Download Exercise Testing in the Respiratory/Pulmonary Setting 2017

5/1/2017
La Prueba de Esfuerzo en el Marco de Cuidados
Respiratorios y Neumología
Darío Fuentes, PhD, CPFT
2017 – 13th Annual
North Regional Respiratory Care Conference
Wisconsin & Minnesota Societies for Respiratory Care
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Exercise Testing in the Respiratory/Pulmonary Setting
Dario Fuentes, PhD, CPFT
2017 – 13th Annual
North Regional Respiratory Care Conference
Wisconsin & Minnesota Societies for Respiratory Care
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5/1/2017
Disclosure
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Clinical Consultant for Vyaire Medical
This presentation is sponsored by Vyaire Medical/Carefusion
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“Lack of activity destroys the good condition of every human being,
while movement and methodical physical exercise save it and preserve it.”
Plato, 350 B.C.
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Goals
 Understand the importance and application of
exercise testing in the respiratory setting
 Understand the requirements, guidelines, protocols
and procedures of exercise testing in a
clinical/respiratory setting
 General understanding on how to perform exercise
testing in a clinical setting
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Why Exercise
 Exercise is exciting
 Important tool
 Positive effect in your patient population
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Why exercise testing in
Respiratory/Pulmonary?
 It helps with continuum of care
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Indications for Exercise Testing in
Pulmonary Disease
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Asthma
COPD
Pulmonary disease with comorbidities
CF
DOE
ILD/IPF
Scoliosis
Sarcoidosis
PVD (PAH)/Rheumatology/Connective Tissue disease
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Indications for Exercise Testing in
Pulmonary
 Asthma
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Diagnosing Exercise Induced Bronchospasm
Assessment of therapeutic response
Better management
Decrease of lung inflammation
Conditioning lowers work of breathing for a given level
of activity
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Indications for Exercise Testing in
Pulmonary
 COPD
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Evaluation of functional capacity
Evaluation of dynamic hyperinflation
Find out origin of limitation
Decrease re-admission rate
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Indications for Exercise Testing in
Pulmonary
 Pulmonary disease with comorbidities
 Assess origin of limitation (ventilatory, cardiovascular,
metabolic)
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Indications for Exercise Testing in
Pulmonary
 CF
 Evaluation of physical limitations and exerciseassociated symptoms
 Risk assessment
 Exercise prescription
 Prognostic information for clinical outcome and
mortality
 Assessment of lung transplant candidates
 Functional capacity/quality of life
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Indications for Exercise Testing in
Pulmonary
 DOE
 Differential diagnosis
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Indications for Exercise Testing in
Pulmonary
 ILD/IPF
 Evaluation of functional capacity
 Early detection of pulmonary gas exchange
abnormalities
 Determination of oxygen needs
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Indications for Exercise Testing in
Pulmonary
 Scoliosis, pectus excavatum
 Evaluation and progression of disease
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Indications for Exercise Testing in
Pulmonary
 Sarcoidosis
 Early detection of pulmonary gas exchange
abnormalities
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Indications for Exercise Testing in
Pulmonary
 Pulmonary Vascular
Disease/Rheumatology/Connective Tissue disease
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Diagnostic (ERHC)
Prognostic
Evaluation
Assessment of therapeutic response
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Benefits of Exercise Testing in
Pulmonary Disease
Comparison of
activities by METs
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bicycling, mountain,…
Diagnostic
running, marathon
Prognostic
ADULT CONTROL…
Evaluation/Progress Monitoring
jogging, in place
Functional classification of disability
skiing, general
Assess functionality (ADL, METs)
carpentry, sawing…
Exercise prescription
cleaning gutters
Risk Assessment
massage therapist,…
Fitness assessment
ADULT CONTROL…
standing,…
Safety
electrical work (e.g.,…
Determine need for supplemental oxygen
IPAH CHILDREN,…
Assessment of therapeutic response
airline flight attendant
Cardiopulmonary Rehabilitation
pilates, general
Evaluation of preoperative risk (better aerobic capacity shorter ICU stays) football or baseball,…
Pre transplant evaluation
feeding household…
Decrease readmission rate!
walking and carrying…
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walking, household
laundry, fold or hang…
sleeping
0
10
20
30
METs
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What tests are available?
 Field exercise tests
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Stair climbing
Timed walk test (6MWT)
Shuttle walk test
CPET* (mobile devices)
 Laboratory exercise tests
 Stress test (stress ECG, Stress Echo, Nuclear Stress Test)
 Cardiopulmonary Exercise Test (CPET, CPX, VO2 max, Stress
test with O2 or gas exchange)
 Bronchial Challenge
 ERHC
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Most common tests used
6MWT
CPET
 Submaximal test where the
maximum distance covered in
six minutes is measured
(6MWD). Measures the distance
that a patient can quickly walk
on a flat, hard surface in a period
of 6 minutes (the 6MWD).
 Needs to be standardized to be
able to compare between tests
(ATS)
 Non invasive (or minimally
invasive) examination to
simultaneously study the
responses of cardiovascular,
ventilatory, and metabolic
systems to a known exercise
stress.
 Peak VO2 = gold standard of
functional status
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Protocols
 Field Test-6MWT, walking test, hallwalk, O2
evaluation*
 Laboratory: Stress test, CPET. Ramp or Stepwise
 Treadmill: Bruce, Naughton, Balke, Modified Bruce,
Cornell
 Ergometer: 5, 10, 15, 20, 25 Watt/min ramp or step
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Protocols
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6MWT vs CPET
6MWT
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CPET
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Submaximal
It evaluates the global and integrated responses of all the
systems involved during exercise but it only provides one
measurement 6MWD
Does NOT provide specific information on function of organs
and systems involved or the mechanism of exercise limitation
May be a better indication of ADLs
Considered safer because of submaximal nature but not true
(CPET constant monitoring)
Complementary to cardiopulmonary exercise testing
Easier to perform
“…is quick and easy way to objectively estimate impairment
from a previously diagnosed cardiopulmonary disease, but
doesn't help with the differential diagnosis as does
CPET.“(Enright 2003)
“There is enough evidence that 6MWD is a predictor of clinical
outcomes, but is NOT a measure of exercise
tolerance.”(Porszasz 2005)
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Maximal
It evaluates global and integrated responses
of all the systems involved during exercise.
It provides specific information on function
of organs and systems involved in exercise
and mechanism of exercise limitation
Constant ECG monitoring
Gives more information and data
Harder to perform
Requires trained clinicians
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6MWT
 REQUIRED EQUIPMENT
 Countdown timer (or stopwatch)
 Mechanical lap counter
 Two small cones to mark the turnaround points
 A chair that can be easily moved along the walking course
 Worksheets on a clipboard
 A source of oxygen
 Sphygmomanometer
 Pulse oximeter
 Telephone
 Automated electronic defibrillator
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CPET
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CPET = Cardio Pulmonary Exercise Testing
Cells
Relationship
Lungs
(Metabolism)
(Ventilation)
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VO2 (L/min) + Food
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VCO2 (L/min) + ATP
Gas exchange
Gas exchange
(Diffusion & Perfusion)
Exercise (CPET)
Heart
(Cardiac output)
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Ergometers
Which ergometers
are used and why?
Bike
treadmill
Costs
Lower
Higher
Mobility
Good
Less
Needed space
Less
More
Noise
Less
More
Safety
Higher
Lower
Aerobic capacity (VO2peak)
Lower
Higher
Work rate (WR)
Yes
No
Physiological measurements
Easy
Less easy
> 5-6 year
> 3 year
> ~ 100 cm
No limitation
Suitable for children
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Body length
Ergometers
Cycle ergometer
Treadmill
 Weight independent
 Lower O2 uptake and HR
response
 Preferred in pulmonary
 Easier to draw ABG
 Easier automated BP
Measurement (less artifact)
 No need to know how to ride a
bike
 Weight dependent
 Elicits higher O2 uptake and HR
 Preferred in cardiology more
specific to ischemia
 Must be able to walk
 Patient may fall off treadmill
 May need some getting used to
it (if never used before)
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Ergometers
Which ergometers
are used and why?
Arm ergometer
• Individuals using wheelchairs
• Spinal cord-injured back pains
• Rehabilitation
• Pregnancy
• Task specific sports
• Use of small muscles for same load
• Take accessory muscles out of action
• Muscles less conditioned
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• Physiology of exercise
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Protocols
Ramp
Incremental
Steady state
No
Yes (>anaerobic threshold?)
Gas analysis
Smooth
Less smooth
Peak work
Higher
Lower
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What do you need to start an
exercise laboratory?
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Treadmill, ergometer (cycle or arm)
Metabolic cart
Pulse oximeter
BP measuring device
Electrocardiographic device
ABG equipment?
Create an exercise testing laboratory manual (policies,
procedures, and protocols)
 Trained clinicians
 EP
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Laboratory Manual
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Position statements of AHA, ACSM, ACC, AARC, ATS
Laboratory Statement
Procedures Contents
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Indications for testing
 Diagnostic, Prognostic, Functional testing
Absolute and Relative Contraindications to Exercise Testing
Supervision of Exercise Testing
Staffing requirements
General Exercise Test Procedures
 Instructions, consent forms, Pre test screening (history, orthopedic limitations, medications, exercise history, family
history, presence of absolute or relative contraindications)
 Exercise testing procedures (review medical history, consent, explain test purpose, time out, etc.)
Notifications of results
Emergency Procedures
Interpretation Contents
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Standard criteria for exercise interpretation
Impact of Medications on exercise test
Functional Capacity
Guideline References
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How to perform exercise testing?
 Patient pre test conditions and instructions
 Patients should refrain from ingesting food, alcohol or caffeine or using
tobacco products within 3 hours of testing. Drinking water is
encouraged.
 Patients should continue with all prescribed medications, unless
instructed otherwise by ordering physician.
 Patients should be rested prior to the test, and instructed to avoid
significant exertion or exercise on the day of the assessment.
 Clothing should permit freedom of movement and include walking or
jogging shoes.
 If the evaluation is on an outpatient basis, patients should be made
aware that the evaluation can be fatiguing and they may wish to have
someone accompany them
 Information on what test consist of
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How to perform exercise testing?
 Prior to testing
 Calibration (Bio QA)
 Review History, patient chart , demographics, and
obtain extensive history from patient, problem list, lab
results, medications, more history
 Review order
 Consent form
 Prep equipment and patient
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How to perform exercise testing?
 Guidelines ACSM/ATS/AHA/ACC/AARC
 Contraindications
 Absolute
 Relative
 Supervision
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Absolute contraindications
 A recent significant change in the resting ECG suggesting significant ischemia, recent
myocardial infarction (within 2 days) or other acute cardiac event
 Ongoing unstable angina
 Uncontrolled cardiac arrhythmia with hemodynamic compromise
 Active endocarditis
 Symptomatic severe aortic stenosis
 Decompensated heart failure
 Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis
 Acute myocarditis or pericarditis
 Acute aortic dissection
 Physical disability that precludes safe and adequate testing
 Acute systematic infection, accompanied by fever, body aches, or swollen lymph
glands
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Relative Contraindications
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Left main coronary stenosis
Moderate stenotic heart disease
Electrolyte abnormalities (e.g. hypokalemia, hypomagnesemia)
Severe arterial hypertension (i.e. systolic BP of >200mm Hg and/or a diastolic of BP of >110mm Hg) at rest
Tachydysrthythmia or bradydarhythmia
Hypertrophic cardiomyopathy and other forms of outflow tract obstruction with severe resting gradient
Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
High-degree atrioventricular block
Recent stroke or transient ischemic attack
Ventricular aneurysm
Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema)
Chronic infectious disease (e.g. mononucleosis, hepatitis, AIDS)
Mental or physical impairment leading to inability to exercise adequately
Resting hypertension with systolic or diastolic blood pressures >200/110 mm Hg
(Relative contraindications can be superseded if benefits outweigh risks of exercise. In some instances, these
individuals can be exercised with caution and/or using low-level end points, especially if they are asymptomatic at
rest.)
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Supervision
 By a qualified health professional who is appropriately
trained to administer exercise tests (BLS, ACLS)
 Physician
 “In most patients, exercise testing can be safely
supervised by properly trained nurses, physician assistants,
exercise physiologists, physical therapists (RRT*) or
medical technicians working under the direct supervision
of the physician, who should be in the immediate vicinity
or on the premises or the floor and available in case of
emergency situations” (ACC/AHA 2002).
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How to perform exercise testing?
 Phases:
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Baseline (resting measurements)
Warm up
Exercise (continuous measurements)
Recovery (compare to baseline)
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How to perform exercise testing?
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Maximal test
Pt cooperation
Choosing right protocol
8-12 minute goal
Collection of data:
 Measured: Time, Load, RPM, Volume, BF, FEV1, FiO2,
FiCO2, FeO2, FeCO2, SpO2, HR, Rhythm, BP, Borg Score
 Calculated: VO2 , VCO2, RER, VE, O2 Pulse, VD/VT,
VE/VO2, VE/VCO2, PETO2, PETCO2, ABG, A-a gradient
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How to perform exercise testing?
 When to stop
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Maximal effort
Chest pain suggestive of ischemia
Ischemic ECG changes
Complex ectopy
Second or third degree heart block
Fall in systolic pressure 20 mm Hg from the highest value during the test
Hypertension ( 250 mm Hg systolic; 120 mm Hg diastolic)
Severe desaturation: SpO2 80% when accompanied by symptoms and signs of severe
hypoxemia
 Sudden pallor
 Loss of coordination
 Mental confusion
 Dizziness or faintness
 Signs of respiratory failure
Why they stopped
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How to Interpret?
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Case Study
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50 Year old female
Car accident
Diaphragm denervation
ICU, Ventilation…
Motivated by exercise
Out of ICU
On phrenic pacer
Doing Triathlons and competing in nationals
No autonomic function but somatic function
CPET
Positional diaphragm weakness
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Summary
 Exercise has many applications in the pulmonary and
respiratory setting
 Exercise testing is an important and valuable tool in
the pulmonary respiratory setting
 Continue or start using exercise testing as part of
your clinical practice
 Aerobic exercise assessment (Future Vital sign?)
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References
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Questions???
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Thank you
[email protected]
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