The Upper Airway and The Upper Airway and Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

The Upper Airway and The Upper Airway and Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Associate Professor of Medicine - Mayo Clinic College of Associate Professor of Medicine - Mayo Clinic College of MedicineMedicine

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Associate Professor of Medicine - Mayo Clinic College of Associate Professor of Medicine - Mayo Clinic College of MedicineMedicine

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingCardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

• OOOO2max) 2max)

•Index of cardiopulmonary Index of cardiopulmonary fitness (fitness (gold standardgold standard))

• Cardiovascular responseCardiovascular response

• Ventilatory limitation and Ventilatory limitation and breathing strategies breathing strategies

• Gas Exchange Gas Exchange

• Metabolic calculations and Metabolic calculations and derivatives derivatives

• OOOO2max) 2max)

•Index of cardiopulmonary Index of cardiopulmonary fitness (fitness (gold standardgold standard))

• Cardiovascular responseCardiovascular response

• Ventilatory limitation and Ventilatory limitation and breathing strategies breathing strategies

• Gas Exchange Gas Exchange

• Metabolic calculations and Metabolic calculations and derivatives derivatives

Determinates of Exercise Ventilatory Determinates of Exercise Ventilatory ResponseResponse

• Ventilatory demandVentilatory demand• Metabolic demandMetabolic demand• Neuroregulatory and behavior factorsNeuroregulatory and behavior factors• Dead space ventilation Dead space ventilation • Body weightBody weight

• Mechanical limitations imposed by Mechanical limitations imposed by lungs and chest walllungs and chest wall

• Chest wall deformityChest wall deformity

Determinates of Exercise Ventilatory Determinates of Exercise Ventilatory ResponseResponse

Determinates of Exercise Ventilatory Determinates of Exercise Ventilatory ResponseResponse

• Mechanical limitations imposed by lungsMechanical limitations imposed by lungs• Intrinsic Lung DiseaseIntrinsic Lung Disease

• Obstructive pulmonary diseaseObstructive pulmonary disease• Restrictive diseaseRestrictive disease

• Airway toneAirway tone• Bronchodilation or bronchoconstrictionBronchodilation or bronchoconstriction

• Upper airwayUpper airway

• Mechanical limitations imposed by lungsMechanical limitations imposed by lungs• Intrinsic Lung DiseaseIntrinsic Lung Disease

• Obstructive pulmonary diseaseObstructive pulmonary disease• Restrictive diseaseRestrictive disease

• Airway toneAirway tone• Bronchodilation or bronchoconstrictionBronchodilation or bronchoconstriction

• Upper airwayUpper airway

Determining Ventilatory LimitationDetermining Ventilatory Limitation

• Ventilatory Capacity (Ventilatory Capacity (EcapEcap))• Maximal Voluntary Ventilation (MVV)Maximal Voluntary Ventilation (MVV)

• FEVFEV11

• Flow limitationFlow limitation• FV loops during exerciseFV loops during exercise

• End-exercise PaCOEnd-exercise PaCO22

Ventilatory Capacity - MVVVentilatory Capacity - MVVVentilatory Capacity - MVVVentilatory Capacity - MVV

• MVV – 10 - 12 second maneuver that MVV – 10 - 12 second maneuver that is extrapolated to a minute ventilationis extrapolated to a minute ventilation

• FEVFEV11 x 35 or 40 x 35 or 40

• Advantages:Advantages:• General approximation of ventilatory General approximation of ventilatory

capacitycapacity• Readily and widely available, no Readily and widely available, no

analysis neededanalysis needed

• MVV – 10 - 12 second maneuver that MVV – 10 - 12 second maneuver that is extrapolated to a minute ventilationis extrapolated to a minute ventilation

• FEVFEV11 x 35 or 40 x 35 or 40

• Advantages:Advantages:• General approximation of ventilatory General approximation of ventilatory

capacitycapacity• Readily and widely available, no Readily and widely available, no

analysis neededanalysis needed

Ventilatory Capacity - Ventilatory Capacity - MVVMVVVentilatory Capacity - Ventilatory Capacity - MVVMVV• Disadvantages:Disadvantages:

•Volitional effortVolitional effort•Breathing strategy is Breathing strategy is different different •MVV is not a sustained MVV is not a sustained maneuvermaneuver•MVV tested before MVV tested before exercise does not take exercise does not take into account into account bronchodilationbronchodilation

• Disadvantages:Disadvantages:•Volitional effortVolitional effort•Breathing strategy is Breathing strategy is different different •MVV is not a sustained MVV is not a sustained maneuvermaneuver•MVV tested before MVV tested before exercise does not take exercise does not take into account into account bronchodilationbronchodilation

Johnson BD, Weisman IM, Zeballos RJ, Beck KC. Chest 1999;116:488–503.

Freedman S. Resp Physiology (8) 230-244, 1970Freedman S. Resp Physiology (8) 230-244, 1970

Ventilatory CapacityVentilatory CapacityVentilatory CapacityVentilatory Capacity

• Ventilatory or Ventilatory or Breathing reserve:Breathing reserve:

•Ventilatory capacity - Ventilatory capacity - EmaxEmax

•20-30 liters (10-15 L 20-30 liters (10-15 L minimum)minimum)•20-40%20-40%

• ““Ventilatory limitation”Ventilatory limitation”

• Ventilatory or Ventilatory or Breathing reserve:Breathing reserve:

•Ventilatory capacity - Ventilatory capacity - EmaxEmax

•20-30 liters (10-15 L 20-30 liters (10-15 L minimum)minimum)•20-40%20-40%

• ““Ventilatory limitation”Ventilatory limitation”Oxygen Consumption, l/min

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Min

ute

Ven

tila

tio

n, l

/min

0

20

40

60

80

100

120

140

160

180

200

VE Reserve.

VE Capacity.

VE Threshold.

Oxygen Consumption, l/min0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Min

ute

Ven

tila

tio

n, l

/min

0

20

40

60

80

100

120

140

160

180

200

VE Reserve.

VE Capacity.

VE Threshold.

Mottram CD. 10th Ed. Ruppel’s Manual of Pulmonary Function Testing Chap. 7

Ventilatory Limitation Ventilatory Limitation Ventilatory Limitation Ventilatory Limitation

0.00

10.00

20.00

30.00

40.00

50.00

60.00

0 500 1000 1500 2000

VO2

VE

MVV = 43Pred. VO2 1.8 l/m

Flow-Volume Loop AnalysisFlow-Volume Loop AnalysisFlow-Volume Loop AnalysisFlow-Volume Loop Analysis

• Quantify flow limitation Quantify flow limitation rather than a pseudo-rather than a pseudo-ventilatory capacityventilatory capacity

• Define maximal flow-volume Define maximal flow-volume loop (envelope) loop (envelope)

• Use IC maneuvers to Use IC maneuvers to determine changes in EELVdetermine changes in EELV

• Johnson BD. Weisman IM. Zeballos RJ. Beck KC. Chest. 116(2):488-503, 1999 Aug

• Quantify flow limitation Quantify flow limitation rather than a pseudo-rather than a pseudo-ventilatory capacityventilatory capacity

• Define maximal flow-volume Define maximal flow-volume loop (envelope) loop (envelope)

• Use IC maneuvers to Use IC maneuvers to determine changes in EELVdetermine changes in EELV

• Johnson BD. Weisman IM. Zeballos RJ. Beck KC. Chest. 116(2):488-503, 1999 Aug

Volume, l

0 1 2 3 4 5 6

Flo

w, l

/se

c

-10

-8

-6

-4

-2

0

2

4

6

8

10

12

ext FVL

Rest FVL

MFVL

Rest IC

ext IC

Vol of FL

Volume, l

0 1 2 3 4 5 6

Flo

w, l

/se

c

-10

-8

-6

-4

-2

0

2

4

6

8

10

12

ext FVL

Rest FVL

MFVL

Rest IC

ext IC

Vol of FL

• 10 normal subjects10 normal subjects•The major goal of this study was to relate the expiratory pressures during exercise to the pressures associated with flow limitation.

• 10 normal subjects10 normal subjects•The major goal of this study was to relate the expiratory pressures during exercise to the pressures associated with flow limitation.

The Journal of Clinical Investigation Volume 48 1969

Flow Volume Loop ProfilesFlow Volume Loop ProfilesFlow Volume Loop ProfilesFlow Volume Loop Profiles

NormalNormal

Flo

w (

L/s

ec)

Flo

w (

L/s

ec)

10

8

6

4

2

0

2

4

6

8 Severe COPDSevere COPD

1 2 3 4 5 1 2 3 4 5Rest Rest

Ex

Ex

Mottram CD. 10th Ed. Ruppel’s Manual of Pulmonary Function Testing Chap. 7

Flow-Volumes Loop AnalysisFlow-Volumes Loop AnalysisFlow-Volumes Loop AnalysisFlow-Volumes Loop Analysis

• Suspicion of flow limitationSuspicion of flow limitation• ObstructionObstruction• RestrictionRestriction• Intra or extra-thoracic obstructionIntra or extra-thoracic obstruction• Vocal chord dysfunction (VCD)Vocal chord dysfunction (VCD)• Other pseudo-asthma - severe obesityOther pseudo-asthma - severe obesity

• Breathing kineticsBreathing kinetics• Location of tidal breathing on the absolute lung Location of tidal breathing on the absolute lung

volume scalevolume scale• EEVL/TLC EEVL/TLC

• Suspicion of flow limitationSuspicion of flow limitation• ObstructionObstruction• RestrictionRestriction• Intra or extra-thoracic obstructionIntra or extra-thoracic obstruction• Vocal chord dysfunction (VCD)Vocal chord dysfunction (VCD)• Other pseudo-asthma - severe obesityOther pseudo-asthma - severe obesity

• Breathing kineticsBreathing kinetics• Location of tidal breathing on the absolute lung Location of tidal breathing on the absolute lung

volume scalevolume scale• EEVL/TLC EEVL/TLC

• Twenty-four prepubescent children

•Thirteen sportive children (10.8 + 1.1 y.o.)•Eleven untrained children (10.5 + 1.0 y.o.)

• Twenty-four prepubescent children

•Thirteen sportive children (10.8 + 1.1 y.o.)•Eleven untrained children (10.5 + 1.0 y.o.)

J Appl Physiol 99: 1912–1921, 2005

• 20 asthmatics in a stable condition and aged 32+13 yrs with a FEV1 of 101+ 21% pred.

• Conclusion: Conclusion: In asthmatics with exercise-induced tidal expiratory flow limitation, the exercise capacity is reduced as a result of dynamic hyperinflation.

• 20 asthmatics in a stable condition and aged 32+13 yrs with a FEV1 of 101+ 21% pred.

• Conclusion: Conclusion: In asthmatics with exercise-induced tidal expiratory flow limitation, the exercise capacity is reduced as a result of dynamic hyperinflation.

Eur Respir J 2004; 24: 378–384

• 22 years-old female• Cough, chest tightness and wheezing

• Diagnosed with EIB with no

response to BD

• Normal flow volume curve at rest

Sawtooth Pattern

Breathing Kinetics: Breathing Kinetics: FVL AnalysisFVL AnalysisBreathing Kinetics: Breathing Kinetics: FVL AnalysisFVL Analysis

NormalNormal

Breathing Kinetics: Breathing Kinetics: FVL AnalysisFVL AnalysisBreathing Kinetics: Breathing Kinetics: FVL AnalysisFVL Analysis

Flow limitation

Breathing Kinetics: Breathing Kinetics: FVL AnalysisFVL AnalysisBreathing Kinetics: Breathing Kinetics: FVL AnalysisFVL Analysis

Inappropriate Shift

Breathing Kinetics: Breathing Kinetics: FVL AnalysisFVL AnalysisBreathing Kinetics: Breathing Kinetics: FVL AnalysisFVL Analysis

Vocal Cord Dysfunction

Breathing Kinetics: Breathing Kinetics: FVL AnalysisFVL AnalysisBreathing Kinetics: Breathing Kinetics: FVL AnalysisFVL Analysis

Pseudo – Asthma “type 2”

Patient JBPatient JBPatient JBPatient JB

• 16 y.o. male with a chief complaint of 16 y.o. male with a chief complaint of exertional dyspneaexertional dyspnea

• Evaluation of suspected asthmaEvaluation of suspected asthma

• Wrestling and cross-countryWrestling and cross-country

• Meds: Flovent, singulair, XopenexMeds: Flovent, singulair, Xopenex

• 16 y.o. male with a chief complaint of 16 y.o. male with a chief complaint of exertional dyspneaexertional dyspnea

• Evaluation of suspected asthmaEvaluation of suspected asthma

• Wrestling and cross-countryWrestling and cross-country

• Meds: Flovent, singulair, XopenexMeds: Flovent, singulair, Xopenex

Patient JBPatient JBPatient JBPatient JB

Patient JBPatient JBPatient JBPatient JB

Patient JBPatient JBPatient JBPatient JB

Patient CLPatient CLPatient CLPatient CL

• 27 yo female with chief 27 yo female with chief complaint of exertional complaint of exertional dyspneadyspnea

• PMH: Tetralogy of Fallot with PMH: Tetralogy of Fallot with absent pulmonary valve absent pulmonary valve syndrome status post complete syndrome status post complete repairrepair

• CPET ordered to evaluate CPET ordered to evaluate cardiac versus pulmonary cardiac versus pulmonary

• 27 yo female with chief 27 yo female with chief complaint of exertional complaint of exertional dyspneadyspnea

• PMH: Tetralogy of Fallot with PMH: Tetralogy of Fallot with absent pulmonary valve absent pulmonary valve syndrome status post complete syndrome status post complete repairrepair

• CPET ordered to evaluate CPET ordered to evaluate cardiac versus pulmonary cardiac versus pulmonary

Patient CLPatient CLPatient CLPatient CL

Patient CLPatient CLPatient CLPatient CL

Patient EWPatient EWPatient EWPatient EW

• 12 y.o. female referred for prolong QT 12 y.o. female referred for prolong QT syndrome and exercise intolerancesyndrome and exercise intolerance

• HPI:HPI: • Sports physical triggered and ECG Sports physical triggered and ECG

which was read as borderline prolonged which was read as borderline prolonged QT.QT.

• Chest pain and wheezing with exerciseChest pain and wheezing with exercise

• PE: UnremarkablePE: Unremarkable

• 12 y.o. female referred for prolong QT 12 y.o. female referred for prolong QT syndrome and exercise intolerancesyndrome and exercise intolerance

• HPI:HPI: • Sports physical triggered and ECG Sports physical triggered and ECG

which was read as borderline prolonged which was read as borderline prolonged QT.QT.

• Chest pain and wheezing with exerciseChest pain and wheezing with exercise

• PE: UnremarkablePE: Unremarkable

Patient EWPatient EWPatient EWPatient EW

• ECHO: normal ECHO: normal

• Spirometry: FVC 3.17 (95%), FEV1 Spirometry: FVC 3.17 (95%), FEV1 2.78 (97%), ratio 87.7%2.78 (97%), ratio 87.7%

• Normal spirometryNormal spirometry

• CPET with FV Loops ordered to r/o CPET with FV Loops ordered to r/o EIB or vocal chord dysfunctionEIB or vocal chord dysfunction

• ECHO: normal ECHO: normal

• Spirometry: FVC 3.17 (95%), FEV1 Spirometry: FVC 3.17 (95%), FEV1 2.78 (97%), ratio 87.7%2.78 (97%), ratio 87.7%

• Normal spirometryNormal spirometry

• CPET with FV Loops ordered to r/o CPET with FV Loops ordered to r/o EIB or vocal chord dysfunctionEIB or vocal chord dysfunction

Patient EWPatient EWPatient EWPatient EW

• Normal sinus rhythm, normal ECGNormal sinus rhythm, normal ECG• Normal sinus rhythm, normal ECGNormal sinus rhythm, normal ECG

Patient ID: EW816

Interpretation: Normal exercise tolerance, evidence of VCD

Laryngoscope, 109:136-139,1999

• To compare laryngoscopically observed changes in the larynx during exercise in persons (2) with exercise-induced laryngomalacia (EIL) with changes in asymptomatic control subjects (8).

• To compare laryngoscopically observed changes in the larynx during exercise in persons (2) with exercise-induced laryngomalacia (EIL) with changes in asymptomatic control subjects (8).

• 12 normal subjects and 12 normal subjects and 4 patients with DOE 4 patients with DOE and noisy breathingand noisy breathing

• Conclusion: Continuous laryngoscopy with exercise was easy to perform and well tolerated

• 12 normal subjects and 12 normal subjects and 4 patients with DOE 4 patients with DOE and noisy breathingand noisy breathing

• Conclusion: Continuous laryngoscopy with exercise was easy to perform and well tolerated

Laryngoscope, 116:52–57, 2006

Laryngoscope, 119:1776–1780, 2009

Respiratory Medicine (2009) 103, 1911-1918

• 151 of 166 patients 151 of 166 patients with inspiratory with inspiratory distress during distress during exerciseexercise

• 151 of 166 patients 151 of 166 patients with inspiratory with inspiratory distress during distress during exerciseexercise

• The aims of this study were to establish a scoring system for laryngeal obstruction as visualized during the CLE-test as well as to assess reliability and validity of this scoring system.

• The aims of this study were to establish a scoring system for laryngeal obstruction as visualized during the CLE-test as well as to assess reliability and validity of this scoring system.

Eur Arch Otorhinolaryngol (2009) 266:1929–1936

• Conclusion: The CLE-test scoring system is a reliable and valid method that can be used to assess degree of laryngeal obstruction in patients with symptoms of EIIS

• Conclusion: The CLE-test scoring system is a reliable and valid method that can be used to assess degree of laryngeal obstruction in patients with symptoms of EIIS

CPET with FV loops and Direct LaryngoscopyCPET with FV loops and Direct LaryngoscopyCPET with FV loops and Direct LaryngoscopyCPET with FV loops and Direct Laryngoscopy

Patient AJPatient AJPatient AJPatient AJ• 18 year-old athletic female complaining of

dyspnea and wheezing with exertion

• HPI:HPI: • Inspiratory wheezing, epigastric pain Inspiratory wheezing, epigastric pain

and tight feeling around the shoulders and tight feeling around the shoulders and neck with exertionand neck with exertion

• Symptoms start after a minute or so of Symptoms start after a minute or so of sprinting or 5-10 min. of regular exercise sprinting or 5-10 min. of regular exercise

• Symbicort, Singulair and Xopenex x 1 year with no improvement

• 18 year-old athletic female complaining of dyspnea and wheezing with exertion

• HPI:HPI: • Inspiratory wheezing, epigastric pain Inspiratory wheezing, epigastric pain

and tight feeling around the shoulders and tight feeling around the shoulders and neck with exertionand neck with exertion

• Symptoms start after a minute or so of Symptoms start after a minute or so of sprinting or 5-10 min. of regular exercise sprinting or 5-10 min. of regular exercise

• Symbicort, Singulair and Xopenex x 1 year with no improvement

ENT and speech path consult ENT and speech path consult ENT and speech path consult ENT and speech path consult

Laryngoscopy:Laryngoscopy:

• Thick secretions Thick secretions

• Normal mobility of the true vocal folds with full Normal mobility of the true vocal folds with full abduction and complete adductionabduction and complete adduction

• The subglottis was clearThe subglottis was clear

• No paradoxical vocal fold when she attempted to No paradoxical vocal fold when she attempted to mimic her dyspneic episodesmimic her dyspneic episodes

Laryngoscopy:Laryngoscopy:

• Thick secretions Thick secretions

• Normal mobility of the true vocal folds with full Normal mobility of the true vocal folds with full abduction and complete adductionabduction and complete adduction

• The subglottis was clearThe subglottis was clear

• No paradoxical vocal fold when she attempted to No paradoxical vocal fold when she attempted to mimic her dyspneic episodesmimic her dyspneic episodes

Patient AJPatient AJPatient AJPatient AJ

Patient AJPatient AJPatient AJPatient AJ

• Diagnosis: Arytenoid collapse Diagnosis: Arytenoid collapse (laryngeal dysfunction) (laryngeal dysfunction)

• Patient was seen again by ENT and Patient was seen again by ENT and underwent arytenoidectomyunderwent arytenoidectomy

• Diagnosis: Arytenoid collapse Diagnosis: Arytenoid collapse (laryngeal dysfunction) (laryngeal dysfunction)

• Patient was seen again by ENT and Patient was seen again by ENT and underwent arytenoidectomyunderwent arytenoidectomy

Patient TBPatient TBPatient TBPatient TB

• 14 y.o. female with a chief complaint 14 y.o. female with a chief complaint of dyspnea on exertion of dyspnea on exertion

• PMHPMH• Asthma “wheezing with colds”Asthma “wheezing with colds”• Mother described “breathing attacks”Mother described “breathing attacks”

• CXR: NormalCXR: Normal

• Meds: Symbicort, XopenexMeds: Symbicort, Xopenex

• 14 y.o. female with a chief complaint 14 y.o. female with a chief complaint of dyspnea on exertion of dyspnea on exertion

• PMHPMH• Asthma “wheezing with colds”Asthma “wheezing with colds”• Mother described “breathing attacks”Mother described “breathing attacks”

• CXR: NormalCXR: Normal

• Meds: Symbicort, XopenexMeds: Symbicort, Xopenex

Patient TBPatient TBPatient TBPatient TB

Patient TBPatient TBPatient TBPatient TB

Patient TB Patient TB Patient TB Patient TB

Baseline Immediate Post- Exercise

Summary Summary Summary Summary

• Flow volume loop analysis is beneficial Flow volume loop analysis is beneficial in defining flow limitation and other in defining flow limitation and other breathing abnormalities during exercisebreathing abnormalities during exercise

• Continuous video laryngoscopy is a Continuous video laryngoscopy is a well tolerated procedure that can assist well tolerated procedure that can assist in characterizing structural in characterizing structural abnormalities of the upper airway. abnormalities of the upper airway.

• Flow volume loop analysis is beneficial Flow volume loop analysis is beneficial in defining flow limitation and other in defining flow limitation and other breathing abnormalities during exercisebreathing abnormalities during exercise

• Continuous video laryngoscopy is a Continuous video laryngoscopy is a well tolerated procedure that can assist well tolerated procedure that can assist in characterizing structural in characterizing structural abnormalities of the upper airway. abnormalities of the upper airway.

Questions?