Chemoreflex control of breathing during wakefulness

in healthy men and women

Dennis Jensen, Larry A. Wolfe, Denis E. O'Donnell and Gregory A. L. Davies
Journal of Applied Physiology 98:822-828, 2005. First published Nov 19, 2004;
doi:10.1152/japplphysiol.01208.2003
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J Appl Physiol 98: 822 828, 2005.

First published November 19, 2004; doi:10.1152/japplphysiol.01208.2003.

Chemoreflex control of breathing during wakefulness in healthy men and women

Dennis Jensen,1 Larry A. Wolfe,1,2 Denis E. ODonnell,2,4 and Gregory A. L. Davies3
1

School of Physical and Health Education, Departments of 2Physiology and 3Obstetrics and Gynaecology, and
Division of Respirology and Critical Care, Department of Medicine, Queens University, Kingston, Ontario, Canada

Submitted 11 November 2003; accepted in final form 15 November 2004

hypoxia; chemoreflex sensitivity; ventilatory recruitment threshold;

sleep-disordered breathing

mediated by the peripheral chemoreflex, is greater in men than

women (20, 32, 33), whereas others have reported the opposite
result (1). However, others have found that gender has no
effect on either central (1, 13, 18, 26, 30, 34) or peripheral (13,
26, 27, 32, 34) chemoreflex sensitivity.
Divergent results from previous investigations may be due to
different experimental designs. Some studies did not control
for menstrual cycle status of female subjects (20, 21, 28, 30,
32, 34), whereas others made comparisons between men and
women in the luteal phase (37) and follicular phase (FP) (1, 13,
26, 27) of the menstrual cycle. Also, some studies have not
considered oral contraceptive use among female volunteers
(21, 28, 30) or gender differences in body size and/or lung
functional indexes (20, 26, 28).
Recent epidemiological studies (4, 36) have demonstrated
that the prevalence of sleep-disordered breathing (SDB), a
condition of repeated apneas, hypopneas, and breathing oscillations, is two to three times greater in men than women (4,
36). Differences in the central and/or peripheral chemoreflex
control of breathing during wakefulness may reflect a similar
difference during sleep that could contribute to the high male
prevalence of SDB (12, 37).
This study investigated the effect of gender on the ventilatory recruitment threshold (VRT) for CO2 and the ventilatory
response below (i.e., behavioral drives) and above (i.e., chemoreflex sensitivity) this threshold while maintaining constant
backgrounds of hyperoxia and hypoxia, respectively. We hypothesized that neither the hyperoxic nor hypoxic VRT for
CO2 would differ between men and women. In addition, we
hypothesized that the ventilatory response to CO2 below and
above this threshold would be greater in men than women,
independent of the level of O2.

OVARIAN AND TESTICULAR HORMONES influence the control of

breathing via their effects on both central and peripheral
chemoreflexes (2, 33). Progesterone increases central and peripheral chemosensitivity to hypercapnia and hypoxia (2, 33).
This effect is potentiated by estrogen (2, 33). In addition,
testosterone increases peripheral chemoreflex sensitivity to
hypoxia (2, 17, 33), but its effect on central chemoresponsiveness remains unclear (2, 33). Given the effects of reproductive
hormones on ventilatory control as well as gender differences
in endocrine status, it is reasonable to expect that central and/or
peripheral chemoreflex control characteristics may differ between healthy men and women during wakefulness.
Current evidence suggests that the apneic threshold and
sensitivity of the ventilatory response to CO2, mediated by the
central chemoreflex, is greater in men than women (20, 26, 35,
37), regardless of menstrual cycle status (20, 33, 35). Some
studies have shown that the ventilatory response to hypoxia,

Subjects. Healthy, nonsmoking, normally active men (n 14) and

women (n 14), aged 20 35 yr, were recruited at Queens University
through posted announcements and flyers. Subjects had no history of
cardiorespiratory disease, nor were they born at or recently returned
from high altitude. None was taking medications that affect ventilatory control. Female subjects had regular menstrual cycles, as verified
by questionnaire, and had not used oral contraceptives for 6 mo before
experimental testing.
Before study entry, subjects attended an information session to
familiarize them with the laboratory and study procedures. All subjects completed the revised Physical Activity Readiness Questionnaire
(available online at www.csep.ca/forms.asp) to ensure that there were
no contraindications to participation. Demographic information, including age, occupation, and occupational and recreational physical
activity levels, were assessed by questionnaire. To evaluate menstrual

Address for reprint requests and other correspondence: L. A. Wolfe, School

of Physical and Health Education, Queens Univ., Kingston, Ontario, Canada
K7L 3N6 (E-mail: wolfel@post.queensu.ca).

The costs of publication of this article were defrayed in part by the payment
of page charges. The article must therefore be hereby marked advertisement
in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

822

METHODS

8750-7587/05 $8.00 Copyright 2005 the American Physiological Society

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Jensen, Dennis, Larry A. Wolfe, Denis E. ODonnell, and

Gregory A. L. Davies. Chemoreflex control of breathing during
wakefulness in healthy men and women. J Appl Physiol 98: 822 828,
2005. First published November 19, 2004; doi:10.1152/japplphysiol.
01208.2003.This study used a modified CO2 rebreathing procedure
to examine the effect of gender on the chemoreflex control of
breathing during wakefulness in healthy men (n 14) and women
(n 14). Women were tested in the follicular phase of the menstrual
cycle. During rebreathing trials, subjects hyperventilated to reduce the
partial pressure of end-tidal CO2 (PETCO2) below 25 Torr and were
then switched to a rebreathing bag containing a normocapnic hypoxic
or hyperoxic gas mixture. During the trial, PETCO2 increased, while O2
was maintained at a constant level. The point at which ventilation
began to rise as PETCO2 increased was identified as the ventilatory
recruitment threshold (VRT). Ventilation below the VRT was measured, and the slope of the ventilatory response above the VRT was
determined. Gender had no effect on the hyperoxic or hypoxic VRT
for CO2. Central chemoreflex sensitivity was significantly greater in
men than women but not after correction for forced vital capacity.
Measures of peripheral chemoreflex sensitivity were similar between
genders. However, the slope of the tidal volume (VT) response to
hyperoxic and hypoxic CO2 rebreathing (corrected and uncorrected)
was greater in men than women, respectively. We conclude that
central chemoreflex sensitivity is greater in men compared with
women as reflected by differences in ventilatory (uncorrected) and VT
(corrected and uncorrected) responses to CO2. However, gender has
no significant effect on the central chemoreflex VRT for CO2. The
peripheral chemoreflex control of breathing during wakefulness is
similar between men and women.

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

J Appl Physiol VOL

A 12-bit analog-to-digital converter (DAQCard-6062E, National

Instruments) digitized the continuous analog output signals from all
monitoring devices for computer analysis using custom-written software (LabVIEW, National Instruments). The data-acquisition soft E, f, VT, PETCO2,
ware calculated breath-by-breath measures of V
PETO2, SaO2, and HR.
Data analyses. Data from rebreathing experiments were imported
to an analysis program (LabVIEW, National Instruments) designed
specifically for this purpose (J. Duffin, personal communication).
Barometric pressure and room temperature were entered, and measured volumes were corrected to body temperature and pressure,
saturated (BTPS). Data from the first equilibration at the start of
rebreathing and any aberrant points detected by the data-acquisition
software during the experiments were excluded from further analysis.
Subsequently, breath-by-breath PETCO2 was plotted against time and
fitted with a least squares regression line, whose slope depends on the
CO2). The equation for this line
metabolic rate of CO2 production (V
provided a predicted value of PETCO2 vs. time, thereby minimizing
E, VT, and f
interbreath variability due to measurement. Thereafter, V
were plotted against the predicted PETCO2.
Each of these plots was fitted with a model made up of the sum of
two segments separated by one breakpoint. All segments were fitted
through an iterative process whereby the breakpoint and other parameters were varied to obtain an optimal fit to the observed data by
minimizing the sum of squares (Levenberg-Marquardt algorithm)
using commercial software (Sigmaplot 7.0, SPSS). Figure 1 is an
E response of a representative
example of the lines fitted to the V
subject during an isooxic hyperoxic CO2 rebreathing procedure. The
first segment of the response was an exponential decline to a final
E, VT, and
value (i.e., basal). This value was taken as a measure of V
f below the VRT for CO2, respectively. Rarely, a short-term potentiation of breathing was observed after hyperventilation, and its waning
was modeled as an exponential decay.
E, VT, and f began to rise in a linear fashion
The point at which V
in conjunction with a rise in PETCO2 was taken as the VRT for CO2
(Fig. 1). On the basis of the modeling of Duffin et al. (9), we assumed
that the VRT measured under hyperoxic conditions originated from
the central chemoreflex alone, because hyperoxia abolishes virtually

Fig. 1. An example of the ventilatory response to progressive hypercapnia

while O2 was maintained at 150 Torr in a representative subject. Note the
measurement of basal ventilation, the ventilatory recruitment threshold, and
chemoreflex sensitivity. PETCO2, end-tidal PCO2. See text for details.

98 MARCH 2005

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cycle status, female subjects identified the first day of their last
menstrual cycle and the average length of their cycle. This approach
has been validated in our laboratory by using plasma progesterone
measurements (23). The study protocol and consent form were approved by the Research Ethics Board, Faculty of Health Sciences,
Queens University, and all subjects provided written consent.
Basic physical measurements included height and body mass,
forced vital capacity (FVC), forced expired volume in 1 s (FEV1), and
peak expiratory flow (model S-301, Pneumoscan). Body mass index
(BMI) was calculated as body mass/height2 (kg/m2). Body surface
area (BSA; m2) was calculated from height and body mass measurements. All female subjects were tested in the FP (range: 213 days
from the first day of menstruation) of the menstrual cycle when
circulating estrogen and progesterone levels are low and gender
differences in endocrine status are minimized.
Modified rebreathing protocol. Volunteers abstained from aerobic
and muscular conditioning exercise as well as caffeine and alcohol on
the day of testing. Two rebreathing experiments, each separated by at
least 45 min, were completed in the morning (AM) and evening (PM)
of the same day. AM and PM trials were separated by 12 h.
A modified version of Reads (24) rebreathing procedure that
includes prior hyperventilation and maintenance of a constant (i.e.,
isooxia) end-tidal O2 tension (PETO2) was used to evaluate central and
peripheral chemoreflex control characteristics (9). During each trial,
subjects breathed room air for 5 min, using a slow and deliberate
breathing pattern to avoid the short-term potentiation effect described
by Folgering and Durlinger (10). Prior hyperventilation lowered the
body stores of CO2 below 25 Torr, thereby allowing the VRT to be
identified as the partial pressure of end-tidal CO2 (PETCO2) increased
from hypo- to hypercapnia. Furthermore, prior hyperventilation permits measurement of the ventilatory response below this threshold,
independent of the ventilatory chemoreflexes (i.e., basal), estimating
behavioral drives (29). After hyperventilation, subjects were switched
from room air to a rebreathing bag containing a normocapnic (42
Torr) hypoxic or hyperoxic gas mixture. Rebreathing began with three
deep breaths, producing rapid equilibration of the PCO2 in the bag,
lungs, and arterial blood to that of the mixed venous blood. The
equilibration was verified by a plateau in PETCO2 and was a prerequisite for continuing the test. On equilibration, subjects were asked to
breathe as they felt the need.
During rebreathing, PETCO2 increased while isooxia was maintained, under computer control, at a constant hyperoxic (150 Torr) or
hypoxic (50 Torr) level. In its hyperoxic form, the modified rebreathing procedure measures central chemoreflex sensitivity equivalent to
that measured using Reads original technique (19). Continuous measures of arterial blood O2 saturation (SaO2) (model OXI, Radiometer,
Copenhagen, Denmark) and heart rate (HR) (Max-1 electrocardiograph, Marquette) were obtained throughout each test. Rebreathing
was terminated if ventilation exceeded 100 l/min, PETCO2 exceeded 60
Torr, SaO2 fell below 70%, and/or subject discomfort.
Rebreathing apparatus. During rebreathing, subjects wore nose
clips and breathed through a mouthpiece connected to one side of a
three-way T-shaped manual directional valve (11.9-ml dead space;
model 2100a, Hans Rudolph) that permitted switching from room air
to the rebreathing bag. Subjects rebreathed from a 10-liter plastic bag
connected to a volume turbine (model VMM-1100, Alpha Technologies). The volume turbine was coupled to the expiratory end of the T
valve and monitored breath-by-breath changes in minute ventilation
E), tidal volume (VT) and respiratory rate (f). A sampling tube
(V
connected to the mouthpiece side of the T valve permitted continuous
analysis of PETCO2 and PETO2 by using a respiratory mass spectrometer
(model MGA 1100, Perkin-Elmer) at a sample flow rate of 64 ml/min.
Isooxia was maintained by a flow of 100% O2 to the bag side of the
T valve. The testing system was calibrated with gases of known
concentrations and a standard 3.004-liter volume syringe (model
1922, CS-3000 AM Systems) before each rebreathing test.

823

824

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

RESULTS

Physical characteristics. Mean age and BMI were similar

between men and women (Table 1). As expected, body height,
body mass, peak flow, FEV1, FVC, and BSA were significantly
greater in men than women. FEV1/FVC was significantly
greater in women than men. All women were tested within the
FP of the menstrual cycle (8.4 1.0 days from the first day of
menstruation).
Effect of gender on chemoreflex control characteristics.
Significant correlations were observed between body height,
FVC, FEV1, BSA, and both hyperoxic and hypoxic chemoreflex characteristics (Table 2).
J Appl Physiol VOL

Table 1. Physical characteristics of subjects

Variable

Men (n 14)

Women (n 14)

Age, yr
Body height, cm
Body mass, kg
BMI, kg/m2
Peak flow, l/s
FVC, liters
FEV1, liters
FEV1/FVC, %
BSA, m2

25.41.12
1811.8
83.43.29
26.10.9
7.430.18
5.020.14
3.790.12
75.72.26
2.070.05

22.90.66
1641.9*
653.00*
24.10.9
4.980.27*
3.290.14*
2.790.11*
85.52.58*
1.720.04*

Values are means SE; n, no. of subjects. BMI, body mass index; FVC,
forced vital capacity; FEV1, forced expired volume in 1 s; BSA, body surface
area. *Significant between-gender difference; P 0.05.

E and VT were significantly greater in men than

Basal V
women under both hyperoxic and hypoxic conditions (Table
3). However, these differences were abolished after the data
were normalized for FVC (F 0.50, P 0.48). There was no
main effect of gender on the basal f response (F 0.82, P
0.37) during hyperoxic and hypoxic rebreathing.
E (F 2.39, P 0.13)
No main effect of gender on the V
and VT (F 2.58, P 0.11) recruitment threshold for CO2
was observed, independent of the level of isooxia (Table 3). In
contrast, the CO2 recruitment threshold for f was significantly
greater in men than women under both isooxic rebreathing
conditions.
E and VT chemoreflex sensitivities to CO2 were signifiV
cantly greater in men than women under both hyperoxic and
hypoxic rebreathing conditions (Table 3). When comparisons
were made between genders after normalization for FVC,
E chemoreflex sensitivity was not significantly different
mean V
between genders (F 0.10, P 0.76), independent of the
level of O2. In contrast, gender differences in the sensitivity of
the VT response to CO2 during hyperoxic and hypoxic trials
persisted after normalization for FVC. In this regard, elimina E response to CO2 at high
tion of the gender difference in the V
and low levels of O2 could be explained by the effect FVC has
on f because gender differences in the VT response to CO2
remain after correcting for FVC.
Gender had no effect on the peripheral chemoreflex contri E (corrected and uncorrected), VT
bution to the increase in V
(corrected and uncorrected), or f during isooxic hypoxic CO2
rebreathing (Table 4). The observed difference in the uncor E response to hypoxic-hypercapnia may be attributed
rected V
to an effect of gender on central chemoreflex sensitivity.
Effects of isooxic PETO2 (150 vs. 50 Torr) on chemoreflex
control characteristics. There was no main effect of isooxia on
E (F 0.32, P 0.57), VT (F 0.44, P 0.51), or
basal V
f (F 0.01, P 0.93), irrespective of gender (Table 3). The
E and VT was lower, whereas
CO2 recruitment threshold for V
chemoreflex responsiveness was higher, during hypoxic vs.
hyperoxic rebreathing trials, independent of gender. In contrast, the f recruitment threshold for CO2 was significantly
greater, whereas f chemoreflex responsiveness was identical
(F 0.81, P 0.38), during hyperoxic and hypoxic rebreathing trials, independent of gender.
E,
Correlations between chemoreflex characteristics. Basal V
E chemosensitivity estimates obtained from all
VRT, and V
subjects were pooled and grouped according to the isooxic
rebreathing condition (hyperoxic or hypoxic). Correlations

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all peripheral chemoreflex activity (7). Moreover, it was assumed that

the VRT measured under hypoxic conditions derived from the sum of
the central and peripheral chemoreflexes.
E, VT, and f responses above the
The slope of the line fitted to V
VRT was taken as a measure of chemoreflex sensitivity to increases in
E, VT, and f
PETCO2 (Fig. 1). We assumed that the slope of the V
response measured during hyperoxic trials represented central chemoreflex sensitivity, whereas the slope recorded from hypoxic trials
represented the additive effects of central and peripheral chemoreflex
stimulation (9). Thus the slope of the hyperoxic response was subtracted from the slope of the hypoxic response for each subject to
isolate peripheral chemoreflex sensitivity. Because lung volumes vary
in proportion to body size and are usually higher in men than women,
E and VT were corrected for body
basal and sensitivity measures of V
height, body mass, BSA, BMI, FEV1, and FVC, respectively. Comparisons of f responses (i.e., basal, VRT, and sensitivity) were made
between nine women and six men.
Minimum sample size estimate. Sensitivity and VRT measures from
hyperoxic and hypoxic rebreathing conditions were selected as important outcome data for between-gender effects. Minimum sample
size was calculated on the basis of 80% power and a confidence
interval of 0.05 using an unpaired subject formula for the comparison
of means (22). Sample sizes capable of detecting between-gender
differences of 1.5 l min1 Torr1 and 2 Torr were estimated for
sensitivity and VRT parameters, respectively, using standard deviations from Mateika and Ellythy (16). The resulting critical sample
sizes were estimated to be 6 and 9 for hyperoxic and hypoxic
sensitivity parameters and 10 and 9 for hyperoxic and hypoxic VRT
parameters, respectively. Therefore, a sample size of 14 subjects per
group was adequate for this study.
Statistical analyses. Students t-statistics for independent samples
were used for simple between-gender comparisons of physical characteristics. A three-way ANOVA was used to detect main effects for
gender, isooxia, and time of day among the calculated parameters.
Time of day had no effect on the mean data, independent of isooxia.
Furthermore, significant AM-PM correlations (Pearson r) were observed for all hyperoxic (range: r 0.45 0.75; P 0.01) and
hypoxic (range: r 0.67 0.78; P 0.01) rebreathing responses.
Therefore, to reduce random intrasubject variability, data collected
during AM and PM trials were averaged for each subject. A two-way
ANOVA was used to detect differences between genders (men vs.
women) and levels of O2 (hyperoxia vs. hypoxia) on the mean data.
The post hoc test of Tukey (honestly significant difference) was used
to identify between-gender differences under each experimental condition.
Unpaired Students t-statistics were used to identify significant
between-group differences in peripheral chemoreflex sensitivity. Pearson product-moment correlation coefficients (Pearson r) were calculated between hyperoxic and hypoxic chemoreflex parameters and
subject physical characteristics, respectively. Results for all statistical
tests were considered significant if P 0.05. Values are presented as
means SE.

825

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

Table 2. Correlations between hyperoxic and hypoxic rebreathing responses (all subjects) and
anthropometric and spirometric variables

Basal (subthreshold)
E, l/min
V
VT, ml (BTPS)
Sensitivities to CO2
E, lmin1Torr1
V
1

VT, mlmin

Torr

Condition

Age, yr

Height, cm

Weight, kg

Hyperoxic
Hypoxic
Hyperoxic
Hypoxic

0.32
0.22
0.19
0.02

0.44*
0.36
0.44*
0.41*

0.28
0.34
0.30
0.38*

Hyperoxic
Hypoxic
Hyperoxic
Hypoxic

0.29
0.11
0.15
0.26

0.45*
0.39*
0.74
0.69

0.36
0.20
0.72
0.54

BMI, kg/m2

FVC, liters

FEV1, liters

BSA, m2

0.07
0.22
0.07
0.20

0.50*
0.47*
0.50
0.57

0.44*
0.44*
0.48
0.53

0.34
0.37
0.34
0.40*

0.15
0.01
0.37
0.17

0.44
0.37
0.75
0.64

0.45*
0.45*
0.78
0.72

0.42*
0.27
0.77
0.61

E, minute ventilation; VT, tidal volume. *Significant correlation at the P 0.05 level. Significant correlation at the P 0.01 level.
V

DISCUSSION

The primary findings of this study suggest that central

chemoreflex sensitivity is greater in men than women as
E (uncorrected) and VT (both
reflected by differences in V
corrected and uncorrected) responses to hyperoxic and hypoxic
CO2 rebreathing. However, the central chemoreflex VRT for
CO2 is similar in men compared with women. In addition,
gender has no significant effect on the peripheral chemoreflex
control of breathing during wakefulness when women are
tested in the FP of their menstrual cycle.
Critique of methods. The benefits of the modified rebreathing procedure have been described previously (18, 19). Despite
its advantages, the modified rebreathing technique may initiate
responses, such as induction of short-term potentiation, respi-

ratory muscle fatigue, changes in cerebral blood flow (CBF),

and state of arousal and/or anxiety, that could influence the
ventilatory response after voluntary hyperventilation (14,
16, 18).
Short-term potentiation after hypocapnic hyperventilation is
seldom observed during wakefulness in healthy subjects (14,
15, 19). When it is observed, the time constant is much less
than the time required to reach the VRT for CO2 (14 16, 19).
Furthermore, Morelli et al. (20) recently demonstrated that the
time constant of the poststimulus potentiation induced by
hypocapnic hyperventilation was not significantly different
between men and women. Similarly, Jordan et al. (11) found
no evidence of a gender or menstrual cycle phase effect on the
time constant of the ventilatory decline after hypoxic and
hypercapnic ventilatory stimulation, respectively. These findings suggest that short-term potentiation had no effect on the
VRT calculated from hyperoxic and hypoxic rebreathing trials,
independent of gender within the present study.
It is unlikely that the ventilatory response to hyperoxic and
hypoxic CO2 rebreathing was influenced by respiratory muscle
fatigue because subjects breathed through a low-resistance
apparatus for a shorter period of time than that previously
shown to cause diaphragmatic fatigue under loaded conditions

Table 3. Effects of gender on the ventilation, tidal volume, and breathing frequency response to CO2
under hyperoxic and hypoxic rebreathing conditions
Hyperoxia

Basal (subthreshold)
E, l/min
V
F/FVC, lmin111
V
VT, ml (BTPS)
VT/FVC, ml/l
f, breaths/min
Ventilatory recruitment
threshold for CO2
E, Torr
V
VT, Torr
f, Torr
Sensitivities to CO2
E, lmin1mmHg1
V
E/FVC, lmin1mmHg1l1
V
VT, mlmin1mmHg1
VT/FVC, mlmin1mmHg1l1
f, breathsmin1mmHg1

Hypoxia

Women

Men

Women

Men

9.91.1
3.10.4
73146
22920
14.21.1

16.32.1*
3.30.4
1,070156*
20928
16.11.9

10.51.3
3.20.4
78459
24218
13.91.3

17.72.1*
3.60.5
1,159126*
22922
16.21.9

47.50.6
46.80.8
48.81.0

49.30.5
48.40.6
50.60.5*

43.80.6
43.30.6
46.10.9

43.90.7
43.80.5
48.60.6*

2.830.27
0.900.10
102.588.80
31.562.39
1.500.25

4.350.39*
0.890.08
220.0920.51*
43.713.72*
0.950.15

4.160.50
1.270.14
157.0115.68
47.894.35
1.450.28

5.980.69*
1.220.15
335.7243.30*
66.998.25*
1.500.26

Values are means SE. f, Respiratory rate. *Significant between-gender difference, P 0.05.
J Appl Physiol VOL

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among these characteristics were tested by using a Pearson

E and
product-moment correlation analysis. Neither basal V
E chemosensitivity
E and V
VRT (r 0.34, P 0.08) or basal V
(r 0.36, P 0.06) were significantly correlated for hyper E and VRT were not significantly
oxic tests. Similarly, basal V
correlated (r 0.07, P 0.72) for hypoxic tests. However, a
E chemosensi E and V
significant correlation between basal V
tivity (r 0.48, P 0.01) was identified for hypoxic trials.

826

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

Table 4. Effect of gender on the central and peripheral chemoreflex contribution to the ventilatory,
tidal volume, and breathing frequency response to CO2
Central Chemoreflex
Sensitivities to CO2

Women

Men

E, lmin1mmHg1
V
E/FVC, l/min1mmHg1l1
V
VT, mlmin1mmHg1
VT/FVC, mlmin1mmHg1l1
f, breathsmin1mmHg1

2.830.27
0.900.10
102.588.80
31.562.39
1.500.25

4.350.39*
0.890.08
220.0920.51*
43.713.72*
0.950.15

Peripheral Chemoreflex
P Value

0.48
0.37

Women

Men

P Value

1.320.31
0.380.08
54.4312.06
16.333.61
0.160.24

1.640.57
0.340.12
115.6333.74
23.286.41
0.720.49

0.63
0.77
0.10
0.35
0.28

Values are means SE. *Significant between-gender difference, P 0.05.

J Appl Physiol VOL

have been expected. This was not the case. Furthermore,

environmental factors known to influence the state of arousal
E (29) were controlled and
(i.e., lights, noise) and thus V
maintained for each subject and trial, respectively.
It could be argued that random intrasubject variability due to
testing at different times within the same day may have masked
systematic differences between genders. However, we observed significant AM-PM correlations for all hyperoxic and
hypoxic responses, which demonstrates sufficient reproducibility within the pooled data. In addition, AM and PM responses
were averaged for each subject to further reduce both biological and methodological variability, thereby increasing statistical power and the probability of finding between-gender
differences. Furthermore, minimum sample size calculations
were made before the study by using standard deviations from
a recent report using similar subjects and identical methods
(16) that verified the adequacy of statistical power in the
present study. Therefore, it is unlikely that random intrasubject
variability, subject familiarization, and/or other methodological factors influenced the interpretation of our results.
Ventilatory response to hypocapnia in men and women. To
our knowledge, we are the first to report that the ventilatory
response to hypocapnia (i.e., basal) is greater in men than
women during wakefulness. This effect was attributed to a
E
higher basal VT in male volunteers. However, when basal V
and VT were corrected for FVC, the mean responses were
identical. Therefore, the higher FVCs in men compared with
women accounted for the difference in the uncorrected data.
The ventilatory response to hypoxia in the presence of
hypocapnia has been studied with conflicting results. Findings
from our study and previous investigations (6, 9, 19) have
E is similar between hyperoxic and hypoxic trials
shown that V
when PETCO2 is below the recruitment threshold. Duffin et al.
(9) recently demonstrated that the ventilatory responses to
hypocapnia in the presence of isooxic PETO2 values of 150, 100,
80, 60, and 40 Torr were not significantly different. Thus
current evidence suggests that hypoxia has no independent
E when PETCO2 is below the VRT. These data
effect on V
support the hypothesis that ventilation is influenced by a
wakefulness drive to breathe (29), independent of the ventilatory chemoreflexes.
Effect of gender on the central chemoreflex. The existence of
gender differences in the central chemoreflex control of breathing is controversial. Regensteiner et al. (26) have reported that
gender has no effect on absolute measures of central chemoreflex sensitivity, whereas other studies (1, 21, 28, 30, 34, 35, 37)
have reported that the sensitivity of the central chemoreflex is
greater in men than women, regardless of menstrual cycle

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(3). Subjects also rested for at least 45 min between trials to

avoid respiratory muscle fatigue.
Alterations in CBF due to hypoxia and hypercapnia could
affect the sensitivity and/or VRT for CO2 by modifying the
arteriovenous difference and thus the relationship between
PETCO2 and brain tissue PCO2 (PtiCO2). Although this is a
concern when steady-state methods are used (18), it is of lesser
importance when the modified rebreathing procedure is employed (18, 24). Thus the initial equilibration of CO2 at the
start of rebreathing ensures that changes in CBF do not affect
the arteriovenous difference via washout of PtiCO2 and consequently the slope of the ventilatory response to CO2 (25). In
addition, because the subject and bag are a closed system, both
blood circulation and pulmonary ventilation act as mixing
forces to reduce any differences between PETCO2 and PtiCO2
induced by voluntary hyperventilation (18).
The modified rebreathing procedure permits direct measurement of the VRT for CO2 mediated by the central and peripheral chemoreflex. In contrast, other methods identify the chemoreflex threshold by extrapolation of the linear relation be E and PETCO2 to the x-axis (7). Consequently, the
tween V
threshold is taken as the PETCO2 axis intercept and/or apneic
threshold (7). If the extrapolated threshold were a true estimate
of the apneic threshold, then the VRT for CO2 measured using
E,
the modified rebreathing procedure would depend on basal V
independent of the level of O2. However, a significant correlation was not observed in this study or previous studies (14,
E have
16). In addition, exercise-induced increases in basal V
no effect on the VRT for CO2 mediated by either the central (5)
or peripheral chemoreflex (8).
An additional limitation of the extrapolation method is that
subjects with lower chemoreflex sensitivities will inevitably
have much lower extrapolated thresholds than those with
higher chemoreflex sensitivities. Findings from our study and
past investigations (15, 16) have shown that no significant
correlation exists between threshold and sensitivity parameters.
Therefore, the modified rebreathing procedure provides a more
accurate and representative estimate of the VRT for CO2 than
alternative or traditional methods.
Performing a novel task (i.e., voluntary hyperventilation,
breathing through a mouthpiece) without familiarization may
have increased our subjects state of arousal and/or anxiety and
consequently the ventilatory response to CO2. Although basal,
VRT, and sensitivity responses were higher than those reported
by Duffin et al. (9), they are consistent with ongoing studies in
Duffins laboratory (J. Duffin, personal communication) as
well as our own (D. Jensen and L. A. Wolfe, unpublished
observations). If a lack of subject familiarity had had an effect
on our results, differences between AM and PM trials would

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

J Appl Physiol VOL

Effect of gender on the ventilatory patterning response to

CO2. Inconsistencies in the literature regarding the effect of
gender on the chemoreflex control of breathing may exist
because VT and f were not considered. As previously discussed, the slope of the VT response to CO2 (both corrected and
uncorrected) at high and low levels of O2 were significantly
greater in men than women. In addition, the f recruitment
threshold for CO2 was significantly lower in women, independent of the level of O2, even though the slope of the f response
was similar. However, gender had no effect on the peripheral
E (corrected and uncorchemoreflex contribution to the V
rected), VT (corrected and uncorrected), and f response during
hypoxic CO2 rebreathing. These findings are consistent with
Sajkov et al. (27) and suggest that the ventilatory response to
CO2, mediated by the central chemoreflex, is more critically
dependent on an increase in f than VT in women than men. This
may be due, at least in part, to an effect of gender and/or sex
hormones on central neuromodulatory mechanisms that influence the regulation of respiratory rhythm (2). Future studies are
needed to confirm this hypothesis.
Implications for SDB. Recent epidemiological studies (4, 36)
have identified male gender as a predisposing risk factor for the
development of SDB. Differences in airway morphology, fat
distribution, endocrine status, and/or the chemoreflex control
of breathing may explain the greater incidence of SDB in men
compared with women (12).
Chemoreflex drives are the sole support of rhythmic breathing during sleep, as behavioral drives present during wakefulness are withdrawn (31). Zhou et al. (37) recently demonstrated
that both chemosensitivity and the apneic threshold for CO2 are
greater in men than women. These differences, in combination
with the observation that men require a significantly smaller
reduction in PETCO2 to induce central apnea and/or hypopnea
than women (37), may explain the high male prevalence of
SDB.
However, we have shown, in accordance with previous
investigations (15, 16, 20), that behavioral drives to breathe
have no effect on either the central or peripheral VRT for CO2.
Thus our data suggest that gender has no effect on the central
and peripheral VRT for CO2, proceeding withdrawal of behavioral stimuli during sleep. Therefore, gender-related differences in the central and peripheral VRT for CO2 may not
contribute to the greater incidence of SDB in men relative to
women.
We have demonstrated that central chemoreflex sensitivity is
greater in men than women during wakefulness. Therefore,
men may be more susceptible to ventilatory overshoot and a
more pronounced hypocapnia (i.e., decrease in central respiratory drive, initiation and prolongation of recurrent apneic
events) on apnea termination than women, despite similar
central and peripheral VRTs for CO2. However, body size and
CO2 were significantly greater in men compared
therefore V
with women. Thus the degree of ventilatory overshoot required
to reduce PETCO2 below the central and peripheral VRT for CO2
during sleep is also greater in men than women because of the
increasing hyperbolic relation between alveolar CO2 and alve CO2 (7). Taken together, genderolar ventilation at a higher V
related differences in the central and peripheral chemoreflex
control of breathing may not solely explain the pathogenesis
and high male prevalence of SDB (12, 36).

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status (20, 35, 37). In keeping with these latter results, we have
E (uncorrected) and VT (corrected and
shown that both V
uncorrected) responses to isooxic hyperoxic CO2 rebreathing
are greater in men than women. Thus our data support an effect
of gender on central chemoreflex sensitivity that may be
attributed to increased levels of circulating testosterone in men
relative to women. In this regard, laboratory animals treated
with testosterone demonstrate significant increases in central
chemoreflex responsiveness (33).
Only a few studies have examined the effect of gender on the
central chemoreflex threshold for CO2. Most studies have
shown that chemoresponsiveness, and consequently the apneic
threshold for CO2, is greater in men than women (21, 35, 37),
whereas Regensteiner et al. (26) reported that no gender
difference exists. Furthermore, Morelli and coworkers (20)
recently showed that gender has no effect on the VRT for CO2
estimated from isooxic hyperoxic CO2 rebreathing trials. Our
data confirm these latter results as estimates of the central
chemoreflex VRT for CO2 did not differ between genders.
Effect of gender on the peripheral chemoreflex. Several
studies have used the progressive isocapnic hypoxia procedure
to examine the effect of gender on peripheral chemoreflex
sensitivity (1, 13, 26, 34, 35). However, this procedure is
problematic because neither the sensitivity nor threshold of the
interaction between hypoxia and CO2 is apparent from the
E and PETO2. Moreover, the
curvilinear relation between V
PETCO2 chosen to represent isocapnia may be above or below
the VRT for CO2, resulting in an over- or underestimation of
peripheral chemoreflex sensitivity, respectively. For these reasons, we employed the modified rebreathing procedure that, in
its hypoxic form, permits measurement of the threshold and
sensitivity of the ventilatory response to CO2, mediated by the
sum of both central and peripheral chemoreflexes.
E response to CO2 during hypoxic
The sensitivity of the V
trials was significantly greater in men than women but not after
correction for FVC. However, gender differences in the slope
of the VT response persisted even after correction for FVC.
E
Because the peripheral chemoreflex contribution to the V
(corrected and uncorrected), VT (corrected and uncorrected),
and f responses were not significantly different between genders, we concluded that only central chemoreflex sensitivity is
different between men and women. White et al. (35) reported
that peripheral chemoreflex sensitivity (even after correction
for BSA) was significantly greater in men compared with
women. Similarly, Morelli et al. (20) recently demonstrated
that the ventilatory response to isooxic hypoxic CO2 rebreathing is significantly greater in men than women. However, it is
unclear whether gender had an effect on peripheral chemoreflex sensitivity, as Morelli et al. failed to determine the peripheral chemoreflex contribution to the hypoxic-hypercapnic ventilatory response. Nevertheless, our findings are consistent with
the majority of previous investigations showing that gender has
no significant effect on peripheral chemoreflex sensitivity (1,
13, 26, 27, 32, 34). Moreover, findings from our study and a
past investigation (20) demonstrate that the peripheral chemoreflex VRT for CO2 is not significantly different between
genders. Taken together, we conclude that gender has no
significant effect on the peripheral chemoreflex control of
breathing.

827

828

EFFECT OF GENDER ON THE VENTILATORY RESPONSE TO CARBON DIOXIDE

Summary. The present study supports the hypothesis that

central chemoreflex sensitivity is greater in men than women.
However, gender has no effect on the central chemoreflex VRT
for CO2. There is no significant effect of gender on the
peripheral chemoreflex control of breathing during wakefulness when women are tested in the FP of the menstrual cycle.
Further study is recommended to confirm and clarify the effect
of gender and sex hormones on the chemoreflex and neural
control of breathing during wakefulness and sleep.
ACKNOWLEDGMENTS
We acknowledge the technical support of Dr. James Duffin, Safraaz
Mahamed (Respiratory Research Group, University of Toronto), and Ken Hall
(Queens University). We thank Lindsay A. Nettlefold for contribution to data
collection.
GRANTS

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