1. Cardiopulmonary Exercise Testing: ClinicalExamples Darcy D. Marciniuk MD, FRCP(C), FCCP Division of Respirology, Critical Care and Sleep Medicine

2. Conflict of Interest Disclosure Consultancy Fees / Advisory Boards AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region Research Funding AstraZeneca, 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 Bureau AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer Fiduciary Positions Canadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association Employee University of Saskatchewan

3. VariableCHFCOPDILDPVDDe-conditioned Peak VO 2 ↓↓↓↓↓ AT↓ V or indeterminate ↓↓ ↔ or ↓ Peak HR v ↔ or ↓ ↓ O 2 Pulse ↓ ↔ or ↓ ↓↓ V E /MVV ↔ or ↓ ↑ ↔ or ↑ ↔↔ V E /VCO 2 ↑↑↑↑↔ V D /V T ↑↑↑↑↔ PaO 2 ↔v↓↓↔ P A-a O 2 ↔v↑↑↔ (↓= decreased; ↔ = unchanged from normal; ↑ = increased; v = variable)

4. Principles of Interpretation Address 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

5. 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: SaO 2 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 Testing

6. Pulmonary Function BeforeAfter FVC (L) 3.38 3.59 (71% pred) (76% pred) FEV 1 (L) 1.49 1.76 (50% pred) (59% pred) FEV 1 /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 Testing

7. Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 82 45 VO 2 (L/min) 0.36 1.52 58 VO 2 AT (L/min) -- 1.10 (>1.03) V E (L/min) 12.1 44.8 69 BR (L) -- 18.9 SaO 2 (%) 97 98 HR (/min) 68 109 60 Dyspnea/Legs 0.5/0 5/5 ECG no arrhythmias or ischemic changes Cardiopulmonary Exercise Testing “I couldn’t do anymore - my breathing and legs”

8. Moderate COPD

11. Ventilatory Responses MVC (Normal) MVC (Lung Disease) Cardiopulmonary Exercise Testing

12. Moderate COPD

14. Flow (l/sec) Volume (l)

15. 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 O 2 pulse observations are consistent with a component of deconditioning Moderate COPD

16. 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: PC 20 > 32 mg/ml “Unexplained shortness of breath” Cardiopulmonary Exercise Testing

17. Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 65 47 VO 2 (L/min) 0.20 1.32 74 V E (L/min) 9.6 35.5 34 BR (L) -- 68.5 SaO 2 (%) 99 96 HR (/min) 86 151 75 Dyspnea 2 9 Legs 0 3 “I Can’t Breath Anymore” Cardiopulmonary Exercise Testing

18. Unexplained Dyspnea

24. Healthy Normal

25. 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

26. 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 Testing

27. Pulmonary Function FVC (L) 1.82 53% pred FEV 1 (L) 2.1945% pred FEV 1 /FVC83% TLC (L) 3.4750% pred RV (L) 1.2854% pred Dlco (ml/min/mmHg) 9.827% pred Cardiopulmonary Exercise Testing

28. Exercise Measurements Rest End-Exercise %Pred W max (watts) -- 50 29 VO 2 (L/min) 0.34 1.07 44 V E (L/min) 20.1 68.1 106 BR (L) -- (3.9) SaO 2 (%) 97 76 HR (/min) 131 164 100 Dyspnea 0.5 7 Legs 0 7 “Can’t do anymore … breathing and my legs.” Cardiopulmonary Exercise Testing

29. V O 2 (L/min) Workrate (W) 060120180 0 1 2 V O 2 max predicted Wmax predicted Heart Rate (/min) V O 2 (L/min) 100 140 180 60 012 HRmax predicted V O 2 max predicted ILD / (?) Transplant Candidate

30. V CO 2 (L/min) V O 2 (L/min) 0 1 2 01 2 V O 2 max predicted R = 1 V E / V O 2 V E / V CO 2 V O 2 (L/min) 012 40 50 60 70 V O 2 max predicted ILD / (?) Transplant Candidate

31. V E (L/min) V CO 2 (L/min) 012 0 20 40 60 80 FEV 1 x 35 35 V T (L) V E (L/min) f (/min) 0 1 2 3 020406080 20 40 60 VC FEV 1 x 35 ILD / (?) Transplant Candidate

32. P ETCO 2 (mmHg) V O 2 (L/min) 012 10 20 30 40 50 V O 2 max predicted SaO 2 (%) V O 2 (L/min) 70 80 90 100 012 V O 2 max predicted ILD / (?) Transplant Candidate

33. End-Exercise Measurements RA Test O 2 Test %Change SaO 2 (%) 76 92+ 21 HR (/min) 164 158 - 4 (100% pred) (96% pred) Wmax (watts) 50 75+ 50 (29% pred) (44% pred) Dyspnea 7 7 Legs 7 5 RA Test: “Can’t do anymore … breathing and my legs.” O 2 Test: “My breathing gave out.” ILD / (?) Transplant Candidate

34. Workrate (W) SaO 2 (%) 70 80 90 100 060120180 Room Air O2O2 Wmax predicted Workrate (W) Heart Rate ( /min) 60 100 140 180 060120180 Room Air O2O2 Wmax predicted HRmax predicted ILD / (?) Transplant Candidate

35. Interpretation physiologically maximal study with profound exercise limitation –peak VO 2 44% predicted –VO 2 /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

36. 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