2011 Focus Six min walk test .PPT - Foocus

The Six Minute Walk Test
What can be learned after just 6 minutes
Carl D. Mottram, BA RRT RPFT FAARC
Director - Pulmonary Function Labs and Rehabilitation
Associate Professor of Medicine - Mayo Clinic College of Medicine
Six minute walk - Background
• 12 minute field
performance test
• 115 military personnel
• Age: 17-52, mean 22 yrs
• 1 mile flat hard surface
course-mostly running
• Compared the data with
VO 2max
Six minute walk - Background
• 29 patients with chronic bronchitis
• 12 minute walk
• level enclosed hospital corridor
• cover as much ground as possible
• Compared O 2max , FVC, FEV 1 , Distance
walked
McGavin CR et al. BMJ 1 822-3, 1976

Six minute walk - Background
• 10 subjects
• 12 minute walks times 5
per subject
• Distance at two minute
intervals
• Conclusion: Six minute
walk would give you
information without over
tiring subject
Six minute walk- Background
• Guyatt GH
• Control group not
encouraged during walk
• Encouraged walk
• Conclusion: Statisically
significant difference inbetween
those subject
encouraged and those
not.
Six minute walk
• Advantages • Disadvantages
• Practical and inexpensive • Difficult to assess
• Requires no apparatus effort (e.g. HR, E )
• Adjust own pace and use • Reduced
breathing strategies monitoring
• Walking distance is more
clinically related to ADLs
• Objective & reproducible
outcome measurement

Six minute walk - Current Applications
• Exercise tolerance in patients with disease
(functional status)
• Natural history of disease (morbidity and
mortality)
• Pre and post medical intervention comparisons
• Medical intervention
• medication or rehab.
• Surgical intervention (Lung Tx, LVRS)
• Pacemaker
Six minute walk
Why was a Standard developed
Coached O 2 & mode HR RPE S PO 2 Hall
McGavin (1976) Y
Mungall (1979) Y
Butland (1982) Y
Guyatt (1984) Y Y
Bernstein (1994) Y Y Y
Cahalin (1995) N Y/N Y Y >80 Y
Cooper J. (1995)
Y/N
Peeters (1996) Y Y Y
Kotloff (1996) N >90
Mayo Y Y/Y Y Y Y Y
Six minute walk
Why was a Standard developed
• Intralaboratory
• Useful and cost effective tool in
monitoring exercise tolerance
• Interlaboratory
• Consensus on the protocol

Six Minute Mosey
Am J Resp Crit Care Med Vol 166. pp 111–117, 2002
Six minute walk
ATS Consensus Statement Am J Respir Crit Care Med Vol 166. pp 111–117, 2002
• Unobstructed level corridor, 30 meters or 100 ft
long or greater
• Start and end of course should be marked with tape
on floor
• Method to measure distance (e.g floor marks etc.)
• Suggest traffic cones at the end of course
• Use of a treadmill not recommended
• Stevens D. Am J Respir Crit Care Med 1999; 160:1540-1543
• Equipment
• Stopwatch, lap counter, Borg scale, chair,
worksheet and pulse oximeter

Six minute walk - ATSs Standard
Six minute walk - ATSs Standard
Six minute walk - ATSs Standard
• Subject preparation
• Comfortable clothing, light meal, usual
medications
• Pretest measurements
• Blood pressure
• ECG within last 6 months, no c/o angina
• Pulse oximetry (optional)
• Use oxygen if appropriate

Six minute walk - ATSs Standard
• Contraindications
• Absolute
• Unstable coronary disease
• Myocardial infarction within a month
• Relative
• Resting tachycardia > 120 beats/min
• Systolic BP > 180 mmHg
• Diastolic BP > 100 mmHg
• Syncope with exercise
Salzman Chest 2009
Six minute walk - ATSs Standard
• Safety issues
• Performed in a location where a rapid,
appropriate response to an emergency is
possible – crash cart, medications, phone
• Trained medical staff (RRT, RN, CPFT)
with BLS, although ACLS preferred
• If a patient is on oxygen use their
standard rate or as directed by a
physician or a protocol.
Six minute walk - ATSs Standard

Six minute walk - ATSs Standard
• Instruct patient to cover as much ground as
possible in the given time
• Coach and give encouragement
• Standard phases of encouragement
• Practice tests - controversial
• Document and monitor: O 2 flow, mode of
transport, rest and end-exercise S P O 2
• HR & RPE
Six minute walk - ATSs Standard
• Instruct patient to cover as much ground
as possible in the given time
• Coach and give encouragement
• Standard phases of encouragement
• You are doing well, you have 5 minutes to go
• You are doing well, you have 4 minutes to go
• You are doing well, youre half way done etc.
• Do not use other words of encouragement
Six minute walk - ATSs Standard

Six minute walk - Report
6-MINUTE WALK
Date Distance Inspired Gas Mode of O2 Transport SpO2 (end exer.) RPE (6-20)
(ft)
5/18/2002 1,173 3.0 L/min NC Pt. carried unit 90 17
7/26/2002 1,266 3.0 L/min NC Pt. carried unit 94 18
8/15/2002 1,420 2.5 L/min Pt. carried unit 92 17
Interpretation
• 117 healthy men and 173 healthy women, aged 40 -80
• The median distance walked was 576m (1889 ft) for
men and 494m (1620 ft) for women.
• Men = (7.57*ht) – (5.02*age) – 1.76*wt – 309m
• Women = (2.11*ht) – (2.29*wt) – (5.78*age) – 667m
AJRCCM 158; 1384-87 1998

• Minimal clinically important difference
(MCID) for the 6MWT is conservatively
estimated to be 54-80 m (~175-260 ft) using
both distributional and discriminative
methods.
• For an individual patient, the 6MWT would
need to change by about 86 m (280 ft) to be
statistically confident that there has been a
change.
• 460 COPD patients with a
mean FEV1 of 39.2 ±
14.1% predicted and
6MWD of 361 ± 112 m at
baseline.
• Distance should change by
~ 35 m for patients with
moderate to severe COPD
(10% change of baseline)
Eur Respir J 2008; 32: 637–643
Recent Literature

Chest / 135 /5 / May 2009
• Clinical and research role
• Technique
• Coding and reimbursement
Galeazzo IJCOPD August 2009
• 284 patients aged 41 to 86 years (mean age 69.4
years) divided into two groups
• study group (222 patients) undergoing a PR
program
• control group (62 patients) treated only with
drugs.
• 64% had an increase of at least 54 m in the 6MWT
whereas 13% in the control group
• Conclusion: PR is highly effective in improving the
exercise capacity of patients with COPD
• 42 patients post-lung transplant
• 29 performed 6MWT
• Results/Conclusions:
• Patients who walked > 330 m had a median survival of
1178 days versus 263 days for those who walked less
• 6MWD provides more accurate prognostic information
than the commonly used FEV1 or changes in the FEV1
over the 3 months post-BOS onset.

• 64 consecutive patients
with advanced NSCLC
• An initial 6MW 400 m
might be a useful
prognostic factor for
survival in patients with
advanced non-small cell
lung cancer.
• 115 PH patients
• Pulmonary arterial
pressure was 49 + 17
mm Hg
• PH patients with a
6MWD 399 m had a
significantly better
prognosis
Med. Sci. Sports Exerc., Vol. 40, No. 10, pp.
1725–1732, 2008
• 9 pts with NYHA Class II–IV PAH who
were stable on 2 months of sildenafil.
• Decreased by 100 meters

• 23 patients with heart failure
• EF 23±7%, were diagnosed as functional class
NYHA II-III
Am Heart J 2009;158:768
• 24 patients with HF and
reduced inspiratory
pressure (MIP < 70% pred)
• Conclusion: The addition of
inspiratory muscle strength
training to aerobic exericse
improves cardiorespiratory
responses to exercise in
selected patients with CHF
and IMW.
• 17 patients with dilated
cardiomyopathy,
moderate to severe
mitral regurgitation, EF
40%, and a 6-minute
walk distance between
150 and 450 m were
enrolled

Reimbursement
• AMA-CPT code 94620 – Simple Pulmonary Stress
Test
• Minnesotas CMS 2010 technical - $73.73
Case 1
• 28 y.o. male reports increased shortness
of breath
• Occupation: Works in a
manufacturing job, grinding carbide
• CXR ordered
Case 1
• Hard metal disease is a "giant cell interstitial
pneumonitis" that affects a small minority of
workers who manufacture or use high-speed
tungsten carbide saw tips, drill tips, or discs.
• Exposed to fume or dust from the cobalt
used as a binder in the cemented tungsten
carbide metal. Also known as cobalt lung
• Lung transplant 1 year later
• Six minute walk data:

Case 1
Case 2
• 64 y.o female with pulmonary fibrosis
• Evaluation for surgery for a elevated
left hemidiaphragm
• PFT and CXR ordered

Case 2
• Pulmonary rehab
ordered to improve
exercise tolerance
Keep on trucking!
Questions