CPET v 3 - Duke Universitysites.duke.edu/geriatrics/files/2017/04/12_CPET-v-3-handout.pdf · • Managed by CDU Overview Rationale Process Interpretation Clinical applications2 Key

5/7/2017

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Cardio-Pulmonary Exercise TestingCardio-Pulmonary Exercise Testing

Madhav Swaminathan, MD, MMCiProfessor of AnesthesiologyDuke University Health SystemDurham, NC

Madhav Swaminathan, MD, MMCiProfessor of AnesthesiologyDuke University Health SystemDurham, NC

Disclosures

• None

Overview: What it isOverview: What it is

Rationale: Why we need itRationale: Why we need it

Process: How it is doneProcess: How it is done

InterpretationInterpretation

Clinical applicationsClinical applications

Key pointsKey points

Outline

Overview Rationale Process Interpretation Clinical applications Key points

• Functional ability– O2 supply to tissues

– CO2 clearance

• Stress on this system has predictive value

• Simulation of the surgical experience to test functional ability for stress tolerance

What is CPET?

CV CapacityCV Capacity InternalInternalExternalExternal


At a basic level

O2O2

CO2CO2

VQ Matching

• Exercise induces– Increase in ventilation

– Increase in perfusion

• Disease states will affect either or both

• Testing can detect mismatches

Must matchMust match


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IntegratedIntegrated

Cardio-Pulmonary Exercise Testing

• Global assessment• Exercise responses of

– Pulmonary– Cardiovascular– Hematopoietic– Neuropsychological– Musculo-skeletal


DynamicDynamic

Non‐invasiveNon‐invasive

PhysiologicPhysiologic

ObservedObserved

ExpectedExpected

Undiagnosed Exercise

Intolerance

Why do we need CPET?

• 1- MET higher level of MAC

– 13% risk reduction of ACM

– 15% risk reduction of CHD/CVD


Cardiorespiratory Fitness as a Quantitative Predictor of All‐Cause Mortality and

Cardiovascular Events in Healthy Men and WomenKodama S, et al. JAMA 2009;301(19):2024‐35

© 2009 American Medical Association

Cardiorespiratory Fitness

LowLow

IntermediateIntermediate

HighHigh

0 2 4 6 8 10

METS

• Meta analysis of 33 studies

• >185,000 participants

• All-cause mortality and CHD/CVD outcome

Survival of the fittest…


Years of follow up Years of follow up

Exercise Capacity and Mortality among Men Referred for Exercise Testing

Myers J et al. N Engl J Med 2002;346:793‐801.

Exercise capacity is a more powerful predictorof mortality among men than other

established risk factors of cardiovascular disease

Exercise capacity is a more powerful predictorof mortality among men than other

established risk factors of cardiovascular disease

Survival of the fittest…

Low physical activity

Medium physical activity

High physical activity


©2009 by British Medical Journal Publishing Group

Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort

Byberg, L, et al. BMJ 2009;338:b688

• 2,205 men aged 50

• 35-year follow up

Those that increased physical activity reduced their mortality risk.

Risk Reduction Equivalent to Smoking Cessation

Risk Reduction Equivalent to Smoking Cessation

Timeline

BaselineBaseline Full RecoveryFull Recovery

RecoveryRecovery

Survival thresholdSurvival threshold

SurgerySurgery

PrehabPrehab

RehabRehab

From Tim Miller, MD, with permission. Courtesy Mike Grocott, FRCA


Fitness Level

Fitness Level

How is it done?


EquipmentEquipment

Gas AnalyzerGas Analyzer

ComputerComputer

DisplayPhysiological Parameters


PneumotachographPneumotachograph

12‐lead EKG12‐lead EKG

VO2VO2

VCO2VCO2

Static CycleStatic Cycle

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How is it done?


EquipmentEquipment


ComputerComputer




How is it done?


EquipmentEquipment


ComputerComputer




• Breath‐by‐breath gas analysis–Oxygen uptake ‐ VO2

–CO2 production ‐ VCO2

• Graded exercise challenge–Treadmill vs. bike

• Peak Oxygen Consumption (VO2 max)• Anaerobic Threshold (AT)

Cardiovascular

Measurements

• Max aerobic capacity (VO2max)

• Anaerobic Threshold (AT)

• Oxygen Pulse (VO2/HR)

• Vent Equivalents (VE)

– Oxygen (VE/VO2)

– Carbon Dioxide (VE/VCO2)

Work RateWork Rate

HRHR

NIBPNIBP

Gas Exchange

Respiratory

VO2VO2

VCO2VCO2

SpO2SpO2

VTVT

VEVE

RRRR


CalculationsMaximal Aerobic Capacity

Work RateWork Rate

VO2VO2

VCO2VCO2

HRHR

NIBPNIBP

VTVT

VEVE

Gas Exchange

Cardiovascular

Respiratory

SpO2SpO2

RRRR


• Defines the limits of the CPS

• C.O x [C(a-v)O2]

• Max exercise has been performed AND

• Max effort has been given

• Implies limit of individual physiology

– Peak VO2 – exercise capacity in CVD

– MAC in apparently healthy

CalculationsVentilatory ThresholdWork RateWork Rate

VO2VO2

VCO2VCO2

HRHR

NIBPNIBP

VTVT

VEVE

Gas Exchange

Cardiovascular

Respiratory

SpO2SpO2

RRRR


• Submaximal index of exercise capacity

• VE increases exponentially relative to VO2

• VE required to eliminate CO2

• Point at which O2 requirements exceed supply – anaerobic metabolism begins –lactate production rises

• Occurs at approx. 45-65% VO2max

• Not under voluntary control. Not affected by psychological factors

CalculationsVentilatory ThresholdWork RateWork Rate

VO2VO2

VCO2VCO2

HRHR

NIBPNIBP

VTVT

VEVE

Gas Exchange

Cardiovascular

Respiratory

SpO2SpO2

RRRR


Lactate ThresholdLactate

Threshold

Anaerobic ThresholdAnaerobic Threshold

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CalculationsVentilatory ThresholdWork Rate

VO2

VCO2

HR

NIBP

VT

VE

Gas Exchange

Cardiovascular

Respiratory

SpO2

RR


Interpretation


CourtesyTim Miller, MD

Interpretation


Variable Normal Value

VO2Max >84% predicted

VT/AT >40% of VO2Max (up to 80%)

HR >90% age predicted

BP <220/90

O2 Pulse (VO2/HR) >80%

Resp Rate <60/min

VE/VCO2 (at VT) <34

PaO2 > 80 mm Hg

P(A‐a)O2 <35 mm Hg

In specific clinical settings


Measurement CHF COPD ILD Obesity Deconditioning

VO2Max ↓ ↓ ↓ ↓ for IBW ↓

VT ↓ N or ↓ N or ↓ N N or ↓

Peak HR Variable N or ↓ ↓ N or ↓ N or ↓

O2 Pulse ↓ N or ↓ N or ↓ N ↓

VE/VCO2 ↑ ↑↑ ↑ N N

PaO2 N Variable ↓ N or ↑ N

P(A‐a)O2 N Variable or ↑ ↑ ↓ N

Interpretation When to apply CPET?


• Exercise tolerance• CV disease• Respiratory disease• Preoperative evaluation• Pulmonary rehab• Disability assessment• Pre-thoracic transplant

• Triage postop location

• Predict complication risk

• Predict mortality

• Prehab

• Triage postop location

• Predict complication risk

• Predict mortality

• Prehab

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Survival/risk threshold


VT/AT NPeriop

Mortality

>11 ml/min/Kg 132/187 0.8%

<11 ml/min/kg 55/187 18%

<11 ml/min/kg + Ischemia

8/19 42%

• 187 elderly patients• Abdominal surgery• Overall mortality = 7.5%

0

10

20

30

40

50

60

70

80

90

<8 8‐10.9 11‐13.9 >14

VT and Survival

Non‐Survivors Survivors Older et al. Chest 1993; 104:101‐04

Triage Postop Location


0

1

2

3

4

5

6

7

8

9

10

5.1‐8 8.1‐11 11.1‐14 >14

Overall & CV Mortality

CV Mortality Non‐CV Mortality Older et al. Chest 1999; 116:355‐362

• 548 Patients > 60y

• Abdominal surgery

• Postop location (ICU/HDU/Ward) assigned on basis of preop VT+ischemia

• Mortality = 3.9%

• 548 Patients > 60y

• Abdominal surgery

• Postop location (ICU/HDU/Ward) assigned on basis of preop VT+ischemia

• Mortality = 3.9%

Older et al. Chest 1999; 116:355‐362

CPET result Postop location %

AT <11 ICU 28

AT >11 with either myocardial ischemia

or VE/VO2 > 35

HDU 21

All other patients General ward 51

• 21 died (19 were triaged to either ICU/HDU)

• 14/19 had VT<11

• 0% CV mortality among ward admissions

• 21 died (19 were triaged to either ICU/HDU)

• 14/19 had VT<11

• 0% CV mortality among ward admissions

Triage Postop Location


Predict Risk/Complications

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Cardiorespiratory Fitness Predicts Mortality and Hospital Length of Stay After Major Elective

Surgery in Older People.Snowden et al.

Ann Surg. 257(6):999‐1004, June 2013.

© 2013 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.

FIGURE 2 . Age, fitness, and mortality rates from hepatobiliary surgery in 389 patients (Fit = Anaerobic Threshold >10 mL/kg/min, Unfit = Anaerobic Threshold <10 mL/kg/min).


• 389 Patients mean 66y

• Hepato-biliary surgery

• VT/AT was most significant predictor of mortality

• Normal card-pulm fitness – same hospital or ICU LOS regardless of age

• Old + unift = highest LOS and mortality

Does intervention improve outcome?

2

Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing

thoracic surgery for malignant lung lesionsJones, LW, et al.

Cancer. 2007; 110(3):590–598


• 25 patients with operable lung cx

• 5 endurance sessions @ 60-

100% Peak VO2

• CPX at baseline, immed before

and 30d after surgery

• Modest increase in peak VO2

• Some benefit in those who had >80% adherence

• Fitness level decreased after surgery, but not below baseline

• Modest increase in peak VO2

• Some benefit in those who had >80% adherence

• Fitness level decreased after surgery, but not below baseline

Lung cancerLung cancer


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Therapeutic Validity and Effectiveness of Preoperative Exercise on Functional Recovery after Joint

Replacement: A Systematic Review and Meta‐AnalysisHoogeboom, TJ, et al. PLOS One 7(5): e38031


• 737 patients from12 trials

• Resistance, aerobic or functional

exercise in TKR and THR

• 2.5 times/week x 6 weeks

• No beneficial effects on postop functional recovery

• Therapeutic validity of exercise regimes was questionable

• Poor quality data

• Larger trials needed…

• No beneficial effects on postop functional recovery

• Therapeutic validity of exercise regimes was questionable

• Poor quality data

• Larger trials needed…

Total Joint ReplacementTotal Joint

Replacement

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Impact of preoperative change in physical function on postoperative recovery: Argument supporting

prehabilitation for colorectal surgeryMayo NE, et al.

Surgery 2011. 150(3): 505‐514


• Reanalysis of a prehab RCT

• Primary outcome - 6MWT

• Secondary outcomes – mental health/complications

• 95 patients completed prehab

• 75 also assessed postop (9 w)

Colorectal surgeryColorectal surgery


2Overview Rationale Process Interpretation Clinical applications Key points

• 33% improved

• Mental health, exercise capacity

• Women less likely to improve

• Preop improvement more likely to return to baseline

• 29% deteriorated – more complications

• “Meaningful” changes in functional capacity achieved

• Those with poor capacity should consider prehab

• 33% improved

• Mental health, exercise capacity

• Women less likely to improve

• Preop improvement more likely to return to baseline

• 29% deteriorated – more complications

• “Meaningful” changes in functional capacity achieved

• Those with poor capacity should consider prehab

Colorectal surgeryColorectal surgeryImpact of preoperative change in physical function on

postoperative recovery: Argument supporting prehabilitation for colorectal surgery

Mayo NE, et al. Surgery 2011. 150(3): 505‐514


2

The effects of preoperative exercise therapy on postoperative outcome: a systematic review

Valkenet, K et al. Clinical Rehabilitation. 2011;25(2):99‐111


• 12 studies – JR (n=7),

abdominal (n=1),

cardiac (n=4)

• Methodological quality

rated using PEDro

scale

• Preop Exercise: improves LOS in Card/Abd, not in JR

• Inspiratory muscle training: reduces postop pulm complications

• Use intervention in targeted manner

• Preop Exercise: improves LOS in Card/Abd, not in JR

• Inspiratory muscle training: reduces postop pulm complications

• Use intervention in targeted manner

Overall?Overall?

How do you get one for your patient?

• Order the CARD Cardiopulmonary Stress Test

• Call 919-684-2080 to schedule

• Managed by CDU


How do you get one for your patient?

• Order the CARD Cardiopulmonary Stress Test

• Call 919-684-2080 to schedule

• Managed by CDU


Equipment

https://www.davismedical.com/Products/T2100‐Treadmill‐for‐GE‐Stress‐Monitors__GER‐TRE‐T2100.aspx

GE T2100 Treadmill. (GE Inc)

VIAsprint™ 150P and Ergoselect 600 Recumbent Ergometer (BD Inc, NJ)

http://www.carefusion.com/our‐products/respiratory‐care/metabolic‐carts‐cpet‐and‐energy‐expenditure/exercise‐accessories/viasprint‐150p‐bicycle

http://www.carefusion.com/our‐products/respiratory‐care/metabolic‐carts‐cpet‐and‐energy‐expenditure/metabolic‐carts/vmax‐encore‐metabolic‐cart

Vmax® Encore Metabolic Cart with complete PFT system (BD Inc, NJ)


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Report


Peri-Operative Enhancement Team (POET)

CPETCPET

Take home points

• Preoperative functional capacity is a

powerful predictor of adverse outcome

• CPX testing can detect subtle and overt

reductions in functional capacity

• Interventions have yielded marginal results

• Reductions in LOS and complications in

selected groups have offered hopehttp://learningradiology.com/graphics/takehomepoint.gif


Recommended reading1. Balady GJ, et al. Clinician's Guide to cardiopulmonary exercise testing in adults: a

scientific statement from the American Heart Association. Circulation. 2010 Jul 13;122(2):191-225.

2. American Thoracic Society, American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003 Jan 15;167(2):211-77.

3. Forman DE, et al. Cardiopulmonary exercise testing: Relevant but under used. Postgrad Med. 2010 Nov;122(6): 68-66.

4. Arena R, et al. Ordering a cardiopulmonary exercise test for your patient: Key considerations for the physician. Future Cardiol. 2011 Jan;7(1):55-60.

5. Ridgway ZA, et al. Cardiopulmonary exercise testing: a review of methods and applications in surgical patients. Eur J Anaesthesiol. 2010 Oct;27(10):858-65.

Thank you!

Special thanks to Tim Miller, MDSpecial thanks to Tim Miller, MD

Documents

CPET v 3 - Duke Universitysites.duke.edu/geriatrics/files/2017/04/12_CPET-v-3-handout.pdf · • Managed by CDU Overview Rationale Process Interpretation Clinical applications2 Key