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We conclude that arm training reduces the VO2 and VE cost of UAE and UAEX, possibly through improved synchronization and coordination of accessory muscle action during unsupported arm activity.

During arm elevation, normal individuals predominantly recruit the diaphragm, whereas chronic obstructive pulmonary disease (COPD) patients use more the accessory inspiratory and abdominal expiratory muscles. To test that arm elevation is useful to study the ventilatory muscle response in COPD, and to define the factors that determine this response, we studied 34 patients (FEV1 0.95 +/- 0.08 L) during 2 min of arm elevation. Transnasal balloons were used to determine end-inspiratory and end-expiratory gastric (Pg), pleural (Ppl) and transdiaphragmatic (Pdi) pressures. The slope of delta Pg/delta Ppl (= Pgi - Pge/Ppli - Pple) was used to infer respiratory muscle recruitment. With linear regression, the delta Pg/delta Ppl during arm elevation significantly correlated with resting delta Pg/delta Ppl (r = 0.68), hyperinflation (FRC/TLC, r = 0.52), and diaphragmatic tension time index (TTIdi) (r = 0.47). With multiple regression, resting delta Pg/delta Ppl, percentage predicted FRC (FRC %pred) and TTIdi influenced delta Pg/delta Ppl during arm elevation (r = 0.84). Over the 2 min of arm elevation, the dependency upon resting breathing pattern decreased, while hyperinflation and TTIdi became increasingly important. Higher resting TTIdi values were associated with a faster and shallower breathing pattern (f/VT > or = 38) during arm elevation. We conclude that the pattern of respiratory muscle recruitment during arm elevation depends primarily on the resting breathing pattern. Over 2 min, the degree of hyperinflation and the force reserve of the diaphragm increasingly impact on the ability to recruit the diaphragm. Measurement of f/VT during arm elevation is useful to determine functional reserve of the diaphragm in severe COPD.

Transtracheally administered gases decrease inspired minute ventilation in both dogs and humans. To test if this is associated with a decrease in the oxygen cost of breathing and to evaluate subsequent changes in the breathing pattern, we studied five patients with chronic respiratory diseases while they spontaneously breathed air and different flows of tracheally administered gases. In a blinded crossover design, the gas consisted of either oxygen or air at 2, 4, and 6 L/min. Oxygen cost of breathing was estimated by the calculation of pleural pressure-time index (PPTI). The pattern of breathing was evaluated utilizing the tension time index for the diaphragm (TTdi). There were significant decreases in PPTI when the patients received 2, 4, and 6 L/min of transtracheal oxygen or air. TTdi also decreased as gas flow increased. This drop was significant at 6 L/min flow for both gases. We conclude that transtracheally administered gas reduces the oxygen cost of breathing. It also changes the respiratory pattern of the diaphragm to a less demanding pattern. This may offer an alternative form of treatment to rest overworked respiratory muscles.

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