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EXERCISE TESTING Which Patient ? When ?

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.

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EXERCISE TESTING Which Patient ? When ?

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  1. EXERCISE TESTINGWhichPatient? When? Gündeniz AltıayTrakya Üniversitesi Tıp FakültesiGöğüs Hastalıkları Anabilim Dalı EDİRNE

  2. Presantation Plan • ClinicalExerciseTests, • Definitions, • Preoperativeevaluation, • Nationalandinternational data, • Guidelines

  3. ClinicalExerciseTests • 6-minutewalk test, • Shuttlewalk test, • Stairclimbing test, • Exercise-inducedbronchoconstriction, • Cardiacstress test, • Cardiopulmonaryexercise test (CPET) Holden DA et al. Chest 1992;102:1774-79 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

  4. Six-MinuteWalkDistance (6MWD)Test • Basic, pratique test • 6 minute, walkingdistance • Thewalkingcourseshould be a 30 m long • 500 m ═ 15 mL.kg.min VO2max Weisman IM et al. Clinics In Chest Med, 2001;22(4):679-701 Turner SE et al. Chest 2004;126.766-773

  5. IncrementalShuttleWalking Test (SWT) • Symptomlimitedmaximal test • Distance of between two shuttle :10 m • Audiosignals • Goodcorrelationwith 6MWD Weisman IM et al. Clinics In Chest Medicine, 2001;22(4):679-701 Singh SJ et al. Thorax 1992;47:1019-24

  6. The SWT correlatesbetterwithmaximaloxygenuptake (VO2max) than 6MWD. • 450 m of SWT • VO2max >15 mL.kg.min Morales FJ et al. Am Heart J 1999;138:292-298 Onaratti P et al. Eur J Appl Phys 2003; 89:331-36 Lewis ME et al. Heart 2000;86:183-87

  7. Indicationsfor 6MWD and SWT in clinicalpractice Palanga P et al. eur Respir J 2007;29:185-209

  8. StairClimbing Test • A safe and economical exercise test • It was the best predictor of cardiopulmonary complications after lung resection. Olsen GN et al. Chest 1991;99:587-90 Colice GL et al. Chest 2007;132:161S-177S Brunelli A et al. Ann Thorac Surg 2008;86:240-47 Brunelli A et al. Ann Thorac Surg 2008;86:240-47

  9. Cardiopulmonaryexercise test (CPET) • Cardiovascular response • Ventilatory response • Gas exchange • VO2 response • Anaerobic/Ventilatory Threshold

  10. CPET • Metabolic • VO2, VCO2, R, AT, laktat • Cardiac • HR, HRR, ECG, BP, O2 pulse • Respiratory • VE, VT, f, PETO2, PETCO2 • Gasexchange • SpO2, VE/VCO2, VE/VO2 • Acid-base • pH, PaO2, PaCO2 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

  11. Maksimum oxygenconsumptionVO2max – VO2peak • VO2max is thebestindex of aerobiccapacity • Thegoldstandardforcardiorespiratoryfitness • 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

  12. AnaerobicThreshold (AT) • Lactateaccumulation in exercisingmuscleoccurswhenoxygendemandexceedsthesupply. • The AT is usually 50% to 60% in sedantaryindividualsandhigher 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

  13. Anaerobik eşik (AT) • The AT can be determinedinvasivelybymeasuringarteriallactate (goldstandard) • The AT can be determinednoninvasively • Themodified V-slopemethod is most popular Sue DY et al. Chest 1988;94:931-38 Wasserman et al. Principles of Exercise Testing. Lippincott 2005

  14. Indicationsfor CPET in clinicalpractice Palanga P et al. Eur Respir J 2007;29:185-209

  15. PreoperativeEvaluationIndications • Lungcancerresectionalsurgery • Lung volüme reductionsurgery • Evaluationforlungorheart-lungtransplantation • Preoperativeevaluationforotherprocedures

  16. LungCancerResectionalSurgeryand CPET • FEV1 and DLCO havethegreatestutility in operability in low-risk patients. • The CPET is oftennecessarytomoreaccuratelyassessmoderate – tohigh-risk patients. ATS/ACCP. AJRCC 2003;167:211-77 Brunelli A et al. Eur Respir J 2009;34:17-41

  17. Duringexercise - increases ventilation, oxygenuptake, carbondioxideoutputandbloodflow • Similartothe post-op. periodafterlungresection. ATS/ACCP. AJRCCM 2003;167:211-77 Brunelli A et al. Eur Respir J 2009;34:17-41

  18. VO2peak >20  mL/kg/min.or >75% predoperable. • VO2peak <40% or <10 mL/kg/min. contraindicated. • Ifbetweenbothvalues, ppowasestimated • ppo FEV1andDL,CO >40% (havingeitherone) • ppo- VO2peak <35% and >10  mL/kg/min. • Surgicalresection • Theauthorscommunicated adecrease in overallhospitalmortalitycomparedtohistoricalcontrols. Wyser C et al. AJRCCM 1999;159:1450-56

  19. Loewen GM et al. J Thorac Oncol 2007;2:619-25 • Patientswho had a VO2peak <65% (or <16mL/kg/min) weremorelikelytosuffercomplications. • Brunelli et al. foundthatalldeathsafterlungresectionoccured in patientswith a VO2peak <20mL/kg/min. • A recentlypublished meta-analysis has shownthatexercisecapacity, expressed as VO2peak is lower in patientsthatdevelop post-op. cardiorespiratorycompl. afterlungresection. Brunelli A. Chest 2009;135(5):1260-67 Benzo R. Respir Med 2007;101:1790-97

  20. Risk of peri-op.complicationsareoftenstratifiedby VO2peak. • VO2peak <15 mL·kg.min. indicates a significant risk of complications. • The VO2peak lessthan 50-60% predicted is associatedwithhighermorbidityandmortality. Morice RC. Chest 1996;110:161S Bolliger CT. Eur Respir J 1998;11:198-212 Wyser C et al. AJRCCM 1999;159:1450-1456 Win T et al. Chest 2005;127:1159-65 Loowen GM et al. J Thorac Oncol 2007;2:619-25

  21. Akkoca Ö ve ark.. Tüberküloz ve Toraks 2004;52(4):307-314 • Akkoca et al. (26 patient) • VO2peak <10 mL/kg/min. • Complicationratio ═ %75 • Fındıkçıoğlu et al. (25 patient) • VO2max < 15 mL/kg/min. (↑ complication) • VO2max >20 mL/kg/min. (no complication) • Kasikcioglu et al. (44 hasta) • OUES (oxygenuptakeefficiencyslope) : VO2/log10VE • The rate of increase in VO2 againstminuteventilationvolume (VE) • OUES and VO2peak are a betterpredictor of surgicaloutcome. Fındıkçıoğlu A ve ark. Toraks 2005;6(3):214-20 Kasikcioglu et al. Lung Cancer 2009;66:85-88

  22. GUIDELINESERS/ESTS TASK FORCE • Exercisetestsshould be indicated in allpatientsundergoingsurgeryforlungcancerwith FEV1 or DLCO <80%. • Thecut-offvaluesfor VO2peak • >75% predor >20mL/kg/dakqualifiesforpneumonectomy; • <35% predor <10 mL/kg/dakindicateshigh risk foranyresection. • Evidence is not sufficienttorecommendcut-offvaluesforlobectomy. Level of evidence 2++; grade of recommendation B Brunelli A et al. Eur Respir J 2009;34:17-41

  23. RCRI: REVISED CARDİAC RİSK INDEX High risk surgery (lobectomyorpneumonectomy) Ischaemicheartdisease (prior MI, anginapectoris Heartfailure Insulin-dependentdiabetes Previousstroke of TIA Creatinine ≥2 mg.dL Brunelli et al. Eur Respir J 2009;34:17-41

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

  25. ACCP GUIDELINES • FEV1 or DLCO < 80% pred • Predictedpostoperative lung function (PPO) • Increased risk • PPO DLCO x FEV1 < 1,650 or PPO FEV1 < 30% Grade of recommendation, 1C Colice GL et al. Chest 2007;132:161S-177S

  26. ACCP GUIDELINES • İncreased risk • PPO FEV1 < 40% or PPO DLCO < 40% pred • Perform CPET Grade of recommendation, 1C Colice GL et al. Chest 2007;132:161S-177S

  27. GUIDELINESDİAGNOSİS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES • İncreased risk • VO2max< 15 mL/kg/min and • PPO FEV1orDLCO < 40% • VO2max< 10 mL/kg/min. • It is recommended that these patients be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C Colice GL et al. Chest 2007;132:161S-177S

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

  29. Low-technologyexercise: stair, 6 minwalkdistanceorshuttle? • If CPET wereunavailable, thenanothertype of exercise test should be considered. • Theshuttlewalk test has beenreportedto be morereproducibleandmorehighlycorrelatedwith V02peak. Swinburn CR et al. Thorax 1985;40:581-86 Morgan AD et al. Respir Med 1989;83:388-87 Singh SJ et al. Eur Respir J 1994; 7:2016-20

  30. ShuttleWalk Test (SWT) • 25 shuttles ═ VO2peak of 10 mL/kg/min. • >400 m at shuttlewalk test ═ VO2peak >15mL/kg/min. • Thepatientswhoexceed 400 m on the SWT may not need VO2 assessment. Singh SJ et al. Eur Respir J 1994;7:2016-20 BTS Guidelines. Thorax 2001;56:89-108 Win T et al. Thorax 2006;61:57-60

  31. ShuttleWalk Test (SWT) Recommendations • It should notbe used alone to select patients for operation. • It could beused as a screening test. • Thewalking <400 m mayhave VO2peak <15 mL·kg·min. • The 6MWD should not be usedtoselectpatientsforoperation. Level of evidence 2+; grade of recommendation C Brunelli et al. Eur Respir J 2009;34:17-41

  32. StairClimbing Test • Ithas historically been used as a surrogate CPET. • Lobectomy; climb three flights of stairs, • Pneumonectomy; climb five flights of stairs. • Climbing three flights : FEV1 of > 1.7 L and • Climbing five flights: FEV1 of > 2 L. Bolton JWR. Chest 1987;92:783-787

  33. Climb five flights of stairs will have a V̇o2max of > 20 • Cannot climb one flight of stairs will have a V̇o2max of <10 • Even though FEV1 or DLCO of < 40%ppo, • The ability to climb > 12 to 14 m of stairs, • approximately three flights of stairs, • Low risk for postoperative complications for lobectomy Pollock M et al. Chest 1993;104:1378-83 Brunelli A et al. Chest 2002;121:1106-10 Olsen GN et al. Chest 1991;99:587-90

  34. 536 patientswithlungcancer • Exerciseoxygendesaturation; 2 cut-off • saturation level <90% or • desaturation>4% • The risk of complications was approximately two-fold higherin patients with oxygen desaturation >4% at peak exercise. • Those patients in whom EOD >4% is observed shouldbe further assessed with a formal CPET. Brunelli A et al. Eur J Cardiothorac Surg 2008;33:77-82

  35. 640 patients – majorlungresection • Climbing <12 m • two-foldand 13-foldhigherrates • >22 m (<1% mortality) • Even in patientswithppo-FEV1 and/orppo-DLCO <40%, themortality rate in thoseclimbing >22 m waszero. Brunelli A et al. Ann Thorac Surg 2008;86:240-47

  36. ACCP GUIDELINES • Increased risk • <25 shuttles or • less than one flight of stairs • They should be counseled about nonstandard surgery and nonoperative treatment for their lung cancer. Grade of recommendation, 1C Colice GL et al. Chest 2007;132:161S-177S

  37. ERS/ESTS TASK FORCE • The stair climbing test is a cost-effectivetest capable of predicting morbidity and mortality after lungresection better than traditional spirometry values. • It shouldbe used as a first-line functional screening test to selectthose patients that can undergo safely to operation (heightof ascent >22 m) Level of evidence 2++; gradeof recommendation B. Brunelli et al. Eur Respir J 2009;34:17-41

  38. EXERCİSE OXYGEN DEASATURATİON (EOD) • TheSWTand 6-MDT may be moreeffective in identifyingpatientswhodesaturationduringexercisethan is the CPET. • >4% desaturationduringexercise had beenreportedtoindicate an increased risk for peri-operativecomplications. Turner SE et al. Chest 2004;126:766-773 Pierce RJ et al. AJRCCM 1994;150:947-55 Ninan M et al. Ann Thorac Surg 1997;64:328-33 British Thoracic Society. Thorax 2001;56:89-108 Brunelli A et al. Eur J Cardiothorac Surg 2008;33:77-82

  39. ACCP GUIDELINE • Arterial oxygen saturation < 90% indicates an increased risk for perioperative complications with standard lung resection. • It is recommended that these patients undergo further physiologic testing. Grade of recommendation, 1C Colice GL et al. Chest 2007;132:161S-177S

  40. ERS/ESTS TASK FORCE Statement • Patients with EOD >4duringstair climbing may have an increased rate of complications andmortality after lung resection. • They needto befurther assessed with formal CPET. Level of evidence 2+. Brunelli A et al. Eur Respir J 2009;34:1-41

  41. Lung-VolumeReductionSurgery (LVRS)andExerciseTests • 6-MWD <200 m is an excellentpre-operativepredictorof unacceptable post-operativemortality at 6 month. • Specificity of 84%. • A randomisedcontrolledstudy, indicatedthat a pre-operativeSWT distance <150 m was a predictor of high peri-op.mortality. Szekely et al. Chest 1997;111:550-58 Brunelli A et al. Eur J Cardithorac Surg 2005;27:367-72

  42. Lung-VolumeReductionSurgery (LVRS) Thethresholdfor a successfuloutcome • 150 m forthe SWT • 200 m forthe 6-MWT

  43. Heart-Lung, LungTransplantationandExerciseTests • Inpatientsintolerant of a β-blocker, a cut-offforVO2peak ≤14 ml/kg/minshould be usedtoguidelisting • Inthe presence of a β-blocker, a cut-offforpeakVO2peak ≤12 ml/kg/minshould be usedtoguidelisting • Inyoungpatients (<50 years) andwomen, includingpercent of predicted (≤50%) VO2peak Level of Evidence: B Mandeep et al.J Heart Lung Transplant 2006;25(9):1024-42

  44. CPET beforehigh-risk surgery • Themajorintra-abdominalsurgery is associatedwith an increase in oxygendemand of 40% ormore. • “TheImprovingSurgicalOutcomesGroup” recommendedtheuse of CPET beforehigh-risk surgery.

  45. Elderly Surgical PopulationCPET 187 pts Major Abdo Surgery CPX tested AT ml/min/kg <11 55pts >11 132pts Overall Mortality 7.8% Non-Surgical 5.9% MORTALITY 18% MORTALITY 0.8% P<0.001 Older Pl et al. Chest 1993;104(3):701-704.

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