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Original Research: ASTHMA |

The Utility of Cardiopulmonary Exercise Testing in Difficult Asthma

Diarmuid M. McNicholl, MBBCh, BAO; Jacqui Megarry, MPhil; Lorcan P. McGarvey, MD; Marshall S. Riley, MD; Liam G. Heaney, MD
Author and Funding Information

From the Centre for Infection and Immunity (Drs McNicholl, McGarvey, and Heaney), Queen’s University Belfast; and the Regional Respiratory Centre (Drs McNicholl, Riley, and Heaney and Ms Megarry), Belfast City Hospital, Belfast, Northern Ireland.

Correspondence to: Liam Heaney, MD, Regional Respiratory Centre, Belfast City Hospital, Lisburn Rd, Belfast, Northern Ireland, UK, BT9 7AB; e-mail: l.heaney@qub.ac.uk


Funding/Support: This study was supported by a fellowship from Asthma UK and Northern Ireland Chest, Heart and Stroke.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(5):1117-1123. doi:10.1378/chest.10-2321
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Background:  Unexplained persistent breathlessness in patients with difficult asthma despite multiple treatments is a common clinical problem. Cardiopulmonary exercise testing (CPX) may help identify the mechanism causing these symptoms, allowing appropriate management.

Methods:  This was a retrospective analysis of patients attending a specialist-provided service for difficult asthma who proceeded to CPX as part of our evaluation protocol. Patient demographics, lung function, and use of health care and rescue medication were compared with those in patients with refractory asthma. Medication use 6 months following CPX was compared with treatment during CPX.

Results:  Of 302 sequential referrals, 39 patients underwent CPX. A single explanatory feature was identified in 30 patients and two features in nine patients: hyperventilation (n = 14), exercise-induced bronchoconstriction (n = 8), submaximal test (n = 8), normal test (n = 8), ventilatory limitation (n = 7), deconditioning (n = 2), cardiac ischemia (n = 1). Compared with patients with refractory asthma, patients without “pulmonary limitation” on CPX were prescribed similar doses of inhaled corticosteroid (ICS) (median, 1,300 μg [interquartile range (IQR), 800-2,000 μg] vs 1,800 μg [IQR, 1,000-2,000 μg]) and rescue oral steroid courses in the previous year (median, 5 [1-6] vs 5 [1-6]). In this group 6 months post-CPX, ICS doses were reduced (median, 1,300 μg [IQR, 800-2,000 μg] to 800 μg [IQR, 400-1,000 μg]; P < .001) and additional medication treatment was withdrawn (n = 7). Patients with pulmonary limitation had unchanged ICS doses post CPX and additional therapies were introduced.

Conclusions:  In difficult asthma, CPX can confirm that persistent exertional breathlessness is due to asthma but can also identify other contributing factors. Patients with nonpulmonary limitation are prescribed inappropriately high doses of steroid therapy, and CPX can identify the primary mechanism of breathlessness, facilitating steroid reduction.


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