Cardiopulmonary exercise testing in patients with asthma: What is its clinical value?

Maximal exercise capacity, peripheral muscle strength, sleep quality, and quality of life in adult patients with stable asthma

OBJECTIVE

The prevalence of asthma is increasing gradually worldwide. The pathophysiological process of asthma causes some alterations in the respiratory system and decreases oxygen-carbon dioxide exchange and respiration volume. These alterations may affect maximal exercise capacity, peripheral muscle strength, sleep quality, and disease-specific quality of life but have yet to be comprehensively investigated. To compare maximal exercise capacity, pulmonary function, peripheral muscle strength, dyspnea, sleep quality, and quality of life in adult patients with asthma, healthy controls were aimed.

METHODS

Forty-one adult stable asthmatic patients (GINA I-III) and 41 healthy subjects were compared. Exercise capacity (cardiopulmonary exercise test [CPET]), pulmonary function (spirometry), peripheral muscle strength (dynamometer), dyspnea (modified Medical Research Council [mMRC] dyspnea scale), quality of life (Asthma Quality of Life Questionnaire [AQLQ]) and sleep quality (Pittsburgh Sleep Quality Index [PSQI]) were evaluated.

RESULTS

Peak VO2, VO2kg, MET, VE, HR, %VE, %HR, VCO2 parameters of CPET, FVC, FEV1, FEF25-75%, and FEV1/FVC and quadriceps femoris, shoulder abductors, and hand grip muscle strength were significantly decreased in patients with asthma (p < 0.05). MMRC dyspnea scale score was increased, and AQLQ and PSQI scores decreased in asthma patients (p < 0.05).

CONCLUSIONS

Cardiac and pulmonary system responses to peak exercise worsened, and maximal exercise capacity and peripheral muscle strength decreased in adult patients with stable asthma. In addition, dyspnea during daily activities increases, and quality of life and sleep quality are impaired. A variety of exercise training that would benefit asthmatic patients' outcomes should be investigated.

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Identifying limitations to exercise with incremental cardiopulmonary exercise testing: a scoping review

Cardiopulmonary exercise testing (CPET) is a comprehensive and invaluable assessment used to identify the mechanisms that limit exercise capacity. However, its interpretation remains poorly standardised. This scoping review aims to investigate which limitations to exercise are differentiated by the use of incremental CPET in literature and which criteria are used to identify them. We performed a systematic, electronic literature search of PubMed, Embase, Cochrane CENTRAL, Web of Science and Scopus. All types of publications that reported identification criteria for at least one limitation to exercise based on clinical parameters and CPET variables were eligible for inclusion. 86 publications were included, of which 57 were primary literature and 29 were secondary literature. In general, at the level of the cardiovascular system, a distinction was often made between a normal physiological limitation and a pathological one. Within the respiratory system, ventilatory limitation, commonly identified by a low breathing reserve, and gas exchange limitation, mostly identified by a high minute ventilation/carbon dioxide production slope and/or oxygen desaturation, were often described. Multiple terms were used to describe a limitation in the peripheral muscle, but all variables used to identify this limitation lacked specificity. Deconditioning was a frequently mentioned exercise limiting factor, but there was no consensus on how to identify it through CPET. There is large heterogeneity in the terminology, the classification and the identification criteria of limitations to exercise that are distinguished using incremental CPET. Standardising the interpretation of CPET is essential to establish an objective and consistent framework.

Mild airways obstruction: spirometric diagnostic pitfalls and solutions

PURPOSE OF REVIEW

Spirometry is a validated tool in the diagnosis of obstructive airways disease. However, it may be insufficiently sensitive in detecting airflow limitation in the small airways. This review highlights common clinical scenarios wherein airflow limitation may be missed or overlooked.

RECENT FINDINGS

This article covers recent literature on the interpretation of lung function test, focusing on detection of mild obstructive airways disease. It also sheds light on the contextual difficulties of defining mild airflow limitation on spirometry.

SUMMARY

We highlight the consensus definition of mild obstructive airways disease and emphasize that this definition does not necessarily mean mild in certain disease-specific contexts. Several spirometric findings outside of a reduced forced expiratory volume in one second/forced vital capacity ratio should raise suspicion of mild obstruction.

How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis

Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.

Pulmonary rehabilitation improves exercise capacity, health-related quality of life, and cardiopulmonary function in patients with non-small cell lung cancer

BACKGROUND

Lung cancer significantly impairs exercise capacity and health-related quality of life (HRQL). Pulmonary rehabilitation (PR) has demonstrated positive effects on exercise capacity and HRQL in lung cancer patients. However, its impact on cardiopulmonary function needs further exploration. The aim of this study was to explore the effects of PR on cardiopulmonary function, exercise capacity and HRQL in patients with lung cancer.

METHODS

Patients with lung cancer were enrolled in a 12-week PR program. Each participant underwent a thorough evaluation, which included spirometry, cardiopulmonary exercise testing, respiratory muscle strength test, and evaluation of HRQL using the Chronic Obstructive Pulmonary Disease Assessment Test (CAT).

RESULTS

Fifty-six patients completed the PR program. Following PR, exercise capacity significantly improved, as evidenced by increased peak oxygen uptake and work rate (both p < 0.05). Exertional symptoms were notably reduced, including leg soreness and dyspnea at peak exercise, accompanied by a decrease in the CAT score (all p < 0.05). Furthermore, improvements in cardiopulmonary function were observed, encompassing respiratory muscle strength, ventilatory equivalent, tidal volume, stroke volume index, and cardiac index at peak exercise (all p < 0.05).

CONCLUSIONS

PR demonstrated notable enhancements in cardiopulmonary function, exertional symptoms, exercise capacity, and HRQL in patients with lung cancer.

High-intensity aerobic exercise training improves exercise capacity, dyspnea, and fatigue in patients with severe asthma using triple inhaler

Objectives

Asthma is a chronic respiratory disease that affects millions of people worldwide and causes severe symptoms such as wheezing, coughing, and breathing difficulty. Despite modern treatments, 3%-10% of patients develop severe asthma, which requires high-dose medications, and they may still experience frequent and severe symptoms, exacerbations, and psychological impacts. This study aimed to investigate the effects of high-intensity aerobic exercise training (HIAET) in patients with severe asthma.

Materials and Methods

Patients with severe asthma were recruited, and cardiopulmonary exercise tests, dyspnea, and leg fatigue scores were performed before HIAET. Participants underwent a 12-week hospital-based HIAET, which involved exercising twice weekly to reach 80% of their peak oxygen uptake (VO2).

Results

Eighteen patients with severe asthma underwent HIAET, which resulted in significant improvement in peak VO2 (1214.0 ± 297.9-1349.4 ± 311.2 mL/min, P = 0.004) and work rate (80.6 ± 21.2-96.2 ± 24.8 watt, P < 0.001) and decrease in dyspnea (5.1 ± 1.8-4.1 ± 1.2, P = 0.017) and fatigue scores (5.2 ± 2.3-4.0 ± 1.2, P = 0.020) at peak exercise. No significant changes were observed in spirometry results, respiratory muscle strength, or circulatory parameters.

Conclusion

HIAET can lead to improved exercise capacity and reduced dyspnea and fatigue scores at peak exercise without changes in spirometry, respiratory muscle strength, and circulatory parameters.

The impact of anti-eosinophilic therapy on exercise capacity and inspiratory muscle strength in patients with severe asthma

Introduction

Exercise limitation is frequently described among asthmatic patients and could be related to different mechanisms of the pulmonary, cardiovascular and muscular systems. Despite this, cardiopulmonary exercise testing (CPET) does not have an established role in the management of severe asthma. The aim of our study was to investigate the role of CPET and inspiratory pressure measurement in exercise capacity and muscle strength in severe asthmatic patients treated with anti-IL-5 therapy.

Methods

A monocentric observational study was conducted at Hanover Medical School, Germany, from April 2018 to June 2019. Patients affected by severe asthma treated with either mepolizumab or benralizumab were included. All patients underwent CPET before the initiation of antibody therapy and after 3 months, and follow-up visits were scheduled at 3, 6 and 12 months with plethysmography, inspiratory pressure measurement and blood gas analysis.

Results

14 patients were enrolled: 10 (71.4%) females, median age 52 years (IQR 47-61). Seven patients were treated with benralizumab, seven with mepolizumab. Oxygen uptake (V'_O2 peak) did not change significantly after 3 months of antibody treatment, while the mean value of the breathing reserve exhaustion reduced significantly from 78% to 60% (p=0.004). Whereas at baseline seven patients depleted the breathing reserve and two of them experienced oxygen desaturation during exercise, at 3 months no one presented any desaturation or breathing reserve exhaustion. The inspiratory pressure remained unchanged before and after the antibody therapy.

Conclusion

CPET could show hints of alveolar recruitment and ventilatory efficiency in severe asthma patients treated with antibody therapy.

Does the severity of asthma affect exercise capacity and daily physical activity?

OBJECTIVE

Exercise capacity, daily physical activity, and psychological profile are crucial aspects in the management of asthmatic patients. Whether these features are expressed in a different way in mild-moderate (MMA) and severe asthma (SA) is unknown.

METHODS

In this observational cross-sectional study, patients matching the American Thoracic Society/European Respiratory Society (ATS/ERS) definition for SA underwent incremental cardiopulmonary exercise testing (CPET), full lung function testing, and an evaluation of daily step count and physical activity. Questionnaires on quality of life, general fatigue, and presence of anxiety and depression traits (Hospital Anxiety and Depression Scale - HADS) were administered. Patients were compared with a cohort of age- and gender-matched MMA patients.

RESULTS

We enrolled 16 SA, 17 MMA patients, and 16 healthy subjects. Compared to MMA, SA subjects showed a median (interquartile range) reduced peak oxygen consumption during CPET (20.4 (17.2-23.3) vs. 25.6 (18.5-30.3) ml/min/kg; p = 0.019), a reduced resting lung function (FEV1% of predicted 77 (67-84) vs. 96 (84-100); p < 0.001) and a pronounced anxiety trait at HADS (9.5 (3-11.7) vs. 4.0 (2.0-7.5); p = 0.023). In addition, SA patients showed a significantly higher reduction in inspiratory capacity from rest to peak (310 (160-520) vs. 110 (-65-325) ml; p = 0.031). We found no significant differences in mean daily step count or quality of life.

CONCLUSIONS

Compared to MMA, SA patients present a reduced exercise capacity and a more pronounced anxiety trait, but not worse daily physical activity or quality of life. These aspects should be considered in the clinical management and research development of SA.

Cardiopulmonary exercise testing and pulmonary function testing for predicting the severity of CTEPH

Background

Cardiopulmonary exercise testing (CPET) and pulmonary function testing (PFT) are noninvasive methods to evaluate the respiratory and circulatory systems. This research aims to evaluate and monitor chronic thromboembolic pulmonary hypertension (CTEPH) noninvasively and effectively by these two methods. Moreover, the research assesses the predictive value of CPET and PFT parameters for severe CTEPH.

Methods

We used data from 86 patients with CTEPH (55 for test set, and 31 for validation set) at the Shanghai Pulmonary Hospital Affiliated to Tongji University. The clinical, PFT and CPET data of CTEPH patients of different severity classified according to pulmonary artery pressure (PAP) (mm Hg) were collected and compared. Logistic regression analysis was performed to appraise the predictive value of each PFT and CPET parameter for severe CTEPH. The performance of CPET parameters for predicting severe CTEPH was determined by receiver operating characteristic (ROC) curves and calibration curves.

Results

Data showed that minute ventilation at anaerobic threshold (VE @ AT) (L/min) and oxygen uptake at peak (VO₂ @ peak) (mL/kg/min) were independent predictors for severe CTEPH classified according to PAP (mm Hg). Additionally, the efficacy of VE @ AT (L/min) and VO₂ @ peak (mL/kg/min) in identifying severe CTEPH was found to be moderate with the area under ROC curve (AUC) of 0.769 and 0.740, respectively. Furthermore, the combination of VE @ AT (L/min) and VO₂ @ peak (mL/kg/min) had a moderate utility value in identifying severe CTEPH with the AUC of 0.843.

Conclusion

Our research suggests that CPET and PFT can noninvasively and effectively evaluate, monitor and predict the severity of CTEPH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01668-3.

Validity and reliability of 6-minute pegboard and ring test in patients with asthma

OBJECTIVE

The 6-minute pegboard and ring test (6PBRT) is a test of upper-extremity functional capacity designed for and validated in chronic obstructive pulmonary disease. The aim of this study was to evaluate the validity and reliability of the 6PBRT in asthma patients.

METHODS

Thirty-four adults (30 women, 4 men) with well-controlled asthma were included. Unsupported upper-extremity exercise capacity was assessed using 6PBRT, maximal arm exercise capacity using an arm ergometer, handgrip strength using a hand dynamometer, activities of daily living with the London Chest Activities of Daily Living Scale (LCADL), Milliken ADL scale (MAS) and health-related quality of life using the Asthma Quality of Life Questionnaire (AQLQ) and Health Assessment Questionnaire Disability Index (HAQ-DI).

RESULTS

The 6PBRT showed moderate to excellent test-retest reliability with an intraclass correlation coefficient (ICC) value of 0.872 [95% confidence interval (CI) 0.702-0.941]. The 6PBRT was reproducible according to Bland-Altman analysis, with upper and lower limits of agreement of 53.51 and -25.08 rings moved, respectively. The 6PBRT score was significantly correlated with maximum workload (r = 0.514, p = 0.002) achieved in the arm ergometer test, change in dyspnea during 6PBRT (r = -0.402, p = 0.020), LCADL-self-care (r = -0.364, p = 0.037), MAS total (r = 0.483, p = 0.005), AQLQ-symptom domain (r = 0.420, p = 0.026) and HAQ-DI total scores (r = -0.390, p = 0.025).

CONCLUSIONS

The 6PBRT can be used as a valid and reliable test to evaluate functional arm exercise capacity in patients with well-controlled asthma.

[Physical activity and pulmonary rehabilitation in adults with asthma]

Physical activity is reduced in people with asthma compared to the general population, especially in situations where patients have uncontrolled asthma symptoms, persistent airflow obstruction and other long-term medical problems, in particular obesity and anxiety. Exertional dyspnea, which is of multifactorial origin, is the main cause of reduced physical activity reduction and draws patients into a vicious circle further impairing quality of life and asthma control. Both the resumption of a regular physical activity, integrated into daily life, adapted to patients' needs and wishes as well as physical and environmental possibilities for mild to moderate asthmatics, and pulmonary rehabilitation (PR) for severe and/or uncontrolled asthmatics, improve control of asthma, dyspnea, exercise tolerance, quality of life, anxiety, depression and reduce exacerbations. A motivational interview to promote a regular programme of physical activity in mild to moderate asthma (steps 1 to 3) should be offered by all health professionals in the patient care pathway, within the more general framework of therapeutic education. The medical prescription of physical activities, listed in the Public Health Code for patients with long-term diseases, and pulmonary rehabilitation should be performed more often by specialists or the attending physician. Pulmonary rehabilitation addresses the needs of severe asthma patients (steps 4 and 5), and of any asthmatic patient with poorly controlled disease and/or requiring hospitalized for acute exacerbations, regardless of the level of airflow obstruction, and/or with associated comorbidities, and before prescribing biological therapies.

Determinants of exercise capacity in children and adolescents with severe therapy-resistant asthma

OBJECTIVE

To evaluate the exercise capacity of children and adolescents with severe therapy resistant asthma (STRA) aiming to identify its main determinants.

METHODS

Cross-sectional study including individuals aged 6-18 years with a diagnosis of STRA. Clinical (age and gender), anthropometric (weight, height and body mass index) and disease control data were collected. Lung function (spirometry), cardiopulmonary exercise testing (CPET) and exercise-induced bronchoconstriction (EIB) test were performed.

RESULTS

Twenty-four patients aged 11.5 ± 2.6 years were included. The mean forced expiratory volume in one second (FEV₁) was 91.3 ± 9.2%. EIB occurred in 54.2% of patients. In CPET, the peak oxygen uptake (VO_2peak) was 34.1 ± 7.8 mL kg^-1 min^-1. A significant correlation between ventilatory reserve and FEV₁ (r = 0.57; p = 0.003) was found. Similarly, there was a significant correlation between CPET and percent of FEV₁ fall in the EIB test for both V_E/VO₂ (r = 0.47; p = 0.02) and V_E/VCO₂ (r = 0.46; p = 0.02). Patients with FEV₁<80% had lower ventilatory reserve (p = 0.009). In addition, resting heart rate correlated with VO_2peak (r=-0.40; p = 0.04), V_E/VO₂ (r = 0.46; p = 0.02) and V_E/VCO₂ (r = 0.48; p = 0.01).

CONCLUSIONS

Exercise capacity is impaired in approximately 30% of children and adolescents with STRA. The results indicate that different aspects of aerobic fitness are influenced by distinct determinants, including lung function and EIB.