Cardiopulmonary Exercise Testing Cases

Transcription

1 Canadian Respiratory Conference Cardiopulmonary Exercise Testing Cases Darcy D Marciniuk, MD FRCPC FCCP Associate Vice-President Research, University of Saskatchewan Professor, Respirology, Critical Care and Sleep Medicine Royal University Hospital, Saskatoon, SK, CANADA

2 Cardiopulmonary Exercise Testing Conflict of Interest Disclosure Consultancy AstraZeneca, Boehringer-Ingelheim, Canadian Foundation for Healthcare Improvement, Chinese Committee of Health and Family Planning, GlaxoSmithKline, Health Canada, Lung Association of Saskatchewan, Novartis, Regina-Qu Appelle Health Region, Saskatoon Health Region, Saskatchewan Ministry of Health Research Funding (managed by the University of Saskatchewan) AstraZeneca, Boehringer Ingelheim, Canada Health Infoway, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Lung Health Institute of Canada, Novartis, Saskatchewan Health Research Foundation, Schering-Plough Fiduciary Positions Lung Health Institute of Canada Employee University of Saskatchewan

3 Reason for Stopping Exercise Visual Analogue Scale / Borg Scale PETCO 2 PETO 2 Perceived Shortness of Breath Perceived Leg Fatigue FLOW CO 2 O 2 VT RR Cuff (Sphygmomanometer) VE VCO 2 VO 2 RQ Rhythm/ Ischemia Blood Pressure Arterial Blood Gases VE/VCO 2 VE/VO 2 ECG Heart Rate PaO 2, PaCO 2, Hgb, COHgb, ph, Lactate, SaO 2 P(A-a)O 2, P(a-ET)CO 2, VD/VT O 2 Pulse Pulse Oximetry DVO 2 /DWR Cycle Ergometer Work Rate, RPM SpO 2 With Thanks to Ron Clemens

4 Cardiopulmonary Exercise Testing Which protocol is the gold standard for diagnostic purposes in the clinical exercise laboratory? a Exercise-Induced Bronchoconstriction (EIB) Challenge Study b Endurance Workload Study c Incremental Workload Study d 6-Minute Walk Test e Incremental Shuttle Walk Test

5 Cardiopulmonary Exercise Testing Which protocol is the gold standard for diagnostic purposes in the clinical exercise laboratory? a Exercise-Induced Bronchoconstriction (EIB) Challenge Study b Endurance Workload Study c Incremental Workload Study d 6-Minute Walk Test e Incremental Shuttle Walk Test

6 Workload Cardiopulmonary Exercise Testing CPET Protocols Incremental Endurance EIB Challenge 75% VEmax 6% VEmax 1% VEmax 9% VEmax Time Time Time

7 Cardiopulmonary Exercise Testing Case #1 Clinical Background 57-yr-old male with Amyloidosis - vocal cord infiltration and central airway involvement hoarse voice x 5 yrs, increasing SOBOE (~3 blocks) x 1 year Considering surgery O/E: SaO 2 96%, vitals normal, stridor with forced inspiration, otherwise normal Medications: diuretic (for hypertension) ECG: normal Echocardiogram: normal Amyloidosis with worsening activity limitation?central airway cause

8 Cardiopulmonary Exercise Testing Pulmonary Function FVC (L) % pred FEV 1 (L) % pred FEV 1 /FVC 69% TLC (L) % pred RV (L) % pred DLco (ml/min/mmhg) % pred maximal, symptom-limited, incremental cycle ergometry, 25 watts/min

9 Flow (L/s) Volume (L)

10 Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 AT (L/min) (>123) V E (L/min) BR (L) SaO 2 (%) HR (/min) Dyspnea/Legs / 7/7 ECG no arrhythmias or ischemic changes I have to stop I can t do anymore

11 Case #1 - Amyloidosis VD/VT VO 2 max VO 2 max predicted predicted Wmax predicted PETCO 2 (mmhg) VO 2 max VO 2 max predicted predicted Heart Rate ( /min) SpO 2 (%) x 35 VO 2 max predicted f ( /min) O 2 Pulse (ml/beat) 3 3 R=1 2 HRmax predicted VCO 2 (L/min) Workrate (W) x 35 FEV VE/VO 2 VE/VCO VE (L/min) VT (L) VC FEV VCO 2 (L/min) VE (L/min)

12 Case #1 - Amyloidosis predicted VO 2 max 3 3 R=1 2 1 Wmax predicted VCO 2 (L/min) Workrate (W) 1 2 3

13 Case #1 - Amyloidosis Heart Rate ( /min) O 2 Pulse (ml/beat) predicted VO 2 max HRmax predicted VE/VO 2 VE/VCO

14 Case #1 - Amyloidosis x 35 f ( /min) 12 FEV 1 x VC 3 VE (L/min) 6 3 VT (L) FEV VCO 2 (L/min) VE (L/min)

15 Case #1 - Amyloidosis PETCO 2 (mmhg) predicted VO 2 max VD/VT 2 predicted VO 2 max

16 Case #1 - Amyloidosis SpO 2 (%) predicted VO 2 max

17 Case #1 - Amyloidosis Flow (L/s) Maximal Rest Sub-maximal Exercise End ex no audible stridor during exercise Volume (L)

18 Cardiopulmonary Exercise Testing Why did this patient with Amyloidosis involving the central airways most likely discontinue exercise? a Abnormal ventilatory mechanics attributable to central obstruction b Chronotropic insufficiency c Inotropic insufficiency d De-conditioning e Pulmonary hypertension

19 Cardiopulmonary Exercise Testing Why did this patient with Amyloidosis involving the central airways most likely discontinue exercise? a Abnormal ventilatory mechanics attributable to central obstruction b Chronotropic insufficiency c Inotropic insufficiency d De-conditioning e Pulmonary hypertension

20 Cardiopulmonary Exercise Testing Key Observations physiologically maximal study (peak HR > 9% predicted) exercise limitation with reduced work (mild) and aerobic capacity (moderate) respiratory system was not exercise limiting - mechanical ventilatory reserve, normal gas exchange, normal breathing pattern, no inspiratory or expiratory tidal flowlimitation during exercise characteristic of central airway obstruction - surgery unlikely to enhance activity limitation, likely deconditioning [+/- cardiac]

21 Central Airway Obstruction: Post-Intubation Flow (L/s) Maximal Rest Mid-exercise End-exercise Volume (l) audible stridor developed during exercise (~45% predicted peak VO 2 )

22 Flow (L/s) Flow (L/s) Before Surgery After Surgery Maximal Rest Sub-maximal Exercise End ex Maximal Rest Sub-maximal Exercise End Exercise Volume (L) Volume (L)

23 Flow (L/sec) Flow (L/sec) Flow (L/sec) Flow (L/sec) Cardiopulmonary Exercise Testing Flow-Volume Curves During Exercise Normal COPD ILD Obesity Predicted Maximal Rest End Exercise Predicted Maximal Rest End Exercise Predicted Maximal Rest End Exercise Predicted Maximal Rest End Exercise Volume (L) Volume (L) Volume (L) Volume (L)

24 Cardiopulmonary Exercise Testing Case #2 Clinical Background 62-yr-old female, retired nurse, 4 pk/yr smoking history severe COPD Non-ischemic cardiomyopathy (post-breast carcinoma therapy) - EF 3% Progressive worsening SOB despite maximal therapy Meds lots! O/E: HR 8; B/P 95/7; SpO 2 95%; BS; S4 ECG: paced CXR: big heart, black lungs Cardiologist: it s your lungs Worsening shortness of breath cardiomyopathy and severe COPD

25 Cardiopulmonary Exercise Testing Pulmonary Function FVC (L) 18 75% pred FEV 1 (L) 67 35% pred FEV 1 /FVC 34% TLC (L) % pred RV (L) % pred DLco (ml/min/mmhg) 78 44% pred maximal, symptom-limited, incremental, cycle ergometry, room air, 5 watts/min

26 Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 AT (L/min) (>36) V E (L/min) BR (L) -- 1 SaO 2 (%) HR (/min) Dyspnea/Legs 5/ 4/7 ECG no arrhythmias or ischemic changes My legs just quit!

27 Case #2 - Severe COPD and Cardiomyopathy VD/VT Wmax predicted PETCO 2 (mmhg) Heart Rate ( /min) SpO 2 (%) FEV 1 x 35 f ( /min) O 2 Pulse (ml/beat) R = HRmax predicted VCO 2 (L/min) VE/VO 2 VE/VCO Workrate (W) VE (L/min) 3 FEV 1 x VT (L) VC VCO 2 (L/min) VE (L/min)

28 Case #2 - Severe COPD and Cardiomyopathy 1 1 R = Wmax predicted VCO 2 (L/min) Workrate (W)

29 Case #2 - Severe COPD and Cardiomyopathy HRmax predicted Heart Rate ( /min) O 2 Pulse (ml/beat) VE/VO 2 VE/VCO

30 Case #2 - Severe COPD and Cardiomyopathy 3 25 VC 3 FEV 1 x 35 2 VE (L/min) 2 1 VT (L) f ( /min) VCO 2 (L/min) 5 VE (L/min) FEV 1 x 35

31 VD/VT Case #2 - Severe COPD and Cardiomyopathy PETCO 2 (mmhg)

32 Case #2 - Severe COPD and Cardiomyopathy SpO 2 (%)

33 Case #2 - Severe COPD and Cardiomyopathy Flow (L/s) Maximal Rest End Ex Volume (l)

34 Cardiopulmonary Exercise Testing Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort

35 Cardiopulmonary Exercise Testing Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort

36 Cardiopulmonary Exercise Testing Key Observations markedly abnormal study with significant limitation associated with reduced work and aerobic capacity aerobic work inefficiency (attributed to technique, high level of ventilation, etc) blunted heart rate response (with plateau) achieved maximal predicted ventilation, marked flow limitation and increase in EELV no oxygen desaturation no arrhythmias or ischemic changes

37 Cardiopulmonary Exercise Testing Implies the Cardiologist was Correct? but how can that be?

38 Cardiopulmonary Exercise Testing Exercise Measurements Before After %Change HR (/min) W max (watts) T Lim (minutes) 4:54 5: [7% pred] [78% pred] V E (L/min) [96% pred] [12% pred] SaO 2 (%) 93 92

39 Severe COPD and Cardiomyopathy Pacemaker Adjustment Wmax predicted Heart Rate ( /min) O 2 Pulse (ml/beat) HRmax predicted Workrate (W) Baseline After HR Baseline HR After O2 Pulse Baseline O2 Pulse After 4 2

40 Severe COPD and Cardiomyopathy Pacemaker Adjustment Flow (L/s) 8 Maximal 3 6 Rest End Ex Baseline FEV 1 x 35 4 End Ex After VE (L/min) Baseline VCO 2 (L/min) After Volume (l)

41 Cardiopulmonary Exercise Testing Let s Ask The Question Again: Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort

42 Cardiopulmonary Exercise Testing Let s Ask The Question Again: Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort

43 Cardiopulmonary Exercise Testing Some Observations and Comments the patient demonstrated abundant abnormally significant cardiac and respiratory responses - many reasons for impaired exercise but the results (after increasing the maximal paced heart rate) highlight the fundamental importance of circulatory function and cardiac output (HR SV) to exercise performance even in someone with severe COPD! and whose Cardiologist repeatedly assured the patient her lungs were the only problem!

44 Respiratory System Responses Normal MVC (Maximal Ventilatory Capacity) VE (L/min) MVC Lung Disease Lung Disease Normal Trained

45 HR (min -1 ) Cardiovascular System Responses HRmax predicted Heart Disease Normal COPD Trained

46 Cardiopulmonary Exercise Testing Case #3 Clinical Background 16-yr-old female with shortness of breath in gym class and during sports No syncope, chest pain, or palpitations Mother is also concerned her daughter is not able to keep up with her peers (Mom was a university track competitor) No meds, no significant past/family history O/E: normal, no murmurs ECG: normal CXR: normal PFT: normal MCT: PC 2 > 32 mg/ml Unexplained shortness of breath

47 Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 AT (L/min) --? (>19) V E (L/min) BR (L) SaO 2 (%) HR (/min) Dyspnea/Legs / 9/3 ECG no arrhythmias or ischemic changes I m so short of breath

48 Case #3 Unexplained Dyspnea VD/VT Wmax predicted PETCO 2 (mmhg) Heart Rate ( /min) SpO 2 (%) FEV 1 x 35 O 2 Pulse (ml/beat) f ( /min) HRmax predicted 2 R = VCO 2 (L/min) VE/VO 2 VE/VCO Workrate (W) VE (L/min) 12 FEV 1 x VT (L) VC VCO 2 (L/min) VE (L/min)

49 Case #3 Unexplained Dyspnea Wmax predicted 2 2 R = VCO 2 (L/min) Workrate (W)

50 Heart Rate ( /min) Case #3 Unexplained Dyspnea O 2 Pulse (ml/beat) 2 HRmax predicted VE/VO 2 VE/VCO

51 Case #3 Unexplained Dyspnea FEV 1 x 35 f ( /min) FEV 1 x 35 VC VE (L/min) 6 VT (L) VCO 2 (L/min) VE (L/min)

52 VD/VT Case #3 Unexplained Dyspnea PETCO 2 (mmhg)

53 Case #3 Unexplained Dyspnea SpO 2 (%)

54 Case #3 Unexplained Dyspnea Flow (L/s) 12 8 Maximal Rest Sub-maximal Exercise End Exercise Volume (l)

55 Cardiopulmonary Exercise Testing Why does this 16-yr-old experience increased shortness of breath with physical activity? a Mild pulmonary hypertension b Hyperventilation syndrome c Mitochondrial myopathy d Exercise-induced bronchoconstriction e We still don t know

56 Cardiopulmonary Exercise Testing Why does this 16-yr-old experience increased shortness of breath with physical activity? a Mild pulmonary hypertension b Hyperventilation syndrome c Mitochondrial myopathy d Exercise-induced bronchoconstriction e We still don t know

57 Cardiopulmonary Exercise Testing Key Observations 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 are not typical of a known pathologic disease process all other responses are normal no evidence of worrisome underlying diseases or processes?psychologic contributors

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