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Unexplained exertional intolerance associated with impaired systemic oxygen extraction.

Kathryn H Melamed1, Mário Santos2,3, Rudolf K F Oliveira4

  • 1Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, University of California at Los Angeles, 10833 Le Conte Avenue, 43-229 CHS, Los Angeles, CA, 90095, USA. kmelamed@mednet.ucla.edu.

European Journal of Applied Physiology
|September 8, 2019
PubMed
Summary

Abnormal systemic oxygen extraction (SOE) is a key cause of exertional intolerance in some patients. This limitation stems from muscle mitochondria, microcirculation, or hyperventilation, impacting oxygen use during exercise.

Keywords:
Cardiopulmonary exercise testingChronic fatigue syndromeExertional intoleranceHyperventilationPoor systemic oxygen extraction

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Area of Science:

  • Cardiopulmonary medicine
  • Exercise physiology

Background:

  • Exertional intolerance is often attributed to cardiopulmonary issues, neglecting peripheral factors.
  • Systemic oxygen extraction (SOE) plays a crucial role in exercise capacity.

Purpose of the Study:

  • To investigate the hypothesis that abnormal SOE is the predominant cause of exercise limitation in a subset of patients.
  • To identify the prevalence and characteristics of patients with SOE-limited exertional intolerance.

Main Methods:

  • Review of invasive cardiopulmonary exercise test (iCPET) data from 313 patients with unexplained exertional intolerance.
  • Definition of poor SOE as peak (Ca-vO2)/[Hb] ≤ 0.8 and VO2max < 80% predicted, excluding cardiac/pulmonary mechanical limits.
  • Categorization of normal subjects into hyperventilators (HV) and non-hyperventilators (NL) based on PaCO2 levels.

Main Results:

  • Impaired SOE was identified as the sole cause of exertional intolerance in 12.5% of patients.
  • Patients with poor SOE and HV exhibited less acidemic blood (higher pHa) due to relative hypocapnia compared to NL.
  • A subset of poor SOE patients showed alkalemia, normal PvO2, and increased SvO2 at peak exercise.

Conclusions:

  • A distinct cohort of patients experiences exercise limitation solely due to impaired SOE.
  • Potential underlying causes include skeletal muscle mitochondrial abnormalities, limb muscle microcirculatory dysregulation, or hyperventilation.
  • Hyperventilation can lead to a leftward shift in the oxyhemoglobin dissociation curve, further impairing oxygen delivery.