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Ventilatory inefficiency, defined as high minute ventilation (<jats:italic>V\u2032<\/jats:italic><jats:sub>E<\/jats:sub>) relative to carbon dioxide output (<jats:italic>V\u2032<\/jats:italic><jats:sub>CO<jats:sub>2<\/jats:sub><\/jats:sub>), is a hallmark characteristic of pulmonary vascular diseases, which contributes to exercise intolerance and disability in these patients. The mechanisms of ventilatory inefficiency are multiple and include high physiologic dead space, abnormal chemosensitivity and an altered carbon dioxide (CO<jats:sub>2<\/jats:sub>) set-point. A normal<jats:italic>V\u2032<\/jats:italic><jats:sub>E<\/jats:sub>\/<jats:italic>V\u2032<\/jats:italic><jats:sub>CO<jats:sub>2<\/jats:sub><\/jats:sub>makes a pulmonary vascular disease such as pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) unlikely. The finding of high<jats:italic>V\u2032<\/jats:italic><jats:sub>E<\/jats:sub><jats:italic>\/V\u2032<\/jats:italic><jats:sub>CO<jats:sub>2<\/jats:sub><\/jats:sub>without an alternative explanation should prompt further diagnostic testing to exclude PAH or CTEPH, particularly in patients with risk factors, such as prior venous thromboembolism, systemic sclerosis or a family history of PAH. In patients with established PAH or CTEPH, the<jats:italic>V\u2032<\/jats:italic><jats:sub>E<\/jats:sub>\/<jats:italic>V\u2032<\/jats:italic><jats:sub>CO<jats:sub>2<\/jats:sub><\/jats:sub>may improve with interventions and is a prognostic marker. 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