Physiological and clinical relevance of exercise ventilatory efficiency in COPD

Exercise ventilation (V'_E) relative to carbon dioxide output (V'_CO ) is particularly relevant to patients limited by the respiratory system, e.g. those with chronic obstructive pulmonary disease (COPD). High V'_E-V'_CO (poor ventilatory efficiency) has been found to be a key physiological abnormality in symptomatic patients with largely preserved forced expiratory volume in 1 s (FEV₁). Establishing an association between high V'_E-V'_CO and exertional dyspnoea in mild COPD provides evidence that exercise intolerance is not a mere consequence of detraining. As the disease evolves, poor ventilatory efficiency might help explaining "out-of-proportion" breathlessness (to FEV₁ impairment). Regardless, disease severity, cardiocirculatory co-morbidities such as heart failure and pulmonary hypertension have been found to increase V'_E-V'_CO In fact, a high V'_E-V'_CO has been found to be a powerful predictor of poor outcome in lung resection surgery. Moreover, a high V'_E-V'_CO has added value to resting lung hyperinflation in predicting all-cause and respiratory mortality across the spectrum of COPD severity. Documenting improved ventilatory efficiency after lung transplantation and lung volume reduction surgery provides objective evidence of treatment efficacy. Considering the usefulness of exercise ventilatory efficiency in different clinical scenarios, the V'_E-V'_CO relationship should be valued in the interpretation of cardiopulmonary exercise tests in patients with mild-to-end-stage COPD.