Nasal patency, aerobic capacity, and athletic performance MICHAEL S. BENNINGER, MD. J. R. SARPA, MD, TARIQ ANSARI, MD, and JOSEPH WARD, MD, Detroit,
Michigan The patency of the nasal airway may directly affect pulmonary ventilation, with obstruction and increased nasal resistance resulting in increased pulmonary resistance, hypoxia, and hypercapnea. Nine aerobic athletes were evaluated to assess the role of the nasal airway on aerobic capacity and athletic performance. A step-ladder graded maximal aerobic capacity test was performed under three test conditions: obstructed, decongested with oxymetazoline hydrochloride, and saline control. No differences in maximum V02, work load, oxygen saturation, maximal blood pressure, heart rate, or respiratory rate were noted between test conditions. Pre-exercise nasal resistance was lower in the decongested compared to control conditions, but no differences were found after exercise. Athletic performance was not influenced by nasal patenCy in this model. (OTOLARYNGOL HEAD NECK SURG 1992;107:101.)
T h e upper airways respond to the demands of exercise by increasing total airflow. This is accomplished by an increase in minute ventilation, bronchodilatation,' an increase in total laryngeal area,2and a reduction in nasal Even if larger fractions of air are transmitted by way of the oral route4-and most individuals breathe spontaneously through their mouths during exercise8-the nasal airway may play an important regulatory function for the upper airway. 1 . 3 . 9 Previous studies in both human beings and animals have shown a correlation between nasal obstruction and an increase in pulmonary resistance, hypercapnia, hypoxia,"." and sleep disturbances. I 2 Despite such observations, the role of the nasal airway in exercise capacity and athletic performance is not well understood. The purpose of this study was to evaluate the relationship of nasal airway patency on aerobic capacity and exercise workload under nasal occlusion, nasal decongestion, and control test conditions.
From the Departments of Otolaryngology-Head and Neck Surgery (Drs. Benninger and Sarpa) and Pulmonary Medicine (Drs. Ansari and Ward), Henry Ford Hospital. Presented at the Annual Meeting of the American Rhinologic Society, Waikoloa, Hawaii, May 9, 1991. Received for publication Nov. 12, 1991; accepted March 5 , 1992. Reprint requests: Michael S . Benninger, MD, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd.. Detroit, MI 48202. 23 I 1 I37645
METHODS AND MATERIAL
Nine trained athletes who exercised aerobically for at least 4 hours per week comprised the study group. Subjects were excluded if they had a history of persistent nasal obstruction, nasal trauma, previous nasal surgery, nasal allergic disorders, or had acute nasal-sinus symptoms at the time of testing. Anterior rhinoscopy was performed to rule out nasal pathology. One triathlete, two biathletes, three runners, one cyclist, one aerobic dance instructor, and one general aerobic fitness athlete composed the final group. There were two women and seven men. All subjects were evaluated under three test conditions-obstructed, decongested, and placebo controlwith the test order being determined by randomization tables (Table 1). All subjects served as their own controls. To ensure that test results were not affected by level of conditioning, all three tests were completed within a 3-week period and no two tests were performed on consecutive days. The congested test condition was simulated by taping the external nasal airway in a fashion that no air leak could occur, but no internal nasal pressure or mucosamucosa contact occurred. The tape was evaluated after exercise to verify complete occlusion throughout the study. Decongestion was achieved by spraying the nose with 0.05% oxymetazoline hydrochloride 15 minutes before exercise, with decongestion being verified by nasal plethysmography. Control conditions were achieved by spraying the nose with saline 15 minutes before exercise.
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
101
102
OtolaryngologyHead and Neck Surgery
BENNINGER et al.
Table 1. Test conditions Obstructed
Table 2. Mean results for test conditions Decongested
Nasal occlusion (tape) Nasal resistance Spirometry Oxymetazolrne hydrochloride Exercise Spirometry Nasal resistance Spirometry Exercise Spirometry Nasal resistance
Congested Decongested
Placebo control
Nasal resistance Placebo (saline) Spirometry Nasal resistance Exercise Spirometry Nasal resistance
Spirometry
The spirometry was performed on the Medgraphics system 1085 (Medgraphics, St. Paul, Minn.) according to the guidelines laid down by the American Thoracic Society (ATS). Expiratory flows were measured by a pneumotachograph after a forceful expiratory maneuver from total lung capacity (TLC). The forced expiratory volume in one second (FEV,), the forced vital capacity (FVC), and the forced expiratory$ow rates between 25% and 75% of vital capacity (FEF25-75) were derived from the flow volume curves produced by the integration of the flow signal from the pneumotachograph during at least three forced expiratory maneuvers. The actual values were selected from the three efforts according to the ATS guidelines. Airway Resistance
Nasal and total airway resistance (Raw) in cm H,O/L/sec and thoracic gas volume (TGV) were measured by the panting maneuver in the body plethysmography (Medgraphics 1085). The mean of at least five successive measurements were calculated. Specific airway resistance (sRaw) was calculated from the Raw and the TGV. Airway conductance (Gaw) and specific airway conductance (sGaw) were calculated as reciprocals of Raw and sRaw. Cardiopulmonary Exercise Testing The exercise testing was done on a Medgraphics cardiopulmonary system 2000 (Medgraphics, St. Paul, Minn.) linked to a Siemens-Elema bicycle Ergometer (Model 3803). Each subject was screened by a standard 12-lead EKG to rule out any resting EKG abnormalities. Standard instructions and explanations were provided to the subjects. The workload was incrementally graded-20 watts every minute. EKG, pulse oximeter, heart rate, and respiratory rate were monitored continuously during the test. The blood pressure was recorded at least once every minute. Exhaled gases and volumes were continuously measured by a gas analyzer (Medgraphics system 2000). Maximum O2 consumption
VO, (mlimin) Workload (watts) Heart rate (1 minute) Respiratory rate (1 minute) O2Saturation (%) Systolic BP (mm Hg)
2626 275 156 47 92 6 177
2639 268 148 45 91 9 180
Control
264 1 264 157 42 92 3 170
(VO,) was measured in ml/min. The subjects were instructed to keep pedalling at 60 rpm until they were unable to continue, at which time the test was terminated. Their reasons for quitting were noted. Statistical Analysis
To test for differences between the congested, decongestant, and control measurements, a repeated measures analysis of variance was done for maximum VO, workload, heart rate, and respiratory rate. For FEV, and FEF25-75, to test for differences between groups (congested, decongested, and control) and between the pre-exercise and post-exercise testing, a two-way analysis of variance with repeated measures on both factors was done. Similarly, in order to test .for group and time differences, a two-way analysis of variance with repeated measures on both factors was done for evaluation of nasal resistance. Statistical significance was achieved if a p value was less than 0.05.
RESULTS Mean results of V02,workload, heart rate, respiratory rate, O2 saturation, and maximal systolic blood pressure are listed in Table 2. There was no difference between groups with regards to VO, ( p = 0.986), workload ( p = 0.276), heart rate ( p = 0.661), or respiratory rate ( p = 0.199). Although the FEV, and FEF25-75 were noted to be similar between the three test conditions (Table 3), there was a difference between the pre-exercise and post-exercise results within each test condition. An increase in both FEV, ( p = 0.049) and FEF25-75 was noted post-exercise ( p = 0.003). The results of nasal resistance are noted in Table 4. There was no difference in nasal resistance between the decongestant and placebo control groups after exercise ( p = 0.550). There was, however, a decrease resistance after oxymetazoline in the pre-exercise evaluation in comparison to the resistance before oxymetazoline spray ( p = 0.007). No difference was noted in the preexercise resistance between the resting resistance and after saline nasal spray (0.1219).
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
Volume 107 Number 1 July 1992
Nasal potency, aerobic capacity, and athletic performance 103
Table 4. Nasal resistance (cm H,O/L/sec)
Table 3. Spirometry results ~
~
~
~
Congested
Decongested
Control
4 10 4 20
4 16 4 35
4 13
Decongested
Control
3.35 2.16 2.09 1.26
3.09
~~~~~~~~~~
FEV, (Iiters)
Pre-exercise Post-exercise FEF 25-75 (liters) Pre-exercise Post-exercise
4 39 5 00
4 26 4 94
4 24
1.84 1.25
4 33 4 81
DISCUSSION The nose provides a conduit for airflow for respiration and smell. It filters air, exchanges heat and water vapor, absorbs water soluble gases, and provides resistance to nasal airflow. l 3 The mechanical, tactile, and nociceptive sensation of the nasal mucosa is from the ophthalmic (V,) and maxillary (V,) divisions of the trigeminal nerve. Sympathetic fibers from the thoracic spinal cord and parasympathetic fibers from the superior salivatory nucleus reach the nose by complex pathways by way of the trigeminal nerve and regulate the secretory and vasomotor activities of the nose.6 Although the neurologic pathways of the rhinosinobronchial reflex have not been completely established, the vagal nerve is thought to be involved in the efferent pathway, which can result in changes in pulmonary resistance.6 Studies have shown that nasal obstruction can cause measurable increases in lower airway resistance, laryngeal resistance, increased PCO?, and decreased PO,.'o.'' Although these early studies have been q u e ~ t i o n e d ,it' ~ has been postulated that the nasal airway plays an important regulatory function for the upper a i ~ w a y ' .and ~.~ an effect of nasal patency in pulmonary function has been s h o ~ n . ~ . ' An . ' ~ inhibition of exercise-induced bronchoconstriction in asthmatic patients has occurred with nasal breathing, whereas bronchoconstriction recurred with mouth breathing.* Acute nasal obstruction has produced objective findings of disturbed sleep and obstructive airway events in normal subjects. I* Exercise results in decreased nasal resistance.'-' This response is primarily a result of reduced blood flow and blood content of the m u c o ~ a . 'It~ may be adaptive to allow improved ventilation or may be a result of redistribution of nasal blood to the muscles, heart, and skin.I5 Increased nasal ventilation does seem to occur and results in a secondary decrease in mucociliary transport. If nasal resistance plays an important role in the regulation of the upper airway and nasal occlusion adversely affects pulmonary function, it might be postulated that nasal obstruction may adversely affect athletic performance. This potential improvement was not j6
Pre-study Post oxymetazoline hydrochloride Post-exercise Pre-Post exercise difference
substantiated in this study. Neither workload nor VO, was different among the three test conditions. The purpose, therefore, of this exercise-induced decrease in nasal resistance is unknown. With increased work rates, airflow is diverted from the nasal to oral It is doubtful that the decrease in nasal resistance has a significant effect on total ventilation and overall respiratory mechanic^.^ The changes that occur, however, may play an important role in conditioning the air during exercise and over a wide range of ventilation The decongesting role of exercise itself in this study resulted in airway patency at the termination of activity comparable to that of previous decongestion with oxymetazoline hydrochloride followed by exercise. It might be expected, therefore, that no change in athletic performance would be detected between these two groups at the termination of a step-ladder, somewhatprolonged exercise activity. With shorter aerobic activities in which high-level workloads are achieved more quickly, the differences between these groups could potentially be seen favoring the previous decongested group. This, however, could not explain the lack of differences between the obstructed test and the other two test conditions in this study. It is difficult to extrapolate the results of this study to athletic competition. Some long distance aerobic athletes use decongesting nasal sprays for the perceived benefit of improved performance. With the critical importance of the psyche on performance, it is possible that such medications allow increased confidence that can affect performance in a positive fashion. Such hope for performance enhancement by pharmacologic means would be contrary to the fundamental principles of sport and sportsmanship and, therefore, should not be used for such purposes. Although oxymetazoline hydrochloride does not grossly appear to acutely change performance and has minimal associated risks, neosynephrine or oral decongestants may have a more significant benefit as a result of greater systemic effects but may also carry greater risks when used during exercise." This study used only subjects with normal nasal anatomy and physiology. Individuals with chronic nasal obstruction resulting from anatomic problems such as marked septa1 deviations or those with chronic func-
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
OtolaryngologyHead and Neck Surgery
104 BENNINGER et 01.
tional problems such as allergic or vasomotor rhinitis may be more disadvantaged than those with normal nasal function. Most rhinologic surgeons can relate anecdotal cases of athletes who espouse improved performance after septa1 surgery. It is difficult to objectively evaluate such results because level of conditioning can change dramatically over the penoperative time course. Much investigation would be needed to determine whether or not improvements in anatomic obstruction truly change athletic performance. Questions can be raised with regard to the accuracy of the VO, values found in this study because they are below normal, despite trained aerobic athletes as subjects, Three problems exist with regard to aerobic testing in this model. Bicycle VO, evaluations have lower values than those performed running. Toe clips were not used and an upright body position might also affect results. Despite all attempts, absolute mask seal could not be completely assured because of marked body movement at maximal workloads. Using each individual as his or her own control would seem to assist in allowing accuracy. Furthermore, not only were VO, levels not different, but workloads were also similar among test conditions, suggesting that athletic performance was not affected by the various test conditions. The purpose of this study was not to measure the specific changes in nasal resistance that occurred during exercise. Rhinomanometry or peak inspiratory flow rates’* would be preferred methods to plethysmography if more accurate values were required or if the findings were to be compared to others. Plethysmography was used because of its simplicity and convenience in our laboratory setting and for general assessments of resistance with the subjects acting as their own controls. All subjects were, in fact, found to have decreased nasal resistance after decongestion and after exercise when compared to pre-test conditions. Nonetheless, it is of interest that the post-exercise resistance under control and decongested test conditions were similar, verifying the magnitude of the decongestion that occurs with exercise. CONCLUSION
No differences were found in maximal aerobic oxygen consumption or workload with variations in nasal patency in trained aerobic athletes with no history of
nasal dysfunction. Nasal decongestants should not be used with the hopes of improved performance. Whether medical or surgical treatment might alter athletic performance in those with chronic nasal disorders should be further investigated. REFERENCES
1. Jackson RT. Nasal-cardiopulmonary reflexes: a role of the larynx. Ann Otol Rhinol Laryngol 1976;85:65-70. 2. Hurbis CG, Schild JA. Laryngeal changes during exercise and exercise-induced asthma. Ann Otol Rhinol Laryngol 1991;100:34-7. 3. Merty JS, McCaffrey TV, Kern EB. Role of the nasal airway in regulation of airway resistance during hypercapnea and exercise. OTOLARYNGOL HEADNECKSURC1982;92:302-7. 4. Forsythe RD, Cole P, Shephard RJ. Exercise and nasal patency. J Appl Physiol 1983;55:860-5. 5. Richerson HB, Seebohm PM. Nasal airway response to exercise. J Allergy 1968;41:269-84. 6. Raphael GD, Meredith SD, Baraniuk JN, Kaliner MA. Nasal reflexes. Am J Rhinol 1988;2:109-16. 7. Cole P. Forsyth R, Haight JSJ. Effects of cold air and exercise on nasal patency. Ann Otol Rhinol Laryngol 1983;92:196-8. 8. Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada IF. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Resp Dis 1978;118:6.5-73. 9. deWit G . The function of the nose in the aerodynamics of respiration. Rhinology 1978;11:59-67. 10. Ogura JH, Harvey JE. Nasopulmonary mechanics-experimental evidence of the influence of the upper airway upon the lower. Acta Otolaryngol 1971;71:123-32. 11. Ogura JH, Suemitsu M, Nelson JR, Kavamoto S . Relationship between pulmonary resistance and changes in arterial blood gas tension in dogs with nasal obstruction, and partial laryngeal obstruction. Ann Otol Rhinol Laryngol 1973;82:668-83. 12. Olson KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. OTOLARYNGOL HEAD NECKSURG1981;89:804-10. 13. Kimmelman CP. The problem of nasal obstruction. Otolaryngol Clin North Am 1989;22:253-64. 14. Kimmelman CP. The systemic effects of nasal obstruction. Otolaryngol Clin North Am 1989;22:461-6. IS. Falck B, Aust R, Svanholm H, Backlund L. The effect of physical work on the mucosal blood flow and gas exchange in the human maxillary sinus. Rhinology 1989;27:241-50. 16. Cederlund A, Carnner P, Svartengren M. Nasal mucociliary transport before and after jogging. Phys Sports Med 1987;lS: 93-8. 17. Pentel PR. Vigorous exercise and decongestant therapy: increased cardiac risk? JAMA 1988;260:553-4. 18. Wihl J-A, Malm L. Rhinomanometry and nasal peak expiratory and inspiratory flow rate. Ann Allergy 1988;61:50-5.
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
310
Otolaryngology Head and Neck Surgery March 1993
News and Announcements
held July 26-30, 1993, at the Tamarron Resort in Durango, Colorado. This 28 hour review and update will encompass all the clinically important areas of MR imaging. Important new concepts and pathological/imaging correlations in the body, musculoskeletal system, ENT, head and neck, brain, and spine will be explored. Daily case presentations will supplement these lectures and will serve to test the registrants' diagnostic abilities in MR imaging. This complete review of MR imaging will be presented by nationally recognized leaders in magnetic resonance imaging. As a result of this comprehensive review, registrants will become familiar with current applications of MR imaging and will be able to integrate many of these applications directly into their practice. Program chairmen for this presentation will be Robert Quencer, MD (University of Miami), Victor Haughton, MD (Medical College of Wisconsin). Twenty-eight credits of Category I will be available. For further information, please contact Marti Carter, CME, Inc., 11011 West Nort Ave., Milwaukee, Wisconsin 53226, or call (414) 771-9520. Ear, Nose, and Throat Diseases: 1993 Update
Children's Hospital of Pittsburgh will hold its 18th Annual Symposium, "Ear, Nose, and Throat Diseases in Children: A 1993 Update." This symposium will be held July 30-31, 1993. CME credits will be awarded.
For further information, please contact the Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue at DeSoto St., Pittsburgh, Pennsylvania 15213, or call (412) 692-8577. Twenty-fifth Annual Meeting - Head and Neck Oncologists
The Association of Head and Neck Oncologists of Great Britain will sponsor the Twenty-fifth Annual Meeting of Head and Neck Oncology, to be held in Edinburgh, Scotland, United Kingdom, on August 23-26, 1993. International and local faculty will present extensive social and family programs. For further information, please contact Mr. P. J. Bradley, Honorary Secretary, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital, Queens Medical Centre, Nottingham, NG7 2UH, England, or phone 0602421421. Sixth International Congress on Interventlonal Ultrasound
The Sixth International Congress on Interventional Ultrasound will be held in Copenhagen, Denmark, on September 7-10, 1993. For further information, please contact Christian Nolsoe, Congress Secretary, Department of Ultrasound, Herlev Hospital, University of Copenhagen, DK-2730 HerlevDenmark, or call + 45/ 44 53 53 00 ext. 3240.
CORRECTION
The Supplement to the December 1992 issue of the JOURNAL (Volume 107, Number 6, Part 2), incorrectly listed Dr. Bruce R. Gordon as Chief of Otolaryngology at the Massachusetts Eye and Ear Institute. Dr. Joseph Nadol is Chief of Otolaryngology at the Massachusetts Eye and Ear Infirmary. Dr. Gordon is Chief of Otolaryngology at Cape Cod Hospital.
Michigan The patency of the nasal airway may directly affect pulmonary ventilation, with obstruction and increased nasal resistance resulting in increased pulmonary resistance, hypoxia, and hypercapnea. Nine aerobic athletes were evaluated to assess the role of the nasal airway on aerobic capacity and athletic performance. A step-ladder graded maximal aerobic capacity test was performed under three test conditions: obstructed, decongested with oxymetazoline hydrochloride, and saline control. No differences in maximum V02, work load, oxygen saturation, maximal blood pressure, heart rate, or respiratory rate were noted between test conditions. Pre-exercise nasal resistance was lower in the decongested compared to control conditions, but no differences were found after exercise. Athletic performance was not influenced by nasal patenCy in this model. (OTOLARYNGOL HEAD NECK SURG 1992;107:101.)
T h e upper airways respond to the demands of exercise by increasing total airflow. This is accomplished by an increase in minute ventilation, bronchodilatation,' an increase in total laryngeal area,2and a reduction in nasal Even if larger fractions of air are transmitted by way of the oral route4-and most individuals breathe spontaneously through their mouths during exercise8-the nasal airway may play an important regulatory function for the upper airway. 1 . 3 . 9 Previous studies in both human beings and animals have shown a correlation between nasal obstruction and an increase in pulmonary resistance, hypercapnia, hypoxia,"." and sleep disturbances. I 2 Despite such observations, the role of the nasal airway in exercise capacity and athletic performance is not well understood. The purpose of this study was to evaluate the relationship of nasal airway patency on aerobic capacity and exercise workload under nasal occlusion, nasal decongestion, and control test conditions.
From the Departments of Otolaryngology-Head and Neck Surgery (Drs. Benninger and Sarpa) and Pulmonary Medicine (Drs. Ansari and Ward), Henry Ford Hospital. Presented at the Annual Meeting of the American Rhinologic Society, Waikoloa, Hawaii, May 9, 1991. Received for publication Nov. 12, 1991; accepted March 5 , 1992. Reprint requests: Michael S . Benninger, MD, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd.. Detroit, MI 48202. 23 I 1 I37645
METHODS AND MATERIAL
Nine trained athletes who exercised aerobically for at least 4 hours per week comprised the study group. Subjects were excluded if they had a history of persistent nasal obstruction, nasal trauma, previous nasal surgery, nasal allergic disorders, or had acute nasal-sinus symptoms at the time of testing. Anterior rhinoscopy was performed to rule out nasal pathology. One triathlete, two biathletes, three runners, one cyclist, one aerobic dance instructor, and one general aerobic fitness athlete composed the final group. There were two women and seven men. All subjects were evaluated under three test conditions-obstructed, decongested, and placebo controlwith the test order being determined by randomization tables (Table 1). All subjects served as their own controls. To ensure that test results were not affected by level of conditioning, all three tests were completed within a 3-week period and no two tests were performed on consecutive days. The congested test condition was simulated by taping the external nasal airway in a fashion that no air leak could occur, but no internal nasal pressure or mucosamucosa contact occurred. The tape was evaluated after exercise to verify complete occlusion throughout the study. Decongestion was achieved by spraying the nose with 0.05% oxymetazoline hydrochloride 15 minutes before exercise, with decongestion being verified by nasal plethysmography. Control conditions were achieved by spraying the nose with saline 15 minutes before exercise.
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
101
102
OtolaryngologyHead and Neck Surgery
BENNINGER et al.
Table 1. Test conditions Obstructed
Table 2. Mean results for test conditions Decongested
Nasal occlusion (tape) Nasal resistance Spirometry Oxymetazolrne hydrochloride Exercise Spirometry Nasal resistance Spirometry Exercise Spirometry Nasal resistance
Congested Decongested
Placebo control
Nasal resistance Placebo (saline) Spirometry Nasal resistance Exercise Spirometry Nasal resistance
Spirometry
The spirometry was performed on the Medgraphics system 1085 (Medgraphics, St. Paul, Minn.) according to the guidelines laid down by the American Thoracic Society (ATS). Expiratory flows were measured by a pneumotachograph after a forceful expiratory maneuver from total lung capacity (TLC). The forced expiratory volume in one second (FEV,), the forced vital capacity (FVC), and the forced expiratory$ow rates between 25% and 75% of vital capacity (FEF25-75) were derived from the flow volume curves produced by the integration of the flow signal from the pneumotachograph during at least three forced expiratory maneuvers. The actual values were selected from the three efforts according to the ATS guidelines. Airway Resistance
Nasal and total airway resistance (Raw) in cm H,O/L/sec and thoracic gas volume (TGV) were measured by the panting maneuver in the body plethysmography (Medgraphics 1085). The mean of at least five successive measurements were calculated. Specific airway resistance (sRaw) was calculated from the Raw and the TGV. Airway conductance (Gaw) and specific airway conductance (sGaw) were calculated as reciprocals of Raw and sRaw. Cardiopulmonary Exercise Testing The exercise testing was done on a Medgraphics cardiopulmonary system 2000 (Medgraphics, St. Paul, Minn.) linked to a Siemens-Elema bicycle Ergometer (Model 3803). Each subject was screened by a standard 12-lead EKG to rule out any resting EKG abnormalities. Standard instructions and explanations were provided to the subjects. The workload was incrementally graded-20 watts every minute. EKG, pulse oximeter, heart rate, and respiratory rate were monitored continuously during the test. The blood pressure was recorded at least once every minute. Exhaled gases and volumes were continuously measured by a gas analyzer (Medgraphics system 2000). Maximum O2 consumption
VO, (mlimin) Workload (watts) Heart rate (1 minute) Respiratory rate (1 minute) O2Saturation (%) Systolic BP (mm Hg)
2626 275 156 47 92 6 177
2639 268 148 45 91 9 180
Control
264 1 264 157 42 92 3 170
(VO,) was measured in ml/min. The subjects were instructed to keep pedalling at 60 rpm until they were unable to continue, at which time the test was terminated. Their reasons for quitting were noted. Statistical Analysis
To test for differences between the congested, decongestant, and control measurements, a repeated measures analysis of variance was done for maximum VO, workload, heart rate, and respiratory rate. For FEV, and FEF25-75, to test for differences between groups (congested, decongested, and control) and between the pre-exercise and post-exercise testing, a two-way analysis of variance with repeated measures on both factors was done. Similarly, in order to test .for group and time differences, a two-way analysis of variance with repeated measures on both factors was done for evaluation of nasal resistance. Statistical significance was achieved if a p value was less than 0.05.
RESULTS Mean results of V02,workload, heart rate, respiratory rate, O2 saturation, and maximal systolic blood pressure are listed in Table 2. There was no difference between groups with regards to VO, ( p = 0.986), workload ( p = 0.276), heart rate ( p = 0.661), or respiratory rate ( p = 0.199). Although the FEV, and FEF25-75 were noted to be similar between the three test conditions (Table 3), there was a difference between the pre-exercise and post-exercise results within each test condition. An increase in both FEV, ( p = 0.049) and FEF25-75 was noted post-exercise ( p = 0.003). The results of nasal resistance are noted in Table 4. There was no difference in nasal resistance between the decongestant and placebo control groups after exercise ( p = 0.550). There was, however, a decrease resistance after oxymetazoline in the pre-exercise evaluation in comparison to the resistance before oxymetazoline spray ( p = 0.007). No difference was noted in the preexercise resistance between the resting resistance and after saline nasal spray (0.1219).
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
Volume 107 Number 1 July 1992
Nasal potency, aerobic capacity, and athletic performance 103
Table 4. Nasal resistance (cm H,O/L/sec)
Table 3. Spirometry results ~
~
~
~
Congested
Decongested
Control
4 10 4 20
4 16 4 35
4 13
Decongested
Control
3.35 2.16 2.09 1.26
3.09
~~~~~~~~~~
FEV, (Iiters)
Pre-exercise Post-exercise FEF 25-75 (liters) Pre-exercise Post-exercise
4 39 5 00
4 26 4 94
4 24
1.84 1.25
4 33 4 81
DISCUSSION The nose provides a conduit for airflow for respiration and smell. It filters air, exchanges heat and water vapor, absorbs water soluble gases, and provides resistance to nasal airflow. l 3 The mechanical, tactile, and nociceptive sensation of the nasal mucosa is from the ophthalmic (V,) and maxillary (V,) divisions of the trigeminal nerve. Sympathetic fibers from the thoracic spinal cord and parasympathetic fibers from the superior salivatory nucleus reach the nose by complex pathways by way of the trigeminal nerve and regulate the secretory and vasomotor activities of the nose.6 Although the neurologic pathways of the rhinosinobronchial reflex have not been completely established, the vagal nerve is thought to be involved in the efferent pathway, which can result in changes in pulmonary resistance.6 Studies have shown that nasal obstruction can cause measurable increases in lower airway resistance, laryngeal resistance, increased PCO?, and decreased PO,.'o.'' Although these early studies have been q u e ~ t i o n e d ,it' ~ has been postulated that the nasal airway plays an important regulatory function for the upper a i ~ w a y ' .and ~.~ an effect of nasal patency in pulmonary function has been s h o ~ n . ~ . ' An . ' ~ inhibition of exercise-induced bronchoconstriction in asthmatic patients has occurred with nasal breathing, whereas bronchoconstriction recurred with mouth breathing.* Acute nasal obstruction has produced objective findings of disturbed sleep and obstructive airway events in normal subjects. I* Exercise results in decreased nasal resistance.'-' This response is primarily a result of reduced blood flow and blood content of the m u c o ~ a . 'It~ may be adaptive to allow improved ventilation or may be a result of redistribution of nasal blood to the muscles, heart, and skin.I5 Increased nasal ventilation does seem to occur and results in a secondary decrease in mucociliary transport. If nasal resistance plays an important role in the regulation of the upper airway and nasal occlusion adversely affects pulmonary function, it might be postulated that nasal obstruction may adversely affect athletic performance. This potential improvement was not j6
Pre-study Post oxymetazoline hydrochloride Post-exercise Pre-Post exercise difference
substantiated in this study. Neither workload nor VO, was different among the three test conditions. The purpose, therefore, of this exercise-induced decrease in nasal resistance is unknown. With increased work rates, airflow is diverted from the nasal to oral It is doubtful that the decrease in nasal resistance has a significant effect on total ventilation and overall respiratory mechanic^.^ The changes that occur, however, may play an important role in conditioning the air during exercise and over a wide range of ventilation The decongesting role of exercise itself in this study resulted in airway patency at the termination of activity comparable to that of previous decongestion with oxymetazoline hydrochloride followed by exercise. It might be expected, therefore, that no change in athletic performance would be detected between these two groups at the termination of a step-ladder, somewhatprolonged exercise activity. With shorter aerobic activities in which high-level workloads are achieved more quickly, the differences between these groups could potentially be seen favoring the previous decongested group. This, however, could not explain the lack of differences between the obstructed test and the other two test conditions in this study. It is difficult to extrapolate the results of this study to athletic competition. Some long distance aerobic athletes use decongesting nasal sprays for the perceived benefit of improved performance. With the critical importance of the psyche on performance, it is possible that such medications allow increased confidence that can affect performance in a positive fashion. Such hope for performance enhancement by pharmacologic means would be contrary to the fundamental principles of sport and sportsmanship and, therefore, should not be used for such purposes. Although oxymetazoline hydrochloride does not grossly appear to acutely change performance and has minimal associated risks, neosynephrine or oral decongestants may have a more significant benefit as a result of greater systemic effects but may also carry greater risks when used during exercise." This study used only subjects with normal nasal anatomy and physiology. Individuals with chronic nasal obstruction resulting from anatomic problems such as marked septa1 deviations or those with chronic func-
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
OtolaryngologyHead and Neck Surgery
104 BENNINGER et 01.
tional problems such as allergic or vasomotor rhinitis may be more disadvantaged than those with normal nasal function. Most rhinologic surgeons can relate anecdotal cases of athletes who espouse improved performance after septa1 surgery. It is difficult to objectively evaluate such results because level of conditioning can change dramatically over the penoperative time course. Much investigation would be needed to determine whether or not improvements in anatomic obstruction truly change athletic performance. Questions can be raised with regard to the accuracy of the VO, values found in this study because they are below normal, despite trained aerobic athletes as subjects, Three problems exist with regard to aerobic testing in this model. Bicycle VO, evaluations have lower values than those performed running. Toe clips were not used and an upright body position might also affect results. Despite all attempts, absolute mask seal could not be completely assured because of marked body movement at maximal workloads. Using each individual as his or her own control would seem to assist in allowing accuracy. Furthermore, not only were VO, levels not different, but workloads were also similar among test conditions, suggesting that athletic performance was not affected by the various test conditions. The purpose of this study was not to measure the specific changes in nasal resistance that occurred during exercise. Rhinomanometry or peak inspiratory flow rates’* would be preferred methods to plethysmography if more accurate values were required or if the findings were to be compared to others. Plethysmography was used because of its simplicity and convenience in our laboratory setting and for general assessments of resistance with the subjects acting as their own controls. All subjects were, in fact, found to have decreased nasal resistance after decongestion and after exercise when compared to pre-test conditions. Nonetheless, it is of interest that the post-exercise resistance under control and decongested test conditions were similar, verifying the magnitude of the decongestion that occurs with exercise. CONCLUSION
No differences were found in maximal aerobic oxygen consumption or workload with variations in nasal patency in trained aerobic athletes with no history of
nasal dysfunction. Nasal decongestants should not be used with the hopes of improved performance. Whether medical or surgical treatment might alter athletic performance in those with chronic nasal disorders should be further investigated. REFERENCES
1. Jackson RT. Nasal-cardiopulmonary reflexes: a role of the larynx. Ann Otol Rhinol Laryngol 1976;85:65-70. 2. Hurbis CG, Schild JA. Laryngeal changes during exercise and exercise-induced asthma. Ann Otol Rhinol Laryngol 1991;100:34-7. 3. Merty JS, McCaffrey TV, Kern EB. Role of the nasal airway in regulation of airway resistance during hypercapnea and exercise. OTOLARYNGOL HEADNECKSURC1982;92:302-7. 4. Forsythe RD, Cole P, Shephard RJ. Exercise and nasal patency. J Appl Physiol 1983;55:860-5. 5. Richerson HB, Seebohm PM. Nasal airway response to exercise. J Allergy 1968;41:269-84. 6. Raphael GD, Meredith SD, Baraniuk JN, Kaliner MA. Nasal reflexes. Am J Rhinol 1988;2:109-16. 7. Cole P. Forsyth R, Haight JSJ. Effects of cold air and exercise on nasal patency. Ann Otol Rhinol Laryngol 1983;92:196-8. 8. Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada IF. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Resp Dis 1978;118:6.5-73. 9. deWit G . The function of the nose in the aerodynamics of respiration. Rhinology 1978;11:59-67. 10. Ogura JH, Harvey JE. Nasopulmonary mechanics-experimental evidence of the influence of the upper airway upon the lower. Acta Otolaryngol 1971;71:123-32. 11. Ogura JH, Suemitsu M, Nelson JR, Kavamoto S . Relationship between pulmonary resistance and changes in arterial blood gas tension in dogs with nasal obstruction, and partial laryngeal obstruction. Ann Otol Rhinol Laryngol 1973;82:668-83. 12. Olson KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. OTOLARYNGOL HEAD NECKSURG1981;89:804-10. 13. Kimmelman CP. The problem of nasal obstruction. Otolaryngol Clin North Am 1989;22:253-64. 14. Kimmelman CP. The systemic effects of nasal obstruction. Otolaryngol Clin North Am 1989;22:461-6. IS. Falck B, Aust R, Svanholm H, Backlund L. The effect of physical work on the mucosal blood flow and gas exchange in the human maxillary sinus. Rhinology 1989;27:241-50. 16. Cederlund A, Carnner P, Svartengren M. Nasal mucociliary transport before and after jogging. Phys Sports Med 1987;lS: 93-8. 17. Pentel PR. Vigorous exercise and decongestant therapy: increased cardiac risk? JAMA 1988;260:553-4. 18. Wihl J-A, Malm L. Rhinomanometry and nasal peak expiratory and inspiratory flow rate. Ann Allergy 1988;61:50-5.
Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on February 28, 2016
310
Otolaryngology Head and Neck Surgery March 1993
News and Announcements
held July 26-30, 1993, at the Tamarron Resort in Durango, Colorado. This 28 hour review and update will encompass all the clinically important areas of MR imaging. Important new concepts and pathological/imaging correlations in the body, musculoskeletal system, ENT, head and neck, brain, and spine will be explored. Daily case presentations will supplement these lectures and will serve to test the registrants' diagnostic abilities in MR imaging. This complete review of MR imaging will be presented by nationally recognized leaders in magnetic resonance imaging. As a result of this comprehensive review, registrants will become familiar with current applications of MR imaging and will be able to integrate many of these applications directly into their practice. Program chairmen for this presentation will be Robert Quencer, MD (University of Miami), Victor Haughton, MD (Medical College of Wisconsin). Twenty-eight credits of Category I will be available. For further information, please contact Marti Carter, CME, Inc., 11011 West Nort Ave., Milwaukee, Wisconsin 53226, or call (414) 771-9520. Ear, Nose, and Throat Diseases: 1993 Update
Children's Hospital of Pittsburgh will hold its 18th Annual Symposium, "Ear, Nose, and Throat Diseases in Children: A 1993 Update." This symposium will be held July 30-31, 1993. CME credits will be awarded.
For further information, please contact the Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue at DeSoto St., Pittsburgh, Pennsylvania 15213, or call (412) 692-8577. Twenty-fifth Annual Meeting - Head and Neck Oncologists
The Association of Head and Neck Oncologists of Great Britain will sponsor the Twenty-fifth Annual Meeting of Head and Neck Oncology, to be held in Edinburgh, Scotland, United Kingdom, on August 23-26, 1993. International and local faculty will present extensive social and family programs. For further information, please contact Mr. P. J. Bradley, Honorary Secretary, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital, Queens Medical Centre, Nottingham, NG7 2UH, England, or phone 0602421421. Sixth International Congress on Interventlonal Ultrasound
The Sixth International Congress on Interventional Ultrasound will be held in Copenhagen, Denmark, on September 7-10, 1993. For further information, please contact Christian Nolsoe, Congress Secretary, Department of Ultrasound, Herlev Hospital, University of Copenhagen, DK-2730 HerlevDenmark, or call + 45/ 44 53 53 00 ext. 3240.
CORRECTION
The Supplement to the December 1992 issue of the JOURNAL (Volume 107, Number 6, Part 2), incorrectly listed Dr. Bruce R. Gordon as Chief of Otolaryngology at the Massachusetts Eye and Ear Institute. Dr. Joseph Nadol is Chief of Otolaryngology at the Massachusetts Eye and Ear Infirmary. Dr. Gordon is Chief of Otolaryngology at Cape Cod Hospital.
