The Upper Airway and
Cardiopulmonary Exercise Testing
Carl Mottram, BA RRT RPFT FAARC
Director - Pulmonary Function Labs & Rehabilitation
Associate Professor of Medicine - Mayo Clinic College of
Medicine
Cardiopulmonary Exercise Testing
• Oxygen consumption (VO2max)
•Index of cardiopulmonary
fitness (gold standard)
• Cardiovascular response
• Ventilatory limitation and
breathing strategies
• Gas Exchange
• Metabolic calculations and
derivatives
Determinates of Exercise Ventilatory Response
• Ventilatory demand
• Metabolic demand
• Neuroregulatory and behavior factors
• Dead space ventilation
• Body weight
• Mechanical limitations imposed by
lungs and chest wall
• Chest wall deformity
Determinates of Exercise Ventilatory
Response
• Mechanical limitations imposed by lungs
• Intrinsic Lung Disease
• Obstructive pulmonary disease
• Restrictive disease
• Airway tone
• Bronchodilation or bronchoconstriction
• Upper airway
Determining Ventilatory Limitation
• Ventilatory Capacity (VEcap)
• Maximal Voluntary Ventilation (MVV)
• FEV1
• Flow limitation
• FV loops during exercise
• End-exercise PaCO2
Ventilatory Capacity - MVV
• MVV – 10 - 12 second maneuver that
is extrapolated to a minute ventilation
• FEV1 x 35 or 40
• Advantages:
• General approximation of ventilatory
capacity
• Readily and widely available, no
analysis needed
Ventilatory Capacity MVV
• Disadvantages:
•Volitional effort
•Breathing strategy is
different
•MVV is not a sustained
maneuver
•MVV tested before
exercise does not take
into account
bronchodilation
Johnson BD, Weisman IM, Zeballos RJ, Beck KC.
Chest 1999;116:488–503.
Freedman S. Resp Physiology (8) 230-244, 1970
Ventilatory Capacity
2
0
0
• Ventilatory or
1
8
0
1
6
0
Breathing reserve:
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•Ventilatory capacity -
1
0
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8
0
MinuteVntilaon,l/min
VEmax
•20-30 liters (10-15 L
minimum)
•20-40%
1
2
0
• “Ventilatory limitation”
6
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4
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Mottram CD. 10th Ed. Ruppel’s Manual of
Pulmonary Function Testing Chap. 7
Ventilatory Limitation
60.00
50.00
MVV = 43
VE
40.00
Pred. VO2
1.8 l/m
30.00
20.00
10.00
0.00
0
500
1000
VO2
1500
2000
Flow-Volume Loop Analysis
• Quantify flow limitation
rather than a pseudoventilatory capacity
1
2
1
0
M
F
V
L
8
• Define maximal flow-volume
e
x
t
F
V
L
loop (envelope)
4
• Use IC maneuvers to
2
Flow,l/sec
determine changes in EELV
V
o
lo
f
F
L
6
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2
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• Johnson BD. Weisman IM. Zeballos
RJ. Beck KC. Chest. 116(2):488-503,
1999 Aug
4
6
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8
1
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1
2
3
4
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5
6
The Journal of Clinical Investigation Volume 48 1969
• 10 normal subjects
•The major goal of this
study was to relate the
expiratory pressures
during exercise to the
pressures associated with
flow limitation.
Flow Volume Loop Profiles
10
8
Flow (L/sec)
6
4
Ex
2
0
2
Ex
1
2
3
4
Rest
5
1
2
3
4
5
Rest
4
6
8
Normal
Severe COPD
Mottram CD. 10th Ed. Ruppel’s Manual of Pulmonary Function Testing Chap. 7
Flow-Volumes Loop Analysis
• Suspicion of flow limitation
• Obstruction
• Restriction
• Intra or extra-thoracic obstruction
• Vocal chord dysfunction (VCD)
• Other pseudo-asthma - severe obesity
• Breathing kinetics
• Location of tidal breathing on the absolute
lung volume scale
• EEVL/TLC
J Appl Physiol 99: 1912–1921, 2005
• Twenty-four prepubescent
children
•Thirteen sportive children
(10.8 + 1.1 y.o.)
•Eleven untrained children
(10.5 + 1.0 y.o.)
Eur Respir J 2004; 24: 378–384
• 20 asthmatics in a stable
condition and aged 32+13 yrs
with a FEV1 of 101+ 21%
pred.
• Conclusion: In asthmatics with
exercise-induced tidal
expiratory flow limitation, the
exercise capacity is reduced as
a result of dynamic
hyperinflation.
• 22
years-old female
• Cough, chest tightness and
wheezing
• Diagnosed with EIB with no
response to BD
• Normal flow volume curve at rest
Sawtooth Pattern
Breathing Kinetics: FVL Analysis
Normal
Breathing Kinetics: FVL Analysis
Flow limitation
Breathing Kinetics: FVL Analysis
Inappropriate Shift
Breathing Kinetics: FVL Analysis
Vocal Cord Dysfunction
Breathing Kinetics: FVL Analysis
Pseudo – Asthma “type 2”
Patient JB
• 16 y.o. male with a chief complaint of
exertional dyspnea
• Evaluation of suspected asthma
• Wrestling and cross-country
• Meds: Flovent, singulair, Xopenex
Patient JB
Patient JB
Patient JB
Patient CL
• 27 yo female with chief
complaint of exertional
dyspnea
• PMH: Tetralogy of Fallot with
absent pulmonary valve
syndrome status post complete
repair
• CPET ordered to evaluate
cardiac versus pulmonary
Patient CL
Patient CL
Patient EW
• 12 y.o. female referred for prolong QT
syndrome and exercise intolerance
• HPI:
• Sports physical triggered and ECG
which was read as borderline prolonged
QT.
• Chest pain and wheezing with exercise
• PE: Unremarkable
Patient EW
• ECHO: normal
• Spirometry: FVC 3.17 (95%), FEV1
2.78 (97%), ratio 87.7%
• Normal spirometry
• CPET with FV Loops ordered to r/o
EIB or vocal chord dysfunction
Patient EW
• Normal sinus rhythm, normal ECG
Exercise
Workload
Time
O2 saturation (SpO2)
VO2
VO2/kg
R
Cardiac Function
Heart Rate
Blood Pressure CUFF
Oxygen Pulse
Ventilation
Minute Ventilation
watts
min:sec
%
l/min
ml/kg
REST Maximum
160 Pred Max %Pred Max
12:00
98
95
0.299
2.079
2.343
89
34.5
0.74
1.04
bpm
mmHg
VO2/HR
73
94/56
4
192
152/54
11
199
170/88
96
89/61
1/min
8.0
67.6
108.0
63
Interpretation: Normal
exercise tolerance,
evidence of VCD
Patient ID: EW816
Laryngoscope, 109:136-139,1999
• To compare laryngoscopically observed changes in
the larynx during exercise in persons (2) with
exercise-induced laryngomalacia (EIL) with
changes in asymptomatic control subjects (8).
Laryngoscope, 116:52–57, 2006
• 12 normal subjects and
4 patients with DOE
and noisy breathing
• Conclusion: Continuous
laryngoscopy with
exercise was easy to
perform and well tolerated
Laryngoscope, 119:1776–1780, 2009
Respiratory Medicine (2009) 103, 1911-1918
• 151 of 166 patients
with inspiratory
distress during
exercise
Eur Arch Otorhinolaryngol
(2009) 266:1929–1936
• The aims of this study were to
establish a scoring system for
laryngeal obstruction as visualized
during the CLE-test as well as to
assess reliability and validity of
this scoring system.
• Conclusion: The CLE-test scoring system is
a reliable and valid method that can be used
to assess degree of laryngeal obstruction in
patients with symptoms of EIIS
CPET with FV loops and Direct Laryngoscopy
Patient AJ
• 18 year-old athletic female complaining of
dyspnea and wheezing with exertion
• HPI:
• Inspiratory wheezing, epigastric pain and
tight feeling around the shoulders and
neck with exertion
• Symptoms start after a minute or so of
sprinting or 5-10 min. of regular exercise
• Symbicort, Singulair and Xopenex x 1 year
with no improvement
ENT and speech path consult
Laryngoscopy:
• Thick secretions
• Normal mobility of the true vocal folds
with full abduction and complete adduction
• The subglottis was clear
• No paradoxical vocal fold when she
attempted to mimic her dyspneic episodes
Patient AJ
Patient AJ
• Diagnosis: Arytenoid collapse
(laryngeal dysfunction)
• Patient was seen again by ENT and
underwent arytenoidectomy
Patient TB
• 14 y.o. female with a chief complaint of
dyspnea on exertion
• PMH
• Asthma “wheezing with colds”
• Mother described “breathing attacks”
• CXR: Normal
• Meds: Symbicort, Xopenex
Patient TB
Patient TB
Patient TB
Baseline
Immediate Post- Exercise
Summary
• Flow volume loop analysis is beneficial
in defining flow limitation and other
breathing abnormalities during exercise
• Continuous video laryngoscopy is a
well tolerated procedure that can assist
in characterizing structural
abnormalities of the upper airway.
Questions?