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Original Articles: General Thoracic

Performance at Symptom-Limited Stair-Climbing Test is Associated With Increased Cardiopulmonary Complications, Mortality, and Costs After Major Lung Resection

Unit of Thoracic Surgery, Umberto I Regional Hospital, Ancona, Italy

Accepted for publication March 14, 2008.

^_* Address correspondence to Dr Brunelli, Via S Margherita 23, Ancona, 60129, Italy (Email: alexit_2000{at}yahoo.com).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 27–29, 2008.

General thoracic surgery: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
Background: Exercise tests are increasingly used during preoperative evaluation before lung resection. This study assessed the association between performance at the symptom-limited stair-climbing test and postoperative cardiopulmonary morbidity, mortality, and costs after major lung resections.

Methods: As part of their routine preoperative evaluation, 640 patients who had lobectomy (n = 533) or pneumonectomy (n = 107) for lung cancer from January 2000 through April 2007 performed a preoperative symptom-limited stair-climbing test. Sensitivity/specificity analysis was used to identify the best cutoff values of altitude climbed (number of steps x height of the step in m) associated with outcome. Univariate and multivariate regression analyses (validated by bootstrap) were used to test associations between preoperative and operative factors and postoperative cardiopulmonary complications, mortality, and postoperative costs.

Results: The altitude reached at the stair-climbing test was reliably associated with increased cardiopulmonary complications (p = 0.04), mortality (p = 0.02), and costs (p < 0.0001). In patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold (p < 0.0001), 13-fold (p < 0.0001), and 2.5-fold higher, respectively, than in patients who climbed more than 22 m.

Conclusions: Performance at a maximal stair-climbing test was reliably associated with postoperative morbidity and mortality. We recommend the use of this simple and economic test in all lung resection candidates. Patients who perform poorly at the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management.

Exercise testing is increasingly used to assess the functional reserve of candidates for lung resection. Exercise is attractive before the operation because it increases utilization of oxygen peripherally and requires the entire interlocking lung/heart/vascular oxygen transport system to react [1]. In the lung, exercise determines an increase in ventilation, oxygen consumption (O₂), carbon dioxide excretion, and blood flow, similar to those experienced after lung resection. Therefore, the potential exists to evaluate much of the cardiopulmonary system with just one test.

Different exercises are used in clinical practice and have been correlated with postoperative outcome after lung resection: those applying limited technology, such as walking and stair climbing, and those directly measuring the oxygen consumption by using gas analyzers during cycle ergospirometry or on the treadmill. All these tests may yield different information and should ideally be viewed as complementary rather than mutually exclusive. Nevertheless, their relative place in the preoperative functional work-up is still mostly undetermined [2].

Like other diagnostic tools, even the use of exercise testing before operation cannot leave out of consideration the current financial constraints imposed by the managed care system that demand the optimization of pathways of care with an appropriate and cost-effective utilization of limited resources. In this regard, previous studies have shown that stair climbing is extremely cost-effective, being simple, rapid, inexpensive, requiring few personnel and equipment, and capable to predict cardiopulmonary complications after lung resection [3–8]. Unfortunately, the performance at the stair-climbing test has been variably expressed as the number of steps, flights of stairs, or meters climbed. These differences in measurements have made it difficult to reproduce the results across different centers and to identify cutoff values that can be reliably integrated in functional algorithms.

Since January 2000, we have instituted a symptom-limited stair-climbing test systematically for all candidates for lung resection as a part of their preoperative evaluation. The present series is an expansion of our previous study (20% of the patients in the present series were also included in our previous study) that reported our initial experience with this test, but because of the smaller sample size, could not adequately investigate outcomes such as mortality and costs or validate clinically useful cutoffs [8].

Thus, this investigation had two main objectives. The first was to evaluate the association between the altitude reached during the stair-climbing test and postoperative outcomes such as morbidity, mortality, and postoperative hospital costs in a consecutive series of patients undergoing major lung resection. The second objective to verify whether the use of this test in our clinical practice made it possible to operate on more patients with prohibitive pulmonary function.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
We analyzed 640 consecutive patients undergoing major lung resections, including 533 lobectomies/bilobectomies and 107 pneumonectomies, at our institution from January 2000 through April 2007. All patients performed a preoperative symptom-limited stair-climbing test as part of their routine functional evaluation. During the same period, another 90 patients who underwent major lung resections did not perform a stair-climbing test or any other exercise tests for severe underlying incapacitating comorbidities (limiting musculoskeletal, neurologic, peripheral vascular, systemic diseases), contraindication (recent cardiac ischemia or cerebrovascular disease), or refusal to perform the test.

This is an observational analysis performed on a prospectively compiled electronic database. Informed consent was obtained from all patients to use their data for clinical research. The database was approved by the local Institutional Review Board (IRB).

All patients underwent a preoperative functional cardiologic evaluation and pulmonary function studies, including measurement of carbon monoxide lung diffusion capacity (DLCO) and maximal stair-climbing test. Cycle-ergospirometry with O₂ peak measurement was performed selectively until December 2005 in patients with limited respiratory reserve and with poor performance at the stair-climbing test and systematically in all patients thereafter as part of an investigational protocol.

Contraindications for a major lung resection were a predicted postoperative forced expiratory volume in 1 second (ppoFEV₁) and predicted postoperative DLCO (ppoDLCO) of less than 30% of predicted normal values associated with an insufficient exercise tolerance defined as O2peak of less than 10 mL/kg/min. For these patients, nonoperative options or a minor resection, whenever technically and oncologically feasible, were considered.

Lung resections were usually performed through a muscle-sparing lateral thoracotomy by qualified thoracic surgeons. Postoperative treatment was standardized and focused on early mobilization, chest physiotherapy and physical rehabilitation, thoracotomy pain control, and antibiotic and antithrombotic prophylaxis. Postoperative chest pain was controlled by means of continuous intravenous analgesia, which was titrated to keep the pain visual score below 4 on a scale of 0 to 10 during the first postoperative 48 to 72 hours. The pain score was assessed twice daily, during morning and afternoon rounds.

Postoperative morbidity and mortality were considered as those occurring within 30 days postoperatively or for a longer period if the patient was still in the hospital.

Fixed and variable costs were retrieved from the Hospital's Accounting and Pharmacy Departments data systems. For the purpose of this study, the costs were collected in Euros, converted to US$ (conversion rate $:, 1.3), and corrected according to the current inflation rate as of December 2007.

Fixed costs included capital, employee salaries, building maintenance, and utilities. Variable costs included patient care supplies, food, radiographic film, laboratory reagents, and medications with their delivery systems such as intravenous catheters or bottles, and the cost of other postoperative therapeutic procedures, including cardioversion, bronchoscopy, and blood transfusions.

A number of other preoperative and operative variables were tested for possible association with outcomes and costs (see Appendix [9–14] for an explanation of variables).

Stair-Climbing Test
All the patients in the study completed a symptom-limited stair-climbing test preoperatively (usually within 1 week of the operation). This form of exercise was approved by our IRB as a test for preoperative selection.

All the patients with a concomitant cardiac disease underwent a cardiologic evaluation before performing the stair-climbing test. No patients were excluded from this analysis after the cardiac evaluation, but they were allowed to perform the test only when deemed in a hemodynamically stable state. No formal preoperative rehabilitation program was used in this series.

Our hospital has 16 flights of stairs, each one consisting of 11 steps. Each step is 0.155 m high. The stairwell where the tests are performed is in the central block of the hospital, and every floor is rapidly accessible in case of an emergency by a rescue team consisting of a critical care physician and a cardiologist always on call within the building. The patients were asked to climb, at a pace of their own choice, the maximum number of steps and to stop only for exhaustion, limiting dyspnea, leg fatigue, or chest pain. All patients were accompanied by a physician who interacted with them and assessed their symptoms. The physician could use a cordless phone in case of emergency. Arterial blood pressure, heart rate, and respiratory rate were recorded before and immediately after the exercise. During the exercise, the patient's pulse rate and capillary oxygen saturation were monitored by means of a portable pulse oximeter with a finger probe. All tests were performed on room air. No complications related to the stair-climbing test were observed in this series.

Statistical Analysis
To define cutoff levels that may help to stratify the risk in clinical practice, the altitude reached at the stair-climbing test was categorized. Thresholds levels were selected by using sensitivity/specificity analyses (Table 1). Two height values (12 m and 22 m) were selected that could optimize selection criteria for both outcomes. A patient who climbed less than 12 m had the highest probability of developing postoperative complications or to die and thus, under a clinical management perspective, would need additional preoperative tests. Conversely, a patient who climbed more than 22 m had the lowest chance to develop complications or to die and therefore may not require an additional preoperative workup.

Variables with a p < 0.10 at univariate analysis were then used as independent variables in the stepwise logistic regression analyses. Dependent variables were morbidity and mortality. Multivariate regression analysis was used to test the association between several preoperative and operative factors, including stair-climbing altitude, and postoperative costs. All data were complete with the exception of DLCO, which was 95% complete. Missing data were imputed by averaging the nonmissing values. To avoid multicollinearity, only one variable in a set of variables with a correlation coefficient greater than 0.5 was selected by the bootstrap procedure and used in the regression model. A p < 0.1 was selected for retention of variables in the final model.

Logistic regression analyses were then validated by bootstrap analyses with 1000 samples. In the bootstrap procedure, repeated samples of the same number of observations as the original database (640) were selected with replacement from the original set observations. For each sample, stepwise logistic regression was performed entering the variables with p < 0.1 at univariate analysis. The stability of the final model can be assessed by identifying the variables that enter most frequently in the repeated bootstrap models and comparing those variables with the variables in the final model. If the final stepwise model variables occur in a majority (>50%) of the bootstrap models, these are judged to be stable [15–17].

All the statistical tests were two-tailed, and a significance level of 0.05 was accepted. The analysis was performed with STATA 8.2 software (StataCorp, College Station, TX).

	Results

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
The characteristics of the patients analyzed in this study are reported in Table 2. Cardiopulmonary morbidity was 23.4% (n = 150) and mortality was 3.3% (n = 21).

Stepwise logistic regression analysis showed that significant and reliable factors associated with mortality were pneumonectomy (p = 0.02), ppoFEV₁ (p = 0.03), cardiac comorbidity (p = 0.003), and stair climbing altitude level (p = 0.02; Table 6).

After pneumonectomy, patients climbing more than 22 m had a mortality rate of 6.3% (2 of 32) vs 11% (8 of 75) of those climbing less than 22 m (p = 0.5). After lobectomy, the mortality rates of patients climbing more than 22 m was 0.4% (1 of 260) vs 17% (7 of 42) of those not reaching 12 m (p < 0.0001).

The unplanned intensive care unit (ICU) admission rates for major complications in patients climbing more than 22 m, between 12 and 22 m, and less than 12 m were 1.7% (5 of 292), 7% (21 of 294), and 17% (9 of 54), respectively (p < 0.0001). Of the patients admitted to ICU, the mortality rate of those climbing less than 12 m was 71% (5 of 7).

During the same period, other 88 patients underwent sublobar resections for lung cancer. This group had a morbidity rate of 15% (n = 13) and mortality of 2.2% (n = 2). Eight patients were not able to climb more than 12 m, and their morbidity rate was 25% (n = 2) and mortality was 13% (n = 1). Conversely, of the 29 patients climbing more than 22 m, only 1 had complications and none died.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
Exercise tests are regarded as global tests capable to uncover deficits in the oxygen transport system. Patients with reduced aerobic reserve may be unable to cope with the increased oxygen demand typically occurring in the postoperative period. In case of major complications, this unbalance may determine a protracted oxygen debt, and as a consequence, a multiorgan failure may ensue [18]. Exercise tests may thus simulate the surgical stress and detect potential defects in the heart/lung/vascular chain of the oxygen transport system. For this reason, exercising a patient before lung resection has become an increasingly used practice in many centers.

Nevertheless, the increased pressure exerted on our profession by health care managers and administrators requires pathways of care to be optimized and cost-contained. The choice of preoperative tests should be tailored to specific patients' needs and be evidence-based. Even recently published guidelines [2] recommend exercise testing only in selected patients and as the last step of the functional algorithm after pulmonary function tests, DLCO, and split lung function estimation. In this regard, the use of low-technology exercises such as stair climbing, which has already proven to be cost-effective in predicting complications after lung resection [3–8], may deserve consideration as a first-stage screening test applicable to most lung resection candidates with minimal additional consumption of resources.

In a previous series [8], we found that the height reached at the stair-climbing test was a significant predictor of complications after lung resection. Nevertheless, the small sample size precluded us from being able to validate reliable cutoffs that could be used in clinical practice and be potentially integrated in existing functional algorithms or from analyzing other outcomes such as mortality rates and costs. Therefore, the objectives of this study were to (1) verify the association between the altitude reached at preoperative maximal stair-climbing test and postoperative outcomes (morbidity, mortality, and costs) and (2) assess the clinical impact of the use of this functional test in selecting patients traditionally regarded at prohibitive risk (ppoFEV₁ or ppoDLCO < 40%) for major lung resection.

We have been using a symptom-limited stair-climbing test since January 2000 as part of the routine functional workup of all lung resection candidates. We found this test appealing for it is rapid, safe, familiar to the patients (requiring few instruction), and requires minimal equipment and personnel. In addition, several studies have reported that this test yields higher value of O₂peak than cycle ergometry [6, 19, 20]. An explanation for this finding is that stair climbing is a more stressful exercise than cycling or the treadmill because it involves a larger muscle mass, and it is extremely motivating for the patients, who are pushed to reach a visible objective represented by the next landing. Less than 10% of our patients stopped their test before they reached a landing.

We found that in patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold, 13-fold, and 2.5-fold higher than in patients who climbed more than 22 m, respectively. Most notably, the mortality rate in patients who climbed more than 22 m was only 1%. The progressive increase of the morbidity and mortality rates with the reduction of the altitude climbed preoperatively indirectly demonstrates that stair climbing is a stressful exercise capable of uncovering deficits in the patient's aerobic capacity.

Our results confirm previous findings of Holden and colleagues [6], who reported that 4 of 5 patients who died postoperatively were not able to climb higher than 8 m (44 steps in their setting). Similarly, Olsen and colleagues [5] found that the completion of at least 3 flights of stairs (13 m in their setting) seemed to best separate patients with and without complications.

In our view, one of the most interesting results of our analysis was that the use of the stair-climbing test in our clinical practice allowed us to operate on 73 patients traditionally considered at prohibitive risk by standard spirometric criteria (ppoFEV₁ < 40%, ppoDLCO < 40%). These patients underwent operation on the basis of their satisfactory performance at the stair-climbing test coupled in selected cases with a sufficient O₂peak at cycle ergospirometry. The mortality rate in this high-risk group of patients was 4.1% and within acceptable levels. This finding may have important clinical implications. In fact, no patient can be deemed inoperable solely by spirometric criteria. Stair climbing proved to be superior with respect to spirometric variables in discriminating patients with poor outcome. In patients with ppoFEV₁ or ppoDLCO < 40%, or both, none of those climbing more than 22 m died vs a mortality rate of 20% in those climbing less than 12 m.

We also found that the altitude reached during the stair-climbing test was a reliable factor associated with postoperative hospital costs. This is explained by the increased resources utilization of patients who climbed less than 12 m, including an increased complication rate, prolonged hospital stay, and more frequent ICU admissions. We already demonstrated that risk-adjusted econometric models estimating hospital costs may be used as an additional tool for monitoring the performance of thoracic surgery units and planning allocation of resources [21]. In the future, ergometric indicators may be added to econometric models to improve their precision.

This large prospective series investigating the importance of the stair-climbing test on the outcome of a homogeneous group of patients undergoing to major lung resection has some potential limitations. First, this was an observational analysis, and although data have been prospectively collected, patients were not randomly allocated to surgical intervention. Inadvertent inherent selection biases are always to be considered in this type of analysis [22].

Second, the number and height of steps in stair flights may vary among centers. We tried to standardize the results by reporting the performance in altitude, as suggested by Pate and colleagues [23], but the reproducibility of the results generated in this study needs to be verified in other settings. In the future, stepping machines can substitute for this test and provide more reproducible results, provided their cost-effectiveness in predicting postoperative outcome will be similar to stair climbing.

Third, although stair climbing is very effective in assessing global physical fitness, it is not able to completely reveal the physiologic mechanisms affecting the patient's performance, such as cardiac, respiratory, pulmonary, vascular, and muscular. Thus, in patients with an impaired exercise tolerance at the stair-climbing test, more sophisticated exercise tests should be used (cycle ergospirometry with O₂peak measurement) to detect the physiopathologic mechanisms influencing the performance to be optimized before intervention, such as cardiologic treatment, rehabilitation, and respiratory therapy.

Finally, not all lung resection candidates can perform exercise tests. We already showed that these patients display an increased risk of death compared with case-matched patients who are able to perform the test [24]. For these patients, exercise parameters are not available for risk stratification, and alternative methods of risk assessment should be researched [24].

According to the results generated in our analysis, we recommend the systematic use of symptom-limited stair climbing as a first-line screening test in all candidates for lung resection. All pneumonectomy candidates and all patients climbing less than 12 m should undergo a formal cardiopulmonary exercise test with measurement of O₂peak to optimize their perioperative treatment. These patients may also benefit from a preoperative rehabilitation program and in the immediate postoperative period, planned advanced care management in the ICU or in an intermediate care setting. We also recommend a cardiopulmonary exercise test for those patients climbing between 12 and 22 m with a ppoFEV₁ or ppoDLCO lower than 40%, or both. Conversely, lobectomy candidates climbing more than 22 m and without cardiac comorbidity, even in case of ppoFEV₁ or ppoDLCO lower than 40%, could undergo operation without additional testing.

In conclusion, we were able to demonstrate that the stair-climbing test is very cost-effective in stratifying the surgical risk. Therefore, we recommend the use of this simple and economic test in all lung resection candidates. Those patients who perform poorly on the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management. Future studies are needed to better correlate performances during the stair-climbing test and cycle ergospirometry to more precisely define the relative role of these two exercises in the preoperative functional workup of lung resection candidates.

	Appendix

 
Preoperative and Operative Variables

The following variables were initially screened for a possible association with postoperative morbidity, mortality and costs: age, sex, body mass index (BMI, kg/m²), forced expiratory volume in 1 second (FEV₁), carbon monoxide lung diffusion capacity (DLCO), predicted postoperative FEV₁ (ppoFEV1), predicted postoperative DLCO (ppoDLCO), cardiac comorbidity, type of operation (lobectomy vs pneumonectomy), neoadjuvant chemotherapy, and height reached at maximal stair climbing test (<12 m; 12 to 22 m; > 22 m).

Stair climbing height was categorized by sensitivity and specificity analyses (Table 1).

Pulmonary function tests were performed according to the American Thoracic Society criteria. Results of spirometry were collected after bronchodilator administration. The DLCO measurement was performed by the single breath method.

Values for FEV₁, ppoFEV₁, DLCO, and ppoDLCO were expressed as percentages of predicted for age, sex, and height. Values for ppoFEV₁ and ppoDLCO were calculated by taking into account the number of functioning segments removed during the operation. A quantitative lung perfusion scan was also performed in all pneumonectomy candidates according to published guidelines [9].

For the purpose of the present study and in accordance with previous investigations [10, 11], a concomitant cardiac disease was defined as follows: previous cardiac operation, previous myocardial infarction, history of coronary artery disease, or current treatment for arrhythmia, cardiac failure or hypertension.

	Outcome Variables

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
For the purpose of this study, according to previous studies [11–13] and to the European Association for Cardio-thoracic Surgery/European Society of Thoracic Surgeons thoracic surgery database [14], the following complications were included: respiratory failure requiring mechanical ventilation for more than 48 hours, pneumonia (chest roentgenograms, infiltrates, increased white blood cell count, fever); atelectasis requiring bronchoscopy, adult respiratory distress syndrome, pulmonary edema, pulmonary embolism, myocardial infarction (suggestive electrocardiogram findings and increased levels of myocardial enzymes), hemodynamically unstable arrhythmia requiring medical treatment; cardiac failure (suggestive chest roentgenograms, physical examination, and symptoms); acute renal failure (change in serum creatinine >2 mg/dL compared with preoperative values), and stroke. Postoperative morbidity and mortality were considered as those occurring within 30 days postoperatively or for a longer period if the patient was still in the hospital.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 
DR CLIFF CHOONG (Cambridge, UK): Alex, congratulations on a great study and a very nice presentation. When I started my training years ago, one of my mentors, Mr Ken Graham, used to say if the patient cannot climb up two flights of stairs, then you should not consider doing any resectional surgery for the patient. Clearly, that is very subjective and very crude, and it is good to see from your study an objective method of risk stratifying patients using stair climbing. In my current practice, for patients whom I consider as borderline candidates for surgery, I would often walk with them up two flights of stairs to assess their functional capabilities. I am therefore very delighted to actually see this very objective study that you have come up with.

I have a few questions. Have you correlated this work with other risk-stratification models? For example, other objective exercise studies like 6-minute walk tests and so forth? And is this being practiced anywhere else? I certainly think that with the presentation you have done and, hopefully, with the publication of this work, it will be taken up by more people. Once again, congratulations on the nice work and presentation.

DR BRUNELLI: Thank you very much. We did not correlate other tests (ie, 6-minute walking or shuttle test with stair climbing). There have been some studies in the past doing that. And the most interesting finding was that the oxygen consumption measured during the stair-climbing test was much higher than the oxygen consumption measured while performing other tests and even cycle ergometry. This is explained by the fact that with the stair-climbing test, you use a much larger amount of muscle mass and probably because the test is more motivating for the patients. But we don't have any personal experience in comparing these different forms of exercise.

To your second question if the test is used in other centers, to my knowledge, yes. There is a questionnaire on the ESTS [European Society of Thoracic Surgeons] Web site, which is promoted by the ERS [European Respiratory Society] and the ESTS joint task force on fitness for radical surgery in patients with lung cancer. The questionnaire was devised to assess current practice in preoperative functional evaluation of these patients. One of the questions is, which is the low-tech exercise test more frequently used in your practice? Stair-climbing test resulted as more frequently being used than, for example, 6-minute walking or shuttle test in many centers.

DR LESLIE J. KOHMAN (Syracuse, NY): I have two questions. One, you have stated that this is completely safe. Was there any concern among people in your hospital that this might not be safe; that is, an unmonitored stress test being done in a stairwell? I presume since you are presenting this as research, that it passed a human subjects committee. Did they have any objections to this on that basis?

My second question, have you done cardiopulmonary rehabilitation on a subset of these patients who didn't meet your criteria for resection, remeasured them and turned them into resection candidates by a brief course of cardiopulmonary rehabilitation, and if so, what did that program consist of? Thank you.

DR BRUNELLI: Thank you. Of course, we are always concerned about the safety of these patients, because you exercise them in remote area that may be difficult to rapidly access for rescue if some complication occurs.

Our patients are always accompanied by a trained physician with a cordless phone that may be use in case of an emergency to call the emergency department physician who is always on call within our hospital. We are trying to find a surrogate for the stair-climbing test that could be performed in an office, in a safer environment with a crash cart at hand.

In discussing safety issues to obtain permission to perform the test from our IRB, we confronted our cardiologists in the hospital, collecting information about safety of exercise tests (cycle ergometry) in very complicated patients, heart failure, and post-CABG [coronary artery bypass graft] patients. The incidence of morbidity or mortality is incredibly low, even in these patients. All patients in this series performed before the test a full cardiologic examination. And they were deemed to be suitable for the test only if in stable cardiac condition. In high-risk patients with a recent myocardial infarction or a known history of ischemic cardiac disease on effort, we don't perform the test or we perform cycle ergometry first with full cardiopulmonary monitoring and then stair climbing test.

And your second question was?

DR KOHMAN: Rehab.

DR BRUNELLI: Rehab. Of course, we think that may be useful. We did not implement any formal rehab program in this series, but that is a good idea, and I agree with you that patients not meeting operability criteria may benefit of a rehabilitation program.

DR DANIEL L. MILLER (Atlanta, GA): I enjoyed your presentation. When I trained at the Mayo Clinic, Dr Pairolero would take us out in the stairwell, and he would go up to the top first because, you know, Pete would be up there in about 3 seconds, and the resident had to walk the patient up. And usually the patient did better than the resident at that time so it was a pretty good test.

But my question is in regards to the pneumonectomy patients. What we have seen, and we have done this a little bit, and when they don't make it, we do send them through pulmonary rehab. We use an accelerated 3-week program, and we have had them come back.

It is interesting that probably about 70%, 80% of them have improved enough to go on to surgery, but some of them don't. And what we have found on those evaluations is that these are people who have a little CO₂ retention, and on evaluation of their heart, they actually have a patent foramen ovale. And so what happens is they have a little bit of right-to-left shunting when they are exercising and so forth. And we have really used a bubble study at the time of our evaluation to look for a patent foramen, especially for an extrapleural pneumonectomy. So it is something to look at in the back of your mind that those patients aren't to be corrected when you change their pressures and so forth. But I enjoyed your study.

DR BRUNELLI: Thank you very much.

DR MILLER: Thank you.

DR SCOTT J. SWANSON (New York, NY): I had a question for you. It seemed like, at least in the paper, about 10% of patients didn't do this—or maybe it was 15%—for various reasons, and some of those may be people you really want to know about. And you mentioned it a minute ago, is there anything else that can be done where you might still be able to assess those people either with hand aerobic activity or treadmill or something that might be helpful?

DR BRUNELLI: In my opinion, if the patient is not able to perform a stair-climbing test, usually they can't perform any other kind of exercise test, unfortunately. And so our instruments to evaluate these patients are very limited. We already published a paper few years ago on this subject. We used propensity scores to match who were able to exercise (independent of the altitude reached) with those who were not able to perform a stair-climbing test for various severe underlying comorbidities. We found that the mortality rates in these patients were threefold higher.

DR SWANSON: Well, it just seems to me 12 meters by your measurements is about 80 steps, and I can tell you probably 30% of my patients could not make it up 80 steps and yet they seemed to get through surgery reasonably well. So that's a pretty high bar. I don't know what other people think about that, but 80 steps is a pretty long way.

DR BRUNELLI: I don't know what to tell you, but that's what we found.

DR SWANSON: It's like six or seven flights of stairs.

DR BRUNELLI: No. Actually, in our setting, it is three flights of stairs of 22 steps each.

DR SWANSON: Three flights?

DR BRUNELLI: Yeah.

DR SWANSON: Big flights.

DR BRUNELLI: Yeah.

DR MICHAEL S. MULLIGAN (Seattle, WA): The last question is mine. I am looking at your algorithm, and I look at the last two bullets, and there are a lot of patients in between. And in your talk and in your manuscript you talk about reverting to cardiopulmonary exercise testing to identify presumably modifiable risk facts to improve their candidacy for surgery. But the safe message here I am assuming is that a documented O₂ max is still the bottom line?

DR BRUNELLI: Absolutely.

DR MULLIGAN: This is a cost-saving maneuver. So if you happen to have the patient who has got a O₂max of 7, and through sheer guts and grit he makes it up a flight of stairs or three flights of stairs, you are not recommending taking that person to surgery?

DR BRUNELLI: No, absolutely.

DR MULLIGAN: So I just wanted to clarify that by way of comment, that this is great, we are trying to limit the number of formal exercise tests we get and learn and use the data we get from them to modify risks if possible. But those tests don't lie, and we have got a lot of validated data.

DR BRUNELLI: Yes, the stair-climbing test is ideal as a first-line screening test.

DR MULLIGAN: Right.

DR BRUNELLI: The O₂max remains the gold standard for functional evaluation, but stair climbing may help in selecting those patients that would or would not need it.

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Top Abstract Introduction Patients and Methods Results Comment Outcome Variables Discussion References

 

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