1600 - Friday - PFT and CPET Case Studies - Marciniuk PDF

[PFT and …] Exercise
CHEST
Test Examples
Board
Review Darcy D. Marciniuk, MD, FRCP(C), FCCP
Professor of Medicine
Course Respirology, Critical Care and Sleep Medicine
University of Saskatchewan
2014 Royal University Hospital
Saskatoon, SK, CANADA
CardioPulmonary
Exercise Tes5ng
Conflict of Interest Disclosure

I have no rela+ons with industry or
pharmaceu+cal/device companies that
relate to the topic of this presenta+on
© 2014 American College of Chest Physicians

CardioPulmonary
Exercise Tes5ng
Pulmonary Func6on Tes6ng

Common Technical Problems
and Test Results


Poor Start -‐ Coughing During
Hesita6on Test
Volume (L)
1.0
Back Extrapola6on
0.8 Through
Steepest Part of
Curve
0.6
0.4
Extrapolated Volume
0.2 >150 mLs
New Time Zero
0.0 0.5 1.0 1.5 2.0

Time
(sec)
Early GloQc Variable / Submax
Closure Effort
HOW ARE YOU TODA
Y
CardioPulmonary
Exercise Tes5ng
Exercise Tes6ng
Results from Normals and
Various Disease States

Healthy 63-‐yr-‐old male, normal PFTs
Exercise Measurements
Rest End-‐Exercise %Pred
Wmax (waGs) -‐-‐ 170 95
VO2 (L/min) 0.45 2.09 94
VE (L/min) 17.3 90.7 76
BR (L) -‐-‐ 35.1
VE/VCO2 40 35
SaO2 (%) 96 96
HR (/min) 80 166 98
Borg (dyspnea/legs) 0/0 5/7
“my legs just quit”
Healthy Normal
0
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Fit 34-‐yr-‐old female, normal PFTs
Wmax (waGs) -‐-‐ 210 148
VO2 (L/min) 0.17 2.50 149
VE (L/min) 8.6 90.1 95
BR (L) -‐-‐ 5.1
VE/VCO2 48 33
SaO2 (%) 99 93
HR (/min) 78 172 92
“ I’ve had enough “
CardioPulmonary
Exercise Tes5ng
The exercise test results for this

34-‐yr-‐old female are:
a.  Normal
b.  Abnormal -‐ mechanical ven+latory
limita+on
c.  Abnormal -‐ cardiovascular limita+on
d.  Abnormal -‐ pulmonary vasculature

64-‐yr-‐old male, moderate COPD, FEV1 1.53 L [54% pred]
Wmax (waGs) -‐-‐ 90 62
VO2 (L/min) 0.27 1.22 66
AT (L/min) 1.05 -‐-‐ 57
VE (L/min) 16.3 55.1 103
BR (L) -‐-‐ (1.5)
SaO2 (%) 97 95
HR (/min) 105 142 85
“ I can’t breath anymore “
Moderate COPD
1
Moderate COPD
2
Moderate COPD
3
Moderate COPD
4
Moderate COPD
5
Moderate COPD
CardioPulmonary
Exercise Tes5ng
The VE/VCO2 was most likely elevated

(>40 at AT) in this pa6ent because of:
a.  Early anaerobic threshold
b.  Arterial oxygen desatura+on
c.  Anxiety
d.  Increased dead space ven+la+on
e.  Measurement error because of
underlying lung disease
43-‐yr-‐old male, Cardiomyopathy, LVEF 31%, normal PFTs, SOB
Wmax (waGs) -‐-‐ 160 84
VO2 (L/min) 0.22 1.75 71
AT (L/min) 0.82 -‐-‐ 33
VE (L/min) 7.4 77.6 65
BR (L) -‐-‐ 42.5
PaO2 (mmHg) 87 117
HR (/min) 78 178 97
“ I’m just pooped “
Cardiomyopathy
3 3
.
VO2max predicted
2 2
VCO2 (L/min)
VO2 (L/min)
R=1
V O 2max predicted
Wmax predicted
1 1
.
.
0 0
0 50 100 150 200 0 1 2 3
.
Workrate (W) VO2 (L/min)
Cardiomyopathy
12 50
HRmax predicted
180
VE/VCO2
40
O2 Pulse (mL/beat)
Heart Rate ( /min)
V O 2max predicted
.
150 8
V O 2max predicted
.
30
120
VE/VO2
4
.
.
20
90
.
.
60 0 10
0 1 2 3 0 1 2 3
. .
VO2 (L/min) VO2 (L/min)
Cardiomyopathy
50
VC
FEV1 x 35 4
120
40
35 3
VE (L/min)
fb ( /min)
80
VT (L)
FEV 1 x 35
30
2
.
40
1 20
0 0 10
0 1 2 3 0 40 80 120
. .
VCO2 (L/min) VE (L/min)
Cardiomyopathy
120
(mmHg) P(A-‐a) = 3
110
VO 2max predicted
PAO2
100
.
90
PaO2
P(A-‐a) = 4
80
0 1 2 3
.
VO2 (L/min)
CardioPulmonary
Exercise Tes5ng
Which characteris6c finding is seen

with severe CHF during exercise?
a.  Absent ven+latory reserve ie. a reduced
VE/MVV ra+o
b.  Arterial oxygen desatura+on
c.  Oscillatory breathing paGern and
ven+la+on
d.  Reduced end-‐inspiratory lung volume
(EILV)
e.  Late anaerobic threshold
CardioPulmonary
Exercise Tes5ng
CHF -‐ Oscillatory Breathing and Ven6la6on
Agostoni P, et al. Chest 2008; 133:197-‐203 Corra U, et al. Chest 2002; 121:1572-‐1580
72-‐yr-‐old male, IPF, TLC 65% pred, DLco 43% pred
Wmax (waGs) -‐-‐ 95 64
VO2 (L/min) 0.26 1.19 67
VE (L/min) 14.7 57.0 93
BR (L) -‐-‐ 4.0
PaO2 (mmHg) 72 49
HR (/min) 83 132 81
Dyspnea 0 6
Legs 0 5
“my breathing”
IntersWWal Lung Disease
2 170
. HRmax predicted
VO2max predicted
150
1.5
Heart Rate (/min)

VO2 (L/min)
VO2max predicted
130
Wmax predicted
1
110
.
.
0.5
90
0 70
0 40 80 120 160 0 0.5 1 1.5 2

.
2 80
VE / VCO2
70
R=1
1.5
.
60
VCO2 (L/min)
VO2max predicted
.
VO2max predicted
1 50
VE / VO2
40
.
.
0.5
.
30
0 . 20
0 0.5 1 1.5 2 0 0.5 1 1.5 2
. .
80 3 40
VC
FEV1 x 35 2.5
60 35
2
VE (L/min)
35
f (/min)
VT (L)
40 1.5 30
1
.
FEV1 x 35
20 25
0.5
0 0 20
0 0.5 1 1.5 2 0 20 40 60
. .
0.6 50 10
0.5 45 5
PaCO2 (mmHg)
VO2max predicted
BE (meq/L)
VO2max predicted
VD / VT
0.4 40 0
.
.
0.3 35 -5
0.2 30 -10
0 0.5 1 1.5 2 0 0.5 1 1.5 2
. .
120
(mmHg) 100
VO2max predicted
24 P(A -a) O2 47
80
.
PaO2
60
40
0 0.5 1 1.5 2
.
VO2 (L/min)
CardioPulmonary
Exercise Tes5ng
ILD pa6ents typically demonstrate

which finding during CPET?
a.  Elevated anaerobic threshold
b.  Slow, deep breathing paGern
c.  Normal ven+latory mechanical
reserve
d.  Reduced FEV1 immediately following
exercise
e.  Arterial oxygen desatura+on
56-‐yr-‐old male, Scleroderma, TLC 45% pred, DLco 27% pred
Wmax (waGs) -‐-‐ 50 29
VO2 (L/min) 0.34 1.07 44
VE (L/min) 20.1 68.1 106
BR (L) -‐-‐ (3.9)
SaO2 (%) 97 76
HR (/min) 131 164 100
Dyspnea 0.5 7
Legs 0 7
“Can’t do anymore … breathing and my legs.”
ILD / Pulmonary Vascular
. 180
VO2max predicted
HRmax predicted
2
Heart Rate (/min)

140
VO2 (L/min)
Wmax predicted
VO2max predicted
1
100
.
.
0 60
0 60 120 180 0 1 2
.
70
R=1
VE / VCO2
.
VCO2 (L/min)
60
VO2max predicted
VO2max predicted
.
1
VE / VO2
50
.
.
.
.
0 . 40
0 1 2 0 1 2
. .
80 3 60
FEV1 x 35
VC
60
35 2
VE (L/min)
f (/min)
VT (L)
40 40
1
.
20
FEV1 x 35
0 0 20
0 1 2 0 20 40 60 80
. .
50 100
40
PETCO2 (mmHg)
90
VO2max predicted
VO2max predicted
SaO2 (%)
30
80
.
.
20
10 70
0 1 2 0 1 2
. .
End-‐Exercise Measurements
RA Test O2 Test Change
SaO2 (%) 76 92 + 21
HR (/min) 164 158 -‐ 4
(100% pred) (96% pred)
Wmax (waGs) 50 75 + 50
(29% pred) (44% pred)
Dyspnea 7 7
Legs 7 5
RA Test: “Can’t do anymore … breathing and my legs.”

O2 Test: “My breathing gave out.”
180 100
HRmax predicted
Heart Rate ( /min)
140 90
Wmax predicted
Wmax predicted
SaO2 (%)
100 80
Room Air Room Air

O2 O2
60 70
0 60 120 180 0 60 120 180
Workrate (W) Workrate (W)

16 yr-‐old female, SOBOE, normal PFTs, -‐ve MCT
Wmax (waGs) -‐-‐ 65 47
VO2 (L/min) 0.20 1.32 74
VE (L/min) 9.6 35.5 34
BR (L) -‐-‐ 68.5
SaO2 (%) 99 96
HR (/min) 86 151 75
Dyspnea 2 9
Legs 0 3
FEV1 following exercise – 3% increase at 10 minutes
“I Can’t Breath Anymore”
Unexplained Dyspnea
2 2
VO2max predicted
R= 1
1.5 1.5
VCO2 (L/min)
VO2 (L/min)
Wmax predicted
VO 2max predicted
1 1
0.5 0.5
0 0
0 50 100 150 0 0.5 1 1.5 2
Unexplained Dyspnea
200 20 70
HRmax predicted
60
15
O2 Pulse (mL/beat)
Heart Rate ( /min)
VE/VCO2
150
VO 2max predicted
50
VO 2max predicted 10
40
100
VE/VO2
5
30
50 0 20
0 0.5 1 1.5 2 0 0.5 1 1.5 2
Unexplained Dyspnea
120 4 100
FEV1 x 35
VC
90 35
3 75
VE (L/min)
f ( /min)
VT (L)
60 2 50
FEV1 x 35
30 1 25
0 0 0
0 1 2 3 0 30 60 90 120
Unexplained Dyspnea
0.4 50
0.3
PET CO2 (mmHg)

VO 2max predicted
40
VO 2max predicted
VD/VT
0.2
30
0.1
0 20
0 0.5 1 1.5 2 0 0.5 1 1.5 2

Unexplained Dyspnea
100
95
VO 2max predicted
SpO2 (%)
90
85
80
0 0.5 1 1.5 2
VO2 (L/min)
Unexplained Dyspnea
12 Maximal
Rest
Sub-‐maximal Exercise
End Exercise
8
4
Flow (L/s)
-‐4
-‐8
-‐2 0 2 4 6
Volume (l)
CardioPulmonary
Exercise Tes5ng
Why does this 16-‐yr-‐old pa6ent

experience SOB with physical ac6vity?
a.  Pulmonary Hypertension
b.  Primary Hyperven+la+on Syndrome
c.  Mitochondrial Myopathy
d.  Exercise-‐Induced Bronchoconstric+on
e.  Central Tracheal Obstruc+on

CardioPulmonary
Exercise Tes5ng
Good Luck With

The Exam !!!

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[PFT and …] Exercise

Conﬂict of Interest Disclosure

© 2014 American College of Chest Physicians

Pulmonary Func6on Tes6ng

© 2014 American College of Chest Physicians

0.0 0.5 1.0 1.5 2.0

© 2014 American College of Chest Physicians

The exercise test results for this

© 2014 American College of Chest Physicians

The VE/VCO2 was most likely elevated

Which characteris6c ﬁnding is seen

CHF -­‐ Oscillatory Breathing and Ven6la6on

Heart Rate (/min)

0 40 80 120 160 0 0.5 1 1.5 2

ILD pa6ents typically demonstrate

Heart Rate (/min)

RA Test: “Can’t do anymore … breathing and my legs.”

Room Air Room Air

Workrate (W) Workrate (W)

PET CO2 (mmHg)

VO2 (L/min) VO2 (L/min)

Why does this 16-­‐yr-­‐old pa6ent

© 2014 American College of Chest Physicians

Good Luck With

© 2014 American College of Chest Physicians

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CHF -‐ Oscillatory Breathing and Ven6la6on

Why does this 16-‐yr-‐old pa6ent