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PubMedDate not supplied

Human exposure to sulfur dioxide and ozone: absence of a synergistic effect.

Studies of the human health effects of exposure to a combination of ozone and sulfur dioxide have produced somewhat conflicting results; the possibility of a synergistic enhancement of toxicity when the two gases are present simultaneously remains equivocal. We evaluated the effects of 0.40 ppm sulfur dioxide, 0.40 ppm ozone, and the combination of these two under one environmental condition (25 degrees C and 45% relative humidity). Subjects alternately walked and rested during a 2-hr exposure. Subjects exposed to filtered air or to 0.40 ppm sulfur dioxide showed no significant changes in pulmonary function. When exposed to either ozone or ozone plus sulfur dioxide, significant decreases in maximum expiratory flow, forced vital capacity, and inspiratory capacity were observed. There were no significant differences in response between ozone alone and ozone plus sulfur dioxide exposures, thus, in our subjects on synergistic effects were discernible.

Adolescent↗

PubMed2006

Plethysmography and impulse oscillometry assessment of tiotropium and ipratropium bromide; a randomized, double-blind, placebo-controlled, cross-over study in healthy subjects.

AIMS: Spirometry, plethysmography and impulse oscillometry (IOS) measure different aspects of lung function. These methods have not been compared for their ability to assess long- and short-acting anticholinergic agents. We therefore performed a double-blind, placebo-controlled, four-way cross-over study in 30 healthy subjects. METHODS: Single doses of tiotropium bromide (Tio) 54 and 18 mcg, ipratropium bromide (IB) 40 mcg and placebo were administered. Specific conductance (sGaw), total lung capacity (TLC), inspiratory capacity (IC) and residual volume (RV) were measured using plethysmography, while IOS measured resistance (R5-25) and reactance (RF and X5). Pulmonary function was measured for 26 h post dose. RESULTS: Tio caused significant improvements in sGaw, forced expiratory voume in 1 s (FEV(1)), maximum mid-expiratory flow (MMEF) and R5-R25 at time points up to 26 h, with no clear differences between doses. IB improved the same parameters, but only up to 8 h. The weighted mean change (0-24 h) caused by Tio 54 mcg compared with placebo for FEV(1) was 240 ml (95% confidence interval 180, 300), while for sGaw the ratio of geometric means (Tio compared with placebo) was 1.35 (1.28, 1.41). Neither drug caused consistent statistically significant changes in RF, forced vital capacity, TLC or IC over 26 h. RV was significantly improved from 8 to 24 h by Tio 54 mcg only. CONCLUSIONS: In addition to spirometry, IOS resistance measurements and sGaw can distinguish between the effects of long- and shortacting anticholinergic effects in healthy subjects.

Adult↗

PubMed2004

Respiratory function in pregnancy at sea level and at high altitude.

OBJECTIVE: To determine the effect of pregnancy on respiratory function in a non-Caucasian group and determine whether there was an interaction between pregnancy and altitude of residence. DESIGN: Prospective cross sectional study. SETTING: Antenatal clinics in Peru, at sea level in Lima and at high altitude in Cerro de Pasco. SAMPLE: Peruvian women with singleton pregnancies; 122 living at sea level and 192 living at 4300 m altitude in the Peruvian Andes. At each location, 19 non-pregnant women were also studied. METHODS: Respiratory function was measured in pregnant and non-pregnant women living at sea level and at 4300 m. MAIN OUTCOME MEASURES: Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEFR), total lung capacity (TLC), inspiratory capacity (IC), residual volume (RV), expiratory residual volume (ERV) and functional residual capacity (FRC). RESULTS: At sea level, RV and TLC were higher in the third compared with the first trimester (P < 0.05). At high altitude, FEV1 (P < 0.01), ERV (P < 0.01) and FRC (P < 0.01) were lower in the third compared with the first trimester. Pregnant and non-pregnant women at high altitude were 4 cm shorter (P < 0.0001) and had larger lung volumes (P < 0.01); their total lung capacities were approximately 1 L greater than women living at sea level (P < 0.0001). CONCLUSION: These results suggest that the effect of pregnancy on the respiratory function of healthy women is influenced by altitude of residence.

Altitude↗

PubMed1990

Lung function 8-18 years after intermittent positive pressure ventilation for hyaline membrane disease.

Lung function and respiratory symptoms were studied in 40 children aged 8-18 years who had been ventilated for hyaline membrane disease after birth; 11 had had bronchopulmonary dysplasia. Also studied were 38 age matched children who had had hyaline membrane disease but had not required ventilation, 25 unmatched children who were born prematurely but did not develop hyaline membrane disease, and 39 randomly selected pupils of similar age. There was no difference in thoracic gas volume, total lung capacity, inspiratory vital capacity, residual volume, or transfer factor for carbon monoxide between the groups. Respiratory symptoms during the three years before the study and the frequency of clinically diagnosed asthma in patients and their family were similar in all the children with hyaline membrane disease irrespective of whether they had been ventilated or had had bronchopulmonary dysplasia. The children with bronchopulmonary dysplasia, however, had a lower forced expiratory volume in one second (FEV1) before bronchodilator (73% predicted) than the other groups (88-95% predicted). Children who had required ventilation had lower values for specific airways conductance (sGaw) and a greater increase in FEV1 (delta FEV1) after salbutamol (13%) than non-ventilated children (6%); delta FEV1 was associated with the peak pressure of intermittent positive pressure ventilation, a family history of asthma and a history of wheezing, recurrent respiratory illnesses, and a doctor's diagnosis of asthma during the three years before the study. These findings indicate that after eight years of age patients with bronchopulmonary dysplasia have more reversible airways obstruction, compatible with increased bronchial smooth muscle tone.

Adolescent↗

PubMed1991

Responses of baboons to prolonged hyperoxia: physiology and qualitative pathology.

Cardiopulmonary responses to prolonged hyperoxia and their relationships to the development of lung pathology have not been fully characterized in primates. In this study, circulatory hemodynamics and pulmonary function, vascular permeability, and leukocyte sequestration were measured in male baboons after 100% O2 exposure and related to ultrastructural changes of lung injury by electron microscopy. Three groups of animals were exposed to 100% O2 in an exposure cage for 40, 66, and 80 h, respectively. A fourth group of animals was exposed in a cage for 80 h and then anesthetized and ventilated with 100% O2 for additional time. These animals were exposed for a total duration of 110 h or until death from the injury. Physiological responses to hyperoxia were characterized by decreases in total lung capacity and inspiratory capacity at 80 and 110 h. A significant increase in pulmonary leukocyte accumulation was noted by 80 h. Extravascular lung water and permeability surface-area product increased at 80 and 110 h. Cardiac output and stroke volume also decreased, and systemic vascular resistance increased after 80 and 110 h of hyperoxia. Histopathological changes were present in the lungs of all but the 40-h exposure group. Animals exposed for 66 h showed endothelial injury and neutrophil accumulation. By 80 h, animals showed endothelial cell destruction, interstitial edema, and type I cell injury. At 110 h, animals showed substantial destruction of endothelial and type I epithelial cells, exposure of alveolar basement membrane, congestion of capillaries, and substantial interstitial edema. The data indicate that histological changes by electron microscopy precede physiological responses to hyperoxic pulmonary injury in baboons by as much as 14 h and that the physiological responses to early hyperoxic injury are relatively insensitive to the pathological injury.

Animals↗

PubMed2006

The effect of tiotropium on exacerbations and airflow in patients with COPD.

This randomised, double-blind, parallel-group, 1-yr study compared the effect of tiotropium 18 microg once daily (n=500) and placebo (n=510) on exacerbations, associated health resource use (HRU) and airflow limitation in chronic obstructive pulmonary disease (COPD) patients. The mean+/-sd number of exacerbations during the past year was 2.14+/-1.40, the mean weekly morning peak expiratory flow (PEF) was 259.6+/-96.1 L.min-1 and the mean forced expiratory volume in one second (FEV1) was 1.37+/-0.45 L. Tiotropium significantly delayed the time to first exacerbation by approximately 100 days, reduced the proportion of patients experiencing more than one exacerbation by 17%, and decreased the number of exacerbations by 35% and exacerbation days by 37% versus placebo. Tiotropium also decreased HRU versus placebo, as indicated by the significant reductions in the use of concomitant respiratory medications, antibiotics and oral steroids, and the number of unscheduled physician contacts. Mean weekly morning PEF improved significantly with tiotropium versus placebo from week 1 until the end of the study. At the end of the study, tiotropium significantly improved trough (pre-dose) FEV1, forced vital capacity, slow vital capacity and inspiratory capacity versus placebo. In conclusion, tiotropium reduced exacerbations and associated health resource use, and improved airflow over 1 yr in chronic obstructive pulmonary disease patients.

Aged↗

PubMed2006

Dyspnea during exercise in hyperbaric conditions.

INTRODUCTION: Length-tension and force-velocity characteristics of respiratory muscles and hyperinflation are the likely determinants of dyspnea in subjects exercising under hyperbaric conditions. We hypothesize that hyperinflation plays a minor role and that the reduced velocity of shortening of the respiratory muscles modulates dyspnea for any given pleural pressure. METHODS: We studied five normal subjects who performed an incremental exercise test on a cycloergometer in both normobaric (SL) and hyperbaric (4 ATA) conditions. We measured breathing pattern, inspiratory pleural pressure swing (Pessw), Delta Pes (i.e., the difference between the most and the less negative pleural pressures during tidal breathing), and dyspnea intensity (Borg score). End-expiratory lung volume (EELV) changes were evaluated by measuring changes in inspiratory capacity. Mean inspiratory flow (VT/TI) was used as an index of velocity of shortening of respiratory muscles. RESULTS: Compared with SL, at 4 ATA, peak exercise ventilation (VE) (84.5 vs 62.2 L x min(-1)) and VT/TI (2.99 vs 2.16 L x s)(-1) were lower, Pessw (30.9 vs 38.6 cm H2O) and Delta Pes (43.8 vs 62.2 cm H2O) were higher, and Borg score was not different (7.60 vs 8.20 au). EELV decreased progressively during exercise but remained higher than at SL. Borg score was greater for a same VE and lower for a same Delta Pes. VT/TI was lower for a same Pessw. The differences in EELV between SL and 4 ATA did not relate with the concurrent changes in Borg score. CONCLUSION: The results confirm our hypothesis that during exercise in hyperbaric conditions, decreased velocity of shortening of respiratory muscles modulates pressure-induced increases in dyspnea, with hyperinflation playing a minor role.

Adult↗

PubMedDate not supplied

Pulmonary function assessment in children and teenagers before and after surgical treatment for rheumatic valve disease.

OBJECTIVE: To assess pulmonary function in children and adolescents subjected to correction of rheumatic valve disease in order to quantify changes caused by factors inherent to surgery and rheumatic heart disease. METHODS: This was a longitudinal and quantitative intervention study, undertaken at a children's hospital that is a center of excellence for the state of Pernambuco (Instituto Materno Infantil de Pernambuco), between December 2004 and May 2005. Eighteen children suffering from rheumatic fever and indicated for surgery to repair or replace the mitral valve were assessed preoperatively and again on the first and fifth postoperative days. The parameters recorded were minute volume, rapid shallow breathing index, peak expiratory flow, forced vital capacity and inspiratory capacity. RESULTS: All patients were aged 8 to 17 years (mean 12.4+/-2.1), they had a mean body mass index of 16.1+/-2.2, and were weaned off invasive mechanical ventilation during the first 10 postoperative hours. All parameters had undergone significant deterioration on the first day (statistically significant, p < or = 0.01), demonstrating gradual improvement up to the last day of assessment, although, with the exception of minute volume which was no longer significantly different from the fourth day onwards (p > 0.01), without returning to baseline levels. CONCLUSION: We observed that the pulmonary dysfunction that results from this type of heart surgery is maintained until at least the fifth postoperative day. It appears that this dysfunction is influenced by the pain and mechanical alterations caused by sternotomy and reduced pulmonary compliance post surgery.

Adolescent↗

PubMed2003

Effect of 2-5 years of tobacco smoking on ventilatory function tests.

Smoking is a pernicious scourge of the world today. There is paucity of literature on the effect of acute smoking on ventilatory functions. The present work is undertaken to study the effect of 2-5 years of tobacco smoking on ventilatory functions. The study group consisted of 30 male, young, healthy subjects, free from cardiopulmonary diseases and with history of smoking of 2-5 years duration, on an average of 10 cigarettes per day. The control group consisted of 30 age-and sex-matched healthy individuals who had naver smoked tobacco. The ventilatory function tests were carried out using electronic spriolyser. There was a significant lowering of the following parameters in smokers: Vital capacity (VC), inspiratory reserve volume (IRV), inspiratory capacity (IC), forced vital capacity (FVC), forced expiratory volume at the end of first second (FEV1), maximum midexpiratory flow (MMEF), peak expiratory flow (PEF), midexpiratory flow75 (MEF75), maximum voluntary ventilation (MVV). This study shows that 2-5 years of tobacco smoking leads to a definite tendency to narrowing of both the large and the small airways.

Adult↗

PubMed2003

A longitudinal study of antenatal changes in lung function tests and importance of postpartum exercises in their recovery.

A study of changes in lung function tests during pregnancy was undertaken in fifty pregnant women beginning from third month of gestation. Fifty nonpregnant age and height matched women formed the controls. Forced Vital Capacity (FVC), Timed Vital Capacity (FEV1), Inspiratory Capacity (IC), Expiratory Reserve Volume (ERV) and peak Expiratory Flow Rate (PEFR) were performed in each month of pregnancy. However ten subjects were not available for follow-up during postpartum period. Remaining forty women were divided into two groups of twenty each. Group I performed daily graded active exercises to strengthen the anterior abdominal wall muscles. Group II women did not perform any exercises. It was observed that the antenatal changes in percent FVC and FEV1 were insignificant, but the decline in ERV and PEFR were very highly significant (P < 0.001) and the increment in IC was significant (P < 0.05). In the postpartum period the percentage variation of values in group I was less than 5% from controls (P > 0.05) and in group II it was 15-20% from controls (P < 0.05), resulting in a significant variation in group II women as compared to the controls. It is concluded that there are adaptive changes in lung functions in the antenatal period. We stress the importance of regular graded active exercises in the postpartum period for the speedy recovery of these changes.

Adult↗

PubMed2005

Body structure and respiratory efficiency among high altitude Himalayan populations.

To understand the morphological and physiological variations among the temporary and permanent residents of high altitude, this study was undertaken at Leh, Ladakh. It is situated at 3500 m (11500 feet) above sea level, the mean barometric pressure was 500 tors and air temperature varied from 2 degrees C to 20 degrees C. The highland Tibetans showed broadest chest and most developed musculature closely followed by Ladakhi Bods. These high altude natives also displayed significantly higher value of vital capacity, forced vital capacity, and inspiratory capacity. The better respiratory efficiency observed among high altitude residents indicates higher degree of adaptation to high altitude hypoxia. Temporary residents were observed to be tallest and fattest with lower trunk fat predominance of all the four groups and showed narrowest chest and lower respiratory efficiency as compared to high altitude natives. The duration of stay at high altitude has clearly brought about a perceptible difference in body dimensions and respiratory functions of various groups of adult males studied at same altitude.

Adaptation, Physiological↗

PubMedDate not supplied

[Radiographic measurement of the total pulmonary capacity: comparison of 2 planimetric methods].

We analyzed accuracy and reproducibility of a radiographic method for calculation of total lung capacity (TLC) from the sum of pulmonary area. Pulmonary area from a routine postero-anterior and lateral chest radiography was measured by two methods: using a planimeter (standard) and with a virgin radiographic plaque with lines separating squares of 1cm per side. Plethismographic TLC was obtained adding the functional residual capacity to inspiratory capacity. We studied 13 healthy subjects (mean age of 30 years, eight males), 13 with interstitial lung disease (mean age of 45 years, two males) and 12 with chronic bronchitis or emphysema (mean age of 63 years, three males). Measured TLC varied from 1.9 to 7.2 liters. The linear regression equation found was: TLC = 0.007 total lung area (cm2) 0.572, R = 0.906, P less than 0.001 which is very similar to that reported by Harris et al.8 Interobserver variability in the measurement was very small taking into account that no efforts were made to uniformize the observers. Main interobserver differences were in the tracing of the lung limits, and not in the actual measurement of the lung area. We found no differences between the two methods for measuring lung area except that the planimeter is faster and more reproducible. Radiographic method for measuring TLC is accurate and available in most places.

Adult↗

PubMed1979

Pulmonary function in quadriplegia: effects of a corset.

Fifteen quadriplegic patients underwent multiple pulmonary function studies performed in 2 positions, sitting and supine, and in both positions under 2 circumstances, wearing and not wearing a corset. Analysis of variance showed that 3 volumes were significantly improved (p less than 0.05) supine, especially without the corset: vital capacity (C), inspiratory capacity (IC) and tidal volume (Vt). Although most pulmonary function tests were improved when the patients were supine the trends when sitting were for improvement when wearing a corset. Most of these patients were studied at least 1 year postinjury and results are not substantially different from those 6 months postinjury. Corsets do not have an untoward effect on pulmonary function tests.

Adult↗

PubMed2001

Effects of abdominal trussing on breathing and speech in men with cervical spinal cord injury.

Abdominal trussing constitutes an inward fixation of the abdominal wall. In the context of speech habilitation/rehabilitation, it is sometimes used to supplant, in part, the function of a paralyzed or paretic abdominal wall. A paralyzed or paretic abdominal wall may be found in individuals with cervical spinal cord injury or in individuals with other neurologic disorders, such as muscular dystrophy. This research was designed to study the effects of trussing as a dinical treatment. A study was designed to systematically and precisely place the abdominal wall at one position (50% inward) to study the effects of trussing (as compared to an untrussed condition) on lung volume and oral reading in three men with cervical spinal cord injury (C5-C6). Results showed that abdominal trussing increased vital capacity, realized via an increase of inspiratory capacity, presumably by optimization of the function of the diaphragm. With the increase in inspiratory capacity, longer utterance duration for oral reading was observed. With increased utterance duration, more syllables were produced per utterance, and pauses occurred at appropriate linguistic locations. Oral reading samples for trussed and untrussed conditions were submitted to preference judgment by a group of 10 judges. For two of the three men studied, oral reading during trussing was preferred because of longer phrases and pauses taken at suitable linguistic boundaries. The findings from this study support clinical impressions that abdominal trussing may be useful in improving speech in individuals with a paralyzed or paretic abdomen whose breathing function for speech is diminished.

Abdominal Muscles↗

PubMed2005

[Clinical and functional benefits of adding theophylline to a standard treatment with short acting bronchodilators in patients with COPD].

BACKGROUND: Although theophylline is considered a third line bronchodilator drug for the treatment of chronic obstructive pulmonary disease (COPD), it is widely used in Chile, because it is administered orally and has a moderate cost. AIM: To evaluate if theophylline adds clinical and/or functional benefits when associated to standard recommended inhaled bronchodilator therapy. SUBJECTS AND METHODS: Thirty-eight stable COPD patients who accepted to participate in the study approved by the Ethics Committee of our institution were studied. Using a randomized double-blind placebo-controlled study, theophylline (250 mg) or placebo was administered twice a day for 15 days in addition to inhaled salbutamol and ipratropium bromide. Prior to and at the end of the study, patients underwent: a) a spirometry to evaluate changes in dynamic pulmonary hyperinflation using slow vital capacity (SVC) and inspiratory capacity (IC), b) the 6 min walking distance (6 MWD); and c) measurement of maximal inspiratory and expiratory pressures. Dyspnea and quality of life (QoL) were evaluated using appropriate questionnaires. RESULTS: Compared to placebo, patients on theophylline showed significant increases in SVC (p=0.014), IC (p=0.002), and 6 MWD (p=0.005). They also experienced an improvement in dyspnea (p=0.042) and QoL (p=0.011). All patients improved at least one of these parameters with 53% of the patients showing an improvement in 3 or more. CONCLUSIONS: Our results indicate that adding theophylline to standard treatment with inhaled bronchodilators provides additional benefits in stable COPD patients by reducing dynamic pulmonary hyperinflation, improving exercise tolerance, dyspnea and QoL.

Administration, Inhalation↗

PubMed2006

Reproducibility of measurements of inspiratory work capacity in cystic fibrosis patients.

The evaluation of respiratory muscle endurance (RME) is regarded as being clinically relevant to the assessment of respiratory muscle function. The reproducibility of a non-invasive measure of assessing RME was determined by measuring inspiratory work capacity (IWC) (using a computerised system). Measurements were obtained on two occasions in 20 adult cystic fibrosis (CF) patients (22.7+/-3.4 years, mean+/-S.D.) and 20 age (23.4+/-4.4 years) and gender (10 male, 10 female in each group) matched healthy controls. The coefficients of reliability (CR), intra-class correlation coefficients (ICC) and limits of agreement (bias+/-2 S.D.) were determined. CR values for the CF patients and controls were above 90% and with ICC of 0.99 in both CF patients and controls. The differences in IWC between study days were within +/-2 S.D. of the mean difference in all but one CF and one control subject. These data suggest that measures of IWC may be considered reliable when used to assess RM function in both controls and in patients with CF.

Adult↗

PubMed1992

Effect of fatigue on maximal inspiratory pressure-flow capacity.

The inspiratory muscles can be fatigued by repetitive contractions characterized by high force (inspiratory resistive loads) or high velocities of shortening (hyperpnea). The effects of fatigue induced by inspiratory resistive loaded breathing (pressure tasks) or by eucapnic hyperpnea (flow tasks) on maximal inspiratory pressure-flow capacity and rib cage and diaphragm strength were examined in five healthy adult subjects. Tasks consisted of sustaining an assigned breathing frequency, duty cycle, and either a "pressure-time product" of esophageal pressure (for the pressure tasks) or peak inspiratory flow rate (for the flow tasks). Esophageal pressure was measured during maximal inspiratory efforts against a closed glottis (Pesmax), maximal transdiaphragmatic pressure was measured during open-glottis expulsive maneuvers (Pdimax), and maximal inspiratory flow (VImax) was measured during maximal inspiratory efforts with no added external resistance before and after fatiguing pressure and flow tasks. The reduction in Pesmax) with pressure fatigue (-25 +/- 7%) was significantly greater than the change in Pesmax with flow fatigue (-8 +/- 8%, P less than 0.01). In contrast, the reductions in Pdimax (-11 +/- 8%) and VImax (-16 +/- 3%) with flow fatigue were greater than the changes in Pdimax (-0.6 +/- 4%, P less than 0.05) or VImax (-3 +/- 4%, P less than 0.05) with pressure fatigue. We conclude that respiratory muscle performance is dependent not only on the presence of fatigue but whether fatigue was induced by pressure tasks or flow tasks. The specific impairment of Pesmax and not of Pdimax or flow with pressure fatigue may reflect selective fatigue of the rib cage muscles.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway Resistance↗

PubMedDate not supplied

Pre-operative short-term pulmonary rehabilitation for patients of chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery.

The role of pre-operative short-term pulmonary rehabilitation in patients with chronic obstructive pulmonary disease who undergo coronary artery bypass graft surgery has been assessed for the first time prospectively. Forty-five patients posted for coronary artery bypass graft surgery were randomised to receive either short-term pulmonary rehabilitation (group I) or no such programme (group II). Patients of both the groups were evenly matched with respect to age, sex, body surface area, duration and severity of chronic obstructive pulmonary disease and coronary artery disease. Normal individuals who evenly matched with the study group were assessed for normal respiratory function parameters. Pre-operative and post-operative peak expiratory flow rate, inspiratory capacity, post-operative ventilation time, post-operative pulmonary complication and hospital stay were determined in both the groups. Peak expiratory flow rate (220.0 +/- 12.9 and 324.3 +/- 84.3 in group I, 218.0 +/- 16.4 and 260.5 +/- 35.2 in group II) and inspiratory capacity (844.0 +/- 147.4 and 1100.0 +/- 158.1 in group I, 830.0 +/- 117.4 and 1090 +/- 137 in group II) were significantly lower before and after surgery respectively in both groups compared to normal values. Even though both groups showed a significant rise in post-operative peak expiratory flow rate and inspiratory capacity after surgery, the post-operative peak expiratory flow rate and inspiratory capacity in group I was significantly higher than in group II. In group I, the post-operative ventilation time (24.5 +/- 6.00 hours), post-operative complications (n = 4) and hospital stay (12.4 +/- 3.6 days) were significantly lower than in group II (35.2 +/- 22.3 hours, n = 11, 18.8 +/- 6.6 days respectively). These data suggest that short-term pulmonary rehabilitation is feasible and effective in improving pulmonary functions before and after surgery and in reducing surgical morbidity and cost of medical care significantly.

Breathing Exercises↗