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Exercise Testing

VO2 testing and COVID19
Laura Caldarera
Hello all! Does anyone have any information regarding metabolic exercise testing procedures once we can back to testing. I work in Maryland in a pediatric cardiology practice. We are now allowed to start elective medical procedures but I can find no guidance specific to metabolic exercise testing. Wondering what others have found or plan to do. Thanks!
Brittany Overstreet
In a hybrid research/community testing/clinical setting we have yet to return but based on discussions of changes to policies we are expected considerable changes to VO2max testing given the possibility to spreading COVID19 through wearing of the facemask. CEP conducting test will likely be required to be in extensive PPE, lab coats washed after each test, at least 15 minutes between tests for full cleaning of facility (not really new), use of disposable filters for each person instead of the reusable white/purple filters that come with metabolic cart. We are still waiting to see what changes will be necessary to the cleaning of the masks but no decision has been made official.

You may need to consider testing patients for COVID19 24-49 hours prior to testing as well as day of screenings, temperature checks, etc. These are some procedures I have heard medical clinics taking for elective operations.

If we have any other updates I will keep posted! Hope this is helpful.
Laura Caldarera
Thank you for this info! I’m glad others are thinking along the same lines as we are. We are hoping to start testing in June with filters, PPE and extra cleaning time between patients. Thanks again!
Mark Patterson
Thanks to Dr. Brawner for the comments, links and information. I think his insight is always appreciated.

At Kaiser Permanente in Colorado, we never totally shut down. We continued with regular and nuclear imaging stress testing, but did shut down cardiopulmonary stress testing for a little while.

We did decide ultimately to leave it up to the patient if they were to wear a mask with testing, but would not require them to do so, it was up to their level of comfort. I personally do not like the idea of possible interference to proper ventilation during an exercise test and possible downstream issues.

As far as cardiopulmonary exercise testing specifically, we use Hans Rhudolph masks, so the edition of a surgical type mask under that would make exercise almost intolerable. We already used filters on baseline PFTs and already were changing out everything a patient put on their face or was breathing through during testing, cleaned between each test. It required re calibration of sensor each time, but seemed to make sense to me.

Back to regular ECG only and nuclear imaging exercise stress testing, I think there are several things to consider:


1. Possible interference of proper ventilation leading to increased number of sub-optimal or peak effort tests. Physiologically may not cause significant o2 de-saturations, but enough impairment that despite adequate delivery from the heart and extraction at the muscles, may still cause premature termination of exercise. Since most of our testing is done without collecting pulmonary data, we are at a loss of truly understanding if an adequate stress was completed. Even with our cardiopulmonary stress tests, if someone does get an RQ over 1.0 or 1.1, there is enough data out there that suggests that RQs at that level still do not guarantee a “max” or “peak” effort.

2. There are some that might give a pretty good effort where one feels Ok with the results. The unfortunate use of 85% of predicted maximum as a diagnostic worthy test can lead to false sense of security that an adequate test was completed. It has been shown in multiple studies that termination of exercise testing at 85% can possibly lead to significant risk of false negative results and thus we would be doing a disservice to our patients.

3. If patients seem to work as hard as they can and stop sub-maximally or if the increased work of breathing causes discomfort in the chest with exercise testing that is not angina, then this can trigger additional downstream testing. This may increase the reliance on nuclear imaging stress testing, which exposes patients to unnecessary high doses of radiation, increased time and cost to the patient, increased cost to the organization that was not necessary.

4. Psychologically, the mask can cause issues too. A high percentage of people that we test are coming in for dyspnea or dyspnea on exertion and they already feel impaired to begin with. The addition of a required mask may cause extra anxiety, hyperventilation and premature test termination. Those with known pulmonary conditions and people like myself with history of asthma may find this hard to do with a mask on, I have already tried it myself and had to stop considerably early. I understand the bias in my one-person research study, but was enough to make me hesitant to have anyone wear a mask during exercise testing.

5. Staff: we are in unchartered waters here. We have not even required the wearing of a level 1 mask during cold and flu season in the past, just taking “reasonable precautions” has been our guideline. At the start when we dropped to very few tests, only 2 days a week, we went with level 2 surgical masks in the department. Over the past 2 months with this volume of testing, we did not have anyone get sick or test positive for COVID 19. That being said and understanding the potential for asymptomatic patients and staff, the addition of a face shield seems to have been a good addition and reasonable as well. Our Emergency Operations Center has endorsed this combination too and they are the ones who have been in touch with the state and other government agencies about best practices at this point.

6. Testing Rooms: Other procedural and surgical areas are spacing their procedures out a bit to allow rooms more time to ventilate and for more thorough cleaning practices. In our clinics we have at a minimum 2 testing rooms which would allow us to alternate rooms which would allow for 30+ minutes of ventilation and extra cleaning time. If we for any reason go down to a single room or increase our volume that would require both rooms to be running at the same time, would want to adjust schedule to allow for this. I would advocate for a minimum of 20 minutes between testing in the same room.

Anyway, that is what is going on with us, hope all of you are safe and well!

Mark
Laura Caldarera
Great information! Thanks Mark Patterson.
Clinton A. Brawner
Laura & others- MGC Diagnostics hosted a webinar recently on reopening your pulmonary lab. The recording is available here: https://mgcdiagnostics.com/events/webinar-restarting-your-lab/. ERS released a brief resource which is available here: https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h.

I suggest working with your infection control team to sort out how they want to categorize the work you do in your lab and the status of COVID in your area. The CDC does not recognize PFTs or exercise testing as aerosol-generating procedures (AGP). I understand that this does not make sense to many, but I believe it is partly due to the variability in defining aerosol vs. droplets. Some infection control teams have decided that exercise testing is an AGP and others have agreed with the CDC. Your procedures and the level of PPE will be determined based on this.

At Henry Ford Hospital in Detroit where we perform ~600 CPETs annually in Cardiology, our lab has been shut down for the past 2+ months. The current plan is to reopen May 18 with the highest priority patients first (e.g., LVAD/transplant evaluations). After an onsite evaluation of our lab by our infection control, they determined that CPET is not an AGP. Therefore, employees and the patient will be wearing a surgical mask. A face shield has been discussed internally, but not recommended by infection control. We will be screening patients at multiple points to avoid patients that are suspected of COVID infection. We plan try to use a filter during exercise, although prior to COVID this was not recommended due to the increased work of breathing. Initial data from our QA testing showed similar numbers with vs. without a filter in an apparently healthy individual. Additional time will be scheduled between tests to clean the room.

Best wishes.
Laura Caldarera
Thank you so much! This is extremely helpful info and much in-line with what we are planning. We are going to use filters as well knowing that our data may be slightly skewed. It’s good to hear that your preliminary star shows the filters may not make such a big difference. Please keep us posted with your progress. I will do the same! Thanks again!
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