cardiopulmonary exercise testing: clinicalexamples darcy d. marciniuk md, frcp(c), fccp division of...

Cardiopulmonary Cardiopulmonary Exercise Testing: Exercise Testing:

ClinicalClinicalExamplesExamples

Darcy D. MarciniukDarcy D. MarciniukMD, FRCP(C), FCCPMD, FRCP(C), FCCP

Division of Respirology, Critical Division of Respirology, Critical Care and Sleep MedicineCare and Sleep Medicine

Conflict of Interest Disclosure

Consultancy Fees / Advisory BoardsAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region

Research FundingAstraZeneca, Boehringer Ingelheim, Canadian Agency for Drugs and Technology in Health, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Novartis, Nycomed, Pfizer, Saskatchewan Health Research Foundation, Saskatchewan Ministry of Health, Schering-Plough

Speaker’s BureauAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer

Fiduciary PositionsCanadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association

EmployeeUniversity of Saskatchewan

Variable CHFCHF COPDCOPD ILDILD PVDPVD De-De-conditionedconditioned

Peak VOPeak VO22 ↓↓ ↓↓ ↓↓ ↓↓ ↓↓

ATAT ↓↓ V or V or indeterminateindeterminate ↓↓ ↓↓ ↔ ↔ or ↓or ↓

Peak HRPeak HR vv ↔ ↔ or ↓or ↓ ↓↓ ↔ ↔ or ↓or ↓ ↔ ↔ or ↓or ↓

OO22 Pulse Pulse ↓↓ ↔ ↔ or ↓or ↓ ↔ ↔ or ↓or ↓ ↓↓ ↓↓

VVEE/MVV/MVV ↔ ↔ or ↓or ↓ ↑↑ ↔ ↔ or ↑or ↑ ↔↔ ↔↔

VVEE/VCO/VCO22 ↑↑ ↑↑ ↑↑ ↑↑ ↔↔

VVDD/V/VTT ↑↑ ↑↑ ↑↑ ↑↑ ↔↔

PaOPaO22 ↔↔ vv ↓↓ ↓↓ ↔↔

PPA-aA-aOO22 ↔↔ vv ↑↑ ↑↑ ↔↔

(↓= decreased; ↔ = unchanged from normal; ↑ = increased; v = variable)

Principles of InterpretationAddress fundamental questions when interpreting exercise test results:

– are the results normal or abnormal?– how limited is the patient?– what factors are responsible for the

limitation?– what abnormal patterns of response are

demonstrated?– what clinical disorders may result in

these patterns of response?

Cardiopulmonary Exercise Testing

Clinical Background – Case #1

• 64-yr-old male with COPD. Medication increased recently, but shortness of breath with exertion unchanged. No chest pain, no other significant history. Meds: tiotropium, salmeterol, salbutamol prn

• O/E: SaO2 96%, decreased breath sounds, all else normal

• ECG: no significant abnormalities • CXR: hyperinflation, vascular deficiency• Echocardiogram: normal ventricular

function• “Moderate COPD with significant limitation.

Rehab referral”

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Pulmonary Function Before After

FVC (L) 3.38 3.59

(71% pred) (76% pred)

FEV1 (L) 1.49 1.76 (50% pred) (59% pred)

FEV1/FVC 44% 49%TLC (L) 6.86 (105% pred)RV (L) 3.36 (135% pred)Dlco (ml/min/mmHg) 22.5 ( 65% pred)maximal incremental, room air, 10 watts/min cycle

ergometer

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Exercise Measurements

Rest End-Exercise %Pred

Wmax (watts) -- 82 45VO2 (L/min) 0.36 1.52 58VO2 AT (L/min) -- 1.10

(>1.03)VE (L/min) 12.1 44.8 69BR (L) -- 18.9SaO2 (%) 97 98HR (/min) 68 109 60Dyspnea/Legs 0.5/0 5/5ECG no arrhythmias or ischemic changes

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

“I couldn’t do anymore - my breathing and legs”

0

1

2

3

0 50 100 150 200

VO

2(L

/min

)

Workrate (W)

VO2max predicted

Wm

axp

red

icte

d

R=1

VO

2max

pre

dic

ted

0

1

2

3

0 1 2 3

VC

O2

(L/m

in)

VO2 (L/min)

Moderate COPDModerate COPD

VO

2max

pre

dic

ted

0

5

10

15

20

50

100

150

200

0 1 2 3

O2

Pu

lse

(mL

/be

at)

He

art

Ra

te (

/min

)

VO2 (L/min)

HRmax predicted

VO

2max

pre

dic

ted

20

30

40

50

0 1 2 3

VE

/VO

2V

E/V

CO

2

VO2 (L/min)

Moderate COPDModerate COPD

35

FEV1 x 35

0

25

50

75

0 0.5 1 1.5 2

VE

(L/m

in)

VCO2 (L/min)

FE

V1

x 35

VC

0

10

20

30

40

0

1

2

3

0 25 50 75

f ( /

min

)

VT

(L)

VE (L/min)

Moderate COPDModerate COPD

Ventilatory Responses

NormalLung

Disease

VE(L

/min

)

VO2 (L/min)

MVC (Normal)

MVC (Lung Disease)

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

VO

2max

pre

dic

ted

0

0.1

0.2

0.3

0.4

0 1 2 3

VD

/VT

VO2 (L/min)

VO

2max

pre

dic

ted

20

30

40

50

0 1 2 3

PE

TC

O2

(mm

Hg

)

VO2 (L/min)

Moderate COPDModerate COPD

VO

2max

pre

dic

ted

80

85

90

95

100

0 1 2 3

Sp

O2(%

)

VO2 (L/min)

Moderate COPDModerate COPD

Flo

w (

l/se

c)

Volume (l)

Interpretation• physiologically sub-maximal study• significant exercise limitation with

reduced work and aerobic capacity• although abnormal responses evident,

respiratory system was not limiting– mechanical ventilatory reserve, no oxygen

desaturation, flow-volume curves• no ECG/rhythm disturbances [prior normal

echocardiogram] – suggest heart rate and O2 pulse observations

are consistent with a component of deconditioning

Moderate COPDModerate COPD

Clinical Background – Case #2

• 16-yr-old female who presents with shortness of breath in gym class. Mother is concerned she is also not able to keep up with her peers (Mom was a university track & field competitor)

• No meds, no significant past/family history

• O/E: normal, no murmurs• ECG: normal; CXR: normal• PFT: normal• MCT: PC20 > 32 mg/ml• “Unexplained shortness of breath”

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Exercise Measurements Rest End-Exercise

%PredWmax (watts) -- 65 47

VO2 (L/min) 0.20 1.32 74

VE (L/min) 9.6 35.5 34BR (L) -- 68.5SaO2 (%) 99 96HR (/min) 86 151 75Dyspnea 2 9Legs 0 3“I Can’t Breath Anymore”

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

0

0.5

1

1.5

2

0 0.5 1 1.5 2

VC

O2

(L/m

in)

VO2 (L/min)

VO

2max

pre

dic

ted

R = 1

0

0.5

1

1.5

2

0 50 100 150

VO

2(L

/min

)

Workrate (W)

VO2max predicted

Wm

axp

red

icte

d

Unexplained Dyspnea

20

30

40

50

60

70

0 0.5 1 1.5 2

VE

/VO

2V

E/V

CO

2

VO2 (L/min)

VO

2max

pre

dic

ted

0

5

10

15

20

50

100

150

200

0 0.5 1 1.5 2

O2

Pu

lse

(m

L/b

ea

t)

He

art

Ra

te (

/m

in)

VO2 (L/min)

HRmax predicted

VO

2max

pre

dic

ted

Unexplained Dyspnea

0

25

50

75

100

0

1

2

3

4

0 30 60 90 120

f (

/min

)

VT

(L)

VE (L/min)

FE

V1

x 35

VC

0

30

60

90

120

0 1 2 3

VE

(L/m

in)

VCO2 (L/min)

FEV1 x 35

35

Unexplained Dyspnea

20

30

40

50

0 0.5 1 1.5 2

PE

TC

O2

(mm

Hg

)

VO2 (L/min)

VO

2max

pre

dic

ted

0

0.1

0.2

0.3

0.4

0 0.5 1 1.5 2

VD

/VT

VO2 (L/min)

VO

2max

pre

dic

ted

Unexplained Dyspnea

80

85

90

95

100

0 0.5 1 1.5 2

Sp

O2

(%)

VO2 (L/min)

VO

2max

pre

dic

ted

Unexplained Dyspnea

Unexplained Dyspnea

-8

-4

0

4

8

12

-2 0 2 4 6

Flow

(L/s

)

Volume (l)

Maximal

Rest

Sub-maximal Exercise

End Exercise

Healthy Normal

Interpretation• physiologically sub-maximal study• exercise limitation with reduced work

(significant) and aerobic capacity (mild)• respiratory system was not exercise

limiting– mechanical ventilatory reserve, no oxygen

desaturation, – respiratory responses not typical of a known

disease process

• all other responses are normal• other [… psychologic] contributors to the

patient’s symptoms?

Unexplained Dyspnea

Clinical Background – Case #3

• 56-yr-old male with Rheumatoid Arthritis x 5 years. 6 month history of decreasing exercise tolerance and increasing dry cough.

• O/E: clubbed, reduced chest expansion, late inspiratory crackles, stigmata of RA

• ECG:sinus tachycardia with RA enlargement

• “56-year-old man with Rheumatoid Arthritis and Interstitial Lung Disease. ?transplant”

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Pulmonary Function

FVC (L) 1.82 53% predFEV1 (L) 2.19 45% pred

FEV1/FVC 83%

TLC (L) 3.47 50% predRV (L) 1.28 54% predDlco (ml/min/mmHg) 9.8 27% pred

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Exercise Measurements

Rest End-Exercise %PredWmax (watts) -- 50 29

VO2 (L/min) 0.34 1.07 44

VE (L/min) 20.1 68.1 106

BR (L) -- (3.9)SaO2 (%) 97 76HR (/min) 131 164 100Dyspnea 0.5 7Legs 0 7“Can’t do anymore … breathing and my legs.”

Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

VO

2 (L

/min

)

Workrate (W)

0 60 120 180

0

1

2

VO2max predicted

Wm

ax

pre

dic

ted

Hea

rt R

ate

(/m

in)

VO2 (L/min)

100

140

180

60

0 1 2

HRmax predicted

VO

2ma

x p

red

icte

d

ILD / (?) Transplant Candidate

VC

O2

(L/m

in)

VO2 (L/min)

0

1

2

0 1 2

VO

2ma

x p

red

icte

d

R = 1

VE

/ V

O2

VE

/ V

CO

2

VO2 (L/min)

0 1 2

40

50

60

70

VO

2ma

x p

red

icte

d

ILD / (?) Transplant Candidate

VE

(L

/min

)

VCO2 (L/min)

0 1 2

0

20

40

60

80

FEV1 x 35

35

VT

(L)

VE (L/min)

f (

/min

)

0

1

2

3

0 20 40 60 80

20

40

60

VC

FE

V1 x

3

5

ILD / (?) Transplant Candidate

PE

TC

O2

(m

mH

g)

VO2 (L/min)

0 1 2

10

20

30

40

50

VO

2ma

x p

red

icte

d

SaO

2

(%)

VO2 (L/min)

70

80

90

100

0 1 2

VO

2ma

x p

red

icte

d

ILD / (?) Transplant Candidate

End-Exercise Measurements RA Test O2 Test

%ChangeSaO2 (%) 76 92 +

21HR (/min) 164 158 - 4

(100% pred) (96% pred)

Wmax (watts) 50 75 + 50 (29% pred) (44% pred)

Dyspnea 7 7Legs 7 5RA Test: “Can’t do anymore … breathing and my legs.”

O2 Test: “My breathing gave out.”

ILD / (?) Transplant Candidate

Workrate (W)

SaO

2

(%)

70

80

90

100

0 60 120 180

Room Air

O2

Wm

ax

pre

dic

ted

Workrate (W)

Hea

rt R

ate

( /m

in)

60

100

140

180

0 60 120 180

Room Air

O2

Wm

ax

pre

dic

ted

HRmax predicted

ILD / (?) Transplant Candidate

Interpretation• physiologically maximal study with

profound exercise limitation– peak VO2 44% predicted– VO2/kg = 10.8 ml/kg/min

• absent ventilatory reserve, significant arterial oxygen desaturation, ventilatory inefficiency, rapid/shallow breathing pattern

• abnormal cardiovascular responses• improved performance [but not

normalization] with supplemental oxygen

ILD / (?) Transplant Candidate

The Bottom Line …• important to focus on the reason(s) for testing

– ensures a correct and meaningful interpretation

• multitude of graphical and numerical results, and an over-dependence on complicated algorithms contributes to confusion– focus on cardinal measurements and relationships– no single finding or measurement is diagnostic of

any specific disease entity– CPET is never ordered, nor should it be interpreted in

isolation

Cardiopulmonary Exercise Testing