Maximum exercise capacity: Barcroft revisited in a large population

In 1973, the first exercise test was performed at McMaster University Medical Center to provide a standardized approach to clinical exercise testing, based on Barcroft’s maxim that the maximum capacity to exercise is “the essence of the machine,” emphasizing integration between different mechanisms. The test was incremental ergometer exercise to symptom limited maximum. Physiologic and symptom measurements were made before and during exercise. 46,288 tests were collected and entered into a dataset; unique both in terms of the large number and the physiologic variables collected (skeletal muscle strength, gas transfer capacity, symptoms). The objective of this study was to understand CO2 production in relation to oxygen uptake when exercising to maximum capacity. Physiologic factors contributing to maximum exercise capacity (Wmax) were skeletal muscle strength, FEV1 (ventilatory capacity) and DLCO (gas transfer capacity). The response of VCO2 in relation to VO2 (RER) showed a lag in CO2 production (related to CO2 storage), which was longer in subjects with higher maximum exercise capacity. This lag was followed by a progressive increase toward Wmax that reached a maximum value independent of Wmax. The perceived intensity of leg effort and dyspnea increased in a positively accelerating manner in parallel with increases in CO2 output. Maximum power in incremental cycling was symptom limited, dependent on muscle (strength, oxidative capacity), together with FEV1. Previous emphasis on oxygen delivery as limiting exercise, irrespective of clinical diagnosis, may be augmented by the perceptual limitation that accompanies, remarkably symmetrically, the adaptation to CO2 removal maintaining homeostasis in muscle (muscle buffering capacity).