如何对成人心肺运动试验进行全面认识

2022-01-19 刘少飞 MedSci原创

不明原因的劳累性呼吸困难或疲劳可由一些潜在的疾病引起,并且与静止的功能或影像学测试只有微弱的相关性。无创心肺运动测试为同时研究心肺和代谢变化提供了一个独特的、但仍未得到充分利用和认可的机会。

"在医学上,很可能没有任何测试能像心肺运动测试那样,在区分引起运动不耐受症状的广泛疾病方面提供信息和成本效益。如果没有它,对运动不耐受患者的评估可能会因医生的特定亚专业而过于狭窄"。

心肺运动测试(CPET)是一种最大限度的运动测试,同时进行气体交换分析,对运动的生理反应和心肺功能进行综合和全面的评估。与运动心电图相比,在休息和运动时直接无创地测定分钟通气量、心率和呼出气体分析(吸氧量和二氧化碳输出量),可提供关于通气、气体交换、心血管和肌肉骨骼功能相互作用的准确和可重复的数据,并能确定是否偏离正常。

使用CPET检测这些器官系统功能能力的异常,这些异常被放大或只在运动时出现(如冠状动脉疾病[CAD]、右向左分流[R-L分流]),并帮助确定运动受限的病理生理学。值得注意的是,患者报告的症状或陈述的运动不耐受程度与静息功能和影像学检查仅有一定的相关性。因此,CPET在确定运动不耐受的来源、监测疾病的发展、评估治疗反应和提供预后信息方面特别有价值。

CPET的适应症有很多。其中最常见的包括:

1. 确定运动性呼吸困难、运动不耐受或运动引起的低氧血症的原因和严重程度。

2. 评估运动能力和估计各种疾病状态下的预后(包括慢性心力衰竭)。

3. 评估围手术期和手术后的并发症风险(例如,胸腔、心脏和内脏手术;手术和支气管镜下的肺容积缩小)。

4. 心血管、肺血管和肺部疾病以及肌肉骨骼疾病的早期检测和风险分层。

5. 测量对治疗(如药物、康复)的反应。

6. 指导和监测康复(如心脏、肺部)以及预防和运动医学中的个人体育训练。

7. 评估职业医学中个人最大和持续运动能力的限制/损害。

CPET提供了一个客观和可重复的机会,以确定一个人为什么抱怨劳累性呼吸困难并量化运动能力的限制。它不仅可以帮助区分肺部、肺血管和心血管疾病,而且还可以揭开潜在的、往往是复杂的机制。因此,在病人接受广泛的诊断工作之前,应进行CPET,在休息状态下寻找运动时发生的异常。CPET可能比医学上的任何其他测试涵盖了更广泛的潜在鉴别诊断,而且也可能具有成本效益,因为它可以指导诊断并促进治疗决策。此外,许多病人认为CPET是他们临床检查中非常有用的一部分。这都表明,CPET应该更频繁地使用,特别是在常规使用中,时间的支出,如与运动心电图相比,是很低的。此外,CPET的诊断价值明显超过非鉴别性的运动表现测试(运动心电图、6分钟步行测试等,不提供运动耐力的信息),因为预后重要的关键变量可以通过同时测量通气性气体交换来确定,即使是在亚最大运动水平。然而,由于各种原因,如费用、缺乏专业知识或报销等,这种全球性的心肺参考测试越来越有可能从门诊专科医疗中消失。这种不一致性的部分原因是,CPET声明可能被认为是复杂的,而且往往不能提供实用的、易于理解的指导。CPET可以被看作是一个复杂的测试(基于它所提供的独特的丰富信息),但不一定是一个困难的工具,可以由非专业人员很好地执行。然而,对于那些有兴趣学习如何分析和解释CPET结果的人来说,缺乏一个紧凑和容易获得的介绍,可能会限制这种强大的参考方法的广泛使用。因此,CPET应该在临床上得到推广,培训应该成为呼吸系统专科医学培训的一个必修内容。在这方面,德国心血管研究中心的CPET标准操作程序示例建议,最初在指导下应用5次CPET,随后在监督下独立进行和解释至少20次CPET。虽然这个介绍并不全面,但我们试图为参与CPET的执行和解释的人提供一个实用的指南,并鼓励在指示的情况下更多地使用这种专业的参考检查。

参考文献:

Glaab T, Taube C. Practical guide to cardiopulmonary exercise testing in adults. Respir Res. 2022 Jan 12;23(1):9. doi: 10.1186/s12931-021-01895-6. PMID: 35022059; PMCID: PMC8754079.

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    2022-07-07 aids222
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    2022-02-18 胡国宏
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    2022-01-19 屋顶瞄爱赏月

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