Exercise and the lungs: From physiology to pathophysiology – a narrative review
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Exercise represents a dynamic integration of rapidly activated respiratory, cardiovascular and musculoskeletal responses to meet rising metabolic demands. While the human body has a remarkable ability for exertion and endurance, in disease states, and particularly in respiratory disease, these mechanisms are often compromised, resulting in dyspnoea and reduced exercise tolerance. This review outlines normal exercise physiology, including cardiac, ventilatory and skeletal muscle adaptations to enhance oxygen uptake and delivery to working muscle, and examines how these are altered in conditions such as asthma, chronic obstructive pulmonary disease, interstitial lung disease and pulmonary hypertension. Key management considerations are highlighted to support and optimise functional capacity in patients suffering from these conditions. The unique challenges of exercise, with and without respiratory disease, in specific contexts – including underwater diving, high- altitude exposure, and pregnancy – are also discussed. We briefly review policies and prohibitions on medications for competitive athletes with respiratory disease, where adherence to anti-doping regulations, especially regarding inhaled beta-agonists and corticosteroids, is crucial. Overall, understanding the physiological basis for exercise limitation enables clinicians to be more effective in their assessment, therapeutic intervention and counselling for patients seeking to maintain activity and quality of life despite respiratory compromise.
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1. Bramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature 2004;432(7015):345-352. https://doi.org/10.1038/nature03052
2. Brazile TL, Levine BD, Shafer KM. Cardiopulmonary exercise testing. NEJM Evid 2025;4(2):EVIDra2400390. https://doi.org/10.1056/EVIDra2400390
3. Babb TG. Exercise ventilatory limitation: The role of expiratory flow limitation. Exerc Sport Sci Rev 2013;41(1):11-18. https://doi.org/10.1097/JES.0b013e318267c0d2
4. SticklandMK,NederJA,GuenetteJA,O’DonnellDE,JensenD.Usingcardiopulmonary exercise testing to understand dyspnea and exercise intolerance in respiratory disease. Chest 2022;161(6):1505-1516. https://doi.org/10.1016/j.chest.2022.01.021
5. Brazile TL, Levine BD, Shafer KM. Physiological principles of exercise. NEJM Evid 2025;4(1):EVIDra2400363. https://doi.org/10.1056/EVIDra2400363
6. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37(1):153-156. https://doi.org/10.1016/s0735-1097(00)01054-8
7. Blomqvist C, Saltin B. Cardiovascular adaptations to physical training. Annu Rev
Physiol 1983;45:169-189. https://doi.org/10.1146/annurev.ph.45.030183.001125
8. Gielen S, Schuler G, Adams V. Cardiovascular effects of exercise training: Molecular mechanisms. Circulation 2010;122(12):1221-1238. https://doi.org/10.1161/
CIRCULATIONAHA.110.939959
9. Forster HV, Haouzi P, Dempsey JA. Control of breathing during exercise. Compr Physiol 2012;2(1):743-777. https://doi.org/10.1002/cphy.c100045
10. AshhadS,KamK,delNegroCA,FeldmanJL.Breathingrhythmandpatternandtheir influence on emotion. Annu Rev Neurosci 2022;45:223-247. https://doi.org/10.1146/ annurev-neuro-090121-014424
11. Kane DW, Tesauro T, Koizumi T, Gupta R, Newman JH. Exercise-induced pulmonary vasoconstriction during combined blockade of nitric oxide synthase and beta adrenergic receptors. J Clin Invest 1994;93(2):677-683. https://doi.org/10.1172/ JCI117020
12. Caiozzo VJ, Davis JA, Ellis JF, et al. A comparison of gas exchange indices used to detect the anaerobic threshold. J Appl Physiol Respir Environ Exerc Physiol 1982;53(5):1184-1189. https://doi.org/10.1152/jappl.1982.53.5.1184
13. Fry AC, Allemeier CA, Staron RS. Correlation between percentage fiber type area and myosin heavy chain content in human skeletal muscle. Eur J Appl Physiol Occup Physiol 1994;68(3):246-251. https://doi.org/10.1007/BF00376773
14. Felig P, Wahren J. Fuel homeostasis in exercise. N Engl J Med 1975;293(21):1078-1084.
https://doi.org/10.1056/NEJM197511202932107
15. Brooks GA, Mercier J. Balance of carbohydrate and lipid utilisation during exercise: The ‘crossover’ concept. J Appl Physiol 1994;76(6):2253-2261. https://doi.org/10.1152/ jappl.1994.76.6.2253
16. Rogatzki MJ, Ferguson BS, Goodwin ML, Gladden LB. Lactate is always the end product of glycolysis. Front Neurosci 2015;9:22. https://doi.org/10.3389/ fnins.2015.00022
17. Hickner RC, Fisher JS, Ehsani AA, Kohrt WM. Role of nitric oxide in skeletal muscle blood flow at rest and during dynamic exercise in humans. Am J Physiol 1997;273(1 Pt 2):H405-H410. https://doi.org/10.1152/ajpheart.1997.273.1.H405
18. Coffey VG, Hawley JA. The molecular bases of training adaptation. Sports Med 2007;37(9):737-763. https://doi.org/10.2165/00007256-200737090-00001
19. Bowtell JL, Marwood S, Bruce M, Constantin-Teodosiu D, Greenhaff PL. Tricarboxylic acid cycle intermediate pool size: Functional importance for oxidative metabolism in exercising human skeletal muscle. Sports Med 2007;37(12):1071-1088. https://doi. org/10.2165/00007256-200737120-00005
20. Global Initiative for Asthma. 2024 Global Strategy for Asthma Management and Prevention. Updated 2024. https://ginasthma.org/wp-content/uploads/2024/05/ GINA-2024-Strategy-Report-24_05_22_WMS.pdf (accessed 2 March 2026).
21. Weiler JM, Bonini S, Coifman R, et al. American Academy of Allergy, Asthma & Immunology Work Group report: Exercise-induced asthma. J Allergy Clin Immunol 2007;119(6):1349-1358. https://doi.org/10.1016/j.jaci.2007.02.041
22. Clemm HH, Olin JT, McIntosh C, et al. Exercise-induced laryngeal obstruction (EILO) in athletes: A narrative review by a subgroup of the IOC Consensus on ‘acute respiratory illness in the athlete’. Br J Sports Med 2022;56(11):622-629. https://doi. org/10.1136/bjsports-2021-104704
23. McFadden E, Gilbert IA. Exercise-induced asthma. N Engl J Med 1994;330(19):1362- 1367. https://doi.org/10.1056/NEJM199405123301907
24. Bougault V, Turmel J, St-Laurent J, Bertrand M, Boulet LP. Asthma, airway inflammation and epithelial damage in swimmers and cold-air athletes. Eur Respir J 2009;33(4):740-746. https://doi.org/10.1183/09031936.00117708
25. Bonsignore MR, Morici G, Vignola AM, et al. Increased airway inflammatory cells in endurance athletes: What do they mean? Clin Exp Allergy 2003;33(1):14-21. https:// doi.org/10.1046/j.1365-2222.2003.01557.x
26. Larsson K, Ohlsen P, Larsson L, Malmberg P, Rydstrom PO, Ulriksen H. High prevalence of asthma in cross country skiers. BMJ 1993;307(6915):1326-1329. https:// doi.org/10.1136/bmj.307.6915.1326
27. Anderson SD, Daviskas E. The airway microvasculature and exercise induced asthma. Thorax 1992;47(9):748-752. https://doi.org/10.1136/thx.47.9.748
28. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: Exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013;187(9):1016-1027. https://doi.org/10.1164/rccm.201303-0437ST
29. Celli B, Fabbri L, Criner G, et al. Definition and nomenclature of chronic obstructive pulmonary disease: Time for its revision. Am J Respir Crit Care Med 2022;206(11):1317-1325. https://doi.org/10.1164/rccm.202204-0671PP
30. Chin RC, Guenette JA, Cheng S, et al. Does the respiratory system limit exercise in mild chronic obstructive pulmonary disease? Am J Respir Crit Care Med 2013;187(12):1315-1323. https://doi.org/10.1164/rccm.201211-1970OC
31. Guenette JA, Chin RC, Cheng S, et al. Mechanisms of exercise intolerance in Global Initiative for Chronic Obstructive Lung Disease grade 1 COPD. Eur Respir J 2014;44(5):1177-1187. https://doi.org/10.1183/09031936.00034714
32. Agustí AGN, Barberá JA, Roca J, Wagner PD, Guitart R, Rodriguez-Roisín R. Hypoxic pulmonary vasoconstriction and gas exchange during exercise in chronic obstructive pulmonary disease. Chest 1990;97(2):268-275. https://doi.org/10.1378/chest.97.2.268
33. Maekura R, Hiraga T, Miki K, et al. Differences in physiological response to exercise in patients with different COPD severity. Respir Care 2014;59(2):252-262. https://doi. org/10.4187/respcare.02201
34. Smith JR, Johnson BD, Olson TP. Impaired central hemodynamics in chronic obstructive pulmonary disease during submaximal exercise. J Appl Physiol 2019;127(3):691-697. https://doi.org/10.1152/japplphysiol.00877.2018
35. Chiles JW, Wilson AC, Tindal R, et al. Differentially co-expressed myofibre transcripts associated with abnormal myofibre proportion in chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle 2024;15(3):1016-1029. https://doi.org/10.1002/ jcsm.13473
36. Nymand SB, Hartmann JP, Ryrsø CK, et al. Exercise adaptations in COPD: The pulmonary perspective. Am J Physiol Lung Cell Mol Physiol 2022;323(6):L659-L666. https://doi.org/10.1152/ajplung.00549.2020
37. Raghu G, Remy-Jardin M, Richeldi L, et al. Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 2022;205(9):e18-e47. https://doi. org/10.1164/rccm.202202-0399ST
38. Faisal A, Alghamdi BJ, Ciavaglia CE, et al. Common mechanisms of dyspnea in chronic interstitial and obstructive lung disorders. Am J Respir Crit Care Med 2016;193(3):299-309. https://doi.org/10.1164/rccm.201504-0841OC
39. Wilkens H, Weingard B, Lo Mauro A, et al. Breathing pattern and chest wall volumes during exercise in patients with cystic fibrosis, pulmonary fibrosis and COPD before and after lung transplantation. Thorax 2010;65(9):808-814. https://doi.org/10.1136/ thx.2009.131409
40. Agusti AGN, Barbera JA. Chronic pulmonary diseases: Chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis. Thorax 1994;49:924-932. https://doi.org/10.1136/thx.49.9.924
41. Agustí AGN, Roca J, Gea J, Wagner PD, Xaubet A, Rodriguez-Roisin R. Mechanisms of gas-exchange impairment in idiopathic pulmonary fibrosis. Am Rev Respir Dis 1991;143(2):219-225. https://doi.org/10.1164/ajrccm/143.2.219
42. Plantier L, Debray MP, Estellat C, et al. Increased volume of conducting airways in idiopathic pulmonary fibrosis is independent of disease severity: A volumetric capnography study. J Breath Res 2016;10(1):016005. https://doi.org/10.1088/1752- 7155/10/1/016005
43. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022;43(38):3618-3731. https://doi.org/10.1093/eurheartj/ehac237
44. Grünig E, Tiede H, Enyimayew EO, et al. Assessment and prognostic relevance of right ventricular contractile reserve in patients with severe pulmonary hypertension. Circulation 2013;128(18):2005-2015. https://doi.org/10.1161/ CIRCULATIONAHA.113.001573
45. Chaouat A, Sitbon O, Mercy M, et al. Prognostic value of exercise pulmonary haemodynamics in pulmonary arterial hypertension. Eur Respir J 2014;44(3):704- 713. https://doi.org/10.1183/09031936.00153613
46. Dumitrescu D, Sitbon O, Weatherald J, Howard LS. Exertional dyspnoea in pulmonary arterial hypertension. Eur Respir Rev 2017;26(145):170039. https://doi. org/10.1183/16000617.0039-2017
47. Tolle J, Waxman A, Systrom D. Impaired systemic oxygen extraction at maximum exercise in pulmonary hypertension. Med Sci Sports Exerc 2008;40(1):3-8. https:// doi.org/10.1249/mss.0b013e318159d1b8
48. Le RJ, Fenstad ER, Maradit-Kremers H, et al. Syncope in adults with pulmonary arterial hypertension. J Am Coll Cardiol 2011;58(8):863-867. https://doi.org/10.1016/j. jacc.2011.04.026
49. Tetzlaff K, Thomas PS. Short- and long-term effects of diving on pulmonary function. Eur Respir Rev 2017;26(143):160097. https://doi.org/10.1183/16000617.0097-2016
50. Hong SK, Cerretelli P, Cruz JC, Rahn H. Mechanics of respiration during submersion in water. J Appl Physiol 1969;27(4):535-538. https://doi.org/10.1152/jappl.1969.27.4.535 51. Tetzlaff K, Reuter M, Leplow B, Heller M, Bettinghausen E. Risk factors for pulmonary barotrauma in divers. Chest 1997;112(3):654-659. https://doi.org/10.1378/
chest.112.3.654
52. Neuman TS, Bove AA, O’Connor RD, Kelsen SG. Asthma and diving. Ann Allergy 1994;73(4):344-350.
53. International Marine Contractors Association (IMCA). IMCA international code of practice for offshore diving. Revision 3.3 - March 2025. https://www.imca-int.com/ resources/technical-library/document/134b165f-c55b-ee11-8def-6045bdd2c9bc/ (accessed 18 June 2025).
54. Department of Employment and Labour, South Africa. Commercial Diving Regulations 2022. https://www.labour.gov.za/DocumentCenter/Pages/Commercial- Diving-Regulations-2022.aspx (accessed 18 June 2025).
55. Nussbaumer-Ochsner Y, Ursprung J, Siebenmann C, Maggiorini M, Bloch KE. Effect of short-term acclimatisation to high altitude on sleep and nocturnal breathing. Sleep 2012;35(3):419-423. https://doi.org/10.5665/sleep.1708
56. Luks AM, Swenson ER. Travel to high altitude with pre-existing lung disease. Eur Respir J 2007;29(4):770-792. https://doi.org/10.1183/09031936.00052606
57. Graham WGB, Houston CS. Short-term adaptation to moderate altitude: Patients with chronic obstructive pulmonary disease. JAMA 1978;240(14):1491-1494.
58. Abdool-Gaffar MS, Calligaro G, Wong ML, et al. Management of chronic obstructive pulmonary disease – A position statement of the South African Thoracic Society: 2019 update. J Thorac Dis 2019;11(11):4408-4427. https://doi.org/10.21037/jtd.2019.10.65
59. Coker RK, Armstrong A, Church AC, et al. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax 2022;77(4):329-350. https://doi. org/10.1136/thoraxjnl-2021-218110
60. Hu X, Cowl CT, Baqir M, Ryu JH. Air travel and pneumothorax. Chest 2014;145(4):688- 694. https://doi.org/10.1378/chest.13-2363
61. Hackett PH, Creagh CE, Grover RF, et al. High-altitude pulmonary edema in persons without the right pulmonary artery. N Engl J Med 1980;302(19):1070-1073. https:// doi.org/10.1056/NEJM198005083021907
62. Schneider SR, Lichtblau M, Furian M, et al. Cardiorespiratory adaptation to short- term exposure to altitude vs. normobaric hypoxia in patients with pulmonary hypertension. J Clin Med 2022;11(10):2769. https://doi.org/10.3390/jcm11102769
63. Luks AM, Hackett PH. Medical conditions and high-altitude travel. N Engl J Med 2022;386(4):364-373. https://doi.org/10.1056/NEJMra2104829
64. Crapo RO. Normal cardiopulmonary physiology during pregnancy. Clin Obstet Gynecol 1996;39(1):3-16. https://doi.org/10.1097/00003081-199603000-00004
65. Pereira A, Krieger BP. Pulmonary complications of pregnancy. Clin Chest Med 2004;25(2):299-310. https://doi.org/10.1016/j.ccm.2004.01.010
66. Stenius-Aarniala B, Piirila P, Teramo K. Asthma and pregnancy: A prospective study of 198 pregnancies. Thorax 1988;43(1):12-18. https://doi.org/10.1136/thx.43.1.12
67. Schatz M, Harden K, Forsythe A, et al. The course of asthma during pregnancy,
post partum, and with successive pregnancies: A prospective analysis. J Allergy Clin
Immunol 1988;81(3):509-517.
68. Mendola P, Laughon SK, Männistö TI, et al. Obstetric complications among US
women with asthma. Am J Obstet Gynecol 2013;208(2):127.e1-127.e8. https://doi. org/10.1016/j.ajog.2012.11.007
69. Grant-Orser A, Metcalfe A, Pope JE, Johannson KA. Pregnancy considerations for patients with interstitial lung disease. Chest 2022;162(5):1093-1105. https://doi. org/10.1016/j.chest.2022.06.024
70. Hemnes AR, Kiely DG, Cockrill BA, et al. Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute. Pulm Circ 2015;5(3):435-465. https://doi.org/10.1086/682230
71. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018;39(34):3165-3241. https://doi.org/10.1093/eurheartj/ehy340
72. Ouzounian JG, Elkayam U. Physiologic changes during normal pregnancy and delivery. Cardiol Clin 2012;30(3):317-329. https://doi.org/10.1016/j.ccl.2012.05.004