Pulmonary Function and

Exercise Testing Examples

Darcy D. Marciniuk, MD, FRCP(C), FCCP
Professor, Division of Respirology, Critical Care and Sleep Medicine
Royal University Hospital, University of Saskatchewan
Saskatoon, SK, CANADA
Conflict of Interest Disclosure
I have no relations with industry or
pharmaceutical/device companies that
relate to the topic of this presentation
Pulmonary Function Testing
Common Technical Problems
and Test Results
Coughing During
Test
Poor Start -
Hesitation
0.0 0.5 1.0 1.5 2.0
Time (sec)
Back Extrapolation
Through
Steepest Part of
Curve
New Time Zero
0.2
1.0
0.8
0.6
0.4
Volume (L)
Extrapolated Volume
>150 mLs
Variable / Submax
Effort
Early Glottic Closure
HOW ARE YOU TODA
Y
Exercise Testing
Results from Normals and
Various Disease States
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 170 95
VO
2
(L/min) 0.45 2.09 94
V
E
(L/min) 17.3 90.7 76
BR (L) -- 35.1
V
E
/VCO
2
40 35
SaO
2
(%) 96 96
HR (/min) 80 166 98
Borg (dyspnea/legs) 0/0 5/7
my legs just quit
Healthy 63-yr-old male, normal PFTs
0
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Healthy Normal
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 210 148
VO
2
(L/min) 0.17 2.50 149
V
E
(L/min) 8.6 90.1 95
BR (L) -- 5.1
V
E
/VCO
2
48 33
SaO
2
(%) 99 93
HR (/min) 78 172 92
Borg (dyspnea/legs) 0/0 7/9
Ive had enough
Fit 34-yr-old female, normal PFTs
Fit 34-yr-old female, normal PFTs
Fit 34-yr-old female, normal PFTs
Fit 34-yr-old female, normal PFTs
Fit 34-yr-old female, normal PFTs
The exercise test results for this
34-yr-old female:
a) Are normal
b) Abnormal - mechanical ventilatory
limitation
c) Abnormal - cardiovascular limitation
d) Abnormal - pulmonary vasculature
e) Made me short of breath
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 90 62
VO
2
(L/min) 0.27 1.22 66
V
E
(L/min) 16.3 55.1 103
BR (L) -- (1.5)
SaO
2
(%) 97 95
HR (/min) 105 142 85
Borg (dyspnea/legs) 0/0 6/4
I cant breath anymore
64-yr-old male, moderate COPD, FEV
1
1.53 L [54% pred]
1
Moderate COPD
2
Moderate COPD
3
Moderate COPD
4
Moderate COPD
5
Moderate COPD
Moderate COPD
The V
E
/VCO
2
was most likely elevated
(>40 at AT) in this patient because of:
a) Early anaerobic threshold
b) Arterial oxygen desaturation
c) Anxiety
d) Increased dead space ventilation
e) Measurement error because of
underlying lung disease
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 160 84
VO
2
(L/min) 0.22 1.75 71
V
E
(L/min) 7.4 77.6 65
BR (L) -- 42.5
PaO
2
(mmHg) 87 117
HR (/min) 78 178 97
Borg (dyspnea/legs) 0/0 4/7
Im just pooped
43-yr-old male, Cardiomyopathy, LVEF 31%, normal PFTs, SOB
.
.
.
.
.
0
1
2
3
0 50 100 150 200
V
O
2
(
L
/
m
i
n
)
Workrate (W)
VO
2
max predicted
W
m
a
x
p
r
e
d
i
c
t
e
d
R=1
0
1
2
3
0 1 2 3
V
C
O
2
(
L
/
m
i
n
)
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
Cardiomyopathy
10
20
30
40
50
0 1 2 3
V
E
/
V
O
2
V
E
/
V
C
O
2
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
.
.
.
.
.
.
.
.
0
4
8
12
60
90
120
150
180
0 1 2 3
O
2
P
u
l
s
e

(
m
L
/
b
e
a
t
)
H
e
a
r
t

R
a
t
e

(

/
m
i
n
)

VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
HRmax predicted
Cardiomyopathy
.
.
0
40
80
120
0 1 2 3
V
E
(
L
/
m
i
n
)

VCO
2
(L/min)
FEV
1
x 35
35
.
10
20
30
40
50
0
1
2
3
4
0 40 80 120
f
b
(

/
m
i
n
)
V
T
(
L
)
VE (L/min)
F
E
V
1
x

3
5
VC
Cardiomyopathy
.
.
80
90
100
110
120
0 1 2 3
P
a
O
2
P
A
O
2
(
m
m
H
g
)

VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
P(A-a) = 4
P(A-a) = 3
Cardiomyopathy
Severe CHF patients typically
demonstrate the following except:
a) Early anaerobic threshold
b) Normal breathing reserve
c) Arterial oxygen desaturation
d) Marked ventilatory inefficiency
e) Oscillatory breathing pattern and
ventilation at rest and during exercise
Agostoni P, et al. Chest 2008; 133:197-203
CHF - Oscillatory Breathing and Ventilation
Corra U, et al. Chest 2002; 121:1572-1580
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 95 64
VO
2
(L/min) 0.26 1.19 67
V
E
(L/min) 14.7 57.0 93
BR (L) -- 4.0
PaO
2
(mmHg) 72 49
HR (/min) 83 132 81
Dyspnea 0 6
Legs 0 5
my breathing
72-yr-old male, IPF, TLC 65% pred, DLco 43% pred
Interstitial Lung Disease
0.5
1.5
V
O
2
(
L
/
m
i
n
)
0 40 80 120 160
Workrate (W)
W
m
a
x
p
r
e
d
i
c
t
e
d
0
1
2
VO
2
max predicted
.
.
H
e
a
r
t

R
a
t
e


(
/
m
i
n
)
0 0.5 1 1.5 2
HRmax predicted
70
90
110
130
150
170
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
VO
2
(L/min)
.
.
V
C
O
2
(
L
/
m
i
n
)
VO
2
(L/min)
0.5
1.5
0 0.5 1 1.5 2
R = 1
0
1
2
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
.
.
0 0.5 1 1.5 2
V
E

/

V
O
2
V
E

/

V
C
O
2
VO
2
(L/min)
20
30
40
50
60
70
80
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
.
.
.
Interstitial Lung Disease
35
0
20
40
60
80
0 0.5 1 1.5 2
V
E
(
L
/
m
i
n
)
VCO
2
(L/min)
FEV
1
x 35
.
.
VE (L/min)
0 20 40 60
VC
0
0.5
1
1.5
2
2.5
3
V
T
(
L
)
20
25
30
35
40
f


(
/
m
i
n
)
F
E
V
1
x


3
5
.
Interstitial Lung Disease
V
D
/

V
T
0 0.5 1 1.5 2
VO
2
(L/min)
0.2
0.3
0.4
0.5
0.6
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
VO
2
(L/min)
P
a
C
O
2
(
m
m
H
g
)
B
E

(
m
e
q
/
L
)
0 0.5 1 1.5 2
-10 30
35
40
45
50
-5
0
5
10
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
Interstitial Lung Disease
P
a
O
2
(
m
m
H
g
)

VO
2
(L/min)
24 47
40
60
80
100
120
0 0.5 1 1.5 2
P(A -a) O
2
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
Interstitial Lung Disease
Interstitial Lung Disease
ILD patients typically demonstrate all
of the following during CPET except:
a) Early anaerobic threshold
b) Slow, deep breathing pattern
c) Arterial oxygen desaturation
d) Marked ventilatory inefficiency
e) Reduced or absent ventilatory
mechanical reserve
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 50 29
VO
2
(L/min) 0.34 1.07 44
V
E
(L/min) 20.1 68.1 106
BR (L) -- (3.9)
SaO
2
(%) 97 76
HR (/min) 131 164 100
Dyspnea 0.5 7
Legs 0 7
Cant do anymore breathing and my legs.
56-yr-old male, Scleroderma, TLC 45% pred, DLco 27% pred
H
e
a
r
t

R
a
t
e


(
/
m
i
n
)
VO
2
(L/min)
60
100
140
180
0 1 2
HRmax predicted
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
V
O
2
(
L
/
m
i
n
)
Workrate (W)
0
1
2
0 60 120 180
VO
2
max predicted
W
m
a
x

p
r
e
d
i
c
t
e
d
.
.
ILD / Pulmonary Vascular
V
C
O
2
(
L
/
m
i
n
)
VO
2
(L/min)
0
1
2
0 1
2
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
R = 1
.
.
.
V
E

/

V
O
2
V
E

/

V
C
O
2
VO
2
(L/min)
40
50
60
70
0 1 2
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
.
.
.
.
ILD / Pulmonary Vascular
V
E
(
L
/
m
i
n
)
VCO
2
(L/min)
0
20
40
60
80
0 1 2
FEV
1
x 35
35
.
.
V
T
(
L
)
VE (L/min)
f


(
/
m
i
n
)
0
1
2
3
0 20 40 60
80
20
40
60
VC
F
E
V
1
x


3
5
.
ILD / Pulmonary Vascular
0 1 2
P
E
T
C
O
2
(
m
m
H
g
)
VO
2
(L/min)
10
20
30
40
50
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
S
a
O
2
(
%
)
VO
2
(L/min)
70
80
90
100
0 1 2
V
O
2
m
a
x

p
r
e
d
i
c
t
e
d
.
.
ILD / Pulmonary Vascular
End-Exercise Measurements
RA Test O
2
Test Change
SaO
2
(%) 76 92 + 21
HR (/min) 164 158 - 4
(100% pred) (96% pred)
Wmax (watts) 50 75 + 50
(29% pred) (44% pred)
Dyspnea 7 7
Legs 7 5
RA Test: Cant do anymore breathing and my legs.
O
2
Test: My breathing gave out.
ILD / Pulmonary Vascular
Workrate (W)
H
e
a
r
t

R
a
t
e

(

/
m
i
n
)

60
100
140
180
0 60 120 180
Room Air
O
2
W
m
a
x

p
r
e
d
i
c
t
e
d
HRmax predicted
Workrate (W)
S
a
O
2
(
%
)
70
80
90
100
0 60 120 180
Room Air
O
2
W
m
a
x

p
r
e
d
i
c
t
e
d
ILD / Pulmonary Vascular
Exercise Measurements
Rest End-Exercise %Pred
W
max
(watts) -- 65 47
VO
2
(L/min) 0.20 1.32 74
V
E
(L/min) 9.6 35.5 34
BR (L) -- 68.5
SaO
2
(%) 99 96
HR (/min) 86 151 75
Dyspnea 2 9
Legs 0 3
I Cant Breath Anymore
16 yr-old female, SOBOE, normal PFTs, -ve MCT
0
0.5
1
1.5
2
0 0.5 1 1.5 2
V
C
O
2
(
L
/
m
i
n
)
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
R= 1
0
0.5
1
1.5
2
0 50 100 150
V
O
2
(
L
/
m
i
n
)
Workrate (W)
VO
2
max predicted
W
m
a
x
p
r
e
d
i
c
t
e
d
Unexplained Dyspnea
20
30
40
50
60
70
0 0.5 1 1.5 2
V
E
/
V
O
2
V
E
/
V
C
O
2
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
0
5
10
15
20
50
100
150
200
0 0.5 1 1.5 2
O
2
P
u
l
s
e

(
m
L
/
b
e
a
t
)
H
e
a
r
t

R
a
t
e

(

/
m
i
n
)

VO
2
(L/min)
HRmax predicted
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
Unexplained Dyspnea
0
25
50
75
100
0
1
2
3
4
0 30 60 90 120
f

(

/
m
i
n
)
V
T
(
L
)
VE (L/min)
F
E
V
1
x

3
5
VC
0
30
60
90
120
0 1 2 3
V
E
(
L
/
m
i
n
)

VCO
2
(L/min)
FEV
1
x 35
35
Unexplained Dyspnea
20
30
40
50
0 0.5 1 1.5 2
P
E
T
C
O
2
(
m
m
H
g
)
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
0
0.1
0.2
0.3
0.4
0 0.5 1 1.5 2
V
D
/
V
T
VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
Unexplained Dyspnea
80
85
90
95
100
0 0.5 1 1.5 2
S
p
O
2
(
%
)

VO
2
(L/min)
V
O
2
m
a
x
p
r
e
d
i
c
t
e
d
Unexplained Dyspnea
-8
-4
0
4
8
12
-2 0 2 4 6
F
l
o
w

(
L
/
s
)
Volume (l)
Maximal
Rest
Sub-maximal Exercise
End Exercise
Unexplained Dyspnea
Why does this 16-yr-old patient
experience increased shortness of
breath with physical activity?
a) Pulmonary Hypertension
b) Mitochondrial Myopathy
c) Primary Hyperventilation Syndrome
d) Exercise-Induced Bronchoconstriction
e) Central Tracheal Obstruction
October 26 31 Chicago,
Illinois