Cardiopulmonary Exercise Testing In Children Research Articles

Cardiopulmonary Exercise Testing in Children and Adolescents with Repaired Tetralogy of Fallot: Mechanisms of Exercise Intolerance and Clinical Implications

Cardiopulmonary Exercise Testing in Children and Adolescents with Repaired Tetralogy of Fallot: Mechanisms of Exercise Intolerance and Clinical Implications

Cardiopulmonary Exercise Testing in Children With Long COVID: A Case-controlled Study.

Cardiopulmonary exercise testing (CPET) is a noninvasive and nonexpensive diagnostic tool, that provides a comprehensive evaluation of the pulmonary, cardiovascular, and skeletal muscle systems' integrated reactions to exercise. CPET has been extensively used in adults with Long COVID (LC), while the evidence about its role in children with this condition is scarce. Prospective, case-controlled observational study. Children with LC and a control group of healthy children underwent CPET. CPET findings were compared within the 2 groups, and within the LC groups according to main clusters of persisting symptoms. Sixty-one children with LC and 29 healthy controls were included. Overall, 90.2% of LC patients (55 of 61) had a pathologic test vs 10.3% (3/29) of the healthy control. Children with LC presented a statistically significant higher probability of having abnormal values of peak VO2 ( P = 0.001), AT% pred ( P <0.001), VO2/HR % ( P = 0.03), VO2 work slope ( P = 0.002), VE/VCO2 slope ( P = 0.01). The mean VO2 peak was 30.17 (±6.85) in LC and 34.37 (±6.55) in healthy patients ( P = 0.007). Compared with healthy controls, children with LC have objective impaired functional capacity (expressed by a low VO2 peak), signs of deconditioning and cardiogenic inefficiency when assessed with CPET. As such, CPET should be routinely used in clinical practice to objectify and phenotype the functional limitations of children with LC, and to follow-up them.

Practical Aspects of Cardiopulmonary Exercise Testing in Children.

The use of cardiopulmonary exercise testing (CPET) in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Furthermore, CPET helps evaluate exercise performance in children with chronic (lung/heart) diseases. For instance, it can ascertain any adverse reaction to exercise and estimate the effects of specific treatment measures. It affords a global assessment of the pathophysiological patterns, responses and abnormalities to exercise that is inadequately reflected by resting lung function and/or cardiac function assessment. Clinical interpretation of the results of a CPET in pediatrics requires specific knowledge regarding pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child's medical condition or disability.

A Systematic Approach for the Interpretation of Cardiopulmonary Exercise Testing in Children with Focus on Cardiovascular Diseases

Cardiopulmonary exercise testing (CPET) is the clinical standard for children with congenital heart disease (CHD), heart failure (HF) being assessed for transplantation candidacy, and subjects with unexplained dyspnea on exertion. Heart, lung, skeletal muscle, peripheral vasculature, and cellular metabolism impairment frequently lead to circulatory, ventilatory, and gas exchange abnormalities during exercise. An integrated analysis of the multi-system response to exercise can be beneficial for differential diagnosis of exercise intolerance. The CPET combines standard graded cardiovascular stress testing with simultaneous ventilatory respired gas analysis. This review addresses the interpretation and clinical significance of CPET results with specific reference to cardiovascular diseases. The diagnostic values of commonly obtained CPET variables are discussed using an easy-to-use algorithm for physicians and trained nonphysician personnel in clinical practice.

Cardiopulmonary Exercise Testing in Children and Young Adolescents after a Multisystem Inflammatory Syndrome: Physical Deconditioning or Residual Pathology?

Multisystem inflammatory syndrome in children (MIS-C) is a serious health condition that imposes a long-term follow-up. The purpose of our pilot study is to evaluate the usefulness of the cardiopulmonary stress test (CPET) in the follow-up after MIS-C. All patients admitted for MIS-C in our hospital in the 12 months preceding the date of observation were considered for inclusion in the study. Pre-existing cardio-respiratory diseases and/or the lack of collaboration were the exclusion criteria. At enrolment, each subject passed a cardiological examination, rest ECG, echocardiogram, 24 h Holter-ECG, blood tests, and a CPET complete of spirometry. A total of 20 patients met the inclusion criteria (11.76 ± 3.29 years, 13 male). In contrast to the normality of all second-level investigations, CPET showed lower-than-expected peakVO2 and peak-oxygen-pulse values (50% of cases) and higher-than-expected VE/VCO2-slope values (95% of cases). A statistically significant inverse correlation was observed between P-reactive-protein values at admission and peakVO2/kg values (p = 0.034), uric acid values at admission, and peakVO2 (p = 0.011) or peak-oxygen-pulse expressed as a percentage of predicted (p = 0.021), NT-proBNP values at admission and peakVO2 expressed as a percentage of predicted (p = 0.046). After MIS-C (4-12 months) relevant anomalies can be observed at CPET, which can be a valuable tool in the follow-up after this condition.

Cardiopulmonary exercise testing in children with congenital heart disease

Exercise capacity assessment in patients with congenital heart disease (CHD) is essential for cardiovascular adaptation and is a key parameter in quality of life assessment. In daily practice, the majority of tests are performed at rest, and some even require sedation. Cardiopulmonary exercise testing (CPET) allows the assessment of the patient's haemodynamic status during exercise and provides important information about heart rate, rhythm, ST-segment analysis, arterial pressure, and parameters such as oxygen consumption, oxygen pulse and the ratio of minute ventilation to carbon dioxide produced, which helps to describe in detail the physiology of the patient in a dynamic state. This allows for assessment of aerobic capacity and helps to distinguish the causes of its limitation - cardiovascular, pulmonary or deconditioning. Objectification of exercise capacity provides a basis for better decision-making regarding follow-up plans, exercise recommendations and future interventions. This review will discuss in detail CPET and its implementation in children with CHD.

Cardiopulmonary Exercise Testing in Children and Adolescents

Cardiopulmonary Exercise Testing in Children and Adolescents

Correlation of anthropometric index and cardiopulmonary exercise testing in children with pectus excavatum

BackgroundCardiopulmonary exercise testing (CPET) is a method used to evaluate functional impairment of patients with various diseases. ObjectiveThe objective was to use CPET to estimate the usability of anthropometric index (AI) in patients with pectus excavatum (PE) as a marker of functional impairment caused by chest deformity. MethodsThe study included 32 paediatric patients (28 males) with PE. Patients underwent CPET using a breath-by-breath exhaled gas analysis method and continuous monitoring of cardiac parameters. ResultsIn both groups, two (overall four) patients met criteria for cardiogenic limitation (low VO2 and low O2Pulse). Mean VO2/WR was below two standard deviations (2SD) in patients with less severe PE; other observed parameters were within normal limits (Z-score ± 2 SD). The AI had no observed correlation with peak ventilation, VO2peak and peak workload. ConclusionThe obtained CPET data do not correlate well with the severity of chest deformity expressed with AI. There were similar physical activity limitations in both examined groups of patients and they did not depend on the severity of the deformity.

Abstract 13065: Blood Pressure Response to Treadmill Cardiopulmonary Exercise Testing in Children With Normal Hearts

Background: Blood pressure (BP) response to the treadmill cardiopulmonary exercise test (CPET) has yet been studied with no standard criteria for abnormal BP responses in children. Our hypothesis was that the reference values of BP responses to the treadmill CPET should be defined by gender and age in children. Objectives: The objective of our study was to describe the BP responses to the treadmill CPET and propose the criteria for abnormal BP responses in children. Methods: The treadmill CPET data were retrospectively analyzed to evaluate the BP responses to exercise during the period of 8 years (2011-2018). Children aged &lt;18 years with normal hearts were included for the analysis. Results: Our cohort consisted of 1,085 children (males 59%) aged 7-17 years. The analysis of variance for Systolic BP at peak exercise (peak SBP) and change (Δ) of SBP showed significant age and gender effects and age-gender interaction effect ( p &lt;0.01). In the multiple linear regression model ( p &lt;0.001), peak SBP (mmHg) was predicted as 100.39 + 4.68 x age (years) for males; 132.27 + 1.37 x age (years) for females. The following criteria for abnormal BP responses in children were proposed. Hypertensive BP response were defined by peak SBP &gt;90% confidence interval upper limit of reference values based on age and gender. Blunted BP response was defined by 1) ΔSBP &lt;10 mmHg for age 7-11 years and &lt;20 mmHg for age 12-17 years in males; and ΔSBP &lt;10 mmHg in females. Conclusion: Blood Pressure response to the treadmill CPET was dependent on age and gender in children with normal hearts. The proposed criteria for abnormal BP responses in children should prove useful in interpreting BP responses in children during the CPET.

New Reference Values for Cardiopulmonary Exercise Testing in Children-Corrigendum.

New Reference Values for Cardiopulmonary Exercise Testing in Children-Corrigendum.

DOZ047.28: Clinical utility of cardiopulmonary exercise testing in children with esophageal atresia

Abstract Background Respiratory morbidity in children with esophageal atresia/tracheoesophageal fistula (OA/TOF), due to impaired mucociliary clearance, recurrent infections, and aspiration, may impair pulmonary function during childhood and this may persist into adult life. Early recognition of reduced lung function could optimize respiratory management and improve long-term outcomes. However, static lung function assessments, using spirometry and body plethysmography, may not sensitively identify impaired lung function. Cardiopulmonary exercise testing (CPET), which involves a dynamic assessment of respiratory function and determines aerobic capacity, degree of fitness, and ventilatory (breathing) reserve during maximal exertion, may detect poor lung function earlier. Aim This study determines the clinical utility of cardiopulmonary exercise testing in children with OA/TOF. Methods Retrospective chart review of children attending a multidisciplinary OA/TOF clinic who underwent spirometry, plethysmography, and a maximal CPET (Bruce Treadmill Protocol). Plethysmography and CPET were performed on the same day in 16 children; 4 children within 2 days and 6 within 2 months. Studies exceeding 2 months were not analyzed (n = 2). Results Thirty-nine children, aged ≥ 7 years, underwent CPET when clinically well. Thirty-two children, 7–18 years, achieved a maximal CPET (82.1%). There was no significant exercise-induced drop in PPFEV1 in any child. One child experienced a reduction in oxygen saturation to 92%. Exercise capacity (VO2MAX, peak oxygen consumption) was normal in 30 children (93.8%). However reduced ventilatory or breathing reserve (BR), defined as &lt;20% predicted, was identified in 18 children (56.3%). Four of these children had no ventilatory reserve (BR = 0). In contrast, spirometry was normal in 20 children (62.5%). Nine (28%) had a mild obstructive or restrictive pattern. One child had moderate restriction and 2 had a mixed pattern. Plethysmography (n = 26) revealed mild restrictive lung disease in 9 (34.6%). An additional 3 children had air-trapping. Conclusion Children with OA/TOF have significant lung function impairment. Spirometry and plethysmography revealed normal or mildly abnormal airway function/lung volumes in the majority of children. CPET identified significant ventilation limitation in over half of all children. CPET assessment is a feasible and sensitive assessment of cardiorespiratory function in children with OA/TOF. Further evaluation of risk factors and longitudinal CPET assessments may inform future management guidelines.

Exercise Science and Child Health: A Tale of Many Journeys.

Children are the most naturally physically active human beings; reduced physical activity is a cardinal sign of childhood disease, and exercise testing provides mechanistic insights into health and disease that are often hidden when the child is at rest. The physical inactivity epidemic is leading to increased disease risk in children and, eventually, in adults in unprecedented ways. Cardiopulmonary exercise testing (CPET) biomarkers are used to assess disease severity, progress, and response to therapy across an expanding range of childhood diseases and conditions. There is mounting data that fitness in children tracks across the life span and may prove to be an early, modifiable indicator of cardiovascular disease risk later in life. Despite these factors, CPET has failed to fulfill its promise in child health research and clinical practice. A major barrier to more accurate and effective clinical use of CPET in children is that data analytics and testing protocols have failed to keep pace with enabling technologies and computing capacity. As a consequence, biomarkers of fitness and physical activity have yet to be widely incorporated into translational research and clinical practice in child health. In this review, the author re-examines some of the long-held assumptions that mold CPET in children. In particular, the author suggests that current testing strategies that rely predominantly on maximal exercise may, inadvertently, obfuscate novel and clinically useful insights that can be gleaned from more comprehensive data analytics. New pathways to discovery may emanate from the simple recognition that the physiological journey that human beings undertake in response to the challenge of exercise may be far more important than the elusive destination of maximal or peak effort.

Cardiopulmonary exercise testing in children and adolescents

In cardiopulmonary exercise testing with children and adolescents, age specific protocols are used together with tools adjustable to their body dimension and development. Assessing weight, height und pubertal stage is a prerequisite for the interpretation of every test. Indications for exercise testing are airway symptoms and findings limited performance, chronic diseases, planning of trainings and scientific studies. The more tests are standardized and used on a large scale, the more normal values are available to compare individual results. However, the interindividual variability of measured values is high, depending as much from the developmental stage of the individual as from protocols, tools and the performing laboratory. Tests are mainly incremental step or ramp tests, test duration should not exceed 10–12 min

New Reference Values for Cardiopulmonary Exercise Testing in Children.

Cardiopulmonary exercise testing is an essential tool to assess cardiorespiratory fitness (CRF) in children. There is a paucity of adequate pediatric reference values that are independent of body size and pubertal stage. The purpose of this study is to provide Z score equations for several maximal and submaximal CRF parameters derived from a prospectively recruited sample of healthy children. In this cross-sectional multicenter study, we prospectively recruited 228 healthy children 12 to 17 yr old in local schools. We performed a symptom-limited cardiopulmonary exercise testing progressive ramp protocol on an electronically braked cycle ergometer. Eighteen CRF parameters were analyzed. We tested several regression models to obtain prediction curves that minimized residual association with age, body size, and pubertal stage. Both the predicted mean and the predicted SD were modeled to account for heteroscedasticity. We identified nonlinear association of CRF parameters with body size and significant heteroscedasticity. To normalize CRF parameters, the use of a single body size variable was not sufficient. We therefore used multivariable models with various combination of height, corrected body mass, and age. Final prediction models yielded adjusted CRF parameters that were independent of age, sex, body mass, height, body mass index, and Tanner stages. We present Z score equations for several CRF parameters derived from a healthy pediatric population. These reference values provide updated predicted means and range of normality that are independent of sex and body size. Further testing is needed to assess if these reference values increase sensitivity and specificity to identify abnormal cardiorespiratory response in children with chronic diseases.

Cardiopulmonary exercise testing in children with cystic fibrosis: one centre's experience

BackgroundWhile exercise testing is increasingly used as a prognostic indicator in cystic fibrosis (CF), it is reported to be underused in UK CF centres, particularly in children. Here, we evaluated...

Relationship Between Habitual Exercise and Performance on Cardiopulmonary Exercise Testing Differs Between Children With Single and Biventricular Circulations.

Increasing habitual exercise has been associated with improved cardiopulmonary exercise testing (CPET) performance, specifically maximal oxygen consumption in children with operatively corrected congenital heart disease. This has not been studied in children following Fontan palliation, a population in whom CPET performance is dramatically diminished. A single-center cross-sectional study with prospective and retrospective data collection was performed that assessed habitual exercise preceding a clinically indicated CPET in children and adolescents with Fontan palliation, transposition of the great arteries following arterial switch operation (TGA), and normal cardiac anatomy without prior operation. Data from contemporaneous clinical reports and imaging studies were collected. The association between percent predicted VO2max and habitual exercise duration adjusted for known covariates was tested. A total of 175 subjects (75 post-Fontan, 20 with TGA, and 80 with normal cardiac anatomy) were enrolled. VO2max was lower in the Fontan group than patients with normal cardiac anatomy (p<0.0001) or TGA (p<0.0001). In Fontan subjects, both univariate and multivariate analysis failed to demonstrate a significant association between habitual exercise and VO2max (p=0.6), in sharp contrast to cardiac normal subjects. In multivariate analysis, increasing age was the only independent risk factor associated with decreasing VO2max in the Fontan group (p=0.003). Habitual exercise was not associated with VO2max in subjects with a Fontan as compared to biventricular circulation. Further research is necessary to understand why their habitual exercise is ineffective and/or what aspects of the Fontan circulation disrupt this association.

Cardiopulmonary Exercise Testing in Children and Adolescents with High Body Mass Index

Consensus has yet to be achieved on whether obesity is inexorably tied to poor fitness. We tested the hypothesis that appropriate reference of cardiopulmonary exercise testing (CPET) variables to lean body mass (LBM) would eliminate differences in fitness between high-BMI (≥ 95th percentile, n = 72, 50% female) and normal-BMI (< 85th percentile, n = 142, 49% female), otherwise-healthy children and adolescents typically seen when referencing body weight. We measured body composition with dual x-ray absorptiometry (DXA) and CPET variables from cycle ergometry using both peak values and submaximal exercise slopes (peak VO2, ΔVO2/ΔHR, ΔWR/ΔHR, ΔVO2/ΔWR, and ΔVE/ΔVCO2). In contrast to our hypothesis, referencing to LBM tended to lessen, but did not eliminate, the differences (peak VO2 [p < .004] and ΔVO2/ΔHR [p < .02]) in males and females; ΔWR/ΔHR differed between the two groups in females (p = .041) but not males (p = .1). The mean percent predicted values for all CPET variables were below 100% in the high-BMI group. The pattern of CPET abnormalities suggested a pervasive impairment of O2 delivery in the high-BMI group (ΔVO2/ΔWR was in fact highest in normal-BMI males). Tailoring lifestyle interventions to the specific fitness capabilities of each child (personalized exercise medicine) may be one of the ways to stem what has been an intractable epidemic.

Reference values for cardiopulmonary exercise testing in children and adolescents in northwest Croatia

Reference values for cardiopulmonary exercise testing in children and adolescents in northwest Croatia

Feasibility and safety of cardiopulmonary exercise testing in children with pulmonary hypertension.

Cardiopulmonary exercise testing helps prognosticate and guide treatment in adults with pulmonary hypertension. Concerns regarding its feasibility and safety limit its use in children with pulmonary hypertension. We aimed to assess the feasibility and safety of cardiopulmonary exercise testing in a large paediatric pulmonary hypertension cohort. We reviewed all consecutive cardiopulmonary exercise tests performed between March, 2004 and November, 2013. The exclusion criteria were as follows: height <120 cm, World Health Organization class IV, history of exercise-induced syncope, or significant ischaemia/arrhythmias. Significant events recorded were as follows: patient-reported symptoms, arrhythmias, electrocardiogram abnormalities, and abnormal responses of arterial O2 saturation. A total of 98 children underwent 167 cardiopulmonary exercise tests. The median age was 14 years (inter-quartile range 10-15 years). Peak oxygen uptake was 20.4±7.3 ml/kg/minute, corresponding to 51.8±18.3% of the predicted value. Peak respiratory quotient was 1.08±0.16. All the tests except two were maximal, being terminated prematurely for clinical reasons. Baseline Oxygen saturation was 93.3±8.8% and was 81.2±19.5% at peak exercise. A drop in arterial O2 saturation >20% was observed in 23.5% of the patients. Moreover, five patients (3.0%) experienced dizziness, one requiring termination of cardiopulmonary exercise testing; five children (3.0%) experienced chest pain, with early cardiopulmonary exercise test termination in one patient. No significant arrhythmias or electrocardiogram changes were observed. Exercise testing in non-severely symptomatic children with pulmonary hypertension is safe and practical, and can be performed in a large number of children with pulmonary hypertension in a controlled environment with an experienced team. Side-effects were not serious and were resolved promptly with test termination.

WS21.6 Prognostic value of breathing reserve index at anaerobic threshold during cardiopulmonary exercise testing in children with cystic fibrosis

Objectives Cardiopulmonary exercise test (CPET) testing is the gold standard exercise test in CF. Elevated breathing reserve index at anaerobic threshold (BRIAT) is a prognostic indicator of mortality in CF adults awaiting transplant, but no data on BRIAT in the paediatric CF population are reported. The aim of this study was to investigate the relationship between BRIAT and morbidity (death or transplant) in children with CF. Methods 39 children with CF with CPET testing data from 2005–2006 at Great Ormond Street Hospital were studied in 2014 as part of a retrospective study on exercise testing. Mortality and morbidity were ascertained. BRIAT was calculated as ratio of exercise minute ventilation at AT versus predicted maximal voluntary ventilation (VE at AT/MVV), and categorised into tertiles (low 0.42). Results Data from a subset of children (n = 17) (mean age 11.8 years, 47% male, mean FEV1 73.1%predicted) were analysed at 6 year follow-up. Six subjects (35%) had died or undergone lung transplantation whilst 11 (65%) were still alive. A significant difference in mean(SD) BRIAT in those who were alive at 6 years follow up [0.44(0.11)] compared to the death/transplant group [0.32(0.06)] was noted (p 0.42) had a higher death/transplant rate (40%) compared with those in the low BRIAT tertile (3%) (p = 0.02, logrank test). Conclusion Data from this study suggest that elevated BRIAT is associated with worse outcome in children with CF. BRIAT may be a useful measure of ventilatory limitation and a potential prognostic indicator in children with CF.