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• W1978443322 abstract "Interpretation of cardiorespiratory exercise tests (CPEX) typically is based on measurement of peak exercise responses compared with predicted maximal values in order to estimate the reserve capacities of the cardiovascular and respiratory systems.1Wasserman K Hansen JE Sue DY et al.Principles of exercise testing and interpretation. 2nd ed. Lea & Febiger, Philadelphia1994: 1-144Google Scholar However, this may be a problem if the patient does not want or is unable to tolerate whatever subjective discomfort occurs and stops exercising before achieving the expected cardiac (at least 85% of predicted maximal heart rate) or respiratory (at least 70% of predicted maximal ventilation) response. Although a patient with a musculoskeletal disorder also may not achieve these exercise “targets,” in most cases the CPEX is interpreted as “submaximal responses or poor effort.”2Mahler DA Franco MJ. Clinical applications of cardiopulmonary exercise testing.J Cardiopulm Rehabil. 1996; 16: 357-365Crossref PubMed Scopus (9) Google Scholar In this issue of CHEST, Medoff and colleagues (see page 913) examined the breathing reserve (peak exercise ventilation/maximal voluntary ventilation [MW]), an established method for interpreting CPEX, at an identifiable submaximal intensity, the lactate threshold. These investigators hypothesized that the breathing reserve measured at the lactate threshold would be useful to indicate a pulmonary limitation (PML) to exercise. Over a 4-year period, they identified 12 persons who exhibited normal cardiorespiratory responses, 32 patients with COPD who had PMLs to exercise, and 29 patients with known or suspected cardiac disease who had cardiovascular limitations to exercise. Of note, 21 other patients with COPD were excluded from the analysis because a lactate threshold was not evident during CPEX. The major findings of the study were that the breathing reserve at the lactate threshold and at peak exercise were highly correlated (r=0.85) and that the breathing reserve at the lactate threshold was significantly higher for the patients with PML than for those in the cardiovascular limitation or normal groups. In fact, a value of 0.42 or higher for the breathing reserve at the lactate threshold predicted a PML with a sensitivity of 97% and a specificity of 95%. A few questions are appropriate in consideration of these findings. First, does an abnormal breathing reserve reflect a PML to exercise? As pointed out by Medoff and colleagues, other pathophysiologic mechanisms may limit exercise in COPD. Such mechanisms include hypoxemia, dynamic hyperinflation, and/or respiratory muscle dysfunction as major possibilities. Until additional methods have been evaluated (eg, flow volume loops during exercise), the use of the breathing reserve remains an established approach for interpretation purposes.1Wasserman K Hansen JE Sue DY et al.Principles of exercise testing and interpretation. 2nd ed. Lea & Febiger, Philadelphia1994: 1-144Google Scholar,3Weisman IM Zeballos RJ. An integrated approach to the interpretation of cardiopulmonary exercise testing.Clin Chest Med. 1994; 15: 421-445PubMed Google Scholar Second, how should the MVV be determined? The two usual choices are to measure ventilation over 12 s or to calculate the value based on the FEV1. Medoff and colleagues chose to calculate the MVV by multiplying the FEV1 by 40. In our laboratory, each patient performs the MVV maneuver twice (with a rest between efforts) before the exercise test. The highest value among the two MVV efforts and FEV1 multiplied by 40 is then selected. Usually, but not always, the values are close. Third, can noninvasive methods be used to estimate the lactate threshold? Although the investigators in this study collected serial samples of arterial blood to determine the lactate threshold, this approach is not practical for the majority of clinical CPEX. Furthermore, such measurements add considerably to the cost of exercise testing. Therefore, the V-slope method (the point at which carbon dioxide production begins to increase more rapidly than oxygen consumption) is being used in many laboratories to identify (estimate) the onset of metabolic acidosis during exercise.4Sue DY Wasserman K Moricca RB et al.Metabolic acidosis during exercise in patients with chronic obstructive pulmonary1 disease: use of the V-slope method for anaerobic threshold determination.Chest. 1988; 94: 931-938Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar Finally, are the results applicable to patients with other respiratory conditions such as interstitial lung disease or pulmonary vascular disease? The answer to this question presently is unknown, and additional studies are required. Despite these uncertainties, the results of this study provide new information to advance the understanding of the interpretation of CPEX in patients who have reduced effort or perform submaximal exertion. The investigation by Medoff and colleagues is an excellent example of clinical research with direct application to patient care. Like all initial findings, prospective testing should be performed to validate the approach and to examine results in patients with other respiratory disorders." @default.
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• W1978443322 date "1998-04-01" @default.
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• W1978443322 title "Use of the Breathing Reserve To Interpret Submaximal Exercise Responses" @default.
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• W1978443322 doi "https://doi.org/10.1378/chest.113.4.858" @default.
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