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

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

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)

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

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

Pulmonary Function BeforeAfter FVC (L) (71% pred) (76% pred) FEV 1 (L) (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

Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 (L/min) VO 2 AT (L/min) (>1.03) V E (L/min) BR (L) SaO 2 (%) HR (/min) 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”

Moderate COPD

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

Moderate COPD

Flow (l/sec) Volume (l)

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

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

Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 (L/min) V E (L/min) BR (L) SaO 2 (%) HR (/min) Dyspnea 2 9 Legs 0 3 “I Can’t Breath Anymore” Cardiopulmonary Exercise Testing

Unexplained Dyspnea

Healthy Normal

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

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

Pulmonary Function FVC (L) % pred FEV 1 (L) % pred FEV 1 /FVC83% TLC (L) % pred RV (L) % pred Dlco (ml/min/mmHg) 9.827% pred Cardiopulmonary Exercise Testing

Exercise Measurements Rest End-Exercise %Pred W max (watts) VO 2 (L/min) V E (L/min) BR (L) -- (3.9) SaO 2 (%) HR (/min) Dyspnea Legs 0 7 “Can’t do anymore … breathing and my legs.” Cardiopulmonary Exercise Testing

V O 2 (L/min) Workrate (W) V O 2 max predicted Wmax predicted Heart Rate (/min) V O 2 (L/min) HRmax predicted V O 2 max predicted ILD / (?) Transplant Candidate

V CO 2 (L/min) V O 2 (L/min) V O 2 max predicted R = 1 V E / V O 2 V E / V CO 2 V O 2 (L/min) V O 2 max predicted ILD / (?) Transplant Candidate

V E (L/min) V CO 2 (L/min) FEV 1 x V T (L) V E (L/min) f (/min) VC FEV 1 x 35 ILD / (?) Transplant Candidate

P ETCO 2 (mmHg) V O 2 (L/min) V O 2 max predicted SaO 2 (%) V O 2 (L/min) V O 2 max predicted ILD / (?) Transplant Candidate

End-Exercise Measurements RA Test O 2 Test %Change SaO 2 (%) HR (/min) (100% pred) (96% pred) Wmax (watts) (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

Workrate (W) SaO 2 (%) Room Air O2O2 Wmax predicted Workrate (W) Heart Rate ( /min) Room Air O2O2 Wmax predicted HRmax predicted ILD / (?) Transplant Candidate

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

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