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ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases

Thomas Radtke, Sarah Crook, Georgios Kaltsakas, Zafeiris Louvaris, Danilo Berton, Don S. Urquhart, Asterios Kampouras, Roberto A. Rabinovich, Samuel Verges, Dimitris Kontopidis, Jeanette Boyd, Thomy Tonia, Daniel Langer, Jana De Brandt, Yvonne M.J. Goërtz, Chris Burtin, Martijn A. Spruit, Dionne C.W. Braeken, Sauwaluk Dacha, Frits M.E. Franssen, Pierantonio Laveneziana, Ernst Eber, Thierry Troosters, J. Alberto Neder, Milo A. Puhan, Richard Casaburi, Ioannis Vogiatzis, Helge Hebestreit
European Respiratory Review 2019 28: 180101; DOI: 10.1183/16000617.0101-2018
Thomas Radtke
1Dept of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
2Epidemiology, Biostatistics and Prevention Institute, Division of Occupational and Environmental Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Sarah Crook
1Dept of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Georgios Kaltsakas
3Lane Fox Respiratory Service, St Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust, London, UK
4First Dept of Respiratory Medicine, National & Kapodistrian University of Athens, Athens, Greece
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Zafeiris Louvaris
5Faculty of Kinesiology and Rehabilitation Sciences, Division of Respiratory Rehabilitation, Dept of Rehabilitation Sciences KU Leuven, University Hospital Leuven, Leuven, Belgium
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Danilo Berton
6Unidade de Fisiologia Pulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Don S. Urquhart
7Dept of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK
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Asterios Kampouras
8Paediatric Dept, 424 General Military Hospital, Thessaloniki, Greece
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Roberto A. Rabinovich
9ELEGI Colt Laboratory, MRC Centre for Inflammation Research, The Queen`s Medical Research Institute, University of Edinburgh, Edinburgh, UK
10Respiratory Medicine Dept, Royal Infirmary of Edinburgh, Edinburgh, UK
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Samuel Verges
11HP2 Laboratory, Grenoble Alpes University, INSERM, Grenoble, France
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Dimitris Kontopidis
12Hellenic Cystic Fibrosis Association, Athens, Greece
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Jeanette Boyd
13European Lung Foundation, Sheffield, UK
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Thomy Tonia
14Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Daniel Langer
5Faculty of Kinesiology and Rehabilitation Sciences, Division of Respiratory Rehabilitation, Dept of Rehabilitation Sciences KU Leuven, University Hospital Leuven, Leuven, Belgium
15Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
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Jana De Brandt
16REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
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Yvonne M.J. Goërtz
17Depat of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
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Chris Burtin
16REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
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Martijn A. Spruit
16REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
17Depat of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
18Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
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Dionne C.W. Braeken
17Depat of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
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Sauwaluk Dacha
5Faculty of Kinesiology and Rehabilitation Sciences, Division of Respiratory Rehabilitation, Dept of Rehabilitation Sciences KU Leuven, University Hospital Leuven, Leuven, Belgium
15Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
19Dept of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
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Frits M.E. Franssen
17Depat of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
18Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
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Pierantonio Laveneziana
20Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire Expérimentale et clinique, Paris, France
21AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée du Département “R3S”, Paris, France
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Ernst Eber
22Division of Paediatric Pulmonology and Allergology, Dept of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Thierry Troosters
23Dept of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
24Pulmonary Rehabilitation, University Hospital Gasthuisberg, Leuven, Belgium
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J. Alberto Neder
25Laboratory of Clinical Exercise Physiology & Respiratory Investigation Unit, Kingston Health Science Center, Queen's University, Kingston, ON, Canada
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Milo A. Puhan
1Dept of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Richard Casaburi
26Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
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Ioannis Vogiatzis
4First Dept of Respiratory Medicine, National & Kapodistrian University of Athens, Athens, Greece
27Dept of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle, UK
29Task Force Co-Chair
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Helge Hebestreit
28Paediatric Dept, University Hospital Würzburg, Würzburg, Germany
29Task Force Co-Chair
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  • For correspondence: hebestreit@uni-wuerzburg.de
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  • FIGURE 1
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    FIGURE 1

    Flow chart describing the usual practice by Task Force members on different protocol phases and specifications during cardiopulmonary exercise testing. It is not intended as a recommendation for clinical practice.

  • FIGURE 2
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    FIGURE 2

    Algorithm for determining maximal effort and cause of exercise limitation. This figure describes how the Task Force members determine the maximal effort and cause of exercise limitation. It is not intended as a recommendation for clinical practice. V′O2: oxygen uptake; V′O2peak: peak oxygen uptake; V′Epeak: peak minute ventilation; MVV: maximum voluntary ventilation; RER: respiratory exchange ratio; HR: heart rate; AT: anaerobic threshold; IC: inspiratory capacity; SpO2: arterial oxygen saturation measured by pulse oximetry.

Tables

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  • TABLE 1

    Exercise mode and protocols used for cardiopulmonary exercise testing

    Lung diseases/lung conditionsStudies nCycle testTreadmill test
    1-min stagesRampUnclear1-min stagesRampUnclear
    COPD/emphysema323162 (50.2)92 (28.5)36 (11.1)27 (8.4)4 (1.2)2 (0.6)
    Asthma197 (36.8)6 (31.6)1 (5.3)5 (26.3)00
    Interstitial lung disease185 (27.8)12 (66.7)1 (5.6)000
    Pulmonary arterial hypertension6424 (37.5)37 (57.8)3 (4.7)000
    Cystic fibrosis7851 (65.4)22 (28.2)03 (3.8)2 (2.6)0
    Primary ciliary dyskinesia11 (100)00000
    Sarcoidosis122 (16.7)6 (50.0)4 (33.3000
    Lung cancer399 (23.1)21 (53.8)7 (17.9)2 (5.1)00
    Unclear respiratory diagnosis33 (100)00000
    Patients undergoing lung transplant or volume reduction surgery or other thoracic surgeries236 (26.1)10 (43.5)4 (17.4)1 (4.3)02 (8.7)
    Other#152 (13.3)10 (66.7)2 (13.3)01 (6.7)0
    Total595272 (45.7)216 (36.3)58 (9.7)38 (6.4)7 (1.2)4 (0.7)

    Data are n (%) for each disease/disease condition. No data were available for tuberculosis and irradiation of the lung. #: this group contains a mix of different lung diseases (i.e. restrictive and obstructive), asbestosis and obstructive sleep apnoea–hypopnea syndrome.

    • TABLE 2

      Reported protocol specifications during cardiopulmonary exercise testing

      Protocol specificationCycle testTreadmill test
      n (%)#Median (IQR)n (%)¶n (%)#Median (IQR)n (%)¶
      Work rate increments487 (89.2)45 (91.8)
      Rest phase264 (48.4)10 (20.4)
      Rest phase duration min+229 (42.0)3 (3–3)139 (59)7 (14.3)3 (2–3)4 (57)
      Unloaded phase warm-up329 (60.3)25 (51.0)
      Unloaded duration min+314 (57.5)3 (2–3)182 (58)19 (38.8)3 (3–4)10 (53)
      Incremental phase duration104 (19.0)19 (38.8)
      Recovery71 (13.0)5 (10.2)
      Recovery duration min+56 (10.3)3 (2–6)18 (32)4 (8.2)3 (2–4)1 (25)

      Data are presented as n (%) or median (interquartile range). #: studies reporting test protocol details; ¶: studies using test duration supported by the literature review; +: percentages are calculated of studies that reported on rest, unloaded and recovery phases.

      • TABLE 3

        Criteria of maximal effort and prediction equations

        VariableCycle testTreadmill test
        ChildrenAdultsChildrenAdults
        1V′O2peakChange of V′O2 <2 mL·min−1·kg−1 for a 5–10% increase in exercise intensity or of <2sd of the average increase in V′O2 during the preceding stages [13]
        Change in V′O2 of <2.1 mL·min−1·kg−1 between consecutive stages [14]Change of V′O2 <2 mL·min−1·kg−1 for a 5–10% increase in exercise intensity or of <2sd of the average increase in V′O2 during the preceding stages [13]Change in V′O2 of <2.1 mL·min−1·kg−1 between consecutive stages [14]
        2V′Epeak/MVV %≥85 [11]≥85 [11]≥85 [11]≥85 [11]
        3ICDecrease in IC >150 mL during exercise [15]Decrease in IC >150 mL during exercise [15]Decrease in IC >150 mL during exercise [15]Decrease in IC >150 mL during exercise [15]
        4RER>1.05 [16]>1.05 [17]>1.05 [16]>1.05 [17]
        5HRpeak % pred or beats·min−1≥195 bpm [18]>100% pred [11]
        231 men and women (aged 20–80 years) [19]
        Female: 209–0.86×age
        Male: 207–0.78×age
        ≥200 bpm [18]>100% pred [11]
        3320 healthy men and women (aged 19–89 years) [17]
        211–0.64×age
        6V′O2peak % pred≥100% predicted
        V′O2peak (L·min−1) [20]:
        Female: V′O2peak=3.08806×height (m)−2.877
        Male: V′O2peak=4.4955×height (m)−4.640
        ≥100% predicted
        V′O2peak (L·min−1) [21]:
        V′O2peak=0.046×height (cm)−0.021×age−0.62×sex (0 male, 1 female)−4.31



        ≥100% predicted
        V′O2peak (mL·min−1·kg−1) [22]:
        Female: 58.90–1.15×age
        Male: 52.35+0.071×age
        V′O2peak (L·min−1): 3703 male and 1234 female children and adolescents (aged 8–16 years) [23]
        Male: 0.623+0.230×age (R2=0.748)
        Female: 0.253+0.124×age (R2=0.529)
        ≥100% predicted
        V′O2peak (mL·min−1·kg−1) [24]:
        4637 healthy men and women (aged 20–90 years)
        Female: 17.21+(0.582×inclination)+(3.317×velocity)−(0.116×weight)−(0.099×age)
        Male: 24.24+(0.599×inclination)+(3.197×velocity)−(0.122×weight)−(0.126×age)
        7783 healthy men and women (aged 20–79 years) [25]
        V′O2 max (mL·min−1·kg−1): 79.9-(0.39×age)−13.7×sex [0 male, 1 female])−(0.127×weight [lbs])
        6Blood lactateUsually not informative, since there is considerable variability in post-exercise blood lactate in children (e.g. max values between 4–13 mmol·L−1 in 11–13-year old children) [26] Minimum post-exercise cut-off values to be validated [27]Post-exercise blood lactate levels ≥8 mmol·L−1 [28, 29]Usually not informative, since there is considerable variability in post-exercise blood lactate in children (e.g. max values between 4–13 mmol·L−1 in 11–13-year old children) [26]
        Minimum post-exercise cut-off values to be validated [27]
        Post-exercise blood lactate levels ≥8 mmol·L−1 [28, 29]

        V′O2peak: peak oxygen uptake; V′O2: oxygen uptake; V′Epeak: peak minute ventilation; MVV: maximum voluntary ventilation; IC, inspiratory capacity; RER, respiratory exchange ratio; HRpeak, peak heart rate.

        • TABLE 4

          Outcome values to report in standard clinical cardiopulmonary exercise testing as employed by the Task Force members

          Exercise capacityCardiovascular limitationGas exchange limitationVentilatory limitation
          Variable relevance
            V′O2peakHRpeakV′E/V′CO2 slopeV′Epeak in % MVVrest
           Peak WRV′O2/WR slopeLowest V′E/V′CO2 value (nadir)
           ATO2pulsepeak
          HR/V′O2 slope
          SpO2peak
          Borg symptom scores
          For studies featuring additional measurements
          VD/VT#VT/IC¶
          PA–aO2peak#IRVpeak¶

          V′O2peak: peak oxygen uptake; WR: work rate; AT: anaerobic threshold; HR: heart rate; V′E: minute ventilation; V′CO2: carbon dioxide production; V′Epeak: peak minute ventilation; MVVrest: maximum voluntary ventilation at rest; V′O2: oxygen uptake; SpO2peak: peak arterial oxygen saturation measured by pulse oximetry; VD/VT: dead space/tidal volume ratio; IC: inspiratory capacity; PA–aO2peak: peak alveolar–arterial oxygen tension difference; IRVpeak: peak inspiratory reserve volume. #: in studies featuring arterial blood gas measurements; ¶: in studies featuring serial inspiratory capacity measurements.

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          ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases
          Thomas Radtke, Sarah Crook, Georgios Kaltsakas, Zafeiris Louvaris, Danilo Berton, Don S. Urquhart, Asterios Kampouras, Roberto A. Rabinovich, Samuel Verges, Dimitris Kontopidis, Jeanette Boyd, Thomy Tonia, Daniel Langer, Jana De Brandt, Yvonne M.J. Goërtz, Chris Burtin, Martijn A. Spruit, Dionne C.W. Braeken, Sauwaluk Dacha, Frits M.E. Franssen, Pierantonio Laveneziana, Ernst Eber, Thierry Troosters, J. Alberto Neder, Milo A. Puhan, Richard Casaburi, Ioannis Vogiatzis, Helge Hebestreit
          European Respiratory Review Dec 2019, 28 (154) 180101; DOI: 10.1183/16000617.0101-2018

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          ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases
          Thomas Radtke, Sarah Crook, Georgios Kaltsakas, Zafeiris Louvaris, Danilo Berton, Don S. Urquhart, Asterios Kampouras, Roberto A. Rabinovich, Samuel Verges, Dimitris Kontopidis, Jeanette Boyd, Thomy Tonia, Daniel Langer, Jana De Brandt, Yvonne M.J. Goërtz, Chris Burtin, Martijn A. Spruit, Dionne C.W. Braeken, Sauwaluk Dacha, Frits M.E. Franssen, Pierantonio Laveneziana, Ernst Eber, Thierry Troosters, J. Alberto Neder, Milo A. Puhan, Richard Casaburi, Ioannis Vogiatzis, Helge Hebestreit
          European Respiratory Review Dec 2019, 28 (154) 180101; DOI: 10.1183/16000617.0101-2018
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