Approach to CPET. CPET Cases. Case 1 4/4/2018. Impaired? Cardiac factors? Ventilatory factors?
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1 Approach to CPET CPET Cases Neil MacIntyre MD Duke University Medical Center Durham NC Impaired? Work,, /kg Cardiac factors?, /, BP, Rhythm Ventilatory factors? Ve/MVV (incl EIB, trapping), PaCO2 Gas exchange factors? PaO2 (), Interp: How impaired, exercise limiting factors, factors abnormal but not exercise limiting Case 1 68 yo woman with exertional dyspnea Mild COPD: FEV1 66% pred Mild CHF on beta blockers Gender: Female Age: 68 years Race: AA Height: 67 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=44 61 RR (bpm) TV (l) ABG (FiO2=0.21) 7.41/42/ /34/74 / Gender: Female Age: 68 years Race: AA Height: 67 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=44 61 RR (bpm) TV (l) ABG (FiO2=0.21) 7.41/42/ /34/74 C. Cardiac limits D. Gas exchange limit 1
2 Gender: Female Age: 68 years Race: AA Height: 67 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=44 61 RR (bpm) TV (l) ABG (FiO2=0.21) 7.41/42/ /34/74 Gender: Female Age: 68 years Race: AA Height: 67 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=44 61 RR (bpm) TV (l) ABG (FiO2=0.21) 7.41/42/ /34/74 Inability to increase, pushed herself to a metabolic acidosis. Dx: Excess beta blockers Case 2 69 yo woman with exertional dyspnea. Normal PFTs except DL 70% pred Gender: Female Age: 69 years Race: Cauc Height: 61 Weight: 130 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV=32 43 RR (bpm) TV (l) Ve/VCO < ABG (FiO2=0.3) 7.37/46/ /49/59 / Gender: Female Age: 69 years Race: Cauc Height: 61 Weight: 130 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV=32 43 RR (bpm) TV (l) Ve/VCO < ABG (FiO2=0.3) 7.37/46/ /49/59 C. Cardiac limits D. Gas exchange limit E. C and D 2
3 Gender: Female Age: 69 years Race: Cauc Height: 61 Weight: 130 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV=32 43 RR (bpm) TV (l) Ve/VCO < ABG (FiO2=0.3) 7.37/46/ /49/59 Gender: Female Age: 69 years Race: Cauc Height: 61 Weight: 130 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV=32 43 RR (bpm) TV (l) Ve/VCO < ABG (FiO2=0.3) 7.37/46/ /49/74 Rising, impaired / at max, hypoxemia. Dx: Pulmonary vascular disease Case 3 70 yo woman with exertional dyspnea and mild arm and leg weakness Gender: Female Age: 70 years Race: Cauc Height: 57 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) 9 22 MVV=25 88 FEV1 x 35 = 56 RR (bpm) TV (l) ABG (FiO2=0.21) 7.37/44/ /50/81 / Gender: Female Age: 70 years Race: Cauc Height: 57 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) 9 22 MVV=25 88 FEV1 x 35 = 56 RR (bpm) TV (l) ABG (FiO2=0.21) 7.37/44/ /50/81 C. Cardiac limit D. Gas exchange limit 3
4 Gender: Female Age: 70 years Race: Cauc Height: 57 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) 9 22 MVV=25 88 FEV1 x 35 = 56 RR (bpm) TV (l) ABG (FiO2=0.21) 7.37/44/ /50/81 Gender: Female Age: 70 years Race: Cauc Height: 57 Weight: 172 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) 9 22 MVV=25 88 FEV1 x 35 = 56 RR (bpm) TV (l) ABG (FiO2=0.21) 7.37/44/ /50/81 Vent limited due to very low MVV (well below expected MVV for FEV1). Dx: ALS Case 4 52 yo woman with exertional dyspnea. No pulmonary diagnosis, normal PFTs Gender: Female Age: 52 years Race: AA Height: 64 Weight: 132 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=70 69 RR (bpm) TV (l) ABG (FiO2=0.21) 7.45/34/ /31/80 / Gender: Female Age: 52 years Race: AA Height: 64 Weight: 132 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=70 69 RR (bpm) TV (l) ABG (FiO2=0.21) 7.45/34/ /31/80 C. Cardiac limit D. Gas exchange limit 4
5 Gender: Female Age: 52 years Race: AA Height: 64 Weight: 132 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=70 69 RR (bpm) TV (l) ABG (FiO2=0.21) 7.45/34/ /31/80 Gender: Female Age: 52 years Race: AA Height: 64 Weight: 132 BMI: (kg/m 2 ) Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) SBP (mmhg) DBP (mmhg) Ve (l/min) MVV=70 69 RR (bpm) TV (l) ABG (FiO2=0.21) 7.45/34/ /31/80 Rapid and low /, high DBP. Dx: CV disease Case 5 54 yo woman with exercise intolerance. History of lung scarring Gender: female Age: 54 Race: caucasian Height: 65 Weight: 134 lb BMI: (kg/m 2 ) 20 Clinical Notes: limited exercise tolerance Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV ABG (FiO2=.21) 7.42/42/ /34/52 / Gender: female Age: 54 Race: caucasian Height: 65 Weight: 134 lb BMI: (kg/m 2 ) 20 Clinical Notes: limited exercise tolerance Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV ABG (FiO2=.21) 7.42/42/ /34/52 C. Cardiac limit D. Gas exchange limit 5
6 Gender: female Age: 54 Race: caucasian Height: 65 Weight: 134 lb BMI: (kg/m 2 ) 20 Clinical Notes: limited exercise tolerance Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV ABG (FiO2=.21) 7.42/42/ /34/52 Gender: female Age: 54 Race: caucasian Height: 65 Weight: 134 lb BMI: (kg/m 2 ) 20 Clinical Notes: limited exercise tolerance Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV ABG (FiO2=.21) 7.42/42/ /34/52 Low max, adequate vent reserve, not at CV limits, marked desaturation. Dx: Gas exchange limitation Case 6 38 yo man with exertional dyspnea. Vague hx of mild asthma with FEV1 3.3 L (82% predicted) Gender: male Age: 38 Race: caucasian Height: 69 Weight: 163 lb BMI: (kg/m 2 ) 20 Clinical Notes: dyspnea with jogging Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV= FEV ABG (FiO2=.21) 7.34/45/ /45/108 / 6
7 Gender: male Age: 38 Race: caucasian Height: 69 Weight: 163 lb BMI: (kg/m 2 ) 20 Clinical Notes: dyspnea with jogging Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV= FEV ABG (FiO2=.21) 7.34/45/ /45/108 Gender: male Age: 38 Race: caucasian Height: 69 Weight: 163 lb BMI: (kg/m 2 ) 20 Clinical Notes: dyspnea with jogging Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV= FEV ABG (FiO2=.21) 7.34/45/ /45/108 C. Cardiac limit D. Gas exchange limit Gender: male Age: 38 Race: caucasian Height: 69 Weight: 163 lb BMI: (kg/m 2 ) 20 Clinical Notes: dyspnea with jogging Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV= FEV pred MVV with new FEV1 = 79.8 new Ve/MVV = ABG (FiO2=.21) 7.34/45/ /45/108 Case 7 69 yo woman with exertional dyspnea. Dx of COPD with FEV1 of 20% predicted Although WNL, and Ve below rest MVV, FEV1 drop of 23% with exercise results in new MVV and evidence for subsequent vent limit. Dx: Late exercise induced bronchospasm Gender: female Age: 69 Race: caucasian Height: 66 Weight: 135lb BMI: (kg/m 2 ): 20 Clinical Notes: COPD - dyspnea on exertion Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV FVC 2.17 IC ABG (FiO2= 0.3) 7.37/57/ /69/74 / 7
8 Gender: female Age: 69 Race: caucasian Height: 66 Weight: 135lb BMI: (kg/m 2 ): 20 Clinical Notes: COPD - dyspnea on exertion Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV FVC 2.17 IC ABG (FiO2= 0.3) 7.37/57/ /69/74 C. Cardiac limit D. Gas exchange limit E. A and C Gender: female Age: 69 Race: caucasian Height: 66 Weight: 135lb BMI: (kg/m 2 ): 20 Clinical Notes: COPD - dyspnea on exertion Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV FVC 2.17 IC ABG (FiO2= 0.3) 7.37/57/ /69/74 Gender: female Age: 69 Race: caucasian Height: 66 Weight: 135lb BMI: (kg/m 2 ): 20 Clinical Notes: COPD - dyspnea on exertion Work (w) VO 2 (l/min) VO 2 (ml/min/kg) (bpm) VO 2 / (ml/beat) Ve (l/min) MVV = FEV FVC 2.17 IC ABG (FiO2= 0.3) 7.37/57/ /69/74 Reaches Ve limit, cardiac limit (with low O2 pulse), and approaches gas exchange limit. Dx: Combined pulmonary and cardiac (likely RV) disease 8
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