross-sectional analysis[J]. [ahead of print]. Ann Phys Rehabil Med, 2021. doi: 10.1016/j.rehab.2021.101501.
[20]	KARJALAINEN J J, KIVINIEMI A M, HAUTALA A J, et al. Determinants and prognostic value of cardiovascular autonomic function in coronary artery disease patients with and without type 2 diabetes[J]. Diabet Care, 2014, 37(1):286-294. doi: 10.2337/dc13-1072
[21]	壮可, 赵燕, 张云梅, 等. 射血分数保留心力衰竭患者心率恢复与运动耐量及预后的关系[J]. 中华心力衰竭和心肌病杂志, 2019, 3(3):129-133.
	ZHUANG K, ZHAO Y, ZHANG Y M, et al. The association with exercise capacity and the prognostic value of heart rate recovery in patients with heart failure with preserved ejection fraction[J]. Chin J Heart Fail Cardiomyopathy, 2019, 3(3):129-133.
[22]	WU C, GUO J, LIU H, et al. The correlation of decreased heart rate recovery and chronotropic incompetence with exercise capacity in idiopathic pulmonary arterial hypertension patients[J]. BioMed Res Int, 2017, 2017:3415401.
[23]	杨国玲, 陈杨, 郭健, 等. 心率恢复评估系统性红斑狼疮相关肺动脉高压女性患者疾病严重程度的价值[J]. 国际呼吸杂志, 2017, 37(5):361-368.
	YANG G L, CHEN Y, GUO J, et al. Heart rate recovery evaluates the severity of pulmonary arterial hypertension due to systemic lupus erythematosus in women patients[J]. Int J Respir, 2017, 37(5):361-368.
[24]	PRASAD V K, HAND G A, SUI X, et al. Association of exercise heart rate response and incidence of hypertension in men[J]. Mayo Clin Proc, 2014, 89(8):1101-1107. doi: 10.1016/j.mayocp.2014.04.022
[25]	HAJDUSEK P, KOTRC M, KAUTZNER J, et al. Heart rate response to exercise in heart failure patients: the prognostic role of metabolic-chronotropic relation and heart rate recovery[J]. Int J Cardiol, 2017, 228:588-593. doi: 10.1016/j.ijcard.2016.11.083
[26]	MANETOS C, DIMOPOULOS S, TZANIS G, et al. Skeletal muscle microcirculatory abnormalities are associated with exercise intolerance, ventilatory inefficiency, and impaired autonomic control in heart failure[J]. J Heart Lung Transplant, 2011, 30(12):1403-1408. doi: 10.1016/j.healun.2011.08.020
[27]	NEDER J A, BERTON D C, ARBEX F F, et al. Physiological and clinical relevance of exercise ventilatory efficiency in COPD[J]. Eur Respir J, 2017, 49(3):1602036. doi: 10.1183/13993003.02036-2016
[28]	朱世立, 谢友红, 黄玮, 等. 个体化适度运动改善肺动脉高压患者心肺功能的效果[J]. 中国康复理论与实践, 2020, 26(4):479-486.
	ZHU S L, XIE Y H, HUANG W, et al. Effect of individualized moderate-intensity exercise prescription on cardiopulmonary function for patients with pulmonary arterial hypertension[J]. Chin J Rehabil Theory Pract, 2020, 26(4):479-486.
[29]	WARD S A. Commentary on "Mechanism of augmented exercise hyperpnea in chronic heart failure and dead space loading" by Poon and Tin[J]. Respir Phys Neurobiol, 2013, 189(1):203-210.
[30]	VAN GESTEL A J, STEIER J. Autonomic dysfunction in patients with chronic obstructive pulmonary disease (COPD)[J]. J Thorac Dis, 2010, 2(4):215-222.
[31]	CHERNEVA R V, YOUROUKOVA V M, CHERNEVA Z V. Dynamic hyperinflation, chronotropic intolerance and abnormal heart rate recovery in non-severe chronic obstructive pulmonary disease patients-reflections in the mirror[J]. [ahead of print]. Pulmonology, 2021. doi: 10.1016/j.pulmoe.2020.12.004.
[32]	BARRON A, DHUTIA N, MAYET J, et al. Test-retest repeatability of cardiopulmonary exercise test variables in patients with cardiac or respiratory disease[J]. Eur J Prev Cardiol, 2014, 21(4):445-453. doi: 10.1177/2047487313518474

项目	所有患者(n = 190)	正常组(n = 101)	延迟组(n = 89)	χ²/Z/t值^a	P值^a
男性(n)	126	71	55	1.530	0.216
年龄(岁)	69(61,74)	67(60,72)	70(63,77)	2.282	0.023
BMI(kg/m²)	21.69±3.03	22.02±2.87	21.33±3.18	1.579	0.116
持续吸烟(n)	38	18	20	0.639	0.424
高血压病(n)	85	45	40	0.003	0.957
糖尿病(n)	19	11	8	0.190	0.663
FVC(L)	2.48(2.04,3.09)	2.63(2.24,3.26)	2.28(1.88,2.83)	2.993	0.003
FVC%pre(%)	78.10(64.36,85.70)	80.11(68.77,91.60)	76.32(61.80,83.90)	2.915	0.004
FEV₁(L)	1.32(0.98,1.64)	1.43(1.06,1.92)	1.09(0.82,1.47)	4.538	< 0.001
FEV₁%pre(%)	52.50(38.69,68.90)	61.35(41.50,73.52)	46.80(36.00,61.10)	3.626	< 0.001
FEV₁/FVC(%)	56.91(43.60,63.53)	60.51(49.21,64.85)	52.05(39.72,60.88)	3.596	<0.001
气道阻塞严重程度分级(Ⅰ/Ⅱ/Ⅲ/Ⅳ级,n)	27/82/64/17	22/45/27/7	5/37/37/10	12.870	0.005
使用糖皮质激素(n)	92	48	44	0.069	0.792
使用β受体激动剂(n)	137	68	69	2.448	0.118
使用M受体抑制剂(n)	89	42	47	2.839	0.092
使用β受体抑制剂(n)	32	18	14	0.148	0.701
使用钙离子拮抗剂(n)	26	11	15	1.424	0.233

参数	所有患者(n = 190)	正常组(n = 101)	延迟组(n = 89)	χ²/Z/t值^a	P值^a
W_max(W)	81.80±29.76	92.25±26.24	69.94±29.19	5.547	< 0.001
W_max%pre (%)	67.00(52.70,92.00)	76.53(60.00,94.08)	62.20(43.00,81.90)	3.933	< 0.001
VO_2max(L/min)	1.14(0.92,1.41)	1.27(1.11,1.57)	1.00(0.82,1.19)	5.983	< 0.001
VO_2max%pre (%)	70.25±23.40	75.36±20.50	64.46±25.20	5.451	< 0.001
VO_2max@kg〔L/(min·kg)〕	18.00(15.00,21.00)	20.00(17.00,23.50)	16.00(13.00,19.00)	5.436	< 0.001
VE_max(L/min)	41.25(32.70,50.60)	44.70(37.00,54.25)	36.45(28.50,46.30)	4.490	< 0.001
BR (L/min)	11.40±16.99	13.80±18.79	8.69±14.31	2.122	0.035
BRexh (n)	111(58.42%)	52(51.49%)	59(66.29%)	4.270	0.039
VD/VT	0.24(0.21,0.27)	0.23(0.20,0.26)	0.25(0.22,0.28)	2.831	0.005
VE/VCO_2slop	28.98(25.21,32.94)	28.62(25.18,32.08)	29.33(25.24,34.09)	0.393	0.695
VE/VCO_2nadir	31.75(28.20,35.40)	29.90(27.25,33.90)	33.20(29.20,36.90)	3.296	0.001
HR-0 (/min)	129.91±21.10	136.04±20.26	122.96±19.98	4.471	< 0.001
HR-1 (/min)	118.03±19.45	116.64±19.66	119.61±19.20	1.053	0.293
HRR_d (/min)	11.88±10.08	19.41±6.89	3.35±5.04	18.118	< 0.001

因素		单因素		多因素模型1		多因素模型2		多因素模型3
因素		P值	OR (95%CI)	P值	OR (95%CI)	P值	OR (95%CI)	P值	OR (95%CI)
性别		0.740	0.865 (0.367~2.037)	0.189	1.974 (0.716~5.438)	0.118	2.163 (0.823~5.686)	0.426	1.459 (0.576~3.695)
年龄		0.068	1.029 (0.998~1.060)	0.123	1.026 (0.993~1.059)	0.272	1.019 (0.985~1.053)	0.078	1.029 (0.997~1.062)
BMI		0.117	0.926 (0.841~1.019)	0.532	0.967 (0.870~1.075)	0.936	1.005 (0.898~1.123)	0.331	0.950 (0.858~1.053)
VD/VT		0.013	4604.187 (5.835~3632731.066)	0.142	493.912 (0.126~1935337.612)	—	—	—	—
VE/VCO_2nadir		0.001	1.101 (1.040~1.166)	—	—	0.004	1.203 (1.032~1.873)	—	—
BR		0.040	0.982 (0.965~0.999)	—	—			0.855	0.932 (0.436~1.991)
气道阻塞严重程度分级	整体	0.009	—	0.046	—	0.011		0.041
	Ⅰ	—	1.00	—	1.00	—	1.00	—	1.00
	Ⅱ	0.018	3.618 (1.248~10.484)	0.025	3.480 (1.170~10.351)	0.028	3.456 (1.144~10.443)	0.021	3.747 (1.215~11.554)
	Ⅲ	0.001	6.030 (2.026~17.941)	0.006	4.925 (1.581~15.338)	0.003	3.456 (1.144~10.443)	0.005	6.233 (1.731~22.438)
	Ⅳ	0.009	6.286 (1.598~24.727)	0.023	5.457 (1.268~23.492)	0.004	8.526 (1.969~36.925)	0.014	7.481 (1.504~37.208)