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
 Case 2
48 year old woman with unexplained exertional dyspnea.

Age 9: CHD (ASD with endocardial cushion defect) with a late

repair at Boston Children’s 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.
 Case 2 (Continued)
Past Medical/Surgical History
Congenital heart disease s/p ASD and MV repair, TV ring
Secondary pulmonary hypertension
Bradycardia 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.
 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.
Our Patient: Resting Echocardiogram
 Basic Workup of Exertional Dyspnea
Lung Disease PFTs
Airways disease
Interstitial Lung Disease Chest Imaging (CXR, CT)
Neuromuscular Disease
Vocal Cord Dysfunction Methacholine Challenge Testing

Heart Disease EKG

Myocardial Disease (Systolic, Diastolic)
Valvular Heart Disease Echocardiography
Coronary Artery Disease
BNP
Pulmonary Vascular Disease Echocardiography, CTPA, V/Q
(Pulmonary Hypertension, PE)
Metabolic Disease CBC, TFTs
Anemia
Thyroid Disease

Deconditioning, Anxiety Exclusion

Our Differential Diagnosis for her Dyspnea:
1. Lung Disease
• Airways disease (Asthma)
• Interstitial Lung Disease
• Vocal Cord Dysfunction
• Thoracic Cage Abnormality (Paralyzed right hemidiaphragm)

2. Heart Disease
• Left ventricular diastolic dysfunction
• Valvular Heart Disease
• Pacemaker Malfunction
• Coronary Artery Disease

3. Pulmonary Vascular Disease (Pulmonary Hypertension, PE)

4. Peripheral (Myopathy/Malnutrition/Neuromuscular dysfunction)
5. Anemia
6. Thyroid Disease
7. Deconditioning
8. Perception/Anxiety
Evaluation of Unexplained Dyspnea

Balady G J et al. Circulation. 2010;122:191-225

Does Anemia cause dyspnea and
exercise limitation?

Cote et al., Eur Resp J. 2007 29:923-929

 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
 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% < 70%

‡ Obesity
defined as
BMI > 30 kg/m2
Pedersen et al., Int J Clin Pract, 2007, 61, 9, 1481–1491
 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

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

6. Disability determination
7. Fitness evaluation
Internal and External Respiration
 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
 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 < 88% on RA
• Significant non-cardiopulmonary disorder that may affect
or be adversely affected by exercise
• Psychiatric/cognitive impairment limiting cooperation
 Relative Contraindications to CPET

• Left main or 3-V CAD

• Severe arterial HTN (>200/120)
• Significant pulmonary HTN
• Tachyarrhythmia, bradyarrhythmia
• High degree AV block
• Hypertrophic cardiomyopathy
• Electrolyte abnormality
• Moderate stenotic valvular heart disease
• Advanced or complicated pregnancy
• Orthopedic impairment
 General Mechanisms of Exercise
Limitation
• Pulmonary
– Ventilatory • Peripheral
– Respiratory muscle dysfunction – Inactivity/Atrophy/ Malnutrition
– Impaired gas exchange – Neuromuscular dysfunction
• Cardiovascular – Reduced oxidative capacity of
– Reduced stroke volume skeletal muscle
– Abnormal HR response • Perceptual
– Circulatory abnormality • Motivational
– Blood abnormality
 General Mechanisms of Exercise
Limitation
• Pulmonary
– Ventilatory • Peripheral
– Respiratory muscle dysfunction – Inactivity/Atrophy/ Malnutrition
– Impaired gas exchange – Neuromuscular dysfunction
• Cardiovascular – Reduced oxidative capacity of
– Reduced stroke volume skeletal muscle
– Abnormal HR response • Perceptual
– Circulatory abnormality • Motivational
– Blood abnormality
 Ventilatory Limits
Figure 7. Flow-volumeto Exercise:
loops.

Expiratory Flow Rates and MVV

Balady G J et al. Circulation. 2010;122:191-225

Oxygenation Limits tokinetics.
Figure 6. V̇o2 Exercise: Oxygen
Deficit and Debt

Balady G J et al. Circulation. 2010;122:191-225

Use of the “V-Slope” Method to detect the
Ventilatory (Anaerobic) Threshold, VT (AT)

Balady G J et al. Circulation. 2010;122:191-225

 CPET Pulmonary Parameters
1. O2 consumed = VO2
2. CO2 produced = VCO2
3. Respiratory Exchange Ratio (RER) = CO2 produced / O2 consumed=VCO2 / VO2
4. Maximum Minute Ventilation (Vemax) = measured exhaled volume (L/min)
5. Maximum Voluntary Ventilation = Peak Ventilation in L/min
• Normal = 35 to 41 times FEV1
6. Breathing Reserve = (Predicted MVV – Vemax /Predicted MVV) x 100%
• Normal > 30%
7. Ventilatory equivalent for CO2 = Ve / VCO2
• Efficiency of ventilation, normal is < 30 and improves during exercise
• Liters of ventilation to eliminate 1 L of CO2
8. Ventilatory equivalent for O2 = Ve / VO2
• Liters of ventilation per L of oxygen uptake
 General Mechanisms of Exercise
Limitation
• Pulmonary
– Ventilatory • Peripheral
– Respiratory muscle dysfunction – Inactivity/Atrophy/ Malnutrition
– Impaired gas exchange – Neuromuscular dysfunction
• Cardiovascular – Reduced oxidative capacity of
– Reduced stroke volume skeletal muscle
– Abnormal HR response • Perceptual
– Circulatory abnormality • Motivational
– Blood abnormality
Cardiac Limits to Exercise:
Maximum HR by Age
 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 Lung disease Anemia

Muscle disease
Deconditioning
 CPET Cardiac Parameters
1. Maximum Heart Rate = HRmax
2. Heart Rate Reserve =
(Predicted HRmax – HRmax)/Predicted HRmax x 100%
Normal is < 15%
3. 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 35:106, 1914
Abnormal Exercise Responses during CPET

Balady G J et al. Circulation. 2010;122:191-225

 CPET Patterns of Cardiac and Pulmonary
Disease during Exercise
CARDIAC PULMONARY
MEASUREMENT SYMBOL
FINDINGS

Maximum Oxygen Consumption VO2max Reduced Reduced

Maximum Heart Rate HRmax > 85% predicted < 85% predicted

Breathing Reserve BR > 30% < 15%

Oxygen Saturation SaO2 > 90% < 90%

Oxygen Pulse VO2max/HR < 12 ml/beat > 12 ml/beat

Ventilatory Equivalent for CO2 VE/VCO2 < 30 > 30

Anaerobic Threshold/VO2max AT (or VT) < 40% > 40%

Adapted from: Balady G J et al. Circulation. 2010;122:191-225

Our Patient
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%

Our Patient: CPET
Parameter Patient Normal

VO2max 22.3 ml/min/kg 30.2 (74%)

RER 1.1 >1.0

HRmax 98 beats/min 168 (58%)

VO2max/HR 13.9 ml/beat 10.5 (132%)

BR (87-38)/87 = 56% > 30%

VE/VCO2 27 < 30

SaO2 96% > 92%

AT (or VT) 69% > 40%

 Our Patient: CPET

87

168

12
Our Differential Diagnosis for her Dyspnea:
1. Lung Disease
• Airways disease (Asthma)
• Interstitial Lung Disease
• Vocal Cord Dysfunction
• Thoracic Cage Abnormality (Paralyzed right hemidiaphragm)

2. Heart Disease
• Left ventricular diastolic dysfunction
• Valvular Heart Disease
• Pacemaker Malfunction
• Coronary Artery Disease

3. Pulmonary Vascular Disease (Pulmonary Hypertension, PE)

4. Peripheral (Myopathy/Malnutrition/Neuromuscular dysfunction)
5. Anemia
6. Thyroid Disease
7. Deconditioning
8. Perception/Anxiety