Cardiopulmonary Cardiopulmonary Exercise Testing: Exercise Testing:
ClinicalClinicalExamplesExamples
Darcy D. MarciniukDarcy D. MarciniukMD, FRCP(C), FCCPMD, FRCP(C), FCCP
Division of Respirology, Critical Division of Respirology, Critical Care and Sleep MedicineCare and Sleep Medicine
Conflict of Interest Disclosure
Consultancy Fees / Advisory BoardsAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region
Research FundingAstraZeneca, 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 BureauAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer
Fiduciary PositionsCanadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association
EmployeeUniversity of Saskatchewan
Variable CHFCHF COPDCOPD ILDILD PVDPVD De-De-conditionedconditioned
Peak VOPeak VO22 ↓↓ ↓↓ ↓↓ ↓↓ ↓↓
ATAT ↓↓ V or V or indeterminateindeterminate ↓↓ ↓↓ ↔ ↔ or ↓or ↓
Peak HRPeak HR vv ↔ ↔ or ↓or ↓ ↓↓ ↔ ↔ or ↓or ↓ ↔ ↔ or ↓or ↓
OO22 Pulse Pulse ↓↓ ↔ ↔ or ↓or ↓ ↔ ↔ or ↓or ↓ ↓↓ ↓↓
VVEE/MVV/MVV ↔ ↔ or ↓or ↓ ↑↑ ↔ ↔ or ↑or ↑ ↔↔ ↔↔
VVEE/VCO/VCO22 ↑↑ ↑↑ ↑↑ ↑↑ ↔↔
VVDD/V/VTT ↑↑ ↑↑ ↑↑ ↑↑ ↔↔
PaOPaO22 ↔↔ vv ↓↓ ↓↓ ↔↔
PPA-aA-aOO22 ↔↔ vv ↑↑ ↑↑ ↔↔
(↓= decreased; ↔ = unchanged from normal; ↑ = increased; v = variable)
Principles of InterpretationAddress 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: SaO2 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 TestingCardiopulmonary Exercise Testing
Pulmonary Function Before After
FVC (L) 3.38 3.59
(71% pred) (76% pred)
FEV1 (L) 1.49 1.76 (50% pred) (59% pred)
FEV1/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 TestingCardiopulmonary Exercise Testing
Exercise Measurements
Rest End-Exercise %Pred
Wmax (watts) -- 82 45VO2 (L/min) 0.36 1.52 58VO2 AT (L/min) -- 1.10
(>1.03)VE (L/min) 12.1 44.8 69BR (L) -- 18.9SaO2 (%) 97 98HR (/min) 68 109 60Dyspnea/Legs 0.5/0 5/5ECG no arrhythmias or ischemic changes
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
“I couldn’t do anymore - my breathing and legs”
0
1
2
3
0 50 100 150 200
VO
2(L
/min
)
Workrate (W)
VO2max predicted
Wm
axp
red
icte
d
R=1
VO
2max
pre
dic
ted
0
1
2
3
0 1 2 3
VC
O2
(L/m
in)
VO2 (L/min)
Moderate COPDModerate COPD
VO
2max
pre
dic
ted
0
5
10
15
20
50
100
150
200
0 1 2 3
O2
Pu
lse
(mL
/be
at)
He
art
Ra
te (
/min
)
VO2 (L/min)
HRmax predicted
VO
2max
pre
dic
ted
20
30
40
50
0 1 2 3
VE
/VO
2V
E/V
CO
2
VO2 (L/min)
Moderate COPDModerate COPD
35
FEV1 x 35
0
25
50
75
0 0.5 1 1.5 2
VE
(L/m
in)
VCO2 (L/min)
FE
V1
x 35
VC
0
10
20
30
40
0
1
2
3
0 25 50 75
f ( /
min
)
VT
(L)
VE (L/min)
Moderate COPDModerate COPD
Ventilatory Responses
NormalLung
Disease
VE(L
/min
)
VO2 (L/min)
MVC (Normal)
MVC (Lung Disease)
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
VO
2max
pre
dic
ted
0
0.1
0.2
0.3
0.4
0 1 2 3
VD
/VT
VO2 (L/min)
VO
2max
pre
dic
ted
20
30
40
50
0 1 2 3
PE
TC
O2
(mm
Hg
)
VO2 (L/min)
Moderate COPDModerate COPD
VO
2max
pre
dic
ted
80
85
90
95
100
0 1 2 3
Sp
O2(%
)
VO2 (L/min)
Moderate COPDModerate COPD
Flo
w (
l/se
c)
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 O2 pulse observations
are consistent with a component of deconditioning
Moderate COPDModerate 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: PC20 > 32 mg/ml• “Unexplained shortness of breath”
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
Exercise Measurements Rest End-Exercise
%PredWmax (watts) -- 65 47
VO2 (L/min) 0.20 1.32 74
VE (L/min) 9.6 35.5 34BR (L) -- 68.5SaO2 (%) 99 96HR (/min) 86 151 75Dyspnea 2 9Legs 0 3“I Can’t Breath Anymore”
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
0
0.5
1
1.5
2
0 0.5 1 1.5 2
VC
O2
(L/m
in)
VO2 (L/min)
VO
2max
pre
dic
ted
R = 1
0
0.5
1
1.5
2
0 50 100 150
VO
2(L
/min
)
Workrate (W)
VO2max predicted
Wm
axp
red
icte
d
Unexplained Dyspnea
20
30
40
50
60
70
0 0.5 1 1.5 2
VE
/VO
2V
E/V
CO
2
VO2 (L/min)
VO
2max
pre
dic
ted
0
5
10
15
20
50
100
150
200
0 0.5 1 1.5 2
O2
Pu
lse
(m
L/b
ea
t)
He
art
Ra
te (
/m
in)
VO2 (L/min)
HRmax predicted
VO
2max
pre
dic
ted
Unexplained Dyspnea
0
25
50
75
100
0
1
2
3
4
0 30 60 90 120
f (
/min
)
VT
(L)
VE (L/min)
FE
V1
x 35
VC
0
30
60
90
120
0 1 2 3
VE
(L/m
in)
VCO2 (L/min)
FEV1 x 35
35
Unexplained Dyspnea
20
30
40
50
0 0.5 1 1.5 2
PE
TC
O2
(mm
Hg
)
VO2 (L/min)
VO
2max
pre
dic
ted
0
0.1
0.2
0.3
0.4
0 0.5 1 1.5 2
VD
/VT
VO2 (L/min)
VO
2max
pre
dic
ted
Unexplained Dyspnea
80
85
90
95
100
0 0.5 1 1.5 2
Sp
O2
(%)
VO2 (L/min)
VO
2max
pre
dic
ted
Unexplained Dyspnea
Unexplained Dyspnea
-8
-4
0
4
8
12
-2 0 2 4 6
Flow
(L/s
)
Volume (l)
Maximal
Rest
Sub-maximal Exercise
End Exercise
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 TestingCardiopulmonary Exercise Testing
Pulmonary Function
FVC (L) 1.82 53% predFEV1 (L) 2.19 45% pred
FEV1/FVC 83%
TLC (L) 3.47 50% predRV (L) 1.28 54% predDlco (ml/min/mmHg) 9.8 27% pred
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
Exercise Measurements
Rest End-Exercise %PredWmax (watts) -- 50 29
VO2 (L/min) 0.34 1.07 44
VE (L/min) 20.1 68.1 106
BR (L) -- (3.9)SaO2 (%) 97 76HR (/min) 131 164 100Dyspnea 0.5 7Legs 0 7“Can’t do anymore … breathing and my legs.”
Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing
VO
2 (L
/min
)
Workrate (W)
0 60 120 180
0
1
2
VO2max predicted
Wm
ax
pre
dic
ted
Hea
rt R
ate
(/m
in)
VO2 (L/min)
100
140
180
60
0 1 2
HRmax predicted
VO
2ma
x p
red
icte
d
ILD / (?) Transplant Candidate
VC
O2
(L/m
in)
VO2 (L/min)
0
1
2
0 1 2
VO
2ma
x p
red
icte
d
R = 1
VE
/ V
O2
VE
/ V
CO
2
VO2 (L/min)
0 1 2
40
50
60
70
VO
2ma
x p
red
icte
d
ILD / (?) Transplant Candidate
VE
(L
/min
)
VCO2 (L/min)
0 1 2
0
20
40
60
80
FEV1 x 35
35
VT
(L)
VE (L/min)
f (
/min
)
0
1
2
3
0 20 40 60 80
20
40
60
VC
FE
V1 x
3
5
ILD / (?) Transplant Candidate
PE
TC
O2
(m
mH
g)
VO2 (L/min)
0 1 2
10
20
30
40
50
VO
2ma
x p
red
icte
d
SaO
2
(%)
VO2 (L/min)
70
80
90
100
0 1 2
VO
2ma
x p
red
icte
d
ILD / (?) Transplant Candidate
End-Exercise Measurements RA Test O2 Test
%ChangeSaO2 (%) 76 92 +
21HR (/min) 164 158 - 4
(100% pred) (96% pred)
Wmax (watts) 50 75 + 50 (29% pred) (44% pred)
Dyspnea 7 7Legs 7 5RA Test: “Can’t do anymore … breathing and my legs.”
O2 Test: “My breathing gave out.”
ILD / (?) Transplant Candidate
Workrate (W)
SaO
2
(%)
70
80
90
100
0 60 120 180
Room Air
O2
Wm
ax
pre
dic
ted
Workrate (W)
Hea
rt R
ate
( /m
in)
60
100
140
180
0 60 120 180
Room Air
O2
Wm
ax
pre
dic
ted
HRmax predicted
ILD / (?) Transplant Candidate
Interpretation• physiologically maximal study with
profound exercise limitation– peak VO2 44% predicted– VO2/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