exercise testing which patient ? when ?

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EXERCISE TESTING EXERCISE TESTING Which Patient? Which Patient? When? When? Gündeniz Altıay Gündeniz Altıay Trakya Üniversitesi Tıp Trakya Üniversitesi Tıp Fakültesi Fakültesi Göğüs Hastalıkları Anabilim Göğüs Hastalıkları Anabilim Dalı Dalı

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EXERCISE TESTING Which Patient ? When ?. Gündeniz Altıay Trakya Üniversitesi Tıp Fakültesi Göğüs Hastalıkları Anabilim Dalı EDİRNE. Presantation Plan. Clinical Exercise Tests , Definitions , Preoperative evaluation , National and international data, Guidelines. Clinical Exercise Tests. - PowerPoint PPT Presentation

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Page 1: EXERCISE TESTING Which Patient ?  When ?

EXERCISE TESTINGEXERCISE TESTINGWhich Patient? When? Which Patient? When?

Gündeniz AltıayGündeniz AltıayTrakya Üniversitesi Tıp FakültesiTrakya Üniversitesi Tıp FakültesiGöğüs Hastalıkları Anabilim DalıGöğüs Hastalıkları Anabilim Dalı

EDİRNEEDİRNE

Page 2: EXERCISE TESTING Which Patient ?  When ?

Presantation PlanPresantation Plan

• Clinical Exercise Tests,Clinical Exercise Tests,

• Definitions,Definitions,

• Preoperative evaluation,Preoperative evaluation,

• National and international data,National and international data,

• Guidelines Guidelines

Page 3: EXERCISE TESTING Which Patient ?  When ?

Clinical Exercise TestsClinical Exercise Tests

6-minute walk test,6-minute walk test, Shuttle walk test,Shuttle walk test, Stair climbing test,Stair climbing test, Exercise-induced bronchoconstriction,Exercise-induced bronchoconstriction, Cardiac stress test,Cardiac stress test, Cardiopulmonary exercise test (CPET)Cardiopulmonary exercise test (CPET)

Holden DA et al. Chest 1992;102:1774-79Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701 ATS/ACCP. Am J Respir Crit Care Med 2003;167:211-77

Page 4: EXERCISE TESTING Which Patient ?  When ?

Six-Minute Walk Distance (6MWD)TestSix-Minute Walk Distance (6MWD)Test

• Basic, pratique testBasic, pratique test

• 6 minute, walking distance6 minute, walking distance

• The walking course should be a 30 m longThe walking course should be a 30 m long

• 500 m ═ 15 mL.kg.min VO2max500 m ═ 15 mL.kg.min VO2max

Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701Turner SE et al. Chest 2004;126.766-773

Page 5: EXERCISE TESTING Which Patient ?  When ?

Incremental Shuttle Walking Test Incremental Shuttle Walking Test (SWT)(SWT)

• Symptom limited maximal testSymptom limited maximal test

• Distance of between two shuttle :10 mDistance of between two shuttle :10 m

• Audio signalsAudio signals

• Good correlation with 6MWDGood correlation with 6MWD

Weisman IM et al. Clinics In Chest Medicine, 2001;22(4):679-701 Singh SJ et al. Thorax 1992;47:1019-24

Page 6: EXERCISE TESTING Which Patient ?  When ?

• The SWT correlates better with maximal oxygen The SWT correlates better with maximal oxygen uptake (VO2max) than 6MWD.uptake (VO2max) than 6MWD.

• 450 m of SWT450 m of SWT• VO2max >15 mL.kg.minVO2max >15 mL.kg.min

Lewis ME et al. Heart 2000;86:183-87

Morales FJ et al. Am Heart J 1999;138:292-298Onaratti P et al. Eur J Appl Phys 2003; 89:331-36

Page 7: EXERCISE TESTING Which Patient ?  When ?

Indications for 6MWD and SWT in clinical practice Indications for 6MWD and SWT in clinical practice

Indication Recommendation grade

Diagnosis of exercise-induced arterial desaturation B

Functional evaluation of patients with COPD, ILD, PPH, and CHF

B

Prognostic evaluation of patients with COPD, ILD, PPH and CHF

B

Functional evaluation of patients with CF C

Prognostic evaluation of patients with COPD or CHF prior to surgery (LVRS, transplantation)

C

Evaluation of the benefits of therapeutic interventions (oxygen supplementation, rehabilitation, surgery)

B

Palanga P et al. eur Respir J 2007;29:185-209

Page 8: EXERCISE TESTING Which Patient ?  When ?

Stair Climbing TestStair Climbing Test

• AA safe and economical exercise test safe and economical exercise test

• IIt was the best predictor of cardiopulmonary t was the best predictor of cardiopulmonary complications after lung resectioncomplications after lung resection..

Olsen GN et al. Chest 1991;99:587-90Colice GL et al. Chest 2007;132:161S-177S Brunelli A et al. Ann Thorac Surg 2008;86:240-47Brunelli A et al. Ann Thorac Surg 2008;86:240-47

Page 9: EXERCISE TESTING Which Patient ?  When ?

Cardiopulmonary exercise test Cardiopulmonary exercise test (CPET)(CPET)

• Cardiovascular responseCardiovascular response

• Ventilatory responseVentilatory response

• Gas exchangeGas exchange

• VOVO22 response response

• Anaerobic/Ventilatory Anaerobic/Ventilatory ThresholdThreshold

Page 10: EXERCISE TESTING Which Patient ?  When ?

CPETCPET

MetaboliMetabolicc

VOVO22, VCO, VCO22, R, AT, laktat , R, AT, laktat

CCardiardiacac

HR, HRR, ECG, BP, OHR, HRR, ECG, BP, O22 pulse pulse

RespiratoryRespiratory

VE, VVE, VTT, f, PETO, f, PETO22, PETCO, PETCO22

GaGass exchangeexchange

SpOSpO22, VE/VCO, VE/VCO22, VE/VO, VE/VO22

AAcciidd--bbaasese

pH, PaOpH, PaO22, PaCO, PaCO22

Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701 ATS/ACCP. Am J Respir Crit Care Med 2003;167:211-77

Page 11: EXERCISE TESTING Which Patient ?  When ?

Maksimum oxygen consumptionMaksimum oxygen consumptionVO2max – VO2peak VO2max – VO2peak

• VO2max is the best index of aerobic capacityVO2max is the best index of aerobic capacity

• The gold standard for cardiorespiratory fitnessThe gold standard for cardiorespiratory fitness

• mL/kg/minute ve predicted %mL/kg/minute ve predicted %

Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701 ATS/ACCP. Am J Respir Crit Care Med 2003;167:211-77

Page 12: EXERCISE TESTING Which Patient ?  When ?

Anaerobic Threshold (AT)Anaerobic Threshold (AT)

• Lactate accumulation in exercising muscle occurs when Lactate accumulation in exercising muscle occurs when oxygen demand exceeds the supply. oxygen demand exceeds the supply.

• The AT is usually 50% to 60% in sedantary individuals The AT is usually 50% to 60% in sedantary individuals and higher in fit individuals.and higher in fit individuals.

Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701 ATS/ACCP. Am J Respir Crit Care Med 2003;167:211-77

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Anaerobik eşik (AT)Anaerobik eşik (AT)

• The AT can be determined invasively by The AT can be determined invasively by measuring arterial lactate (gold standard)measuring arterial lactate (gold standard)

• The AT can be determined noninvasivelyThe AT can be determined noninvasively

• The modified V-slope method is most popularThe modified V-slope method is most popular

Sue DY et al. Chest 1988;94:931-38Wasserman et al. Principles of Exercise Testing. Lippincott 2005

Page 14: EXERCISE TESTING Which Patient ?  When ?

Indications for CPET in clinical practice Indications for CPET in clinical practice

Indication Recommendation grade

Detection of exercise-induced bronchoconstriction A

Detection of exercise-induced arterial oxygen desaturation B

Functional evaluation of subjects with unexplained exertional dyspnoea and/or exercise intolerance and normal resting lung and heart function

D

To recognise specific disease exercise response patterns that may help in the differential diagnosis of ventilatory versus circulatory causes of exercise limitation

C

Functional and prognostic evaluation of patients with COPD B, C

Functional and prognostic evaluation of patients with ILD, PPH and CHF B, B

Functional and prognostic evaluation of patients with CF C, C

Evaluation of interventions

 Maximal incremental test C

 High-intensity constant work-rate "endurance" tests B

Prescription of exercise training BPalanga P et al. Eur Respir J 2007;29:185-209

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Page 16: EXERCISE TESTING Which Patient ?  When ?

Preoperative EvaluationPreoperative EvaluationIndicationsIndications

• Lung cancer resectional surgeryLung cancer resectional surgery

• Lung volüme reduction surgeryLung volüme reduction surgery

• Evaluation for lung or heart-lung transplantationEvaluation for lung or heart-lung transplantation

• Preoperative evaluation for other proceduresPreoperative evaluation for other procedures

Page 17: EXERCISE TESTING Which Patient ?  When ?

Lung Cancer Resectional SurgeryLung Cancer Resectional Surgeryand CPETand CPET

• FEV1 and DLCO have the greatest utility in FEV1 and DLCO have the greatest utility in operability in low-risk patients.operability in low-risk patients.

• The CPET is often necessary to more accurately The CPET is often necessary to more accurately assess moderate – to high-risk patients.assess moderate – to high-risk patients.

ATS/ACCP. AJRCC 2003;167:211-77 Brunelli A et al. Eur Respir J 2009;34:17-41

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• During exercise - increases During exercise - increases ventilation, ventilation,

oxygen uptake, oxygen uptake,

carbon dioxide output and blood flow carbon dioxide output and blood flow

• Similar to the post-op. period after lung resectionSimilar to the post-op. period after lung resection ..

ATS/ACCP. AJRCCM 2003;167:211-77 Brunelli A et al. Eur Respir J 2009;34:17-41

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• VO2peak >20  mL/kg/min.VO2peak >20  mL/kg/min. or >75% pred operable.or >75% pred operable.

• VO2peak <40% or <10 mL/kg/min. contraindicated. VO2peak <40% or <10 mL/kg/min. contraindicated.

• If between both values, ppo was estimatedIf between both values, ppo was estimated• ppo FEVppo FEV11 and and DDL,COL,CO >40% (having either >40% (having either one) one)

• ppo- VO2peak <35% and >10  mL/kg/min.ppo- VO2peak <35% and >10  mL/kg/min.

• Surgical resectionSurgical resection

• The authors communicated aThe authors communicated a decrease in overall hospital mortality decrease in overall hospital mortality compared to historicalcompared to historical controls.controls.

Wyser C et al. AJRCCM 1999;159:1450-56

Page 20: EXERCISE TESTING Which Patient ?  When ?

• Patients who had a Patients who had a VO2peak <65% (VO2peak <65% (oror <16mL/kg/min <16mL/kg/min) were ) were more likely to suffer complications.more likely to suffer complications.

• Brunelli et al. found that all deaths after lung resection Brunelli et al. found that all deaths after lung resection occured in patients with a occured in patients with a VO2peak <20mL/kg/minVO2peak <20mL/kg/min. .

• A recently published meta-analysis has shown that exercise A recently published meta-analysis has shown that exercise capacity, expressed as VO2peak is lower in patients that capacity, expressed as VO2peak is lower in patients that develop post-op. cardiorespiratory compl. after lung resection. develop post-op. cardiorespiratory compl. after lung resection.

Loewen GM et al. J Thorac Oncol 2007;2:619-25

Brunelli A. Chest 2009;135(5):1260-67

Benzo R. Respir Med 2007;101:1790-97

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• Risk of peri-op.complications are often stratified by VO2peak. Risk of peri-op.complications are often stratified by VO2peak.

• VO2peak <15 mL·kg.min. indicates a significant risk of complications.VO2peak <15 mL·kg.min. indicates a significant risk of complications.

• The VO2peak less than 50-60% predicted is associated with higher The VO2peak less than 50-60% predicted is associated with higher morbidity and mortality.morbidity and mortality.

Morice RC. Chest 1996;110:161SBolliger CT. Eur Respir J 1998;11:198-212Wyser C et al. AJRCCM 1999;159:1450-1456Win T et al. Chest 2005;127:1159-65Loowen GM et al. J Thorac Oncol 2007;2:619-25

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• Akkoca et al. (26 patient)Akkoca et al. (26 patient)• VO2peak <10 mL/kg/minVO2peak <10 mL/kg/min. .

• Complication ratio ═ %75Complication ratio ═ %75

• Fındıkçıoğlu et al. (25 patient)Fındıkçıoğlu et al. (25 patient)• VO2max < 15 mL/kg/minVO2max < 15 mL/kg/min. (↑ complication). (↑ complication)

• VO2max >20 mL/kg/minVO2max >20 mL/kg/min. (no complication). (no complication)

• Kasikcioglu et al. (44 hasta)Kasikcioglu et al. (44 hasta)• OUES (oxygen uptake efficiency slope) : VO2/log10VEOUES (oxygen uptake efficiency slope) : VO2/log10VE

• The rate of increase in VO2 against minute ventilation volume (VE)The rate of increase in VO2 against minute ventilation volume (VE)

• OUES and VO2peak are a better predictor of surgical outcome.OUES and VO2peak are a better predictor of surgical outcome.

Akkoca Ö ve ark.. Tüberküloz ve Toraks 2004;52(4):307-314

Fındıkçıoğlu A ve ark. Toraks 2005;6(3):214-20

Kasikcioglu et al. Lung Cancer 2009;66:85-88

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Page 24: EXERCISE TESTING Which Patient ?  When ?

GUIDELINESGUIDELINESERS/ESTS TASK FORCEERS/ESTS TASK FORCE

• Exercise tests should be indicated in all patients undergoing surgery for Exercise tests should be indicated in all patients undergoing surgery for lung cancer with FEV1 or DLCO <80%. lung cancer with FEV1 or DLCO <80%.

• The cut-off values for VO2peak The cut-off values for VO2peak • >75% pred or >20mL/kg/dak qualifies for pneumonectomy; >75% pred or >20mL/kg/dak qualifies for pneumonectomy;

• <35% pred or <10 mL/kg/dak indicates high risk for any resection. <35% pred or <10 mL/kg/dak indicates high risk for any resection.

• Evidence is not sufficient to recommend cut-off values for lobectomy. Evidence is not sufficient to recommend cut-off values for lobectomy.

Level of evidence 2++; grade of recommendation BLevel of evidence 2++; grade of recommendation B

Brunelli A et al. Eur Respir J 2009;34:17-41

Page 25: EXERCISE TESTING Which Patient ?  When ?

Brunelli et al. Eur Respir J 2009;34:17-41

RCRI: REVISED CARDİAC RİSK INDEX

1)High risk surgery (lobectomy or pneumonectomy)

2)Ischaemic heart disease (prior MI, angina pectoris

3)Heart failure

4)Insulin-dependent diabetes

5)Previous stroke of TIA

6)Creatinine ≥2 mg.dL

Page 26: EXERCISE TESTING Which Patient ?  When ?

Bolliger CT et al. Eur Respir J 1998;11:198-212Brunelli A et al. Eur Respir J 2009;34:17-41

# If peak VO2 is not available, CPET can be replaced by stair climbing.

However, if altitude reaching during stair climbing is <22 m, CPET is highly recommended.

Page 27: EXERCISE TESTING Which Patient ?  When ?

ACCP GUIDELINESACCP GUIDELINES

• FEVFEV11 or D or DLCOLCO < 80% < 80% predpred

• PredictedPredicted postoperative lung functionpostoperative lung function (PPO) (PPO)

• IIncreased riskncreased risk• PPO PPO DDLCO x FEV1LCO x FEV1 < 1,650 < 1,650 or or PPO PPO FEVFEV11 < 30% < 30%

Grade of recommendation, 1CGrade of recommendation, 1C

Colice GL et al. Chest 2007;132:161S-177S

Page 28: EXERCISE TESTING Which Patient ?  When ?

ACCP GUIDELINESACCP GUIDELINES

• İncreased riskİncreased risk

• PPO PPO FEVFEV11 < 40% < 40% or or PPO PPO DDLCO LCO < 40% < 40% pred pred

• Perform CPETPerform CPET

Grade of recommendation, 1CGrade of recommendation, 1C

Colice GL et al. Chest 2007;132:161S-177S

Page 29: EXERCISE TESTING Which Patient ?  When ?

GUIDELINESGUIDELINESDİAGNOSİS AND MANAGEMENT OF LUNG DİAGNOSİS AND MANAGEMENT OF LUNG

CANCER: ACCP GUIDELINESCANCER: ACCP GUIDELINES

• İncreased riskİncreased risk• VO2maxVO2max< 15 mL/kg/min < 15 mL/kg/min and and

• PPO PPO FEVFEV11 or or DDLCOLCO < 40 < 40%%

• VO2maxVO2max< 10 mL/kg/min< 10 mL/kg/min. .

• It is recommended that these patients be counseled about It is recommended that these patients be counseled about nonstandard surgery and nonoperative treatment options for nonstandard surgery and nonoperative treatment options for their lung cancer. their lung cancer.

Grade of recommendation, 1C Grade of recommendation, 1C

Colice GL et al. Chest 2007;132:161S-177S

Page 30: EXERCISE TESTING Which Patient ?  When ?

Colice GL et al. Chest 2007;132:161S-177S

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Page 32: EXERCISE TESTING Which Patient ?  When ?

Low-technology exercise: stair, 6 min walk Low-technology exercise: stair, 6 min walk distance or shuttle?distance or shuttle?

• If CPET were unavailable, then another type of exercise test If CPET were unavailable, then another type of exercise test should be considered.should be considered.

• The shuttle walk test has been reported to be more The shuttle walk test has been reported to be more reproducible and more highly correlated with V02peak.reproducible and more highly correlated with V02peak.

Swinburn CR et al. Thorax 1985;40:581-86 Morgan AD et al. Respir Med 1989;83:388-87Singh SJ et al. Eur Respir J 1994; 7:2016-20

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Shuttle Walk Test (SWT)Shuttle Walk Test (SWT)

• 25 shuttles 25 shuttles ══ VO2peak of 10 mL/kg/min. VO2peak of 10 mL/kg/min.

• >400 m at shuttle walk test ═ VO2peak >15mL/kg/min>400 m at shuttle walk test ═ VO2peak >15mL/kg/min..

• The patients who exceed 400 m on the SWT may not need VO2 The patients who exceed 400 m on the SWT may not need VO2 assessment.assessment.

Win T et al. Thorax 2006;61:57-60

Singh SJ et al. Eur Respir J 1994;7:2016-20BTS Guidelines. Thorax 2001;56:89-108

Page 34: EXERCISE TESTING Which Patient ?  When ?

Shuttle Walk Test (SWT)Shuttle Walk Test (SWT)

RecommendationsRecommendations

• IIt should nott should not be used alone to select patients for operation. be used alone to select patients for operation.

• It could beIt could be used as a screening testused as a screening test..

• The The walking <400 m maywalking <400 m may have have VO2peakVO2peak <15 mL·kg·mi <15 mL·kg·min.n.

• The 6MWD should not be used to select patients for operationThe 6MWD should not be used to select patients for operation . .

Level of evidence 2+; grade of recommendation CLevel of evidence 2+; grade of recommendation C

Brunelli et al. Eur Respir J 2009;34:17-41

Page 35: EXERCISE TESTING Which Patient ?  When ?

Stair Climbing TestStair Climbing Test

• It It has historically been used as a surrogate CPET.has historically been used as a surrogate CPET.

• LLobectomyobectomy; ; climb three flights of stairs, climb three flights of stairs,

• Pneumonectomy Pneumonectomy ; ; climb five flights of stairs. climb five flights of stairs.

• CClimbing three flights limbing three flights : : FEVFEV11 of > 1.7 L and of > 1.7 L and

• CClimbing five flightslimbing five flights: : FEV FEV11 of > 2 L. of > 2 L.

Bolton JWR. Chest 1987;92:783-787

Page 36: EXERCISE TESTING Which Patient ?  When ?

• CClimb five flights of stairs will have a V[ olimb five flights of stairs will have a V[ o22max of > 20max of > 20

• CCannot climb one flight of stairs will have a V[ oannot climb one flight of stairs will have a V[ o22max of <10max of <10

• EEven though ven though FEVFEV11 or D or DLCOLCO of < 40% of < 40% ppo, ppo,

• ThThe ability to e ability to climb > 12 to 14 m of stairsclimb > 12 to 14 m of stairs, ,

• approximately three flights of stairs, approximately three flights of stairs,

• LLow risk for postoperative complications ow risk for postoperative complications fofor lobectomyr lobectomy

Brunelli A et al. Chest 2002;121:1106-10Olsen GN et al. Chest 1991;99:587-90

Pollock M et al. Chest 1993;104:1378-83

Page 37: EXERCISE TESTING Which Patient ?  When ?

• 536 patients with lung cancer 536 patients with lung cancer

• Exercise oxygen desaturation; 2 cut-offExercise oxygen desaturation; 2 cut-off

• saturation level <90% or saturation level <90% or

• desaturationdesaturation >4%>4%

• The risk of complications was approximately two-fold The risk of complications was approximately two-fold higherhigher in patients with oxygen desaturation >4% at peak in patients with oxygen desaturation >4% at peak exercise.exercise.

• Those patients in whom EODThose patients in whom EOD >4% >4% is observed should is observed should be be further assessed with a formal CPETfurther assessed with a formal CPET..

Brunelli A et al. Eur J Cardiothorac Surg 2008;33:77-82

Page 38: EXERCISE TESTING Which Patient ?  When ?

• 640 patients – major lung resection640 patients – major lung resection

• Climbing <12 mClimbing <12 m

• two-fold and 13-fold higher ratestwo-fold and 13-fold higher rates

• >22 m >22 m (<1% mortality)(<1% mortality)

• Even in patients with ppo-FEV1 and/or ppo-DLCO <40%, the Even in patients with ppo-FEV1 and/or ppo-DLCO <40%, the mortality rate in those climbing >22 m was zero.mortality rate in those climbing >22 m was zero.

Brunelli A et al. Ann Thorac Surg 2008;86:240-47

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ACCP GUIDELINESACCP GUIDELINES

• Increased riskIncreased risk

• <<25 shuttles 25 shuttles or or

• less than one flight of stairsless than one flight of stairs

• TheTheyy should be counseled about nonstandard surgery should be counseled about nonstandard surgery and nonoperative treatment for their lung cancer. and nonoperative treatment for their lung cancer.

Grade of recommendation, 1C Grade of recommendation, 1C

Colice GL et al. Chest 2007;132:161S-177S

Page 40: EXERCISE TESTING Which Patient ?  When ?

ERS/ESTS TASK FORCEERS/ESTS TASK FORCE

• The The stair climbing test is a cost-effectivestair climbing test is a cost-effective test capable of test capable of predicting morbidity and mortality after lungpredicting morbidity and mortality after lung resection better resection better than traditional spirometry values. than traditional spirometry values.

• It shouldIt should be used as a first-line functional screening test to be used as a first-line functional screening test to selectselect those patients that can undergo safely to operation those patients that can undergo safely to operation (height(height of ascent >22 m)of ascent >22 m)

Level of evidence 2++; gradeLevel of evidence 2++; grade of recommendation B.of recommendation B.

Brunelli et al. Eur Respir J 2009;34:17-41

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EXERCİSE OXYGEN DEASATURATİON (EOD)EXERCİSE OXYGEN DEASATURATİON (EOD)

• The SWTand 6-MDT may be more effective in identifying The SWTand 6-MDT may be more effective in identifying patients who desaturation during exercise than is the CPET.patients who desaturation during exercise than is the CPET.

• >4% desaturation >4% desaturation during exercise had been reported to during exercise had been reported to indicate an increased risk for peri-operative complications. indicate an increased risk for peri-operative complications.

Turner SE et al. Chest 2004;126:766-773

Pierce RJ et al. AJRCCM 1994;150:947-55Ninan M et al. Ann Thorac Surg 1997;64:328-33British Thoracic Society. Thorax 2001;56:89-108Brunelli A et al. Eur J Cardiothorac Surg 2008;33:77-82

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ACCP GUIDELINEACCP GUIDELINE

• AArterial oxygen saturation < 90% rterial oxygen saturation < 90% indicates an increased risk indicates an increased risk for perioperative complications with standard lung resection. for perioperative complications with standard lung resection.

• It is recommended that these patients undergo further It is recommended that these patients undergo further physiologic testing.physiologic testing.

Grade of recommendation, 1C Grade of recommendation, 1C

Colice GL et al. Chest 2007;132:161S-177S

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ERS/ESTS TASK FORCEERS/ESTS TASK FORCE

StatementStatement

• Patients with Patients with EOD >4EOD >4 duringduring stair climbing may have an stair climbing may have an increased rate of complications andincreased rate of complications and mortality after lung mortality after lung resection. resection.

• They needThey need to beto be further assessed with formal CPETfurther assessed with formal CPET..

Level of evidence 2+.Level of evidence 2+.

Brunelli A et al. Eur Respir J 2009;34:1-41

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Lung-Volume Reduction Surgery (LVRS)Lung-Volume Reduction Surgery (LVRS)and Exercise Testsand Exercise Tests

• 6-MWD <200 m 6-MWD <200 m is an excellent pre-operative predictoris an excellent pre-operative predictor of of unacceptable post-operative mortality at 6 month.unacceptable post-operative mortality at 6 month.

• Specificity of 84%. Specificity of 84%.

• A randomised controlled study, indicated that a pre-operative A randomised controlled study, indicated that a pre-operative SWT distance <150 m SWT distance <150 m was a predictor of high peri-op.was a predictor of high peri-op. mortality.mortality.

Brunelli A et al. Eur J Cardithorac Surg 2005;27:367-72

Szekely et al. Chest 1997;111:550-58

Page 46: EXERCISE TESTING Which Patient ?  When ?

Lung-Volume Reduction Surgery (LVRS)Lung-Volume Reduction Surgery (LVRS)

The threshold for a successful outcome The threshold for a successful outcome

• 150 m for the SWT 150 m for the SWT

• 200 m for the 6-MWT200 m for the 6-MWT

Page 47: EXERCISE TESTING Which Patient ?  When ?

Heart-Lung, Lung TransplantationHeart-Lung, Lung Transplantationand Exercise Testsand Exercise Tests

• In patients intolerant of a β-blocker, a cut-off for In patients intolerant of a β-blocker, a cut-off for VO2peak ≤14 VO2peak ≤14 ml/kg/min should be used to guide listingml/kg/min should be used to guide listing

• In the presence of a β-blocker, a cut-off for peak In the presence of a β-blocker, a cut-off for peak VO2peak ≤12 VO2peak ≤12 ml/kg/min should be used to guide listingml/kg/min should be used to guide listing

• In young patients (<50 years) and women, including percent of In young patients (<50 years) and women, including percent of predicted (≤50%) VO2peak predicted (≤50%) VO2peak Level of Evidence: BLevel of Evidence: B

Mandeep et al.J Heart Lung Transplant 2006;25(9):1024-42

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Page 49: EXERCISE TESTING Which Patient ?  When ?

CPET before high-risk surgeryCPET before high-risk surgery

• The major intra-abdominal surgery is associated with an The major intra-abdominal surgery is associated with an increase in oxygen demand of 40% or more.increase in oxygen demand of 40% or more.

• ““The Improving Surgical Outcomes Group” recommended the The Improving Surgical Outcomes Group” recommended the use of CPET before high-risk surgery.use of CPET before high-risk surgery.

Page 50: EXERCISE TESTING Which Patient ?  When ?

Older Pl et al. Chest 1993;104(3):701-704.

187 pts

Major Abdo Surgery

CPX testedAT ml/min/kg

<1155pts

>11132pts

MORTALITY 0.8%MORTALITY 18%

P<0.001

Elderly Surgical PopulationElderly Surgical PopulationCPETCPET

Overall Mortality 7.8%Non-Surgical 5.9%

Page 51: EXERCISE TESTING Which Patient ?  When ?

Elderly Surgical PopulationCPET

187 pts

Major Abdo Surgery

CPX testedAT ml/min/kg

<1155pts

>11132pts

Pre-operative Ischaemia during testing

MORTALITY 4%MORTALITY 42%

P<0.01

AT < 11 AND Pre-Op Ischaemia INDEPENDENT RISK FACTORS

Older Pl et al. Chest 1993; 104(3):701-704.

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Older P et al. Chest 1999;116:355-362

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