Future directions

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It is likely that the scope of exercise testing in clinical practice will extend beyond diseases such as COPD, ILD, PPH and CHF in the future to include diseases whose prevalence is increasing and which often express exercise intolerance, such as the metabolic syndrome [55]. It is also likely that exercise testing will assume greater

Table 4. - Indications for cardiopulmonary exercise testing in clinical practice

Indication

Recommendation grade

Detection of exercise-induced bronchoconstriction

A

Detection of exercise-induced arterial oxygen desaturation

B

Functional evaluation of subjects with unexplained exertional dyspnoea and/or exercise

D

intolerance and normal resting lung and heart function

To recognise specific disease exercise response patterns that may help in the

C

differential diagnosis of ventilatory versus circulatory causes of exercise limitation

Functional and prognostic evaluation of patients with COPD

B, C

Functional and prognostic evaluation of patients with ILD

B, B

Functional and prognostic evaluation of patients with CF

C, C

Functional and prognostic evaluation of patients with PPH

B, B

Functional and prognostic evaluation of patients with CHF

B, B

Evaluation of interventions

Maximal incremental test

C

High-intensity constant work-rate "endurance" tests

B

Prescription of exercise training

B

With the use of this grading system, A is relatively rare and B is usually considered the best achievable. COPD: chronic obstructive pulmonary disease; ILD: interstitial lung disease; CF: cystic fibrosis; PPH: primary pulmonary hypertension; CHF: chronic heart failure. Reproduced from [4] with permission.

Table 5 - Indications for 6-min and shuttle walking tests in clinical practice

Indication

Recommendation grade

Diagnosis of exercise-induced arterial desaturation

B

Functional evaluation of patients with COPD, ILD, PPH and CHF

B

Prognostic evaluation of patients with COPD, ILD, PPH and CHF

B

Functional evaluation of patients with CF

C

Prognostic evaluation of patients with COPD or CHF prior to surgery (LVRS,

C

transplantation)

Evaluation of the benefits of therapeutic interventions (oxygen supplementation,

B

rehabilitation, surgery)

With the use of this grading system, A is relatively rare and B is usually considered the best achievable. COPD: chronic obstructive pulmonary disease; ILD: interstitial lung disease; PPH: primary pulmonary hypertension; CHF: chronic heart failure; CF: cystic fibrosis; LVRS: lung-volume reduction surgery. Reproduced from [4] with permission.

importance in improving the current understanding of the aetiology and management of particular disease processes, such as inflammation and cachexia.

A more widespead utilisation of walking tests in clinical practice is expected, not only because of their ease of implementation, but also because of the need to further investigate the physiological mechanisms responsible for the qualitatively different response profiles that have been demonstrated for walking and cycling in a range of diseases.

Although constant-WR endurance testing is a relatively recent addition to clinical research, its growing popularity among physicians and technicians working in pulmonary exercise laboratories suggests that the use of such protocols will extend beyond COPD and into many other patient populations. This is especially likely in the context of intervention assessment, with possibly greater emphasis being placed on walking-test protocols. Given the interpretational significance of the power-duration relationship in this context, it is likely that this will assume greater importance as a frame of rereference in clinical populations in addition to COPD [56, 57], encouraging the development of robust single-test estimators. In turn this will allow better definition of the critera for WR selection on such tests.

Finally, although little attention has been paid in the past to the analysis of the recovery phase of exercise in patients with lung and heart disease, recent data have been published on the possible utility of some recovery indices in patients with COPD and CHF [58-60]. This is an area which deserves more attention.

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