ALAT
: alanine aminotransferase
ASAT
: aspartate aminotransferase
APAH
: associated pulmonary arterial hypertension
BAS
: balloon atrial septostomy
BMPR2
: bone morphogenetic protein receptor 2
BNP
: brain natriuretic peptide
BPA
: balloon pulmonary angioplasty
BREATHE
: Bosentan

/pdf/2015-esc-ers-guidelines-for-the-diagnosis-and-treatment-of-y26yabnnom.pdf

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).

SERIES “ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING” 

Edited by V. Brusasco, R. Crapo and G. Viegi 

Number 5 in this Series 







This section is written to provide guidance in interpreting pulmonary function tests (PFTs) to medical directors of hospital-based laboratories that perform PFTs, and physicians who are responsible for interpreting the results of PFTs most commonly ordered for clinical purposes. Specifically, this section addresses the interpretation of spirometry, bronchodilator response, carbon monoxide diffusing capacity ( D L,CO) and lung volumes.

The sources of variation in lung function testing and technical aspects of spirometry, lung volume measurements and D L,CO measurement have been considered in other documents published in this series of Task Force reports 1–4 and in the American Thoracic Society (ATS) interpretative strategies document 5.

An interpretation begins with a review and comment on test quality. Tests that are less than optimal may still contain useful information, but interpreters should identify the problems and the direction and magnitude of the potential errors. Omitting the quality review and relying only on numerical results for clinical decision making is a common mistake, which is more easily made by those who are dependent upon computer interpretations.

Once quality has been assured, the next steps involve a series of comparisons 6 that include comparisons of test results with reference values based on healthy subjects 5, comparisons with known disease or abnormal physiological patterns ( i.e. obstruction and restriction), and comparisons with self, a rather formal term for evaluating change in an individual patient. A final step in the lung function report is to answer the clinical question that prompted the test.

Poor choices made during these preparatory steps increase the risk of misclassification, i.e. a falsely negative or falsely positive interpretation for a lung function abnormality or a change …

https://erj.ersjournals.com/content/erj/26/5/948.full.pdf

Interpretative strategies for lung function tests

Lung volumes are subdivided into static and dynamic lung volumes. Static lung volumes are measured by methods which are based on the completeness of respiratory manoeuvres, so that the velocity of the manoeuvres should be adjusted accordingly. The measurements taken during fast breathing movements are described as dynamic lung volumes and as forced inspiratory and expiratory flows.

### 1.1 Static lung volumes and capacities

The volume of gas in the lung and intrathoracic airways is determined by the properties of lung parenchyma and surrounding organs and tissues, surface tension, the force exerted by respiratory muscles, by lung reflexes and by the properties of airways. The gas volumes of thorax and lung are the same except in the case of a pneumothorax. If two or more subdivisions of the total lung capacity are taken together, the sum of the constituent volumes is described as a lung capacity. Lung volumes and capacities are described in more detail in § 2.

#### 1.1.1 Determinants

Factors which determine the size of the normal lung include stature, age, sex, body mass, posture, habitus, ethnic group, reflex factors and daily activity pattern. The level of maximal inspiration (total lung capacity, TLC) is influenced by the force developed by the inspiratory muscles (disorders include e.g. muscular dystrophy), the elastic recoil of the lung (disorders include e.g. pulmonary fibrosis and emphysema) and the elastic properties of the thorax and adjacent structures (disorders include e.g. ankylosis of joints). The level of maximal expiration (residual volume, RV) is determined by the force exerted by respiratory muscles (disorders include e.g. muscle paralysis), obstruction, occlusion and compression of small airways (disorders include e.g. emphysema) and by the mechanical properties of lung and thorax (disorders include diffuse fibrosis, kyphoscoliosis).

Assessing the total lung capacity is indispensable in establishing a restrictive ventilatory defect or in diagnosing abnormal lung distensibility, as may occur in patients …

Lung volumes and forced ventilatory flows

Excess CO2 is generated when lactate is increased during exercise because its [H+] is buffered primarily by HCO-3 (22 ml for each meq of lactic acid). We developed a method to detect the anaerobic threshold (AT), using computerized regression analysis of the slopes of the CO2 uptake (VCO2) vs. O2 uptake (VO2) plot, which detects the beginning of the excess CO2 output generated from the buffering of [H+], termed the V-slope method. From incremental exercise tests on 10 subjects, the point of excess CO2 output (AT) predicted closely the lactate and HCO-3 thresholds. The mean gas exchange AT was found to correspond to a small increment of lactate above the mathematically defined lactate threshold [0.50 +/- 0.34 (SD) meq/l] and not to differ significantly from the estimated HCO-3 threshold. The mean VO2 at AT computed by the V-slope analysis did not differ significantly from the mean value determined by a panel of six experienced reviewers using traditional visual methods, but the AT could be more reliably determined by the V-slope method. The respiratory compensation point, detected separately by examining the minute ventilation vs. VCO2 plot, was consistently higher than the AT (2.51 +/- 0.42 vs. 1.83 +/- 0.30 l/min of VO2). This method for determining the AT has significant advantages over others that depend on regular breathing pattern and respiratory chemosensitivity.

A new method for detecting anaerobic threshold by gas exchange

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk/benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition.

Unpublished clinical trial results are not taken into account. A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in Tables 1 and 2 .

View this table:

Table 1 
Classes of recommendations



View this table:

Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise …

/pdf/guidelines-for-the-diagnosis-and-treatment-of-pulmonary-4pfz1dw03n.pdf

Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)

Principles of Exercise Testing and Interpretation, 5/e - Libros de Medicina - Patologia - 139,00

Principles of Exercise Testing and Interpretation

WASSERMAN, KARLMAN, BRIAN J. WHIPP, SANKAR IX KOYAL, AND WILLIAM L. BEAVER. Anaerobic threshold and respiratory gas exchange during exercise. J. Appl. Physiol. 35(Z): 236-243. 1973.-Alterations in gas exchange were studied in man during exercise increasing in increments of 15 w each minute, to determine the noninvasive indicators of the onset of metabolic acidosis (anaerobic metabolism). Expired airflow and CO 2 and 0 2 tensions at the mouth during the breath were continuously monitored with rapid1 y responding gas analyzers. These measurements were recorded directly as well as processed by a minicomputer, on-line, to give minute ventilation (VE), COP production #co& 02 consumption (voz), and the gas exchange ratio (R), breath-by-breath. The anaerobic threshold (AT) could be identified by the point of I) nonlinear increase in VE, 2) nonlinear increase in Vco2, 3) an increase in end-tidal 02 without a corresponding decrease in endtidal COz, and 4) an increase in R, as work rate was increased during an incremental exercise test. Of these measurements, R was found least sensitive. The AT was determined in 85 normal subjects between 17 and 91 years of age, by these techniques. The lower limit of normal was 45 w (KTo 2 = 1 liter/min), while values for very fit normal adults were as high as 180 w. The patients studied with cardiac disease above functional class I have lower anaerobic thresholds than the least fit normal subjects. The I-min incremental work rate test is associated with changes in gas exchange which can be used as sensitive on-line indicators of the AT, thus bypassing the need for measuring arterial lactate or acid-base parameters to indicate anaerobiosis.

Anaerobic threshold and respiratory gas exchange during exercise.

The measurement of the respiratory gas exchange ratio (R) during a standard exercise test is used to detect the onset of anaerobic metabolism during exercise, which results from failure of the cardiovascular system to supply the oxygen requirements of the tissues. The method described uses end-tidal gas concentrations to calculate R while the exercise test is taking place. Blood sampling is unnecessary, and the results can be determined during the test, thus avoiding exhaustive exercise. The method provides an objective measurement of one of the factors influencing exercise tolerance.

Detecting the threshold of anaerobic metabolism in cardiac patients during exercise

Following thorough evaluation at rest, 265 of 400 current or ex-shipyard workers rode a cycle ergometer with equal work increments each minute to exhaustion while continuous multiple noninvasive cardiorespiratory measures and intermittent intra-arterial blood pressure and blood gas measures were made. Seventy-seven men, with a mean age of 54, including some who were smokers, obese, or hypertensive, were judged to have normal cardiorespiratory systems based on history, physical, electrocardiogram during rest and exercise, chest X-ray, pulmonary function tests, and exercise performance. Their responses to exercise are given. It was unusual to find at maximal exercise a breathing reserve less than 11 L/min, arterial PO2 less than 80 mm Hg, alveolar-arterial PO2 difference greater than 38 mm Hg, arterial-end tidal PCO2 difference greater than 1 mm Hg, respiratory frequency greater than 60, or a dead space/tidal volume ratio greater than 0.28. The normal anaerobic threshold/maximal O2 uptake ratio exceeded 40%. With maximal exercise, the intra-arterial systolic and diastolic pressures rose an average of 68 and 13 mm Hg, respectively. For predicting maximal oxygen uptake and oxygen pulse in an overweight man, we find it preferable to use age and height rather than age and weight.

Karlman Wasserman

Papers

A new method for detecting anaerobic threshold by gas exchange

Principles of Exercise Testing and Interpretation

Anaerobic threshold and respiratory gas exchange during exercise.

Detecting the threshold of anaerobic metabolism in cardiac patients during exercise

Predicted values for clinical exercise testing