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Year : 2008  |  Volume : 25  |  Issue : 3  |  Page : 111-117 Table of Contents   

Exercise testing in assessment and management of patients in clinical practice - Present situation

Department of Pulmonary Medicine, Sleep Medicine, Critical Care, Shree Ramjevan Choudhary Memorial Hospital and Research Centre, Nagpur, Maharashtra

Date of Web Publication19-Jan-2009

Correspondence Address:
Sumer S Choudhary
Shree Ramjevan Choudhary Memorial Hospital and Research Centre, Choudhary Road, Nagpur - 02

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Source of Support: None, Conflict of Interest: None

PMID: 20165662

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Keywords: Exercise; heart; Interpretation; methodology; 6 min walk test; testing

How to cite this article:
Choudhary SS, Choudhary S. Exercise testing in assessment and management of patients in clinical practice - Present situation. Lung India 2008;25:111-7

How to cite this URL:
Choudhary SS, Choudhary S. Exercise testing in assessment and management of patients in clinical practice - Present situation. Lung India [serial online] 2008 [cited 2020 Aug 13];25:111-7. Available from: http://www.lungindia.com/text.asp?2008/25/3/111/59592

   Objective Top

  1. To review recent scientific advances in exercise testing methods and results that is important for a clinical practioner.
  2. To understand the utility and limitations of different methods of exercise testing.
  3. To understand appropriate method in assessment and management of patients.
  4. To appreciate that exercise testing results can have greater clinical meaning when interpreted in context of relevant patient information.
  5. To understand that additional study is required to further characterize both current and future roles of exercise testing in clinical medicine.

   Introduction Top

The need of the hour is to understand the different methods used worldwide to asses the patients exercise performance and response in clinical practice.

Clinical Exercise Testing (CET) is increasingly gaining importance in clinical medicine, by helping the clinician to objectively evaluate the physiological functions. The result helps to predict the outcome and mortality in different clinical circumstances.

   Common Methods to Asses Exercise Response and Performances in Clinical Practice Top

Simple test are easily performed but limits physiological understanding.

More comprehensively performed tests may provide detail information and understanding but is costly and demanding. The clinician has to choose the type of test to perform for a particular patient

Commonly the following test is performed worldwide:-

  1. 6 min walk test
  2. Shuttle Walk Test
  3. Exercise Induced Bronchoconstriction Test
  4. Cardiac Stress Test
  5. Clinical Exercise Test (CET)

   6 Minute Walk Test Top

It is a safe simple and practical test of sub maximal functional capacity, which measures the maximum distance walked by a subject in 6 minutes. Advantage of this test is that it provides an acceptable index of functional disability and correlates with oxygen uptake measured during comprehensive testing. This test gives very limited information regarding physiological contributors to activity related symptoms or about mechanism of exercise limitation. Currently this test is used in lung transplantation, lung volume reduction surgery, pulmonary rehabilitation and in predicting mortality in cardiac patients and patients with pulmonary vascular disorders.

   Shuttle Walk Test Top

It measures the distance walked by a patient in a 10 meter course, being paced by an audio signals from a cassette. The intensity of exercise reached is comparable to test performed on a treadmill, as the walking speed is progressively increased until the patient reaches exhaustion. Modification of maximal SWT for determination of endurance performance - similar to maximal and constant (sub maximal) cycle ergometry may be done.

   Exercise Induced Bronchoconstriction Top

In this physical activity triggers acute airway narrowing in patients with heightened airway responsiveness. In susceptible patients EIB typically occurs 5 to 10 minutes after exercise. and generally resolves in 20 to 30 minutes. In some clinical situation where bronchial challenge is unavailable or not diagnostic EIB should be undertaken.

Common protocols to be followed include exercise on treadmill or cycle ergometry at a workload of 60 %to 80% of predicted maximum or the intensity that will elicit a heart rate of 80% of predicted maximum for 6 to 8 minutes. The goal is to produce ventilation equal to those attained during activity to produce symptom of EIB.

15% percent decrease in FEV1 following exercise is diagnostic of EIB. And 10-15 % decrease in FEV1 would be suggestive of EIB.

   Cardiac Stress Test Top

Common type of exercise testing, the primary purpose of which is diagnosis and management of myocardial infarction. Bruce protocol is commonly used and the single most reliable indication of ischemia is ST segment depression. During this test ECG and BP is measured, but the utility may be enhanced by concurrent measurement of ventilator parameters and respiratory gas exchange.

   Clinical Exercise Testing (CET) Top

CET involves the measurement of respiratory gas exchange i.e. oxygen uptake, carbon dioxide , minute ventilation, other variables while monitoring ECG, blood pressure , pulse oximetry and exertion perceived (Borg Scale) during a maximal symptom limited incremental test on a cycle ergo meter or treadmill. Simultaneous measurement of blood gasses and spirometry provides with more detail information on gas exchange and ventilation.CET provides a global assessment of integrative exercise responses which are not adequately reflected by measurement of individual organ system function on rest. Peak oxygen uptake remains the gold standard for exercise capacity.

It has tradionaly been undertaken with an incremental stepwise or ramp control protocol to exhaustion. In patients of COPD, acute response to an inhaled bronchodilator was assessed using various exercise tests. The authors found endurance time with a constant - workload exercise (80% of maximal work rate)was the most responsive end point to the effect of bronchodilator showing 19% improvement in exercise duration time. Arterial blood gasses measured at 5 minute constant - work exercise testing may give practical and cost effective alternative when arterial oxygen saturation, PaO2, alveolar -arterial oxygen pressure difference and ratio of physiological dead space to tidal volume are required.

   Indications for Exercise Testing in Clinical Practice Top

  1. Evaluation of Exercise Intolerence
  2. Evaluation of Unexplained exertional Dysponea
  3. Evaluation of patients of cardiovascular diseases
  4. Evaluation of Patients of respiratory diseases

    - COPD

    - ILD

    - Pulmonary Vascular Diseases

    - Cystic Fibrosis
  5. Preoperative evaluation
  6. Evaluation for transplantation and Lung Volume Reduction Surgeries
  7. Pulmonary Rehabilitation
  8. Impairment disability
[Table 1] to 11 illustrates the indication, contraindication and guidelines laid down by various international authorities for cardio pulmonary exercise testing in clinical setting.

   Conclusion Top

Cardiopulmonary exercise test is a helpful tool for evaluation of the disease and management in clinical practice and rapidly evolving in one of the important investigative and diagnostic test. There are different methods used in various clinical setting. The clinical exercise testing a simple and easy to perform test for a pulmonologist as compared to the other conducted tests and relatively more simpler and cost effective test, which needs to be more frequently used in our day to day clinical practice in relevant patients.[38][Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8],[Table 9],[Table 10],[Table 11]

   References Top

1.Criner GJ, Cordova FC, Furukawa S, et al. Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in sever chronic obstructive pulmonary disease. Am J Resp Crit Care Med 1999; 160:2018-2027.  Back to cited text no. 1      
2.Singh SJ, Morgan MD, Scott S, et al. Development of shuttle walking test of disability in patients with chronic airway obstruction. Thorax 1992; 47:1019-1024.  Back to cited text no. 2      
3.Miyamoto S, Nagaya N, Satoh T, et al .Clinical correlates and prognostic significance of six minute walk test in patients with primary pulmonary hypertension: comparison with cardiopulmonary exercise testing. Am J Crypt Care Med 2000; 161:487-492.  Back to cited text no. 3      
4.ATS committee on Proficiency Standards for clinical Pulmonary Function Laboratories. ATS statement: guidelines for six minutes walk test. Am J Crit Care Med 2002; 166:111-117.  Back to cited text no. 4      
5.Kadikar A, Maurer J, Kesten S. The six minute walk test: a guide to assessment for lung transplantation .J Heart Lung Transplant 1997; 16:313 -319.  Back to cited text no. 5      
6.Marciniuk DD ,Cockcroft DW. Exercise -induced bronchoconstriction: the role of leukotrienes modifiers in therapy. Can J Allergy Clin Immunol 1998; 3:298 -303 .  Back to cited text no. 6      
7.Cahalin l, Pappagianopoulos P, Prevost S, et al. The relationship of 6 - minute walk to maximal oxygen consumption in transplant candidates with end stage lung disease. Chest 1995; 108: 452 -459.  Back to cited text no. 7      
8.Cypcar D, Lemanske RF. Asthama and exercise.Clin Chest Med; 156:351-368.  Back to cited text no. 8      
9.Bittener V, Weiner DH, Yusuf S, et al. Prediction of mortality and morbidity with a 6 min walk test in patients with left ventricular dysfunction.JAMA 1993; 270:1702-1707.  Back to cited text no. 9      
10.Singh SJ,Morgan MD, Hardman AE, et al. Comparison of oxygen uptake during a conventional treadmill test and the walking test in chronic airflow limitation .Eur Respir J 1994; 7 2016-2020.  Back to cited text no. 10      
11.American Thoracic Society. Guidelines for methacholine and exercise challenge testing-1999 Am J Respir Crit Care Med 2000; 161:309-329.  Back to cited text no. 11      
12.Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines (Committee on Exercise Testing),. J AM Coll Cardiol 1997; 30: 260-315.  Back to cited text no. 12      
13.ZeballosRJ, Weisman IM, Connery SM. Comparison of pulmonary gas exchange measurements between incremental and constant work exercise above the anaerobic threshold. Chest 1998; 113:: 602 -611.  Back to cited text no. 13      
14.Oga T, Nishimura K, Tsukino M, et al. The effects of oxitropium bromide on exercise performance in patients with stable chronic obstructive pulmonary diseases. Am J Respir Crit Care Med 2000; 161: 1897-1901.  Back to cited text no. 14      
15.Weisman IM, Zeballous RJ,eds Integrative approach to the interpretation of cardiopulmonary exercise testing. In: Weisman IM, Zealot RJ, eds. Clinical exercise testing. Basel, Switzerland: Karger. Prog Respir Res 2002:32: 300-322.  Back to cited text no. 15      
16.Weisman IM, Beck K, Casaburi R, et al. American Thoracic Society/ American College of Chest Physicians Joint statement on Cardiopulmonary Exercise Testing. Am J Respir Crit Care Med 2003; 167: 211-277.  Back to cited text no. 16      
17.Beck KC, Weisman IM. Methods for Cardiopulmonary Exercise Testing. Weisman IM, Zeballos RJ, eds. Clinical exercise testing. Basel , Switzerland: Karger. Prog Respir Res 2002;32: 43-59.  Back to cited text no. 17      
18.Johnson BD, Weisman IM, Zeballos RJ, et al. Emerging concepts in the evaluation of ventilatory limitation during exercise. Chest 1999; 116:488-503.  Back to cited text no. 18      
19.Zeballos RJ, Weisman IM. Modalities of clinical exercise testing. In: Weisman IM, Zeballos RJeds. Clinical Exercise Testing. Basel Switzerland: Karger.Prog Respir Res 2002; 32:30-42.  Back to cited text no. 19      
20.Weisman IM , Zeballos RJ . Clinical exerscise testing . Pulm Crit Care Update 1995 ;11:1-9 .  Back to cited text no. 20      
21.Fletcher GF, Balady G, Froelicdher VF, Hartley LH, Haskell WL , Pollock ML, Weisman IM, Exercisde standarda : a stsatement for healthcare professionals from the American heart association . Circulation 1995 ; 91:580-615.  Back to cited text no. 21      
22.Jones NL ,Clinical Exercise testing , 4th ed.1997, Philadelphia: W.B Saunders ; p.xi.  Back to cited text no. 22      
23.American College of sports Medicine. Guidelines for exercise testing and prescription, 4th ed. Philadelphia: Lea and Febiger;1991.p.xv.  Back to cited text no. 23      
24.Committee of exercise testing . ACC/AHA Guidelines for exercise testing :a report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1997 ;30:907-912  Back to cited text no. 24      
25.American College of sports medicine .ACSM guidelines for exercise testing and prescription, 6th ed. Baltimore, MD: Williams and Wilkins; 200.p.xvi.  Back to cited text no. 25      
26.Lollgen H, Ulmer H-V, Crean P, editors. Recommendations and standard guidelines for exercise testing. Report of the task force Conference on ergometry, Titssee1987.Eur Heart J 1988; ( 9 Suppl K) : 1-37.  Back to cited text no. 26      
27.Weisman IM, Zeballos RJ. An integrated approach to the interpretation of cardiopulmonary exercise testing. Clin Chest Med 1994; 15:421-445.  Back to cited text no. 27      
28.Wasserman K, Hansen JE, Sue DY, Whipp BJ, Casaburi r. Principles of exercise testing and interpretation :including pathophysiology and clinical application , 3rd ed. Philadelphia:Lippincott Williams and Williams ;199.p.xv.  Back to cited text no. 28      
29.American college of sports medicine. ACSM guidelines for exercise testing and prescription, 5th .ed. Baltimore: Williams and Wilkins; 1995.p.xvi.  Back to cited text no. 29      
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31.Weisman IM, Zeballous RJ. Clinical exercises Testing. Clin Chest Med 2001; 22: 679-701.  Back to cited text no. 31      
32.Hansen Jed, Sue DY, Wasserman K. Predicted values for clinical exercise testing .Am Rev Respir Dis 1984; 129:s49-s55.  Back to cited text no. 32      
33.Bruce RA, Kusumi F, Hosner D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease . Am Heart j 1973; 85:546-562.   Back to cited text no. 33      
34.Wasserman k,Hansen JE, Sue DY., Whipp BJ, Casaburi R, Principles of exercise testing and interpretation. Phildelphia : Lea and Febiger 1987.p.xiii.  Back to cited text no. 34      
35.American College Of sports medicine. ACSM guidelines for exercise testing and prescription, 5th ed .Baltimore. Williams and Wilkins; 1995.p.xvi.  Back to cited text no. 35      
36.Weisman IM, Zeballous RJ, Clinical evaluation of unexplained dyspnoea. Cardiologia 1996; 41:621-634.  Back to cited text no. 36      
37.Gallagher CG. Exercise limitation and clinical exercise testing in chronic obstructive pulmonary disease.Clin Chest Med 1994; 15:305-326.  Back to cited text no. 37      
38.ATS/ACCP statement on cardipulmonary exercise testing, Am J Respir Crit Care Med Vol 167 pp 211-277, 2003.  Back to cited text no. 38      


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]


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