Prac;cal

issues in Pulmonary Assessment

Rehabilita;on : ! Pulmonary func1on
! Maximal exercise tes;ng
Assessment in pa;ents ! Func;onal exercise tes;ng
with respiratory disease ! Muscle tes;ng

Prof Dr R. Gosselink
! Quality of life
Faculty of Kinesiology and Rehabilita;on Sciences
KU Leuven ! Physical Ac1vity

PEAK OXYGEN UPTAKE, % PREDICTED

120

100
?
80

60

40

20

0
Control GOLD I GOLD II GOLD III GOLD IV

Pinto-Plato et al. Chest 132:1204, 2007 Gosselink et al. Am J Respir Crit Care Med 153:976-980, 1996

1
 Incremental exercise test Maximal tests : Indica1ons

! Exercise (in-)tolerance ?
! Limi1ng factors ?
! Prognosis
! Dyspnea : cardiac-pulmonary ?
! Impairment / disability ?
! Exercise prescrip1on / safety ?
! Preopera've assessment
! Evalua'on for lung transplanta'on
www.thoracic.org 2003

REASONS FOR EXERCISE LIMITATION

Exercise capacity
LUNGS AND AIRWAYS
PSYCHOGENIC
16
MOTIVATION
14
VO2 (ml/min/kg)

NYHA class Functional capacity VO2max

12
I 10 No impairment 26-35ml.min-1
II 8 Minimal impairment 21-25ml.min-1 CARDIOCIRCULATORY
6
III 4 Moderate impairment 16-20ml.min-1

IV 2 Severe impairment <15ml.min-1

0
RESPIRATORY MUSCLES
/h

/h

ng
4. g

ng

Br Heart Journal 1994

ng

in

bi

ti
ti

nd

8k

6k

PERIPHERAL MUSCLES
ub

in
it

ta

5.

Pa
S

cr
S

S
k

k
al

al
W

Tennessee Heart Association eds.

Physicians handbook for evaluating cardiovasular and physical fitness, 1972

2
 IMPAIRED EXERCISE PERFORMANCE/DYSPNEA
Which factors do contribute to exercise limita1on?
Peripheral Anxiety
Cardio- Ven;latory Oxygen transport Mo;va;on
muscle
circulatory in the lungs Selfesteem
strength
O2 O2 O2
l Respiratory
muscle weakness
l Hyperina;on
. . O2
Hypoxemia/Hypercapnia VE Q
during exercise?

CO2
IMT
Body posi;oning
Endurance Interval- Rollator
Muscle training Counseling CO2 CO2 CO2
training training NIV
NEMS Relaxa;on
Ac;ve expira;on
ev. suppl O2
PLB Nutri;on Educa;on Ventilation Cardiac output Muscle

O2 O2 O2

. . O2
Cardiovascular response VE Q
CO2

CO2 CO2 CO2

Ventilation Cardiac output Muscle

3
 Cardio-circulatory ceiling Cardio-circulatory ceiling
O2 O2
Heart rate Heart rate
Predicted by age Predicted by age
220 - age 220 - age
. . 210-(age x 0.65) . . 210-(age x 0.65)
Q Q 200
Q Q
180
160
Stroke volume
HR (bpm)

140
(on itself dicult to measure)
120
100
Signs of heart disease
Ischemia
CO2 80 CO2 Arrhytmias
60
Blood pressure drop
1.0 2.0 3.0 4.0 5.0
VO2 (L/min)

Peak Heart Rate, % predicted

110

90

Ven;latory Response
70

50

30 Maximal exercise
10

-10 Control GOLD I GOLD II GOLD III GOLD IV

Pinto-Plato et al. Chest 132:1204, 2007

4
 Ven;latory limita;on the classical approach
Ven;latory Response Ven;latory
Healthy person 45 yrs FEV1 4.71 L (124%pred) reserve

180
MVV Normal subjects :
160
140 ~ 30%
Exercise maximal ven;la;on is 30 % lower
VE (L/min)

120 VEmax
100 than voluntary max. ven;la;on.
80
60
40 Respiratory pa;ents :
20
0 Decrease or even disappearance of
0 1 2 3 4 ven;latory reserve.
VO2 (L/min)

Ven;latory limita;on the classical approach Ven;latory limita;on the classical approach
Healthy person 45 yrs FEV1 4.71 L (124%pred)
Healthy person 45 yrs FEV1 4.71 L (124%pred) Imagine a smoking induced reduc;on of the FEV1 to 1 L (26%pred)

180 180
160 160
140 140
VE (L/min)

VE (L/min)

120 120
100 100
80 80
60 60
40 40
20 20
0 0
0 1 2 3 4 0 1 2 3 4
VO2 (L/min) VO2 (L/min)

5
 Ven;latory limita;on the classical approach Ven;latory limita;on the classical approach
Healthy person 45 yrs FEV1 4.71 L (124%pred)
Imagine a smoking induced reduc;on of the FEV1 to 1 L (26%pred) O2
180 Airflow obstruction
160
VE / MVV > 0.75 is 'abnormal'
140 PaCO2 will increase MVV: 37.5 x FEV1
VE (L/min)

120 Symptoms of dyspnea

100 MVV (12s)
80
60
40
20
0
Respiratory muscle weakness
0 1 2 3 4 CO2
VO2 (L/min)
Ventilation

Inspiratory muscle strength Expiratory muscle strength

6
 Ven;latory limita;on O2 O2 O2

O2
PaCO2 .
VE
.
Q

VE > 70-80% MVV (=37.5 x FEV1) CO2

Respiratory muscle weakness CO2 CO2 CO2

Ventilation Cardiac output Muscle
Flow-volume loop

Blood gases response

Exercise-induced hypoxemia/desatura;on
Blood gases response at the begining of exercise :
usually shunt
to exercise progressively during exercise :
usually emphysema, brosis

Alveolar hypoven;la;on :
less frequent than EIH/EID

7
 Oxygena1on during exercise Exercise induced desatura;on
0
-1
35 -2
0
-3
-1
30 -4
DL,CO (ml/min/mmHg)

-2
-5
-3
CPX nl, -6
25 -4
-7
-5 6MWD drop CPX
-8
-6
-9 6MWD
20 -7
-10
-8 CPX
6MWD
15 -9
-10
0
-1
10 -2
-3

5 CPX nl, -4

6MWD nl CPX drop, -5

0 6MWD drop
-6

-20 -10 0 10 20 -7
-8 CPX

Exercise-Rest PaO2 (mmHg) -9

-10
6MWD

Ries, Chest 93, 454-459, 1988 Poulain, Chest 2003

O2 O2 O2

. O2
.
VE Q Peripheral muscle func;on
CO2

CO2 CO2 CO2

Ventilation Cardiac output Muscle

8
 Muscular limita1on Factors related to exercise limita1on in COPD
.
VO2max 6MWD
100%
TL,CO 0.73* NS
80%

60% Both FEV1 0.32# NS

Fatigue
40% Dyspnea QF 0.40* 0.64*
20%
PImax NS 0.24*
0%
Controls COPD # = 0.07 * < 0.01

Gosselink et al Am J Respir Crit Care Med 153:976-980; 1996

Killian et al AJRCCM 1995

MUSCLE STRENGTH IN COPD

Interac;on of lungs and muscles
200
119 cm2 80 cm2
180
QF (% pred.)

160
140
VE (L/min)

120 Decondi;oning
Early lac;c acidosis
100 100 High Vd/Vt
80
60
40
20
0
0 1 2 3 4
0 VO2 (L/min)
Normals COPD

9
 Isometric or isokine;c muscle tes;ng

l Isokine;c contrac;on
l Isometric contrac;on
l Expensive equipment

l Norma;ve data

Cybex Norm, Enraf Nonius,
Delft, The Netherlands

Hand-held Dynamometry

l Isometric contrac;on
l MAKE vs. BREAK test
l Electronic hand held device
l Norma;ve data

10
 Microfet, Biometrics, Almere, The
Netherlands
+ anchoring system, developed by the
technical service of the University
Visser et al. Neuromusc. Disorders 2003; 13:744-750 Hospital Gasthuisberg.

150

l EASY - INEXPENSIVE 125

Handknijpkracht
force

l REPRODUCIBLE 100
(%pred)
Handgrip

75
l NORMAL VALUES
50
l VALIDITY AS INDICATOR OF
GENERAL MUSCLE FORCE ? 25

0
0 25 50 75 100 125 150
Knee extension force
Quadricepskracht
(%pred)

11
 Quadriceps Endurance
Muscular limita1on
800
O2
! High score Fa1gue
600
O2 ! Muscle weakness
seconds

400

*
! Peripheral vascular
200 * CO2 problems
0
COPD controls COPD controls ! Myopathy
CO2
Male Female
! Enzyme deciencies
Van t Hul et al Muscle and Nerve 2004; 29:267.

DECREASED Conclusions
VENTILATORY
CAPACITY MUSCLE DECONDITIONING: Exercise intolerance is common in respiratory
INCREASED pa;ents, also with mild disease.

VENTILATORY The impaired respiratory response play a major
REQUIREMENT part.
The peripheral muscle response play an important
role in this exercise intolerance and can be improved
by exercise training.
A cardiovascular part is generally not present in this
REDUCED EXRCISE
exercise intolerance.
CAPACITY

12
 Constant work rate test : Indica;ons Constant work rate test : Indica;ons

! 3 minutes unloaded ! Pre-post treatment

Rehabilita1on, medica1on
! Increase load up to 70% Wmax
! Research protocols focusing on VO2 kine1cs,
! Outcome = Time dynamic hyperina1on,
Symptoms at iso-1me
! Measurements StcO2, symptoms, HR ! Clear benet of steady state

Borgscore (per minute and end)

ATS statement 2003 ATS statement 2003

Eects of exercise training

140
120
100 85%
Wmax
80
VO2max
60
Endurance
40 50%
20
0

Astrand & Rodahl Textbook of work physiology

13
Field exercise tests: what are the op1ons Shulle walking test
BEEP
Increasing speed
! Externally paced test
Shutle walking tests
Incremental shutle walking
Endurance shutle walking
9m

! Self paced tests 10m

Timed walking tests (6/12 min WT) Incremental SHW: speed is gradually increased until the patient can not reach the cone
in the allotted time
Endurance shuttle walking test: The time patients can continue to walk at a preset
fraction of the peak is registered

6 minute walking test

The maximal distance that can be covered
in a specic amount of ;me (6 minutes)

Pa;ent walks in a corridor (>30m long)

Standardize encouragement

Typical measurements include
StcO2, HR, Dyspnea

Repeat the test - learning eect!

MCID: 30 m

14
 6MWT: a test for physical ac1vity? Predict Wmax from 6 minute walking test?
180
Walking time (min)

150

120

90

60

30

0
0 25 50 75 100 125
6mwt %pred

WT COPD WT Control Holland et al. Respira1on 2010

15
 Summary
M
ax

CW tes

St
im

ep
T t

6M
al

SH
te

T
W
st

es
W

Exercise Tolerance
Exercise limita;on
Safety
Risk
Prescrip;on
Acute eect interv.
O2
Bronchodil.
Rollator
Eect of exercise training ()

16