0
Communications to the Editor |

Anaerobic Threshold and Thoracotomy Chest Pain Anaerobic Threshold and Thoracotomy Chest Pain FREE TO VIEW

Alessandro Brunelli, MD; Majed Al Refai, MD; Aroldo Fianchini, MD
Author and Funding Information

Affiliations: University of Ancona Ancona, Italy,  Dokkyo University School of Medicine Tochigi, Japan

Correspondence to: Alessandro Brunelli, MD, Via S Margherita 23, Ancona 60129, Italy; e-mail: alexit_2000@yahoo.com



Chest. 2001;120(5):1747-1748. doi:10.1378/chest.120.5.1747-a
Text Size: A A A
Published online

To the Editor:

We read with great interest the article of Miyoshi et al (August 2000)1 on the early postoperative exercise capacity of 16 patients who had undergone to standard posterolateral thoracotomy and lung resection.

In one of their analyses, they compared the patients (31.3% of those in their series) who did not reach the empirical anaerobic threshold expressed by the venous blood lactate level of 2.2 mmol/L (La-2.2) during oxygen uptake (V̇o2) with those who reached the threshold during the first postoperative cycle ergometer exercise test (mean [± SD], 9 ± 2 postoperative days). Miyoshi et al found that the circulatory and ventilatory parameters were larger in patients with La-2.2 than in those without, and that both heart rate and respiratory reserves were smaller in the patients with La-2.2 than in those without. They concluded that pain from the surgical wound in the chest could be the most important limiting factor for patients without La-2.2 in the early postoperative period, even though subjective factors were not obtained in their study.

We performed a similar prospective study on 122 patients who were enrolled in our study from December 1999 through February 2001 and had undergone muscle-sparing thoracotomies and lung resections (segmentectomy/wedge resection, 15 patients; lobectomy, 88 patients; pneumonectomy, 19 patients) for lung carcinoma. Our exercise methodology consisted of a maximal symptom-limited, stair-climbing test that was administered at the time of the patient’s discharge from the hospital (mean, 8.2 ± 3.3 postoperative days). In our study, 24 patients (19.7% of our series) did not reach the empirical anaerobic threshold of La-2.2 V̇o2. However, no significant differences were detected between this group of patients and the others who reached the La-2.2 V̇o2, in terms of calculated work, maximal V̇o2 (V̇o2max; expressed as milliliters per minute, milliliters per minute per kilogram, or as the percentage of the predicted value), V̇o2max/body surface area ratio, and O2 pulse.2 Moreover, hemodynamic variables (ie, cardiac output, cardiac index, oxygen delivery, extraction ratio, and heart rate reserve), which were calculated by the Fick method, did not result in significant differences between the two groups of patients.

The only parameter that was significantly reduced in the group without La-2.2 vs the group with La-2.2 was the number of steps climbed (mean, 77.2 ± 30.8 vs 101.6 ± 33.2, respectively; p = 0.001[ Student’s t test]).

We performed also a subjective analysis concerning the main symptoms that limited the patients’ exercise, and we found no difference between the two groups of patients. In particular, only three patients in the group without La-2.2 stopped exercising because of chest pain at the surgical wound. Dyspnea was the predominant symptom, followed by leg pain and physical exhaustion, in both groups of patients.

Contrary to what was reported by Miyoshi et al,1 we believe that in the early postoperative period the chest pain from thoracotomy is not the most important limiting factor for the patients who do not reach the empirical anaerobic threshold. However, differences in the type of thoracotomy incision and in the methodology of the exercise test have to be taken into account.

Since there was no difference in the values of ergometric variables between the two groups of patients in our series, a low level of arterial blood lactates at peak exercise in some patients may be explained by a previously reported intersubject variability of the anaerobic threshold value3or may simply reflect the better fitness of some individuals for endurance (aerobic) exercise.4

Miyoshi, S, Yoshimasu, T, Hirai, T, et al (2000) Exercise capacity of thoracotomy patients in the early postoperative period.Chest118,384-390
 
Olsen, GN, Bolton, JWR, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection: two years experience.Chest1991;99,587-590
 
Jones, NL, Makrides, L, Hitchcock, DC, et al Normal standards for an incremental progressive cycle ergometer test.Am Rev Respir Dis1985;131,700-708
 
Wasserman, K The anaerobic threshold measurement to evaluate exercise performance.Am Rev Respir Dis1984;129,535-540
 

Anaerobic Threshold and Thoracotomy Chest Pain

To the Editor:

We thank Dr. Brunelli and his colleagues for their interest in our article (August 2000).1 They performed a similar prospective study on lung cancer patients in the early postoperative period (mean [± SD] postoperative days, 8.2 ± 3.3), using a stair-climbing test. Although they observed patients without a venous blood lactate level of 2.2 mmol/L (La-2.2) [24 subjects; 19.7% of their series], as we did, there was no difference in the values of ergometric variables between patients with and without La-2.2. These findings were different from our results.

As has been pointed out, there were two major differences between our study and that of Brunelli et al. We employed a standard posterolateral thoracotomy in all patients studied, while Brunelli et al performed a muscle-sparing thoracotomy in their patients. This variation may produce differences in postoperative chest pain and compliance of the chest wall, especially in the early postoperative period. Patients are likely to be able to attain a larger maximum oxygen uptake (V̇O2max) if they do not feel chest pain during exercise. The differences between these thoracotomy approaches were not detected by pulmonary function testing.2 A cardiopulmonary exercise test is a loading test for both cardiovascular and respiratory systems, and may be more sensitive when evaluating the differences between these thoracotomy approaches.

The other difference between the two studies is the methodology used for the exercise test. We utilized an incremental exercise test, which was designed to obtain an anaerobic threshold as well as V̇O2max. A stair-climbing test is considered to be constant work under great stress and is not meant for detecting the anaerobic threshold. Although it is simple and useful for clinical use,3 a stair-climbing test has limitations when investigating the mechanism behind the results.

References
Miyoshi, S, Yoshimasu, T, Hirai, T, et al Exercise capacity of thoracotomy patients in the early postoperative period.Chest2000;118,384-390
 
Hazelrigg, SR, Landreneau, RJ, Boley, TM, et al The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.J Thorac Cardiovasc Surg1991;101,394-401
 
Olsen, GN, Bolton, JWR, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection.Chest1991;99,587-590
 

Figures

Tables

References

Miyoshi, S, Yoshimasu, T, Hirai, T, et al (2000) Exercise capacity of thoracotomy patients in the early postoperative period.Chest118,384-390
 
Olsen, GN, Bolton, JWR, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection: two years experience.Chest1991;99,587-590
 
Jones, NL, Makrides, L, Hitchcock, DC, et al Normal standards for an incremental progressive cycle ergometer test.Am Rev Respir Dis1985;131,700-708
 
Wasserman, K The anaerobic threshold measurement to evaluate exercise performance.Am Rev Respir Dis1984;129,535-540
 
Miyoshi, S, Yoshimasu, T, Hirai, T, et al Exercise capacity of thoracotomy patients in the early postoperative period.Chest2000;118,384-390
 
Hazelrigg, SR, Landreneau, RJ, Boley, TM, et al The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.J Thorac Cardiovasc Surg1991;101,394-401
 
Olsen, GN, Bolton, JWR, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection.Chest1991;99,587-590
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543