Using Cardiopulmonary Exercise Testing to Understand Dyspnea and Exercise Intolerance in Respiratory Disease

Stickland, Michael K.; Neder, J. Alberto; Guenette, Jordan A.; O’Donnell, Denis E.; Jensen, Dennis

doi:10.1016/j.chest.2022.01.021

Cited by 61 publications

(41 citation statements)

References 37 publications

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“…Exercise testing is a valuable tool to evaluate functional capacity (i.e. VO 2peak ) and mechanisms of dyspnea and exercise intolerance ( Radtke et al, 2019 ; Stickland et al, 2022 ). This study examined exercise responses in a sample of relatively young, non-obese and comorbidity-free COVID-19 participants to determine whether persistent symptoms/dyspnea were associated with altered cardiorespiratory function.…”

Section: Discussionmentioning

confidence: 99%

Persistent dyspnea after COVID-19 is not related to cardiopulmonary impairment; a cross-sectional study of persistently dyspneic COVID-19, non-dyspneic COVID-19 and controls

et al. 2022

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Background: Up to 53% of individuals who had mild COVID-19 experience symptoms for >3-month following infection (Long-CoV). Dyspnea is reported in 60% of Long-CoV cases and may be secondary to impaired exercise capacity (VO2peak) as a result of pulmonary, pulmonary vascular, or cardiac insult. This study examined whether cardiopulmonary mechanisms could explain exertional dyspnea in Long-CoV.Methods: A cross-sectional study of participants with Long-CoV (n = 28, age 40 ± 11 years, 214 ± 85 days post-infection) and age- sex- and body mass index-matched COVID-19 naïve controls (Con, n = 24, age 41 ± 12 years) and participants fully recovered from COVID-19 (ns-CoV, n = 14, age 37 ± 9 years, 198 ± 89 days post-infection) was conducted. Participants self-reported symptoms and baseline dyspnea (modified Medical Research Council, mMRC, dyspnea grade), then underwent a comprehensive pulmonary function test, cardiopulmonary exercise test, exercise pulmonary diffusing capacity measurement, and rest and exercise echocardiography.Results: VO2peak, pulmonary function and cardiac/pulmonary vascular parameters were not impaired in Long- or ns-CoV compared to normative values (VO2peak: 106 ± 25 and 107 ± 25%predicted, respectively) and cardiopulmonary responses to exercise were otherwise normal. When Long-CoV were stratified by clinical dyspnea severity (mMRC = 0 vs mMRC≥1), there were no between-group differences in VO2peak. During submaximal exercise, dyspnea and ventilation were increased in the mMRC≥1 group, despite normal operating lung volumes, arterial saturation, diffusing capacity and indicators of pulmonary vascular pressures.Interpretation: Persistent dyspnea after COVID-19 was not associated with overt cardiopulmonary impairment or exercise intolerance. Interventions focusing on dyspnea management may be appropriate for Long-CoV patients who report dyspnea without cardiopulmonary impairment.

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Section: Discussionmentioning

confidence: 99%

Persistent dyspnea after COVID-19 is not related to cardiopulmonary impairment; a cross-sectional study of persistently dyspneic COVID-19, non-dyspneic COVID-19 and controls

et al. 2022

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“…testing. CPET were conducted on an electronically braked cycle ergometer (Ergoline800s; SensorMedics; or Lode Corival, Lode BV Medical Technology, Groningen, Netherlands) using a computerized system (Vmax229d or Vmax Encore 29C) according to clinical exercise testing guidelines (Palange et al, 2007;Stickland et al, 2022). The system was calibrated according to manufacturer's guidelines prior to each test.…”

Section: Cardiopulmonary Exercisementioning

confidence: 99%

Exertional dyspnoea in patients with mild‐to‐severe chronic obstructive pulmonary disease: neuromechanical mechanisms

James

Phillips

Vincent

et al. 2022

The Journal of Physiology

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“…Specifically, P ETCO 2 may be higher than alveolar and arterial P CO 2 in health and obesity [8,9], since during exercise more carbon dioxide diffuses into the alveoli as lung volumes decrease during a continued exhalation. Therefore, expiratory P CO 2 increases toward mixed-venous P CO 2 faster during exercise than at rest [5][6][7].…”

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confidence: 96%

“…In their correspondence letter, the authors state that the Vʹ E /Vʹ CO 2 ratio at peak exercise may be used as a clinical marker to better understand the underlying mechanisms of exercise intolerance. While we agree that Vʹ E /Vʹ CO 2 ratio at peak exercise may be useful when evaluating responses following interventions like bariatric surgery, we want to clarify that it is not an appropriate evaluation of ventilatory efficiency, due to the instability of arterial carbon dioxide tension (P CO 2 ) (and P ETCO 2 ) at peak exercise, largely due to respiratory compensation at heavy metabolic demands [5][6][7]. To our knowledge, the prognostic utility of Vʹ E /Vʹ CO 2 in this disease population has not been established.…”

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confidence: 98%

“…In their correspondence, the authors suggest evaluating ΔP ETCO 2 (calculated as the difference between the maximum value obtained during exercise versus the value at peak exercise) and proposed that a threshold value may be a predictor of OSA in patients with morbid obesity. We are cautious to use P ETCO 2 as a clinical marker because of a lack of accuracy and suggest that temperature corrected arterial P CO 2 is preferred in evaluating alveolar ventilation as P ETCO 2 is prone to errors [5][6][7]. Specifically, P ETCO 2 may be higher than alveolar and arterial P CO 2 in health and obesity [8,9], since during exercise more carbon dioxide diffuses into the alveoli as lung volumes decrease during a continued exhalation.…”

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Reply to: “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

et al. 2022

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We thank N. Borasio and co-workers for their correspondence bringing attention to their recent publications [1,2]. The ventilatory response to exercise in patients with obesity is clearly an area of interest, as their original research articles [1, 2], along with others [3], have been published after our review article "Ventilatory efficiency in athletes, asthma and obesity" [4] was first submitted for publication.Ventilatory efficiency after bariatric surgery: recent findings by BORASIO et al. [2] in patients with a baseline body mass index of 43.6±5.3 kg•m −2 show that the minute ventilation (Vʹ E )-carbon dioxide production (Vʹ CO 2 ) slope was reduced following sleeve gastrectomy, while the submaximal partial pressure of end-tidal carbon dioxide (P ETCO 2 ) at anaerobic threshold and Vʹ E /Vʹ CO 2 at the respiratory compensation point (i.e. nadir) were unchanged. The Vʹ E /Vʹ CO 2 ratio at peak exercise was not specifically reported, but can be calculated using Vʹ E , Vʹ CO 2 and respiratory exchange ratio data reported in the published tables [2]. Using these data, the Vʹ E /Vʹ CO 2 ratio at peak exercise appears slightly reduced after sleeve gastrectomy as compared to baseline (30.5 versus 29.1).

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Using Cardiopulmonary Exercise Testing to Understand Dyspnea and Exercise Intolerance in Respiratory Disease

Cited by 61 publications

References 37 publications

Persistent dyspnea after COVID-19 is not related to cardiopulmonary impairment; a cross-sectional study of persistently dyspneic COVID-19, non-dyspneic COVID-19 and controls

Persistent dyspnea after COVID-19 is not related to cardiopulmonary impairment; a cross-sectional study of persistently dyspneic COVID-19, non-dyspneic COVID-19 and controls

Exertional dyspnoea in patients with mild‐to‐severe chronic obstructive pulmonary disease: neuromechanical mechanisms

Reply to: “Ventilatory efficiency in athletes, asthma and obesity”: different ventilatory phenotypes during exercise in obesity?

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