ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases

The objective of this document was to standardise published cardiopulmonary exercise testing (CPET) protocols for improved interpretation in clinical settings and multicentre research projects. This document: 1) summarises the protocols and procedures used in published studies focusing on incremental CPET in chronic lung conditions; 2) presents standard incremental protocols for CPET on a stationary cycle ergometer and a treadmill; and 3) provides patients’ perspectives on CPET obtained through an online survey supported by the European Lung Foundation. We systematically reviewed published studies obtained from EMBASE, Medline, Scopus, Web of Science and the Cochrane Library from inception to January 2017. Of 7914 identified studies, 595 studies with 26 523 subjects were included. The literature supports a test protocol with a resting phase lasting at least 3 min, a 3-min unloaded phase, and an 8- to 12-min incremental phase with work rate increased linearly at least every minute, followed by a recovery phase of at least 2–3 min. Patients responding to the survey (n=295) perceived CPET as highly beneficial for their diagnostic assessment and informed the Task Force consensus. Future research should focus on the individualised estimation of optimal work rate increments across different lung diseases, and the collection of robust normative data.The document facilitates standardisation of conducting, reporting and interpreting cardiopulmonary exercise tests in chronic lung diseases for comparison of reference data, multi-centre studies and assessment of interventional efficacy. http://bit.ly/31SXeB

ARTP statement on cardiopulmonary exercise testing 2021.

Cardiopulmonary exercise testing (CPET) has become an invaluable tool in healthcare, improving the diagnosis of disease and the quality, efficacy, assessment and safety of treatment across a range of pathologies. CPET's superior ability to measure the global exercise response of the respiratory, cardiovascular and skeletal muscle systems simultaneously in a time and cost-efficient manner has led to the application of CPET in a range of settings from diagnosis of disease to preoperative assessment. The Association for Respiratory Technology and Physiology Statement on Cardiopulmonary Exercise Testing 2021 provides the practitioner and scientist with an outstanding resource to support and enhance practice, from equipment to testing to leadership, helping them deliver a quality assured service for the benefit of all patient groups

Eccentric cycling in the immediate postoperative phase following coronary artery bypass surgery: A proof of concept study

Background: Immobility and physical inactivity following coronary artery bypass graft (CABG) surgery can lead to significant functional decline, due to a combination of central haemodynamic and peripheral tissue changes. In the immediate post-operative recovery, there is opportunity for exercise interventions that target skeletal muscle health. Eccentric cycling describes the use of a motor-driven, self-pedalling bicycle ergometer to allow participants to resist the turning of the cycle wheel and thus perform repetitive muscle lengthening contractions. This exercise modality requires lower cardiorespiratory demand than workload-matched concentric exercises such as walking or traditional concentric cycling, while still engaging skeletal muscle. Outpatients with cardiorespiratory and other chronic disease have experienced clinical improvements following low-load eccentric cycling exercise, however there is a paucity of ergometers available for use in a hospital setting, where maintaining haemodynamic stability and minimising patient relocation is imperative. As such, eccentric cycling has not yet been studied in a hospitalised patient cohort, where its value in the immediate post-operative environment needs urgent attention. Aims: This thesis is comprised of two main objectives. First, to design and construct an eccentric cycle ergometer specifically tailored to deliver low loads to patients in an acute care hospital setting. Second, to investigate whether eccentric cycling, provided at the bedside, can be practically and safely performed in the acute recovery after cardiac surgery, by observing the heamodynamic and peripheral muscle oxygen utilisation characteristics, and compare peripheral skeletal muscle oxygenation to walking at hospital discharge. Methods: In study 1, an eccentric cycle ergometer (125 W AC) was custom-designed and built to be used by hospitalised patients, to perform low workload eccentric cycling, using visual feedback (power). The completed mobile eccentric cycle ergometer was tested using eight (n=8) healthy adult participants in a laboratory setting. After confirmation of eccentric workload load capacity, study 2 enrolled hospital patients (age; 61.6±10.3 years, BMI; 28.6±6.2 m2; 23 males and 1 female) to perform repeated bouts of low-intensity eccentric cycling following uncomplicated CABG. Pre and postoperative heart rate, blood pressure, arterial and skeletal muscle oxygen saturation were collected using continuous 12-lead ECG, automated sphygmomanometry and near-infrared spectroscopy respectively. Participants performed 10-minute exercise sessions, under supervision, on up to three occasions, commencing from the third postoperative day until hospital discharge. Workload was self-prescribed based upon ratings of perceived exertion using a maximum of 4/10 as a cut off. Functional capacity was assessed using a 20-meter walk for gait speed performed at hospital discharge. Results: In study 1, all participants completed the protocol in its entirety with no mechanical issues with the ergometer. Mean power output for the two eccentric workloads was 31.1±5.7 W and 56.6±8.8 W respectively. Heart rate (rest: 68±13bpm) and minute ventilation (rest: 12.4±3.5 L.min-1) increased incrementally with workload 1 (HR: 83±16bpm MV: 21.76±6.5 L.min-1, p\u3c0.001 v rest) and workload 2 (HR: 94±14 bpm MV: 26.5±8.9 L.min-1, p\u3c0.001 v rest) while peripheral arterial oxygen saturation (98±1%) and local muscle oxygen saturation of the quadriceps muscle (89±5%) was sustained for both workloads. Participants did not report any muscle soreness following the exercise. The eccentric cycle ergometer performance was deemed reliable for the feasibility study in the post-operative CABG patient cohort. In study 2, mean workload was assessed during consecutive eccentric cycling sessions, with a maximum of three eccentric cycling sessions performed prior to hospital discharge. The mean workload significantly increased during the second and third eccentric cycling sessions, albeit partly as a factor of increased cycling cadence. By the commencement of the third eccentric cycling session, cadence approached the pre-determined limit for safety (30 rpm) and was maintained over the duration of 10 minutes. Rate of perceived exertion increased in line with the workload, but was always retained at or below 4/10, over the course of the 10 minute bout. In session one, heart rate significantly increased from rest (87±11 bpm) to a maximum mean of 93±11 bpm (P\u3c0.05) and this response was equivalent in session two and three (\u3c10bpm despite increased workloads in those 10 min bouts). Muscle oxygen saturation was not disturbed from resting values by the eccentric workloads, maintaining a consistent tissue saturation index of 30-35% whilst arterial oxygen saturation was preserved (\u3e95%). Conclusion: An eccentric cycle ergometer for the hospital environment was successfully designed and constructed and was able to deliver consistent low-workloads to a healthy adult population. Following transfer of this ergometer to a hospital setting, 24 patients performed repeated bouts of eccentric cycling using workloads up to 40 watts, with no significant change in skeletal muscle oxygenation despite increasing workloads. No adverse medical events were encountered during the eccentric cycling exercise. This is the first study of hospitalised patients performing eccentric cycling exercise. The potential for improved patient outcomes, including the attenuation of physical capacity loss, may now be addressed in a range of hospitalised patients with low physiologic reserve

Submaximal Exercise Testing in Cardiovascular Rehabilitation Settings (BEST Study)

Abstract BACKGROUND: This study compared changes in measured versus predicted peak aerobic power (V̇O2 peak) following cardiovascular rehabilitation (CR). Peak cardiopulmonary exercise testing (CPET) results were compared to four V̇O2 peak estimation methods: the submaximal modified Bruce treadmill, Astrand-Ryhming cycle ergometer, and Chester step tests, and the Duke Activity Status Index (DASI). METHODS: Adults with cardiovascular disease (CVD) who completed a 12-week CR program were assessed at baseline and 12 weeks follow-up. CPET, the DASI and three subsequent submaximal exercise tests were performed in a random order. RESULTS: Of the 50 adults (age: 57 ± 11 years) who participated, 46 completed the 12-week CR program and exercise tests. At baseline 69, 68, and 38% of the treadmill, step and cycle tests were successfully completed, respectively. At follow-up 67, 80, and 46% of the treadmill, step and cycle tests were successfully completed, respectively. No severe adverse events occurred. Significant improvements in V̇O2 peak were observed with CPET (3.6 ± 5.5 mL.kg-1.min-1, p < 0.001) and the DASI (2.3 ± 4.2 mL.kg-1.min-1, p < 0.001). Bland-Altman plots of the change in V̇O2 peak between CPET and the four V̇O2 peak estimation methods revealed the following: a proportional bias and heteroscedastic 95% limits of agreement (95% LoA) for the treadmill test, and for the cycle and step tests and DASI, mean bias' and 95% LoA of 1.0 mL.kg-1.min-1 (21.3, -19.3), 1.4 mL.kg-1.min-1 (15.0, -12.3) and 1.0 mL.kg-1.min-1 (13.8, -11.8), respectively. CONCLUSION: Given the greater number of successful tests, no serious adverse events and acceptable mean bias, the step test appears to be a valid and safe method for assessing group-level mean changes in V̇O2 peak among patients in CR. The DASI also appears to be a valid and practical questionnaire. Wide limits of agreement, however, limit their use to predict individual-level changes. Copyright © 2020 Reed, Cotie, Cole, Harris, Moran, Scott, Terada, Buckley and Pipe. KEYWORDS: cardiovascular diseases; exercise test; physiology; rehabilitation; submaxima

HEMODYNAMIC AND METABOLIC RESPONSES DURING SELF-PACED AND RAMP GRADED EXERCISE TESTING TREADMILL PROTOCOLS

Purpose: To investigate: 1) if a self-paced (SP) graded exercise testing protocol elicits similar and reliable maximal oxygen uptake (VO2max) responses compared to a ramp (RAMP) treadmill protocol; 2) the impact of SP on cardiac output (Q), stroke volume (SV), and arteriovenous oxygen difference (a-vO2diff); and 3) the metabolic response during SP through blood lactate (BLa-) accumulation and ventilatory threshold (VT) attainment. Methods: Sixteen recreationally trained men (23.7±3.0 yrs) completed two separate treadmill graded exercise testing protocols. SP consisted of five 2-min stages (10 min total) of increasing speed based on the Borg RPE6-20 scale. RAMP consisted of increases in speed by 0.16 km/hr every 15 s until volitional exhaustion. All tests were performed at 3% incline. VO2 was measured via indirect calorimetry, hemodynamic function was measured via thoracic impedance, and BLa- was measured via portable lactate analyzer. Differences between SP and RAMP protocols were analyzed as group means by using paired samples t-tests (R Core Team (2017)). Results: Maximal values for SP and RAMP were similar (p\u3e0.05) for VO2max (47.1±3.4 vs. 47.4±3.4 mL•kg-1•min-1), heart rate(198±5 vs. 200±6 beat•min-1), ventilation(158.8±20.7 vs. 159.3±19.0 L•min-1), Q (26.9±5.5 vs. 27.9±4.2 L•min-1), SV (145.9±29.2 vs. 149.8±25.3 mL•beat-1), a-vO2diff (18.5±3.1 vs. 19.7±3.1 mL•dL-1), VT (78.2 ± 7.2 vs. 79.0 ± 7.6% VO2max), and peak BLa- (11.7±2.3 vs. 11.5±2.4 mM•L-1), respectively. Conclusions: SP elicits similar physiological responses in comparison to RAMP. These results support SP as a feasible GXT protocol. Electing to employ SP may benefit clinicians and researchers from a time-management perspective

Maximal cardiopulmonary exercise test in patients with chronic low back pain: feasibility, tolerance and relation with central sensitization. An observational study:feasibility, tolerance and relation with central sensitization. An observational study

PURPOSE: To analyze the feasibility of and pain-related tolerance to a maximal cardiopulmonary exercise test (CPET), and the relationship between the aerobic capacity and central sensitization (CS) in patients with chronic low back pain (CLBP).METHODS: An observational study, combining a cross-sectional and a prospective 24-hour follow-up was performed. Participants underwent a maximal CPET on a cycle ergometer and were assessed with three measures of CS (CS Inventory, quantitative sensory testing and heart rate variability). Before the CPET, immediately afterwards and 24 h after, the Pain Response Questionnaire (PRQ) was filled out. The CPET was considered feasible when &gt;80% performed maximally, and tolerable when &lt;20% reported relevant pain increase, body reactions and additional pain medication use in the PRQ. Multiple regression analyses were applied to assess the relationship between the aerobic capacity (VO2max) and CS measures, corrected for confounders.RESULTS: 74 patients with CLBP participated of which 30 were male, mean age was 40.4 years (SD: 12.4) and median VO2max was 23.9 ml/kg/min (IQR: 18.2-29.4). CPET was completed by 92%. No serious adverse events occurred. A relevant pain increase was reported in the upper legs by 40% immediately after CPET and by 28% 24 h afterwards, 27% reported body reactions after 24 h, and 22% increased pain medication use 24 h after CPET. Very weak and not significant relations (rpartial=-0.21 to 0.05; p &gt; 0.10) were observed between aerobic capacity and CS measures.CONCLUSIONS: A maximal CPET is feasible in patients with CLBP. Most, but not all, tolerated it well. CS was not related to aerobic capacity.Implications for rehabilitationMaximal CPET is feasible in patients with CLBP and well tolerated by most patients.Maximal CPET can be safely applied to assess the aerobic capacity of patients with CLBP.Aerobic capacity is unrelated to central sensitization.Outcomes of a maximal CPET and the pain response to straining activity can be used to provide valid information for the decision-making of exercise therapy.</p

Validation of the Cosmed Fitmate for predicting maximal oxygen consumption

The primary purpose of this study was to assess the validity of the Cosmed Fitmate (FM) in predicting maximal oxygen consumption (VO2max), compared to the Douglas bag (DB) method. In addition, this study examined whether measuring submaximal VO2, rather than predicting it, can improve upon the prediction of VO2max. Thirty-two males and sixteen females (Mean ± SD: age 31 ± 10 yr, body mass 72.9 ± 13.0 kg, height 1.75 ± 0.09 m, BMI 23.4 ± 3 kg·m-2) volunteered to participate in the study. Each participant completed a submaximal and a maximal treadmill test using the Bruce protocol on two separate occasions. During the submaximal test, VO2max was predicted using the FM, while during the maximal test VO2max was measured using the DB method. The Cosmed Fitmate predicts VO2max by extrapolating the linear regression relating heart rate and measured VO2 to age-predicted maximum heart rate (HR = 220-age). This study also examined the validity of predicting VO2max by using the ACSM metabolic equations to estimate submaximal VO2. VO2max values from the FM, the DB method, and ACSM prediction equations were analyzed using repeated measures ANOVA and linear regression analyses. The level of significance was set at P \u3c 0.05 for all statistical analyses. There was no significant difference between VO2max predicted by the FM (45.6 ml·kg-1·min-1, SD 8.8) and measured by the DB method (46.5 ml·kg-1·min-1, SD 8.8) (p = 0.152). The results of this study showed that a strong positive correlation (r = 0.897) existed between VO2max predicted by the FM and VO2max measured by the DB method, with a standard error of the estimate (SEE) = 3.97 ml·kg-1·min-1. There was a significant difference in VO2max predicted by the ACSM metabolic equations (51.1 ml·kg-1·min-1, SD 7.98) and VO2max measured by the DB method (p = 0.01). The correlation between these variables was r = 0.758 (SEE = 5.26 ml·kg-1·min-1). These findings suggest that the Fitmate is a small, portable, and easy-to-use metabolic system that provides reasonably good estimates of VO2max, and that measuring submaximal VO2, rather than predicting it from the ACSM metabolic equations, improves the prediction of 2max

PREDICTING MAXIMUM OXYGEN UPTAKE (VO2max) USING A DYNAMICAL SYSTEMS MODEL IN ACUTE LEUKEMIA PATIENTS

PURPOSE: To determine if a dynamical systems model can estimate VO2max using data from a CPET on a cycle ergometer in acute leukemia patients prior to treatment. METHODS: Seventeen patients performed a CPET. The VO2peak obtained during the CPET and predicted values from the dynamical systems model were compared using paired samples t-tests. RESULTS: Significant differences between VO2peak obtained during the CPET ((18.09 ± 4.89) p=.001) and dynamical systems prediction (22.45 ± 7.00 mL/kg/min) was observed. A significant correlation between the predicted and obtained values for the time series was observed (r (16) = 0.96 p <.05), while the model had a percent error of 25%. CONCLUSION: Since transient changes captured in VO2 in response to the demands placed on the equilibria of the dynamical system, the system is not subject to the same physiological CPET limitations, potentially providing a more precise VO2max determination.Master of Art