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Workup of Dyspnea - Pulmonary

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.

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Workup of Dyspnea - Pulmonary

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  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 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.

  3. 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.

  4. Case 2 (Continued) PHYSICAL EXAMINATION Vital Signs P RR BP SpO2 Weight kg/lb BMI 78 16 104/68 97% on RA 59.320/130.821.43 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. Righthemidiaphragm 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

  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. 2010;122:191-225

  9. Does Anemia cause dyspnea and exercise limitation? Cote et al., Eur Resp J. 2007 29:923-929

  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% < 70% ‡ Obesity defined as BMI > 30 kg/m2 Pedersen et al., Int J Clin Pract, 2007, 61, 9, 1481–1491

  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 • Disability determination • Fitness evaluation

  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 < 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 (>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

  19. 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 General Mechanisms of Exercise Limitation

  20. 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 General Mechanisms of Exercise Limitation

  21. Figure 7. Flow-volume loops. Ventilatory Limits to Exercise: Expiratory Flow Rates and MVV Balady G J et al. Circulation. 2010;122:191-225

  22. Figure 6. V̇o2 kinetics. Oxygenation Limits to Exercise: Oxygen Deficit and Debt Balady G J et al. Circulation. 2010;122:191-225

  23. Use of the “V-Slope” Method to detect the Ventilatory (Anaerobic) Threshold, VT (AT) Balady G J et al. Circulation. 2010;122:191-225

  24. CPET Pulmonary Parameters • O2 consumed = VO2 • CO2 produced = VCO2 • Respiratory Exchange Ratio (RER) = CO2 produced / O2 consumed=VCO2 / 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 > 30% • 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 • Ventilatory equivalent for O2 = Ve / VO2 • Liters of ventilation per L of oxygen uptake

  25. 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 General Mechanisms of Exercise Limitation

  26. Cardiac Limits to Exercise: Maximum HR by Age

  27. Oxygen Consumption: Fick Equation Heart disease Heart disease Muscle disease Deconditioning Lung disease Anemia 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)

  28. CPET Cardiac Parameters • Maximum Heart Rate =HRmax • Heart Rate Reserve = (Predicted HRmax – HRmax)/Predicted HRmax x 100% Normal is < 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 35:106, 1914

  29. Abnormal Exercise Responses during CPET Balady G J et al. Circulation. 2010;122:191-225

  30. CPET Patterns of Cardiac and Pulmonary Disease during Exercise Adapted from: Balady G J et al. Circulation. 2010;122:191-225

  31. Our Patient

  32. Our Patient: Pulmonary Function

  33. Our Patient: CPET

  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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