The Role of CPET (cardiopulmonary exercise testing) in Assessing Lung Disease in CF
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1 The Role of CPET (cardiopulmonary exercise testing) in Assessing Lung Disease in CF Dr. Meir Mei-Zahav Kathy and Lee Graub CF Center Schneider CMCI 1 תאריך
2 Exercise in CF You are probably quite sure that exercise: Improves aerobic fitness Lessen the decrease in pulmonary function Improves quality of life
3 Exercise in CF Physical exercise training for cystic fibrosis OBJECTIVES: Cochrane Database Syst Rev Radtke T et al To determine the effects of physical exercise training on aerobic exercise capacity FEV1 QOL other outcomes in cystic fibrosis 13/48 studies, 402 participants, met the inclusion criteria
4 Exercise in CF MAIN RESULTS: Limited evidence that aerobic or anaerobic physical exercise training has a positive effect on the outcome measures Improvement in VO2 max (4/6 studies) unclear effects on FEV1 (2/10 studies) unclear effects QOL (2/5 studies) AUTHORS' CONCLUSIONS: Evidence about the efficacy of physical exercise training in cystic fibrosis is limited
5 Why CPET?
6 Rationale Assessment of health status Assessing exercise associated side effects Assessing exercise intolerance etiology Tool to design individual exercise training
7 Rationale Assessment of health status Assessing exercise associated side effects Assessing exercise intolerance etiology Tool to design individual exercise training
8 Rationale Assessment of health status Health status correlates better with exercise tolerance rather than resting measurements Joint ATS & ACCP statement on CPET Aerobic exercise capacity is associated with Survival Nixon NEJM 1992 CT changes Future decline in FEV 1 Hospitalizations
9 Rationale Assessment of health status Assessing exercise associated side effects Assessing exercise intolerance etiology Tool to design individual exercise training
10 Rationale Assessing exercise associated side effects: Hypoxemia Hypercarbia Cardiac arrhythmia It would be imprudent to prescribe exercise without performing a test Statement on exercise testing in CF- Respiration 2015
11 Rationale Assessment of health status Assessing exercise associated side effects Assessing exercise intolerance etiology Tool to design individual exercise training
12 Rationale Assessing exercise intolerance etiology Exercise intolerance in CF may be due to: Impaired lung function Poor nutritional status Low muscle power Cardiac dysfunction High level of inflammation Low habitual activity
13 Rationale Assessment of health status Assessing exercise associated side effects Assessing exercise intolerance etiology Tool to design individual exercise training
14 Rationale Tool to design individual exercise training 60-80% of peak Vo % of maximal capacity 85% of anaerobic threshold X5/week 30min each Gradually
15 Can resting measures predict exercise capacity in cystic fibrosis? FEV1 BMI LCI PsA Genotype
16 Methods Retrospective study 17 CF centers, 14 countries 726 CF patients ECFS Exercise Working Group T Radtke et al, AnnalsATS in press
17 Study objectives To determine predictors of exercise capacity (VO 2 peak) with a particular focus on CFTR genotype T Radtke et al, AnnalsATS in press
18 VO 2peak (% predicted) Mixed model Parameters predicting Vo2 peak B-coefficients (95% CI s) SE P-value Age (-0.32 to 0.04) Sex (-3.46 to 0.88) Pseudomonas aeruginosa (-4.44 to 0.58) BMI z-score 1.78 (0.78 to 2.77) 0.51 <0.001 FEV 1 (% predicted) 0.41 (0.35 to 0.47) 0.03 <0.001 CFTR group (-4.18 to 2.29) T Radtke et al, AnnalsATS in press
19 Pediatr Pulmonol
20 Rationale Assessment of health status Health status correlates better with exercise tolerance rather than resting measurements Joint ATS & ACCP statement on CPET
21 Assessment of health status Which CPET parameters are important in assessing health status?
22
23 Are there better CPET parameters to assess lung disease severity?
24 Dynamic Hyperinflation
25
26 TV exercise = 0.6*VC
27
28 TV fails to increase IC exercise
29 DH = IC exercise-ic rest Normal- (+) COPD- (-)
30 Dynamic Hyperinflation and Exercise Intolerance in Chronic Obstructive Pulmonary Disease O DONNELL et al AJRCCM 2001
31
32
33 What about dynamic hyperinflation in CF? Very little is known.
34 2013
35 Results
36 Results Dynamic hyperinflation did not predict FEV1 decline in 2 years
37 Conclusions: Dynamic hyperinflation is associated with Reduced lung functions Exercise intolerance But has limited prognostic value
38 38 CPET at Schneider CMCI
39 CPET at Schneider CMCI 50 CF patients performed 1-3 CPETS each in 6/12-9/17 Tests of 6 patients were excluded unacceptable
40 CPET at Schneider CMCI Demographic data: 26 males Age 24.6±6y (9-61y) 18 children
41 CPET at Schneider CMCI Resting PFTs: FVC FEV1 RV/TLC M (SD)% 90 (16) 78 (18) 33 (12) Range %
42 CPET at Schneider CMCI CPET results: M (SD) Median (Range) Normal range VO2 peak % pred. 90 (16) 76 (49-139) >82% Max load -% 74 (16) 73 (44-120) >93% Breathing reserve % 28 (17) 32 (0-62) >30% Resp rate % 128 (36) 139 (67-200) % TV/VC 0.44 (0.08) 0.43 ( ) >0.6
43 TVex/VC normal =0.6
44 Dynamic Hyperinflation Definition: decrease of >5% in IC
45 Dynamic Hyperinflation Valid DH measurements were available in 31 patients 42% demonstrated DH: Mean drop in IC-16% Drop range 6-29% 58% did not have DH Mean change in IC- +7% Range %
46 DH and FEV1 Good correlation between DH and FEV1 DH can predict FEV1-in 31% R=0.56 p=0.001 R 2 =0.31
47 DH and LCI Excellent correlation between DH and LCI DH can predict LCI in 63% R=0.791 p=0.019 R 2 =0.63
48 What about other CPET parameters? VO2 peak Breathing reserve
49 BR and LCI Good correlation between BR and LCI BR can predict LCI in 43% R=0.658 p=0.002 R 2 =0.432
50 VO2 peak and LCI Good correlation between VO2 peak and LCI Vo2 peak can predict LCI in 43% R=0.658 p=0.002 R 2 =0.432
51 VO2 peak and FEV1 Weak correlation between VO2 peak and FEV1 Vo2 peak can predict LCI in 13% R=0.36 p=0.014 R 2 =0.13
52 VO2 peak + BR and LCI Vo2 peak + BR can predict LCI in 85%
53 Does DH have a role in predicting lung disease progression?
54 DH in predicting deterioration FEV1 change in 6 years FEV1 FEV1 Year 0 CPET Year 6
55 DH in predicting deterioration FEV1 change in 6 years DH (13) Non DH (18) p FEV1 in year 0 82±26% 88±20% 0.23 %Drop in FEV1 10±11% 2±8% % DH is associated with lung function deterioration 90% 80% 70% Non-DH DH 60% 1 2 Year 0 Year 6
56 Conclusions Patients with CF have lower exercise capacity and lower aerobic capacity There is a correlation between CPET parameters Work capacity Vo2 max Breathing reserve Dynamic hyperinflation and lung functions (LCI, FEV1) Dynamic hyperinflation is associated with lung function deterioration
57 Thanks PFT technicians Yulia Gendler Prof Blau The CF team at Schneider The patients 57 תאריך
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