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Hijleh AA, Berton DC, Neder-Serafini I, James M, Vincent S, Domnik N, Phillips D, O'Donnell DE, Neder JA. Sex- and age-adjusted reference values for dynamic inspiratory constraints during incremental cycle ergometry. Respir Physiol Neurobiol 2024; 327:104297. [PMID: 38871042 DOI: 10.1016/j.resp.2024.104297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 06/15/2024]
Abstract
Activity-related dyspnea in chronic lung disease is centrally related to dynamic (dyn) inspiratory constraints to tidal volume expansion. Lack of reference values for exertional inspiratory reserve (IR) has limited the yield of cardiopulmonary exercise testing in exposing the underpinnings of this disabling symptom. One hundred fifty apparently healthy subjects (82 males) aged 40-85 underwent incremental cycle ergometry. Based on exercise inspiratory capacity (ICdyn), we generated centile-based reference values for the following metrics of IR as a function of absolute ventilation: IRdyn1 ([1-(tidal volume/ICdyn)] x 100) and IRdyn2 ([1-(end-inspiratory lung volume/total lung capacity] x 100). IRdyn1 and IRdyn2 standards were typically lower in females and older subjects (p<0.05 for sex and age versus ventilation interactions). Low IRdyn1 and IRdyn2 significantly predicted the burden of exertional dyspnea in both sexes (p<0.01). Using these sex and age-adjusted limits of reference, the clinician can adequately judge the presence and severity of abnormally low inspiratory reserves in dyspneic subjects undergoing cardiopulmonary exercise testing.
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Affiliation(s)
- Abed A Hijleh
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Danilo C Berton
- Pulmonary Function Tests Laboratory, Federal University of Rio Grande to Sul, Rua Ramiro Barcelos, 2350 Bloco A, Av. Protásio Alves, 211 - Bloco B e C - Santa Cecília, Porto Alegre, RS 90035-903, Brazil
| | - Igor Neder-Serafini
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Matthew James
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Sandra Vincent
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Nicolle Domnik
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - Devin Phillips
- School of Kinesiology and Health Science, Faculty of Health, York University, Norman Bethune College, 170 Campus Walk Room 341, Toronto, ON M3J 1P3, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University, Kingston General Hospital, Connell 2-200. 102 Stuart St., Kingston, ON K7L 2V7, Canada.
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Neder JA. Cardiopulmonary exercise testing applied to respiratory medicine: Myths and facts. Respir Med 2023; 214:107249. [PMID: 37100256 DOI: 10.1016/j.rmed.2023.107249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O2 uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate ("anaerobic") threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO2 output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea "quantity" and "quality". Based on a conceptual framework that links exertional dyspnoea to "excessive" and/or "restrained" breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Department of Medicine, Division of Respirology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada.
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Neder JA, Berton DC, O'Donnell DE. The Lung Function Laboratory to Assist Clinical Decision-making in Pulmonology: Evolving Challenges to an Old Issue. Chest 2020; 158:1629-1643. [PMID: 32428514 DOI: 10.1016/j.chest.2020.04.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 12/17/2022] Open
Abstract
The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. In this narrative review, we concisely discuss some key challenges to test interpretation that have been affected by these epidemiologic shifts: (a) the confounding effects of advanced age and severe obesity, (b) the contemporary controversies in the diagnosis of obstruction (including asthma and/or COPD), (c) the importance of considering the diffusing capacity of the lung for carbon monoxide (Dlco)/"accessible" alveolar volume (carbon monoxide transfer coefficient) in association with Dlco to uncover the causes of impaired gas exchange, and (d) the modern role of the pulmonary function laboratory (including cardiopulmonary exercise testing) in the investigation of undetermined dyspnea. Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.
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Affiliation(s)
- J Alberto Neder
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada.
| | - Danilo C Berton
- Division of Respirology, Department of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Denis E O'Donnell
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada
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Neder JA, Berton DC, Marillier M, Bernard AC, O.Donnell DE. The role of evaluating inspiratory constraints and ventilatory inefficiency in the investigation of dyspnea of unclear etiology. Respir Med 2019; 158:6-13. [DOI: 10.1016/j.rmed.2019.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
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Arena R, Sietsema KE. Cardiopulmonary exercise testing in the clinical evaluation of patients with heart and lung disease. Circulation 2011; 123:668-80. [PMID: 21321183 DOI: 10.1161/circulationaha.109.914788] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ross Arena
- Department of Physical Therapy, Virginia Commonwealth University, Richmond Virginia 23298-0224, USA.
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McNicholl DM, Megarry J, McGarvey LP, Riley MS, Heaney LG. The utility of cardiopulmonary exercise testing in difficult asthma. Chest 2011; 139:1117-1123. [PMID: 21292756 DOI: 10.1378/chest.10-2321] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Unexplained persistent breathlessness in patients with difficult asthma despite multiple treatments is a common clinical problem. Cardiopulmonary exercise testing (CPX) may help identify the mechanism causing these symptoms, allowing appropriate management. METHODS This was a retrospective analysis of patients attending a specialist-provided service for difficult asthma who proceeded to CPX as part of our evaluation protocol. Patient demographics, lung function, and use of health care and rescue medication were compared with those in patients with refractory asthma. Medication use 6 months following CPX was compared with treatment during CPX. RESULTS Of 302 sequential referrals, 39 patients underwent CPX. A single explanatory feature was identified in 30 patients and two features in nine patients: hyperventilation (n = 14), exercise-induced bronchoconstriction (n = 8), submaximal test (n = 8), normal test (n = 8), ventilatory limitation (n = 7), deconditioning (n = 2), cardiac ischemia (n = 1). Compared with patients with refractory asthma, patients without "pulmonary limitation" on CPX were prescribed similar doses of inhaled corticosteroid (ICS) (median, 1,300 μg [interquartile range (IQR), 800-2,000 μg] vs 1,800 μg [IQR, 1,000-2,000 μg]) and rescue oral steroid courses in the previous year (median, 5 [1-6] vs 5 [1-6]). In this group 6 months post-CPX, ICS doses were reduced (median, 1,300 μg [IQR, 800-2,000 μg] to 800 μg [IQR, 400-1,000 μg]; P < .001) and additional medication treatment was withdrawn (n = 7). Patients with pulmonary limitation had unchanged ICS doses post CPX and additional therapies were introduced. CONCLUSIONS In difficult asthma, CPX can confirm that persistent exertional breathlessness is due to asthma but can also identify other contributing factors. Patients with nonpulmonary limitation are prescribed inappropriately high doses of steroid therapy, and CPX can identify the primary mechanism of breathlessness, facilitating steroid reduction.
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Affiliation(s)
- Diarmuid M McNicholl
- Centre for Infection and Immunity, Queen's University Belfast, Belfast City Hospital, Belfast, Northern Ireland; Regional Respiratory Centre, Belfast City Hospital, Belfast, Northern Ireland
| | - Jacqui Megarry
- Regional Respiratory Centre, Belfast City Hospital, Belfast, Northern Ireland
| | - Lorcan P McGarvey
- Centre for Infection and Immunity, Queen's University Belfast, Belfast City Hospital, Belfast, Northern Ireland
| | - Marshall S Riley
- Regional Respiratory Centre, Belfast City Hospital, Belfast, Northern Ireland
| | - Liam G Heaney
- Centre for Infection and Immunity, Queen's University Belfast, Belfast City Hospital, Belfast, Northern Ireland; Regional Respiratory Centre, Belfast City Hospital, Belfast, Northern Ireland.
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Flaherty KR, Wald J, Weisman IM, Zeballos RJ, Schork MA, Blaivas M, Rubenfire M, Martinez FJ. Unexplained exertional limitation: characterization of patients with a mitochondrial myopathy. Am J Respir Crit Care Med 2001; 164:425-32. [PMID: 11500344 DOI: 10.1164/ajrccm.164.3.2005110] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Exercise intolerance is a common complaint, the cause of which often remains elusive after a comprehensive evaluation. In this report, we describe 28 patients with unexplained dyspnea or exertional limitation secondary to biopsy-proven mitochondrial myopathies. Patients were prospectively identified from a multidisciplinary dyspnea clinic at a tertiary referral center. All patients were without underlying pulmonary, cardiac, or other neuromuscular disorders. Patients underwent history, physical examination, complete pulmonary function testing, respiratory muscle testing, cardiopulmonary exercise testing, and muscle biopsy. Results were compared with a group of normal control subjects. The estimated period prevalence was 8.5% (28 of 331). Spirometry, lung volumes, and gas exchange were normal in patients and control subjects. Compared with control subjects, the patient group demonstrated decreased exercise capacity (maximum achieved V O(2) 67 versus 104% predicted; p < 0.0001) and respiratory muscle weakness (PI(max) 77 versus 115% predicted; p = 0.001). These patients have a characteristic exercise response that was hyperventilatory (peak VE/V CO(2); 55 versus 42) and hypercirculatory (maximum heart rate - baseline heart rate/V O(2)max - baseline V O(2)max; 91 versus 41) compared to control subjects. Patients stopping exercise due to dyspnea (n = 16) (as compared with muscle fatigue, n = 11) displayed weaker respiratory muscles (Pdi(max) 61 versus 115 cm H(2)O; p = 0.01) and were more likely to reach mechanical ventilatory limitation (V Emax/ MVV 0.81 versus 0.58; p = 0.02). The sensation of dyspnea was related to indices of respiratory muscle function including respiratory rate and inspiratory flow. We conclude that mitochondrial myopathies are more prevalent than previously reported. The characteristic physiological profile may be useful in the diagnostic evaluation of mitochondrial myopathy.
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Affiliation(s)
- K R Flaherty
- Dyspnea and Pulmonary Hypertension Clinics, University of Michigan Health System, Ann Arbor, Michigan, USA
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