Workup of Dyspnea - Pulmonary - PowerPoint PPT Presentation


Title: Workup of Dyspnea - Pulmonary


1
Workup of Dyspnea - Pulmonary
  • Joel A Wirth, MD, FCCP
  • Director, Division of Pulmonary and Critical Care
    Medicine, Maine Medical Center
  • Staff Physician, Chest Medicine Associates

2
Case 2
48 year old woman with unexplained exertional
dyspnea. Age 9 CHD (ASD with endocardial
cushion defect) with a late repair at Boston
Childrens Hospital Age 10 Mitral Valve
replacement ( porcine) Age 13 Mechanical
valve. Age 40 MV re-do with a TV ring and
pacemaker placement. Worsening DOE for the
past 8 years. She is a lifelong nonsmoker, has
history of mild asthma. Episodes of daily chest
tightness are very severe, aggravated climbing
stairs, supine position and humidity. Associated
symptoms include dry cough, fatigue, lower
extremity edema and occasional wheezing.
3
Case 2 (Continued)
Past Medical/Surgical History Congenital heart
disease s/p ASD and MV repair, TV
ring Secondary pulmonary hypertension Bradycar
dia s/p pacemaker placement Right
hemidiaphragm paralysis (phrenic nerve injury)
2005 Diastolic heart failure Hepatitis
C Asthma Medications VITAMIN B COMPLEX, VALIUM,
COUMADIN, CITALOPRAM, ATIVAN Social History
Education and Employment Radiation therapist.
Never smoker.
4
Case 2 (Continued)
PHYSICAL EXAMINATION Vital Signs
P RR BP SpO2 Weight kg/lb BMI 78 16 104/68 97
on RA 59.320/130.8 21.43 Physical
Exam Constitutional No apparent distress. Thin
and well developed. Head / Face Normocephalic.
ENT Normal. No mucosal lesions. Respiratory
Normal to inspection and palpation. Lungs CTA.
Right hemidiaphragm diminished excursion to
percussion. Cardiovascular RRR. Crisp MV
Prosthetic HS. No MRG. Abdomen Soft, non-tender
without organomegaly or masses. Back / Spine No
kyphosis or scoliosis. Musculoskeletal No
skeletal tenderness or joint deformity.
Extremities No edema or cyanosis, no
clubbing. Neurological Alert and oriented.
Psychiatric No anxiety or depression.
5
Our Patient Resting Echocardiogram
6
Basic Workup of Exertional Dyspnea
Lung Disease Airways disease Interstitial Lung Disease Neuromuscular Disease Vocal Cord Dysfunction PFTs Chest Imaging (CXR, CT) Methacholine Challenge Testing
Heart Disease Myocardial Disease (Systolic, Diastolic) Valvular Heart Disease Coronary Artery Disease EKG Echocardiography BNP
Pulmonary Vascular Disease (Pulmonary Hypertension, PE) Echocardiography, CTPA, V/Q
Metabolic Disease Anemia Thyroid Disease CBC, TFTs
Deconditioning, Anxiety Exclusion
7
Our Differential Diagnosis for her Dyspnea
  • Lung Disease
  • Airways disease (Asthma)
  • Interstitial Lung Disease
  • Vocal Cord Dysfunction
  • Thoracic Cage Abnormality (Paralyzed right
    hemidiaphragm)
  • Heart Disease
  • Left ventricular diastolic dysfunction
  • Valvular Heart Disease
  • Pacemaker Malfunction
  • Coronary Artery Disease
  • Pulmonary Vascular Disease (Pulmonary
    Hypertension, PE)
  • Peripheral (Myopathy/Malnutrition/Neuromuscular
    dysfunction)
  • Anemia
  • Thyroid Disease
  • Deconditioning
  • Perception/Anxiety

8
Evaluation of Unexplained Dyspnea
Balady G J et al. Circulation. 2010122191-225
9
Does Anemia cause dyspnea and exercise limitation?
Cote et al., Eur Resp J. 2007 29923-929
10
Thyroid Disease Mechanisms for Exertional
Dyspnea
Hyperthyroidism Reduced Heart Rate
Reserve Slower Heart Rate and BP
Recovery Hypothyroidism Impaired oxygen
metabolism Reduced maximal Heart
Rate Reduced maximal Ventilation
11
Causes of dyspnea as assessed by Spirometry
Echocardiography, EKG in 129 Danish Subjects
Only 69 of patients were diagnosed by these 3
tests Heart Disease defined as AFib, LV
systolic dysfunction or valve disease Lung
Disease defined as FEV1 lt 70 Obesity
defined as BMI gt 30 kg/m2
Pedersen et al., Int J Clin Pract, 2007, 61, 9,
14811491
12
Why perform exercise testing for exertional
dyspnea?
  • Cardiopulmonary measurements obtained at rest
  • may not reliably reflect functional capacity or
    limitations
  • Determine if dyspnea is physiologic or pathologic
  • Determine cause of limitation cardiac,
    pulmonary, or peripheral

13
Types of Exercise Tests
  • 6-min walk test
  • Submaximal
  • Shuttle walk test
  • Incremental, maximal, symptom-limited
  • Exercise bronchoprovocation
  • Exertional oximetry
  • Cardiac stress test
  • Exercise echocardiography
  • Cardiopulmonary Exercise Testing (CPET)

14
What can CPET do for YOU?
  • Evaluation of dyspnea
  • Distinguish Cardiac vs Pulmonary vs Peripheral
    limitation
  • Detection of exercise-induced bronchospasm (EIB)
  • Pulmonary rehabilitation
  • Exercise intensity/prescription
  • Response to participation
  • Pre-op evaluation and risk stratification
  • Lung resection
  • Prognostication of life expectancy
  • Congestive Heart Failure/Cardiomyopathy
  • Pulmonary Arterial Hypertension
  • Cystic Fibrosis
  • Assess response to therapy
  • COPD, Asthma, PAH

15
Internal and External Respiration
16
What is CPET?
  • Symptom-limited exercise test
  • Measure workload, ventilation, SpO2, HR, Blood
    Pressure, EKG, oxygen consumed and carbon dioxide
    expired, respiratory exchange ratio (RER)
  • Allows calculation of peak oxygen consumption,
    anaerobic threshold
  • Identifies general cause of exercise limitation
    and if limit is normal or abnormal

17
Contraindications to CPET
  • Acute MI
  • Unstable angina
  • Unstable arrhythmia
  • Acute endocarditis, myocarditis, pericarditis
  • Syncope
  • Severe, symptomatic AS
  • Uncontrolled CHF
  • Acute PE, DVT
  • Respiratory failure
  • Uncontrolled asthma
  • SpO2 lt 88 on RA
  • Significant non-cardiopulmonary disorder that may
    affect or be adversely affected by exercise
  • Psychiatric/cognitive impairment limiting
    cooperation

18
Relative Contraindications to CPET
  • Left main or 3-V CAD
  • Severe arterial HTN (gt200/120)
  • Significant pulmonary HTN
  • Tachyarrhythmia, bradyarrhythmia
  • High degree AV block
  • Hypertrophic cardiomyopathy
  • Electrolyte abnormality
  • Moderate stenotic valvular heart disease
  • Advanced or complicated pregnancy
  • Orthopedic impairment

19
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

20
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

21
Ventilatory Limits to Exercise Expiratory Flow
Rates and MVV
Figure 7. Flow-volume loops.
Balady G J et al. Circulation. 2010122191-225
22
Oxygenation Limits to Exercise Oxygen Deficit
and Debt
Figure 6. V?o2 kinetics.
Balady G J et al. Circulation. 2010122191-225
23
Use of the V-Slope Method to detect the
Ventilatory (Anaerobic) Threshold, VT (AT)
Balady G J et al. Circulation. 2010122191-225
24
CPET Pulmonary Parameters
  • O2 consumed VO2
  • CO2 produced VCO2
  • Respiratory Exchange Ratio (RER) CO2 produced /
    O2 consumedVCO2 / VO2
  • Maximum Minute Ventilation (Vemax) measured
    exhaled volume (L/min)
  • Maximum Voluntary Ventilation Peak
    Ventilation in L/min
  • Normal 35 to 41 times FEV1
  • Breathing Reserve (Predicted MVV Vemax
    /Predicted MVV) x 100
  • Normal gt 30
  • Ventilatory equivalent for CO2 Ve / VCO2
  • Efficiency of ventilation, normal is lt 30 and
    improves during exercise
  • Liters of ventilation to eliminate 1 L of CO2
  • Ventilatory equivalent for O2 Ve / VO2
  • Liters of ventilation per L of oxygen uptake

25
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

26
Cardiac Limits to Exercise Maximum HR by Age
27
Oxygen Consumption Fick Equation
  • Fick Equation
  • Q VO2 / C(a-v)O2
  • VO2 Q x 1.34(SaO2 - SvO2)(Hgb)
  • VO2 SV x HR x 1.34(SaO2 - SvO2)(Hgb)

Heart disease
Heart disease Muscle disease Deconditioning
Lung disease
Anemia
28
CPET Cardiac Parameters
  • Maximum Heart Rate HRmax
  • Heart Rate Reserve

    (Predicted HRmax
    HRmax)/Predicted HRmax x 100 Normal is lt
    15
  • Heart Rate Response (HRR)
  • Change in HR/Change in VO2
  • 4. Oxygen Pulse VO2 / HR SV
  • Fick Equation
  • VO2 SV x HR x C(a-v)O2
  • VO2 / HR SV x C(a-v)O2
  • Oxygen Pulse . . .the amount of oxygen
    consumed by the body from the blood of one
    systolic discharge of the heart. Henderson and
    Prince. Am J Physiol 35106, 1914

29
Abnormal Exercise Responses during CPET
Balady G J et al. Circulation. 2010122191-225
30
CPET Patterns of Cardiac and Pulmonary Disease
during Exercise
MEASUREMENT SYMBOL CARDIAC PULMONARY
MEASUREMENT SYMBOL FINDINGS FINDINGS
Maximum Oxygen Consumption VO2max Reduced Reduced
Maximum Heart Rate HRmax gt 85 predicted lt 85 predicted
Breathing Reserve BR gt 30 lt 15
Oxygen Saturation SaO2 gt 90 lt 90
Oxygen Pulse VO2max/HR lt 12 ml/beat gt 12 ml/beat
Ventilatory Equivalent for CO2 VE/VCO2 lt 30 gt 30
Anaerobic Threshold/VO2max AT (or VT) lt 40 gt 40
Adapted from Balady G J et al. Circulation.
2010122191-225
31
Our Patient
32
Our Patient Pulmonary Function
Parameter Patient Predicted
FVC 2.66L 69
FEV1 2.24L 74
FEV1 84
TLC 4.24L 79
FRC 2.91L 96
RV 1.57L 84
DLCO 15.9 62
33
Our Patient CPET
Parameter Patient Normal

VO2max 22.3 ml/min/kg 30.2 (74)
RER 1.1 gt1.0

HRmax 98 beats/min 168 (58)
VO2max/HR 13.9 ml/beat 10.5 (132)

BR (87-38)/87 56 gt 30
VE/VCO2 27 lt 30
SaO2 96 gt 92

AT (or VT) 69 gt 40
34
Our Patient CPET
87
168
12
35
Our Differential Diagnosis for her Dyspnea
  • Lung Disease
  • Airways disease (Asthma)
  • Interstitial Lung Disease
  • Vocal Cord Dysfunction
  • Thoracic Cage Abnormality (Paralyzed right
    hemidiaphragm)
  • Heart Disease
  • Left ventricular diastolic dysfunction
  • Valvular Heart Disease
  • Pacemaker Malfunction
  • Coronary Artery Disease
  • Pulmonary Vascular Disease (Pulmonary
    Hypertension, PE)
  • Peripheral (Myopathy/Malnutrition/Neuromuscular
    dysfunction)
  • Anemia
  • Thyroid Disease
  • Deconditioning
  • Perception/Anxiety
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Workup of Dyspnea - Pulmonary

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Title: Workup of Dyspnea - Pulmonary


1
Workup of Dyspnea - Pulmonary
  • Joel A Wirth, MD, FCCP
  • Director, Division of Pulmonary and Critical Care
    Medicine, Maine Medical Center
  • Staff Physician, Chest Medicine Associates

2
Case 2
48 year old woman with unexplained exertional
dyspnea. Age 9 CHD (ASD with endocardial
cushion defect) with a late repair at Boston
Childrens Hospital Age 10 Mitral Valve
replacement ( porcine) Age 13 Mechanical
valve. Age 40 MV re-do with a TV ring and
pacemaker placement. Worsening DOE for the
past 8 years. She is a lifelong nonsmoker, has
history of mild asthma. Episodes of daily chest
tightness are very severe, aggravated climbing
stairs, supine position and humidity. Associated
symptoms include dry cough, fatigue, lower
extremity edema and occasional wheezing.
3
Case 2 (Continued)
Past Medical/Surgical History Congenital heart
disease s/p ASD and MV repair, TV
ring Secondary pulmonary hypertension Bradycar
dia s/p pacemaker placement Right
hemidiaphragm paralysis (phrenic nerve injury)
2005 Diastolic heart failure Hepatitis
C Asthma Medications VITAMIN B COMPLEX, VALIUM,
COUMADIN, CITALOPRAM, ATIVAN Social History
Education and Employment Radiation therapist.
Never smoker.
4
Case 2 (Continued)
PHYSICAL EXAMINATION Vital Signs
P RR BP SpO2 Weight kg/lb BMI 78 16 104/68 97
on RA 59.320/130.8 21.43 Physical
Exam Constitutional No apparent distress. Thin
and well developed. Head / Face Normocephalic.
ENT Normal. No mucosal lesions. Respiratory
Normal to inspection and palpation. Lungs CTA.
Right hemidiaphragm diminished excursion to
percussion. Cardiovascular RRR. Crisp MV
Prosthetic HS. No MRG. Abdomen Soft, non-tender
without organomegaly or masses. Back / Spine No
kyphosis or scoliosis. Musculoskeletal No
skeletal tenderness or joint deformity.
Extremities No edema or cyanosis, no
clubbing. Neurological Alert and oriented.
Psychiatric No anxiety or depression.
5
Our Patient Resting Echocardiogram
6
Basic Workup of Exertional Dyspnea
Lung Disease Airways disease Interstitial Lung Disease Neuromuscular Disease Vocal Cord Dysfunction PFTs Chest Imaging (CXR, CT) Methacholine Challenge Testing
Heart Disease Myocardial Disease (Systolic, Diastolic) Valvular Heart Disease Coronary Artery Disease EKG Echocardiography BNP
Pulmonary Vascular Disease (Pulmonary Hypertension, PE) Echocardiography, CTPA, V/Q
Metabolic Disease Anemia Thyroid Disease CBC, TFTs
Deconditioning, Anxiety Exclusion
7
Our Differential Diagnosis for her Dyspnea
  • Lung Disease
  • Airways disease (Asthma)
  • Interstitial Lung Disease
  • Vocal Cord Dysfunction
  • Thoracic Cage Abnormality (Paralyzed right
    hemidiaphragm)
  • Heart Disease
  • Left ventricular diastolic dysfunction
  • Valvular Heart Disease
  • Pacemaker Malfunction
  • Coronary Artery Disease
  • Pulmonary Vascular Disease (Pulmonary
    Hypertension, PE)
  • Peripheral (Myopathy/Malnutrition/Neuromuscular
    dysfunction)
  • Anemia
  • Thyroid Disease
  • Deconditioning
  • Perception/Anxiety

8
Evaluation of Unexplained Dyspnea
Balady G J et al. Circulation. 2010122191-225
9
Does Anemia cause dyspnea and exercise limitation?
Cote et al., Eur Resp J. 2007 29923-929
10
Thyroid Disease Mechanisms for Exertional
Dyspnea
Hyperthyroidism Reduced Heart Rate
Reserve Slower Heart Rate and BP
Recovery Hypothyroidism Impaired oxygen
metabolism Reduced maximal Heart
Rate Reduced maximal Ventilation
11
Causes of dyspnea as assessed by Spirometry
Echocardiography, EKG in 129 Danish Subjects
Only 69 of patients were diagnosed by these 3
tests Heart Disease defined as AFib, LV
systolic dysfunction or valve disease Lung
Disease defined as FEV1 lt 70 Obesity
defined as BMI gt 30 kg/m2
Pedersen et al., Int J Clin Pract, 2007, 61, 9,
14811491
12
Why perform exercise testing for exertional
dyspnea?
  • Cardiopulmonary measurements obtained at rest
  • may not reliably reflect functional capacity or
    limitations
  • Determine if dyspnea is physiologic or pathologic
  • Determine cause of limitation cardiac,
    pulmonary, or peripheral

13
Types of Exercise Tests
  • 6-min walk test
  • Submaximal
  • Shuttle walk test
  • Incremental, maximal, symptom-limited
  • Exercise bronchoprovocation
  • Exertional oximetry
  • Cardiac stress test
  • Exercise echocardiography
  • Cardiopulmonary Exercise Testing (CPET)

14
What can CPET do for YOU?
  • Evaluation of dyspnea
  • Distinguish Cardiac vs Pulmonary vs Peripheral
    limitation
  • Detection of exercise-induced bronchospasm (EIB)
  • Pulmonary rehabilitation
  • Exercise intensity/prescription
  • Response to participation
  • Pre-op evaluation and risk stratification
  • Lung resection
  • Prognostication of life expectancy
  • Congestive Heart Failure/Cardiomyopathy
  • Pulmonary Arterial Hypertension
  • Cystic Fibrosis
  • Assess response to therapy
  • COPD, Asthma, PAH

15
Internal and External Respiration
16
What is CPET?
  • Symptom-limited exercise test
  • Measure workload, ventilation, SpO2, HR, Blood
    Pressure, EKG, oxygen consumed and carbon dioxide
    expired, respiratory exchange ratio (RER)
  • Allows calculation of peak oxygen consumption,
    anaerobic threshold
  • Identifies general cause of exercise limitation
    and if limit is normal or abnormal

17
Contraindications to CPET
  • Acute MI
  • Unstable angina
  • Unstable arrhythmia
  • Acute endocarditis, myocarditis, pericarditis
  • Syncope
  • Severe, symptomatic AS
  • Uncontrolled CHF
  • Acute PE, DVT
  • Respiratory failure
  • Uncontrolled asthma
  • SpO2 lt 88 on RA
  • Significant non-cardiopulmonary disorder that may
    affect or be adversely affected by exercise
  • Psychiatric/cognitive impairment limiting
    cooperation

18
Relative Contraindications to CPET
  • Left main or 3-V CAD
  • Severe arterial HTN (gt200/120)
  • Significant pulmonary HTN
  • Tachyarrhythmia, bradyarrhythmia
  • High degree AV block
  • Hypertrophic cardiomyopathy
  • Electrolyte abnormality
  • Moderate stenotic valvular heart disease
  • Advanced or complicated pregnancy
  • Orthopedic impairment

19
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

20
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

21
Ventilatory Limits to Exercise Expiratory Flow
Rates and MVV
Figure 7. Flow-volume loops.
Balady G J et al. Circulation. 2010122191-225
22
Oxygenation Limits to Exercise Oxygen Deficit
and Debt
Figure 6. V?o2 kinetics.
Balady G J et al. Circulation. 2010122191-225
23
Use of the V-Slope Method to detect the
Ventilatory (Anaerobic) Threshold, VT (AT)
Balady G J et al. Circulation. 2010122191-225
24
CPET Pulmonary Parameters
  • O2 consumed VO2
  • CO2 produced VCO2
  • Respiratory Exchange Ratio (RER) CO2 produced /
    O2 consumedVCO2 / VO2
  • Maximum Minute Ventilation (Vemax) measured
    exhaled volume (L/min)
  • Maximum Voluntary Ventilation Peak
    Ventilation in L/min
  • Normal 35 to 41 times FEV1
  • Breathing Reserve (Predicted MVV Vemax
    /Predicted MVV) x 100
  • Normal gt 30
  • Ventilatory equivalent for CO2 Ve / VCO2
  • Efficiency of ventilation, normal is lt 30 and
    improves during exercise
  • Liters of ventilation to eliminate 1 L of CO2
  • Ventilatory equivalent for O2 Ve / VO2
  • Liters of ventilation per L of oxygen uptake

25
General Mechanisms of Exercise Limitation
  • Pulmonary
  • Ventilatory
  • Respiratory muscle dysfunction
  • Impaired gas exchange
  • Cardiovascular
  • Reduced stroke volume
  • Abnormal HR response
  • Circulatory abnormality
  • Blood abnormality
  • Peripheral
  • Inactivity/Atrophy/ Malnutrition
  • Neuromuscular dysfunction
  • Reduced oxidative capacity of skeletal muscle
  • Perceptual
  • Motivational

26
Cardiac Limits to Exercise Maximum HR by Age
27
Oxygen Consumption Fick Equation
  • Fick Equation
  • Q VO2 / C(a-v)O2
  • VO2 Q x 1.34(SaO2 - SvO2)(Hgb)
  • VO2 SV x HR x 1.34(SaO2 - SvO2)(Hgb)

Heart disease
Heart disease Muscle disease Deconditioning
Lung disease
Anemia
28
CPET Cardiac Parameters
  • Maximum Heart Rate HRmax
  • Heart Rate Reserve

    (Predicted HRmax
    HRmax)/Predicted HRmax x 100 Normal is lt
    15
  • Heart Rate Response (HRR)
  • Change in HR/Change in VO2
  • 4. Oxygen Pulse VO2 / HR SV
  • Fick Equation
  • VO2 SV x HR x C(a-v)O2
  • VO2 / HR SV x C(a-v)O2
  • Oxygen Pulse . . .the amount of oxygen
    consumed by the body from the blood of one
    systolic discharge of the heart. Henderson and
    Prince. Am J Physiol 35106, 1914

29
Abnormal Exercise Responses during CPET
Balady G J et al. Circulation. 2010122191-225
30
CPET Patterns of Cardiac and Pulmonary Disease
during Exercise
MEASUREMENT SYMBOL CARDIAC PULMONARY
MEASUREMENT SYMBOL FINDINGS FINDINGS
Maximum Oxygen Consumption VO2max Reduced Reduced
Maximum Heart Rate HRmax gt 85 predicted lt 85 predicted
Breathing Reserve BR gt 30 lt 15
Oxygen Saturation SaO2 gt 90 lt 90
Oxygen Pulse VO2max/HR lt 12 ml/beat gt 12 ml/beat
Ventilatory Equivalent for CO2 VE/VCO2 lt 30 gt 30
Anaerobic Threshold/VO2max AT (or VT) lt 40 gt 40
Adapted from Balady G J et al. Circulation.
2010122191-225
31
Our Patient
32
Our Patient Pulmonary Function
Parameter Patient Predicted
FVC 2.66L 69
FEV1 2.24L 74
FEV1 84
TLC 4.24L 79
FRC 2.91L 96
RV 1.57L 84
DLCO 15.9 62
33
Our Patient CPET
Parameter Patient Normal

VO2max 22.3 ml/min/kg 30.2 (74)
RER 1.1 gt1.0

HRmax 98 beats/min 168 (58)
VO2max/HR 13.9 ml/beat 10.5 (132)

BR (87-38)/87 56 gt 30
VE/VCO2 27 lt 30
SaO2 96 gt 92

AT (or VT) 69 gt 40
34
Our Patient CPET
87
168
12
35
Our Differential Diagnosis for her Dyspnea
  • Lung Disease
  • Airways disease (Asthma)
  • Interstitial Lung Disease
  • Vocal Cord Dysfunction
  • Thoracic Cage Abnormality (Paralyzed right
    hemidiaphragm)
  • Heart Disease
  • Left ventricular diastolic dysfunction
  • Valvular Heart Disease
  • Pacemaker Malfunction
  • Coronary Artery Disease
  • Pulmonary Vascular Disease (Pulmonary
    Hypertension, PE)
  • Peripheral (Myopathy/Malnutrition/Neuromuscular
    dysfunction)
  • Anemia
  • Thyroid Disease
  • Deconditioning
  • Perception/Anxiety
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