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Published in final edited form as:


Burns. 2011 June ; 37(4): 682686. doi:10.1016/j.burns.2010.12.021.

Prediction of Maximal Aerobic Capacity in Severely Burned


Children
Laura Porro, MDa,b, Haidy G. Rivero, MDa,b, Dante Gonzalez, BSc, Alai Tan, PhDd, David
N. Herndon, MDa,b, and Oscar E. Suman, PhD
aShriners Hospitals for Children, Galveston TX 77550
bDepartment
cSt

of Surgery, The University of Texas Medical Branch, Galveston TX 77555

Marys University in San Antonio, Summer Research Student at UTMB

dOffice

of Biostatistics, The University of Texas Medical Branch, Galveston TX 77555

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Abstract
IntroductionMaximal oxygen uptake (VO2 peak) is an indicator of cardiorespiratory fitness,
but requires expensive equipment and a relatively high technical skill level.
PurposeThe aim of this study is to provide a formula for estimating VO2 peak in burned
children, using information obtained without expensive equipment.
MethodsChildren, with 40% total surface area burned (TBSA), underwent a modified Bruce
treadmill test to asses VO2 peak at 6 months after injury. We recorded gender, age, %TBSA, %3rd
degree burn, height, weight, treadmill time, maximal speed, maximal grade, and peak heart rate,
and applied McHenrys select algorithm to extract important independent variables and Robust
multiple regression to establish prediction equations.
Results42 children; 7 to 17 years old were tested. Robust multiple regression model provided
the equation: VO2=10.33 0.62 *Age (years) + 1.88 * Treadmill Time (min) + 2.3 (gender;
Females = 0, Males = 1). The correlation between measured and estimated VO2 peak was R=0.80.
We then validated the equation with a group of 33 burned children, which yielded a correlation
between measured and estimated VO2 peak of R=0.79.

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ConclusionsUsing only a treadmill and easily gathered information, VO2 peak can be
estimated in children with burns.
Keywords
burns; cardiopulmonary fitness; maximal oxygen consumption

2011 Elsevier Ltd and ISBI. All rights reserved.


Corresponding Author: Oscar E. Suman, PhD, Professor, Department of Surgery, The University of Texas Medical Branch, Shriners
Hospitals for Children-Galveston, 815 Market St., Galveston, TX 77550, PH 409-770-6557, Fax 409-770-6919, oesuman@utmb.edu.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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There are no potential conflicts of interest pertaining to this manuscript for any authors. In addition, no authors have any financial
disclosures related to this manuscript.

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Introduction
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The survival rate of children with severe burns has dramatically increased as a result of
advances in resuscitation and critical care, use of broad-spectrum antimicrobials,
improvements in nutrition, alongside with an early excision and prompt wound closure. [1
2]. As patients survive the acute phase long-term burn-related complications and extensive
physical and functional limitations are present.
One long term functional limitation in burned children is a decrease in cardiopulmonary
function that lasts up to two years after the initial burn injury. [3] Maximal or peak oxygen
uptake (VO2 peak), which reflects cardiopulmonary function, is typically considered an
index of cardiorespiratory fitness. VO2 peak is defined as the maximum volume of oxygen
per unit of time that the body can consume during intense, whole-body exercise. It is
typically, expressed as a rate, either as liters per minute (L/min) or as milliliters per
kilograms body weight per minute (ml/kg/min). VO2 peak is useful in determining the
intensity of exercise training needed to induce beneficial cardiovascular and training effect,
as well as allows tracking of progress during rehabilitation programs[4] [5]. However,
measurement of VO2 peak using indirect calorimetry is costly and often requires technical
training. Consequently, there is probable need to explore methods for estimating the VO2
peak in burned children and most likely it could be helpful in children with other pathologies
or in locations with limited economical resources.

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Therefore, the aim of this study is to provide a simple formula for predicting VO2 peak
using information acquired clinically without the need for expensive equipment. It is
envisioned that such information can then be used in the exercise rehabilitation of burned
children.

Methods
Subjects

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This study was conducted at Shriners Hospitals for Children, Galveston, Texas. Forty two
children with an age range 7 to 17 years old, and who were admitted to our burn unit for
acute care and had an exercise tolerance test at 6 month post burn were included in this
analyses. These children also had 40% or greater total body surface area burn (TBSA) as
evaluated by the "rule of nines" method [6] during excisional surgery in the acute phase of
injury. Patients were excluded if they had one or more of the following: leg amputation,
anoxic brain injury, psychological disorders, quadriplegia, or severe behavior or cognitive
disorders. Additionally, another group of 33 burned children with the same previous
characteristics were randomly selected as the validation group to correlate the results. The
study was reviewed and approved by the Institutional Review Board, of the University
Texas Medical Branch, Galveston, Texas. Before the study each subject (if applicable), and
parent or childs legal guardian had to sign a written informed consent form. All patients
received similar standard medical care and treatment from the time of emergency admission
and acute care of the burn injury until time of discharge.
Exercise testing
At 6 months post-burn injury, all patients in this study returned to Shriners Hospitals for
Children for exercise testing, and underwent a standardized treadmill exercise test, using the
modified Bruce protocol, this test is a widely adopted protocol that has been well validated
to evaluate and asses cardiovascular fitness and for testing maximal aerobic endurance time
in children. This test was chosen as it is well tolerated by the patients. Briefly, this test starts
by walking on the treadmill at speed of 1.7 miles/hour and zero grade of elevation, with the
patient breathing through a 2-way valve system. Subsequently, at three minute intervals,
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stages two and three are performed at a 1.7 miles/hour and 5% grade and 1.7 miles/hour and
10% grade respectively. From this point on, the incline of the treadmill increases by 2%
grade and by a set speed increments (2.5, 3.4, 4.2 miles/hour) at regular intervals of 3
minutes. Subjects were continuously encouraged to complete 3 minutes stages, and the test
was completed once peak volitional effort was achieved, and the respiratory exchange ratio
(R) of 1.10 was achieved, at this point treadmill time was recorded to be used in the
equation. Air that was expired, passed through sensors that quantified both volume and
oxygen concentration, and were analyzed by a computer.
Heart rate and oxygen consumption (VO2) were monitored and analyzed by using methods
previously described [78]. Briefly, breath-by-breath analysis was continuously made of
inspired and expired gases, flow, and volume by using a Medgraphics CardiO2 combined
VO2/ECG exercise system (St. Paul, MN) indirect oxygen calorimeter, and PreVentTM
Pneumotach and a mouth piece.
Heart rate was measured continuously with Precor USA heart rate monitor. The piece of
equipment has a lightweight transmitter, which was held on the chest by a strap, with dry
electrodes on the inner surface and a watch-like device attached to the wrist. Heart rate was
recorded every 5 second and then averaged over 30 second.
Statistical analyses

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We measured the following variables: gender, age, %TBSA, %3rd degree burn, height,
weight, treadmill time, maximal speed, maximal grade, and peak heart rate and considered
them as independent variables and VO2 peak was considered the dependent variable. Next
we performed one portion of a regression analysis to obtain a subset of independent
variables, and finally we proceed to conduct a multiple regression procedure to fit the model
based on the selected variable.

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We applied variable selection routine which uses McHenrys select algorithm [9] to find the
best subset from independent variables providing maximum R-Squared to predict VO2 peak.
It is an extremely fast statistical method which uses the algorithm that seeks a subset of
parameters that provides a maximum value of R-Squared (or a minimum Wilks lambda in
the multivariate case). This algorithm seems to find the best (or very near best) subset in
most situations. It first finds the best single variable. To find the best pair of variables, it
tries each of the remaining variables and selects the one that adds the most, then omits the
first variable and determines if any other variable would add more. If a better variable is
found, it is kept and the worst variable is removed. Another search is now made through the
remaining variables. This switching process continues until no switching will result in a
better subset. Once the optimal pair of variables is found, the best three variables are
searched for in much the same manner. First, the best third variable is found to add to the
optimal pair of variables from the last step. Next, each of the first two variables is omitted
and another, even better, variable is searched for. The algorithm continues until no switching
improves R-Squared.
We kept those selected variables and ignored the rest of the parameters since they did not
significantly add to the ability of the equation to predict VO2 peak and were not included in
the final equation because of the multi-co-linearity, or co-linearity, relationships among the
independent variables. We then applied a Robust multiple regression analysis using Hubers
method [19] to establish our prediction equations (models) for different populations (male,
female and all male and female). These analyses were performed using SAS (SAS Institute
Inc., Cary, NC). The model selection and Robust regression analysis were conducted using
SAS PROC REG and PROC ROBUSTREG procedures (SAS 9.2 Users Manual, SAS

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Institute, Cary, NC). All tests were two sided with significance accepted at p<0.05. All
results are means +/ standard error of the mean.

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Results
Forty two thermally injured children (27 boys, 15 girls) with an age range 7 to 17 years old
(12 0.51) with a 40% or greater total body surface area burn (TBSA) were tested, and form
part of the model development group. Demographic data is presented in Table 1 for both the
model development group and the validation group. We found no significant difference
among the 2 groups in gender, age, %TBSA, %3rd degree burn, height, weight, treadmill
time, speed, grade, and heart rate.
Based on the subset variable selection algorithm, variables treadmill time and age were
candidate variables, (R2=0.62. P=0.008 and P<0.0001 for age and treadmill time,
respectively) (Figure 1) since there was no significant interaction between gender and other
predictors we decided to use a single model for both boys and girls with the gender as a
predictor in the model. We assigned the value of 1 for males and 0 to females. The
correlation between measured VO2 peak and estimated VO2 peak was R2 = 0.65 (Figure 2).
Robust multiple regression model using Hubers method provided the following equation:

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We then proceed to validate our results by applying the equation obtained to the validation
group. The correlation between measured VO2 peak and estimated VO2 peak was R2 = 0.63
(Figure 3).

Discussion
Our study yielded an equation to predict VO2 peak that may be useful as a practical tool for
assessing functional capacity of severely burned children. With R squared values that
represent an acceptable approximation of the VO2 peak measured, the application of the
equation requires no special training or expensive equipment, and the demographics
necessary to predict VO2 peak can be gathered fairly simply either at home, clinic, hospital,
or fitness center.

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Our initial analysis resulted in a prediction equation that took into consideration if the
patient had inhalation injury. Although the R squared value was higher (R2=0.77 versus
0.65), we did not select this equation in order to preserve the simplicity that makes this
equation useful in almost any setting. The R-Squares that guided the variable selection were
shown in Figure 1.
The validation group confirmed the correlation between the VO2 peak measured and VO2
peak estimated, with an R2=0.63. This group allowed us to identify some patients that were
under predicted by our equation. We found that 2 of the patients in this group reached a
greater VO2 peak than the predicted value. This are considered the lesser of two evils since
the patient exceeded or had greater VO2 peak than the expected value.
In children with burns assessing VO2 peak can be a valuable piece of information specific to
exercise rehabilitation or exercise training. For example, an inactive patient receiving the
standard of care without exercise rehabilitation may present VO2 peak values of 23.2
milliliters/minute, 25.9 milliliters/minute and 25 milliliter/minute at discharge, 6 months and
12 months after injury respectively. Contrast this with an active patient that participated in a
comprehensive rehabilitation and exercise program, and had VO2 peak values of 24.6
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milliliters/minute at discharge 33.2 milliliters/minute at 6 months and 38.8 milliliters/minute


at 12 months after injury.[1011] These examples underscore the importance of evaluation
methods of physical fitness especially of the cardiopulmonary system, not only as an initial
evaluation tool, but also in the evaluation of progress overtime.

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There are number of methods that use heart rate alone to predict VO2 peak.[12][5] Okura
and Tanaka established a method to predict VO2 peak from the perceived exertion scale that
can be applied not only in clinically normal people but also in patients with essential
hypertension, through an easily applied procedure thats does not require instrumentation.
[5] However, the results of this study can be considered subjective rather than objective
since it relies in the capacity of the patient to recognize general feelings of physical fatigue,
cardiopulmonary system symptoms and tension in the exercising muscles and joints. [5]
Later in 2003, Sarton-Miller et al developed a non-invasive, and affordable regression-based
method that predicts net oxygen consumption from net heart rate along with several
covariates and is used for estimating net energy expenditure in children performing activities
at high altitude.[12] However, heart rate can be affected by various drugs as beta- blocking
agents and cardiac stimulants, and beta-adrenergic blockade with propranolol has been
recognized as an efficacious therapy in the modulation of the heart response in burns [13
14], subsequently a method that uses heart rate alone to predict VO2 peak should not be
applied in these patients until further study is done. To our knowledge methods to predict
VO2 peak in burn children have not been previously described. However it is important to
note that this formula is specific for pediatric burns patients using the modified Bruce
protocol for the treadmill test.
In summary, using only a treadmill and easily gathered information such as patient
demographics, treadmill speed, and grade, this method of estimating VO2 peak can
significantly improve the ability of rehabilitation specialists in assessing fitness and
determining training levels in the initial assessment and while tracking progress of a patient
with severe burns.

Acknowledgments
We thank Fatemah Emdad, PhD for her collaboration in the statistical analyses; Serina J. McEntire, PhD for her
outstanding job at the Wellness Center. This study was partially supported by grants from the National Institute for
Disabilities and Rehabilitation Research H133A70019 and H133A070026; the National Institutes of Health RO1HD049471, T32-GM08256 and P50 GM060338-08S1; and Shriners Hospitals for Children grant 8760.

References
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7. Suman OE, Herndon DN. Effects of cessation of a structured and supervised exercise conditioning
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Figure 1.

R-Squares that guide the variable selection using McHenrys selection algorithm. Letters
denote the different selection of variable combinations.

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Figure 2.

Predicted peak oxygen consumption (VO2 peak) vs measured VO2 peak, based on the
prediction equation VO2=10.33 0.62 *Age (years) + 1.88 * Treadmill Time (min) + 2.3
(gender) for burn children in the model development group. For gender assigned values are
1 for males and 0 for females.

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Figure 3.

Predicted peak oxygen consumption (VO2 peak) vs measured VO2 peak, based on the
prediction equation VO2=10.33 0.62 *Age (years) + 1.88 * Treadmill Time (min) + 2.3
(gender) for burn children for the validation group. For gender assigned values of 1 for
males and 0 for females were assigned[5].

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3.4
14
179
55
41

Speed (mph)

Grade (%)

HR (bpm)

%TBSA

3rd BSA
3.28

2.03

2.42

0.23

0.10

0.33

2.99

2.63

0.51

42

59

175

13

3.2

13

49

151

27M/7F

13

4.09

2.64

3.09

0.77

0.17

0.83

3.66

3.42

0.56

<0.0001

0.04

0.0003

P Value (if <0.05)

Values shown as mean SEM. (TBSA) is abbreviation for total body surface area; (BSA) body surface area; (n), number of subjects. Both groups were similar in gender, age, %TBSA, %3rd degree burn,
height, weight, treadmill time, speed, grade, and heart rate. P value refers to significance of variable as a predictor.

14

Treadmill Time (min)

147

Height (cm)
44

27M/15F

Sex

Weight (Kg)

12

SEM

Average

Average

SEM

Validation (N=33)

Model Development (N=42)

Age (yrs)

Demographic

Shows demographic characteristics of two groups of patients 6 month post injury

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Table 1
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