Canadian Respiratory Conference - 217 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
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
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
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
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
Workload Cardiopulmonary Exercise Testing CPET Protocols Incremental Endurance EIB Challenge 75% VEmax 6% VEmax 1% VEmax 9% VEmax Time Time Time
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
Cardiopulmonary Exercise Testing Pulmonary Function FVC (L) 451 85% pred FEV 1 (L) 312 84% pred FEV 1 /FVC 69% TLC (L) 675 88% pred RV (L) 179 69% pred DLco (ml/min/mmhg) 427 18% pred maximal, symptom-limited, incremental cycle ergometry, 25 watts/min
Flow (L/s) 16 12 8 4-4 -8-12 -2 2 4 6 8 Volume (L)
Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 17 7 34 186 62 VO 2 AT (L/min) -- 11 (>123) V E (L/min) 144 682 61 BR (L) -- 43 SaO 2 (%) 98 97 HR (/min) 88 158 91 Dyspnea/Legs / 7/7 ECG no arrhythmias or ischemic changes I have to stop I can t do anymore
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 2 2 1 VCO 2 (L/min) 2 1 15 1 15 1 5 5 1 15 2 25 Workrate (W) 1 2 3 5 1 2 3 5 12 x 35 FEV 1 5 4 VE/VO 2 VE/VCO 2 4 3 VE (L/min) 9 6 3 35 VT (L) 4 3 2 1 VC FEV 1 3 2 1 2 1 2 3 4 1 2 3 5 VCO 2 (L/min) 1 3 6 9 12 VE (L/min) 3 4 95 2 9 1 3 85 1 2 3 2 1 2 3 8 1 2 3
Case #1 - Amyloidosis predicted VO 2 max 3 3 R=1 2 1 Wmax predicted VCO 2 (L/min) 2 1 5 1 15 2 25 Workrate (W) 1 2 3
Case #1 - Amyloidosis Heart Rate ( /min) O 2 Pulse (ml/beat) predicted VO 2 max 2 2 5 15 1 HRmax predicted 15 1 5 VE/VO 2 VE/VCO 2 4 3 5 1 2 3 2 1 2 3
Case #1 - Amyloidosis x 35 f ( /min) 12 FEV 1 x 35 5 4 9 35 4 VC 3 VE (L/min) 6 3 VT (L) 3 2 1 FEV 1 2 1 1 2 3 VCO 2 (L/min) 3 6 9 12 VE (L/min)
Case #1 - Amyloidosis PETCO 2 (mmhg) predicted VO 2 max 4 5 3 VD/VT 2 predicted VO 2 max 4 3 1 1 2 3 2 1 2 3
Case #1 - Amyloidosis SpO 2 (%) predicted VO 2 max 1 95 9 85 8 1 2 3
Case #1 - Amyloidosis Flow (L/s) 16 12 Maximal Rest Sub-maximal Exercise End ex 8 4-4 -8-12 no audible stridor during exercise -2 2 4 6 8 Volume (L)
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
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
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]
Central Airway Obstruction: Post-Intubation Flow (L/s) 8 6 4 2-2 -4-6 Maximal Rest Mid-exercise End-exercise -1 1 2 3 4 Volume (l) audible stridor developed during exercise (~45% predicted peak VO 2 )
Flow (L/s) Flow (L/s) Before Surgery After Surgery 16 12 Maximal Rest Sub-maximal Exercise End ex 16 12 Maximal Rest Sub-maximal Exercise End Exercise 8 8 4 4-4 -4-8 -8-12 -2 2 4 6 8 Volume (L) -12-2 2 4 6 8 Volume (L)
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)
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
Cardiopulmonary Exercise Testing Pulmonary Function FVC (L) 18 75% pred FEV 1 (L) 67 35% pred FEV 1 /FVC 34% TLC (L) 455 111% pred RV (L) 238 148% pred DLco (ml/min/mmhg) 78 44% pred maximal, symptom-limited, incremental, cycle ergometry, room air, 5 watts/min
Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 25 37 26 64 7 VO 2 AT (L/min) -- 34 (>36) V E (L/min) 94 238 96 BR (L) -- 1 SaO 2 (%) 93 93 HR (/min) 79 99 59 Dyspnea/Legs 5/ 4/7 ECG no arrhythmias or ischemic changes My legs just quit!
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) 1 75 1 75 R = 1 175 15 HRmax predicted 8 6 5 25 VCO 2 (L/min) 5 25 125 1 75 4 2 VE/VO 2 VE/VCO 2 2 4 6 8 25 5 75 1 Workrate (W) 6 5 4 3 VE (L/min) 3 FEV 1 x 35 2 1 VT (L) 5 25 5 75 1 25 3 VC 2 2 15 1 1 5 2 25 5 75 1 4 35 25 5 75 1 VCO 2 (L/min) 5 1 2 3 VE (L/min) 1 3 2 1 4 3 95 9 85 25 5 75 1 2 25 5 75 1 8 25 5 75 1
Case #2 - Severe COPD and Cardiomyopathy 1 1 R = 1 75 75 5 25 Wmax predicted VCO 2 (L/min) 5 25 2 4 6 8 Workrate (W) 25 5 75 1
Case #2 - Severe COPD and Cardiomyopathy 175 8 6 HRmax predicted Heart Rate ( /min) 15 125 1 75 6 4 2 O 2 Pulse (ml/beat) VE/VO 2 VE/VCO 2 5 4 3 5 2 25 5 75 1 25 5 75 1
Case #2 - Severe COPD and Cardiomyopathy 3 25 VC 3 FEV 1 x 35 2 VE (L/min) 2 1 VT (L) 15 1 2 1 f ( /min) 35 25 5 75 1 1 2 3 VCO 2 (L/min) 5 VE (L/min) FEV 1 x 35
VD/VT Case #2 - Severe COPD and Cardiomyopathy PETCO 2 (mmhg) 4 5 3 2 1 4 3 25 5 75 1 2 25 5 75 1
Case #2 - Severe COPD and Cardiomyopathy SpO 2 (%) 1 95 9 85 8 25 5 75 1
Case #2 - Severe COPD and Cardiomyopathy Flow (L/s) 8 6 4 Maximal Rest End Ex 2-2 -4-6 -1 1 2 3 4 Volume (l)
Cardiopulmonary Exercise Testing Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort
Cardiopulmonary Exercise Testing Why did this patient stop exercise? a COPD b Cardiomyopathy c Both COPD and Cardiomyopathy d Deconditioning e Submaximal Effort
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
Cardiopulmonary Exercise Testing Implies the Cardiologist was Correct? but how can that be?
Cardiopulmonary Exercise Testing Exercise Measurements Before After %Change HR (/min) 99 116 + 16 W max (watts) 25 33 + 32 T Lim (minutes) 4:54 5:59 + 22 63 7 + 11 [7% pred] [78% pred] V E (L/min) 238 254 + 7 [96% pred] [12% pred] SaO 2 (%) 93 92
Severe COPD and Cardiomyopathy Pacemaker Adjustment Wmax predicted Heart Rate ( /min) O 2 Pulse (ml/beat) 1 175 HRmax predicted 8 75 15 6 5 25 2 4 6 8 Workrate (W) Baseline After 125 1 75 5 25 5 75 1 HR Baseline HR After O2 Pulse Baseline O2 Pulse After 4 2
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) 2 1 2-2 Baseline 35 25 5 75 1 VCO 2 (L/min) After -4-6 -1 1 2 3 4 Volume (l)
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
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
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!
Respiratory System Responses Normal MVC (Maximal Ventilatory Capacity) VE (L/min) MVC Lung Disease Lung Disease Normal Trained
HR (min -1 ) Cardiovascular System Responses HRmax predicted Heart Disease Normal COPD Trained
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
Cardiopulmonary Exercise Testing Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 65 47 2 132 74 VO 2 AT (L/min) --? (>19) V E (L/min) 96 355 34 BR (L) -- 685 SaO 2 (%) 99 97 HR (/min) 86 151 75 Dyspnea/Legs / 9/3 ECG no arrhythmias or ischemic changes I m so short of breath
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) 2 2 2 HRmax predicted 2 R = 1 15 1 5 VCO 2 (L/min) 15 1 5 15 1 15 1 5 VE/VO 2 VE/VCO 2 5 1 15 5 1 15 2 Workrate (W) 7 6 5 4 3 VE (L/min) 12 FEV 1 x 35 9 35 6 3 VT (L) 5 5 1 15 2 4 VC 3 2 1 1 75 5 25 2 5 1 15 2 4 1 2 3 5 VCO 2 (L/min) 3 6 9 12 1 VE (L/min) 3 2 1 4 3 95 9 85 5 1 15 2 2 5 1 15 2 8 5 1 15 2
Case #3 Unexplained Dyspnea Wmax predicted 2 2 R = 1 15 15 1 5 VCO 2 (L/min) 1 5 5 1 15 Workrate (W) 5 1 15 2
Heart Rate ( /min) Case #3 Unexplained Dyspnea O 2 Pulse (ml/beat) 2 HRmax predicted 2 7 15 1 15 1 5 VE/VO 2 VE/VCO 2 6 5 4 3 5 5 1 15 2 2 5 1 15 2
Case #3 Unexplained Dyspnea FEV 1 x 35 f ( /min) 12 4 1 FEV 1 x 35 VC 9 35 3 75 VE (L/min) 6 VT (L) 2 5 3 1 25 1 2 3 VCO 2 (L/min) 3 6 9 12 VE (L/min)
VD/VT Case #3 Unexplained Dyspnea PETCO 2 (mmhg) 4 5 3 2 1 4 3 5 1 15 2 2 5 1 15 2
Case #3 Unexplained Dyspnea SpO 2 (%) 1 95 9 85 8 5 1 15 2
Case #3 Unexplained Dyspnea Flow (L/s) 12 8 Maximal Rest Sub-maximal Exercise End Exercise 4-4 -8-2 2 4 6 Volume (l)
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
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
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