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CHAPTER 3 Pre-Exercise Evaluations 51cholesterol and in the kidneys to lower blood pressure. One should pay particularattention to liver function tests such as alanine transaminase (ALT), aspartatetransaminase (AST), and bilirubin as well as to renal (kidney) function tests suchas creatinine, glomerular filtration rate, blood urea nitrogen (BUN), and BUN/creatinine ratio in patients on such medications. Indication of volume depletion andpotassium abnormalities can be seen in the sodium and potassium measurements.These tests should be applied judiciously and not used as finite ranges of normal.PULMONARY FUNCTIONPulmonary function testing with spirometry is recommended for all smokersolder than age 45 years and in any person presenting with dyspnea (shortness ofbreath), chronic cough, wheezing, or excessive mucus production (5). Spirometryis a simple and noninvasive test that can be performed easily. Indications forspirometry are listed in Table 3.4. When performing spirometry, standards for theperformance of the test should be followed (9).Although many measurements can be made from a spirometric test, the mostcommonly used include the forced vital capacity (FVC), the forced expiratoryvolume in one second (FEV 1 ), and the FEV 1 /FVC ratio. Results from thesemeasurements can help to identify the presence of restrictive or obstructive respiratoryabnormalities, sometimes before symptoms or signs of disease are present.The FEV 1 /FVC is diminished with obstructive airway diseases [e.g.,asthma, chronic bronchitis, emphysema, and chronic obstructive pulmonarydisease (COPD)], but remains normal with restrictive disorders (e.g., kyphoscoliosis,neuromuscular disease, pulmonary fibrosis, and other interstitial lungdiseases).The Global Initiative for Chronic Obstructive Lung Disease has classified thepresence and severity of COPD as seen in Table 3.4 (12). The term COPD can be usedwhen chronic bronchitis, emphysema, or both are present, and the spirometry documentsan obstructive defect. A different approach for classifying the severity ofobstructive and restrictive defects has been taken by the American Thoracic Society(ATS) and European Respiratory Society (ERS) Task Force on Standardization ofLung Function Testing, as presented in Table 3.4 (13). This ATS/ERS Task Forceprefers to use the largest available vital capacity (VC), whether it is obtained oninspiration (IVC), slow expiration (SVC), or forced expiration (FVC). An obstructivedefect is defined by a reduced FEV 1 /VC ratio below the fifthpercentile of the predictedvalue. In contrast with using a fixed value for FEV 1 /VC or FEV 1 /FVC of 0.7as the dividing line between normal and abnormal, the use of the fifth percentile ofthe predicted value as the lower limit of normal does not lead to an overestimationof the presence of an obstructive defect in older people. A restrictive defect is characterizedby a reduction in the total lung capacity (TLC), as measured on a lung volumestudy, below the fifth percentile of the predicted value, and a normal FEV 1 /VC.The spirometric classification of lung disease has been useful in predictinghealth status, use of health resources, and mortality. Abnormal spirometry canalso be indicative of an increased risk for lung cancer, heart attack, and strokeand can be used to identify patients in which interventions, such as smokingcessation and use of pharmacologic agents, would be most beneficial.
52 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgTABLE 3.4. INDICATIONS FOR SPIROMETRYA. INDICATIONS FOR SPIROMETRYDiagnosisTo evaluate symptoms, signs, or abnormal laboratory testsTo measure the effect of disease on pulmonary functionTo screen individuals at risk of having pulmonary diseaseTo assess preoperative riskTo assess prognosisTo assess health status before beginning strenuous physical activity programsMonitoringTo assess therapeutic interventionTo describe the course of diseases that affect lung functionTo monitor people exposed to injurious agentsTo monitor for adverse reactions to drugs with known pulmonary toxicityDisability/Impairment EvaluationsTo assess patients as part of a rehabilitation programTo assess risks as part of an insurance evaluationTo assess individuals for legal reasonsPublic HealthEpidemiologic surveysDerivation of reference equationsClinical researchB. THE GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE SPIROMETRICCLASSIFICATION OF COPD SEVERITY BASED ON POSTBRONCHODILATOR FEV 1Stage I Mild FEV 1 /FVC 0.70FEV 1 80% of predictedStage II Moderate FEV 1 /FVC 0.7050% FEV 1 80% predictedStage III Severe FEV 1 /FVC 0.7030% FEV 1 50% predictedStage IV Very severe FEV 1 /FVC 0.70FEV 1 30% predicted or FEV 1 50%predicted plus chronic respiratory failureC. THE AMERICAN THORACIC SOCIETY AND EUROPEAN RESPIRATORY SOCIETYCLASSIFICATION OF SEVERITY OF ANY SPIROMETRIC ABNORMALITY BASED ON FEV 1Degree of SeverityFEV 1 % PredictedMildLess than the LLN but 70Moderate 60–69Moderately severe 50–59Severe 35–49Very severe 35COPD, chronic obstructive pulmonary disease; FEV 1, forced expiratory volume in one second; FVC, forced vital capacity;respiratory failure, arterial partial pressure of oxygen (PaO 2 ) 8.0 kPa (60 mm Hg) with or without arterial partialpressure of CO 2 (PaO 2 ) 6.7 kPa (50 mm Hg) while breathing air at sea level; LLN, lower limit of normal.Modified from Pauwels RA, Buist AS, Calverly PM, et al. Global strategy for the diagnosis, management, and preventionof chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD)Workshop summary. Am J Respir Crit Care Med. 2001;163:1256–76. Available from: http//www.goldcopd.com (lastmajor revision, November 2006); Pellegrino R, Viegi G, Enright P, et al. Interpretive strategies for lung function tests.ATS/ERS Task Force: standardisation of lung function testing. Eur Respir J. 2005;26:948–68.
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