EXP: 516L

Lab
Report 1
Pulmonary Function

Casey Wusterbarth & Kelly Van Berkel

1)
The results of the two exercise test protocols have mixed relationships and show
interesting trends in relation to the physiological measures obtained. These measurements
include a rating of perceived exertion (RPE), dyspnea, and SaO . For good measure, the rate
pressure product (RPP) was calculated at the termination of the test to measure the oxygen
demand of the heart.
According to the results, in terms of systolic blood pressure response, the greatest
demand came from the SLOW USAFSAM treadmill protocol with an average systolic pressure
of 147 mm Hg. The greatest blood pressure response came from the lowest fit female (158/72
mm Hg); however, a similar elevated BP of 152/82 mmHg was observed in one of the high-fit
females. When comparing that blood pressure to the other high-fit female the systolic pressure
was 10 mmHg lower representing a greater aerobic capacity. Although, the high-fit female
suffers from asthma and was experiencing cold-like symptoms, which may represent that
elevated BP response. It was also reported that the high-fit female did not reach her target heart
rate of 138 bpm due to chest pain during the treadmill protocol.
In terms of the RPE results, a different conclusion of aerobic demand may be warranted.
According to the subjects self-reported RPE, the greatest average RPE came from the cycle ramp
protocol. The average RPE rating at test termination was 14, a rating three times greater than the
RPE of 11 recorded from the treadmill protocol. Thus, according to the subjects perceived
exertion, the cycle protocol reached an exertion of somewhat-hard to heavy and the treadmill
protocol reached an exertion of fairly light interestingly. In testing for pulmonary function, a
dyspnea scale is regularly used to rate the patients perceived breathing difficulty. The dyspnea
rating was also similar to the results of the perceived dyspnea for the subjects. The cycle
protocols average dyspnea rating was three compared to the treadmill rating of 2.5. Also, a
curious result was obtained from the dyspnea ratings between the high-fit and low-fit individuals.
A higher dyspnea rating was obtained for both exercise testing modalities in the high-fit subjects
compared to the low-fit individuals. The high-fit subjects recorded an average dyspnea of 3 in
the cycle protocol compared to the 2.5 rating for the low-fit individuals. This rating was
increased to a 4 for the treadmill protocol among the high-fit subjects and a rating of 1 was
obtained for the low-fit subjects. Based on these dyspnea ratings, it can be said that the treadmill
protocol elicited slightly greater dyspnea among the high-fit female subjects and elicited a lower
dyspnea in low-fit female subjects.
The oxygen saturation values obtained pre-test and throughout the exercise test protocols
indicate a reduction in oxygen saturation (SaO ) throughout both the cycle and treadmill
protocols. The greatest reduction in oxygen saturation was seen among one high-fit subject and
both low-fit subjects of the cycling protocol. A reduction of at least 3% was observed in these
subjects. Similar results were seen in the treadmill protocol. The greatest oxygen saturation
difference pre to posttest was seen in one of the high-fit subjects with a 4% reduction.
For good measure the RPP was determined for each subject at test termination. The
smallest RPP of 17,940 mmHg/bpm was seen among one of the high-fit subjects for the cycle
protocol. The greatest RPP of 20,700 mmHg/bpm for the cycle protocol came from a low-fit
subject. In regards to the treadmill protocol, the lowest RPP recorded was 19,044 mmHg/bpm
and was from a low-fit subject. The largest RPP of 21,330 mmHg/bpm was observed in a low-fit
subject. The average RPP obtained among the high and low-fit subjects for the cycle protocol
was equal to 19,009 mmHg/bpm. The average RPP for the treadmill protocol was 741
mmHg/bpm larger at 19,750 mmHg/bpm.
2

Based on the results of both the cycle and treadmill protocols, it can be said that the
treadmill protocol may elicit greater hemodynamic stress based on the values of systolic blood
pressure and terminating HR value. The RPP of all subjects was greater among three of the four
subjects during the treadmill protocol. Also, in terms of breathing capability and ability for gas
exchange to transport O to the working muscles, the cycling protocol showed the greatest
reduction in oxygen saturation. This may have been due to the restricted lung expansion due to
the corset and also the pulmonary mask. Another facilitator may have been the position that the
bike requires. The corset may have added to the subjects being uncomfortable on the cycle as
well. This may have caused the different results from one of the low-fit subjects having a greater
RPP on the cycle instead of the treadmill.
The information obtained through this study, can be utilized in a clinical setting by
selecting the proper protocol for assessing aerobic capacity in patients with mild-moderate
COPD. According to previous research on aerobic testing in patients with mild-moderate COPD
both the treadmill and cycle modalities of testing provide an appropriate representation of the
limitations seen in COPD patients (4,6,10). Based on a study performed by Holm et al. (2013), it
was found that there were similar physiological responses between treadmill and cycle,
indicating that either modality may be appropriate for patients (10). This result is similar to the
findings of this study as well. The observed drop in oxygen saturation was similar for both
testing modalities, supporting the previous statement. However, other studies have found these
responses to be significantly different in terms of increased oxygen desaturation and symptoms
of exercise intolerance (10,11). Therefore, the use of either a treadmill protocol or cycle protocol
is purely dependent on clinician and patient preference, although the use of a treadmill protocol
may be better suited to observe the effect of COPD in mild-moderate patients. The use of these
testing protocols are similar to the ones used in cardiac rehab, but with slight variations in
treadmill and cycle ramp protocols. The most common treadmill ramp protocols include: Balke
and Ware, Naughton, and the SLOW USAFSAM (3). These protocols provide a gradual
progression in intensity or an increase in 1 MET per stage (ACSM). This allows for this specific
special population to adapt to exercise intensity more easily and avoid exacerbating signs and
symptoms of exercise intolerance just minutes into the test.
Overall, the use of either testing modality is warranted according to the current research
on physiological measures in COPD patients and the results of the current study. However, the
use of the treadmill protocols may provide for a greater analysis on functional ability in mildmoderate COPD patients and also because of its ability to elicit a greater VO peak at termination
(6,10,11). Also, the treadmill protocols may be more advantageous due to their relevance in
activities of daily living.
2

2)
CPX testing offers clinicians the ability to obtain an abundance of information beyond
standard exercise testing, that is when appropriately applied and interpreted, can assist in the
management of complex cardiovascular and pulmonary disease (3,16).When comparing the
exercise testing modalities between cardiac rehab and pulmonary rehab, one distinct difference is
made. Instead of performing a standard GXT a CPX is performed to measure many variables that
are limited in patients with COPD. The additional data that can be obtained includes (2,3,7,8,16):

Expiratory ventilation
Minute ventilation
Ventilatory Threshold
V /MVV
Pulmonary gas exchange (Respiratory Exchange Ratio)
O uptake
CO output
Pulse Oximetry/ Arterial blood gases
P CO (Pulse pressure of End-Tidal CO )
Dead space (V )/tidal-volume ratio (ventilation-perfusion ratio)
Blood lactate
E

ET

Exercise training is a primary component of pulmonary rehabilitation. The use of CPX

allows a different look into designing training regimens that are effective and tolerable for COPD
patients or individuals suffering from exertional dyspnea. By using the variables determined
through CPX like the oxygen uptake and minute ventilation, the ventilatory threshold can be
determined. Determining the ventilatory threshold also allows the clinician to estimate the
workload further. This threshold is related to the lactate threshold that determines the work rate
that initiates the accumulation of lactate. Thus, maximizing the clinicians ability to give a proper
diagnosis to the degree of COPD based on the Global Initiative for Chronic Lung Diseases and
individualize the exercise prescription based on peak work rate. Also, by determining the correct
stage with the GOLD staging of COPD provides the clinician with an exercise prescription base
and implications as to the prognosis (2,7,16,19). Current research also supports the use of CPX
to determine the relationship between the functional impairments and prognosis of COPD
patients (9).
The use of the CPX can also help diagnose many other conditions related to
cardiovascular limitations. These limitations include abnormal responses of HR, BP and also
stroke volume. The stroke volume can be estimated through the oxygen saturation compared to
the HR. In patients with COPD heart failure is also very common and the CPX can help diagnose
the presence of heart failure. The presence of a reduced exercise capacity is the cardinal
symptom of chronic heart failure. The determination of peak VO is the most objective
measurement that can assess exercise capacity and the presence of heart failure. According to
research, strong correlations are found between maximal cardiac output, peak VO , and mortality
risk (2,6,14,18). Due to this limited VO peak, the oxygen saturation may fail to increase normally
relative to the energy demands as work rate is increased. This results in the delayed post-exercise
recovery of VO . Based on this information the recovery is very important for COPD patients.
The information provided by the CPX can also help determine the degree to which COPD
patients need medical interventions. The test will help determine the dosage of the common
medications taken for COPD patients. These include: bronchodilators, anti-inflammatory, and
mucolytic agents, etc. In patients with pulmonary issues that are significantly correlated with
pulmonary pressures the CPX can again, thus provide a noninvasive reflection of disease
severity. CPX may also aid in the detection of exercise-induced right-to-left shunting (2, 7,8,16).
With the previously stated gas exchange measures and the resting echocardiogram as the
reference, the sensitivity, specificity, positive and negative predictive values, and accuracy have
been reported to be between 80% and 96% (2,21).
2

3)
Dyspnea is the main symptom perceived by patients affected by COPD. For most patients
ADLs are the main cause of dyspnea (13,20). A study showed that vacuum cleaning was
mentioned most frequently in COPD patient's individual top dyspnea causing activities. The next
most frequently mentioned activities that cause dyspnea involved showering, getting dressed,
climbing stairs, and un/loading washing machine (13).
The physiology of dyspnea in COPD patients is representative of shortness of breath
during activities and also at rest in most cases. Individuals with COPD have an obstruction
within their bronchioles that results in an ability to fully expire air, which results in an increased
residual volume of air left in the lungs. This is known as the hyperinflation of the lungs. Also
linked with the obstruction is the enlargement of gland ducts that creates an excessive cough due
to sputum production, which leads to the development of chronic bronchitis. When all these
mechanisms occur the symptoms of dyspnea occur, which reduces exercise tolerance and ability
to perform activities of daily living. Along with the presence of dyspnea, COPD has damaging
effects to the skeletal muscles. According to studies, COPD patients have significant atrophy in
the peripheral muscles because of the shift to type II muscle fibers (4,11,12,18). These changes
are a result from being in a hypoxic environment for long periods, physical inactivity, and also
hypercapnia. In order to combat these changes pulmonary rehabilitation is recommended and
energy conservation techniques are adopted to better manage their exertional dyspnea.
The use of many energy conservation strategies are used for patients with COPD. The use
of energy conservation techniques, the adaptation of the environment, and the appropriate
posture for the performance of the ADLs have proven efficient in reducing the sensation of
dyspnea, oxygen consumption, production of carbon dioxide and heart rate in patients with
COPD (20). Based on the Cleveland Clinic, the following strategies can be adopted to conserve
energy. In many rehab programs across the country COPD patients have adopted the strategy of
the four Ps. The first is to plan activities ahead of time and schedule them during the time of day
where energy is the highest. This is highly specific for individuals with COPD and may vary
from patient to patient. The second is pacing which allows COPD patients to sustain an energy
level until the task is completed. The basis of this strategy is to allow plenty of time for the
completion of activities and incorporating multiple rest periods. The third is prioritizing and
analyzing what activities are most important and eliminating unnecessary tasks that will deplete
their energy more quickly. The last is positioning, which may be the most effective strategy to
energy conservation. This strategy includes storing items at a convenient height to avoid
excessive and prolonged stooping and stretching.
In terms of positioning on the opposite end of the spectrum, proper body mechanics is
essential. When the body is positioned in a manner that resembles poor posture more energy is
consumed. This is due to the dynamic hyperinflation of the lungs that is constant. When the body
is in a slumped position the lungs cannot fully expire the CO and absorb the oxygen to refuel the
body and its peripheral musculature. This leads to presence of fatigue in COPD patients with
simple tasks. Educating patients regarding the most appropriate postures for each task performed
is essential to energy conservation. Other techniques used by COPD patients are breathing
techniques to maximize the amount of air expired.
The most common breathing technique used by COPD patients is the pursed lip
breathing. This technique involves narrowing the opening of the mouth creating back pressure.
2

This keeps the airways open longer so that the lungs can expire the usual increased residual
volume left in the lungs during usual breathing in COPD patients. By adopting this technique
COPD patients can improve their exchange of oxygen and carbon dioxide and increase the time
they can perform exercise or perform an activity of daily living. A second breathing technique
used in COPD patients is diaphragmatic breathing. This training allows the diaphragm to take
over more of its normal duties of breathing and reduces the energy used and eventually deeper
breaths can be taken (1,15). Both these breathing techniques should first be done at rest so that
the patient acquires the perception of the respiratory movements during inspiration and
expiration and later on during ADLs and exercise (5,17,20). This also helps COPD patients to
better their situation and use their breathing techniques to begin an exercise program to better
their prognosis.
The use of exercise training is also beneficial for COPD patients to improve their quality
of life. One of the primary disabilities of COPD patients is exercise intolerance, but through
exercise training the ability to exercise is restored. Through exercise training the skeletal muscle
dysfunction seen in COPD patients can be reversed. The exercise training in COPD patients
focuses on restoring the type I fibers and training the muscles of the lower body or in
combination of the arms or respiratory muscles. In a recent systematic review of 14 randomized
controlled trials of pulmonary rehabilitation programs significant improvements were made in
exercise tolerance (18. According to recent research, VO peak was increased by at least 20% in
randomized controlled trials during an 8-12 week pulmonary rehab program (12,14,18). More
recently exhaled nitric oxide (NO) was found to be a marker of physical fitness in healthy
subjects and pulmonary rehabilitation has shown to increase exhaled NO in patients with COPD
(18). Thus, representative of improvements in exercise tolerance in patients with COPD. The
maximal exercise capacity and functional ability was increased up to 9 months postrehabilitation. Therefore, supporting the use of exercise training programs to increase energy
conservation and functional capacity (14,18).
In summary, to conserve energy activities with distinct levels of demand should be
organized in such that light, slow activities that require less energy expenditure come first, such
as personal hygiene activities performed while sitting, with upper limb support. Followed by
those performed while sitting without upper limb support. Simplifying the performance of some
tasks by adapting the environment or by using assistive devices may also enhance the energy
conservation in these situations by reducing the need for broad movements of the upper limbs
without support, as well as avoiding bending. Along with eliminating unnecessary activities.
Informing patients of the importance of asking for help from others, when necessary; along, with
organizing time by calculating time spent performing activities and the time needed for rest and
proper positions and postures for ADLs (5,17,20).
2

Appendix A

Resting Measures
Name

RHR

RBP

SaO2

Weight

Kelly (high fit)

87

130/82

99

72.73

86

110/78

98

68.18

86

HR
115/72

BP99

SaO2
63.64

90

100
130/72

130/82
98

99
86.36

Caitlin (high fit)

102

112/80

97

Krista (low fit)

110

115/72

99

Erin (low fit)

105

130/72

98

Pre-Exercise
Values
Caitlin (high
fit)
Name
Krista (low
fit)
ErinKelly
(low(high
fit) fit)

Cycle Ramp Testing Results

High-Fit
Minute

HR

BP

RPE

Dyspnea

SaO2

1
2
3

115
135
138

136/72

13

96

Minute

HR

BP

RPE

Dyspnea

SaO2

101

High-Fit

2
3
4
5
6
7
8

108
118
120
124
125
133
138

118/80
122/80
130/80

7
11
15

1
2
4

97
97
96

Low-Fit
Minute

HR

BP

RPE

Dyspnea

SaO2

118

123

127

140/88

12

95

133

138

150/82

14

95

Minute

HR

BP

RPE

Dyspnea

SaO2

120

124

130

130/78

0.5

97

135

138/78

13

95

Low-Fit

SLOW Treadmill Testing Results

High-Fit 1
Minute

HR

BP

RPE

118

Dyspne
a
-

121

123

150/82

13

98

SaO2
-

124

126

127

152/82

13

96

127

127

127

152/82

14

94

Minute

HR

BP

RPE

99

Dyspne
a
-

102

104

122/78

0.5

98

108

112

114

130/80

98

118

120

123

132/78

98

10

125

11

135

12

138

140/80

11

96

High-Fit 2
SaO2
-

Low-Fit 1
Minute

HR

BP

RPE

Dyspnea

SaO2

115

118

120

122/72

10

0.5

98

124

128

130

130/74

10

0.5

96

133

135

138

138/74

11

96

Minute

HR

BP

RPE

Dyspnea

SaO2

115

117

119

140/72

96

121

124

126

152/72

0.5

97

131

134

138

158/72

0.5

98

Low-Fit 2

Appendix B
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