HISTORY<br />The patient is a 37 year-old Hispanic Man who complained of chest pain and a productive cough at night and after running. The cough started about 5 months before the evaluation. <br />
HISTORY<br />The patient also noted shortness of breath when lying flat in bed. He had a minimal smoking history (3 pack-years) but had worked as a welder for 25 years. He had one brother who was diagnosed with asthma. <br />
HISTORY<br />Previous pulmonary function studies indicated moderate obstruction, but the patient reported worsening cough and breathlessness with exertion.<br />
Interpretation of baseline Spirometry<br />This patient's baseline spirometry, performed 3 months before the EIA evaluation, demonstrates moderate obstruction (FEV1% = 55%) even though his FEV1 is 81% of the expected value. <br />In addition, he shows a 15% and 430-ml increase in FEV1 following inhaled bronchodilator. <br />Because the symptoms were limiting the patient in his job, the referring physician wanted to determine to what extent his obstruction worsened with exertion.<br />
Interpretation of Exercise Test<br />The exercise evaluation was performed appropriately. The target HR range for this patient was 130 to 147 beats per minute (80% to 90% of predicted maximal HR). <br />The target ventilation range was 36 to 54 L/min (40% to 60% of the FEV1×35). On the day of the exercise test, the patient's FEV1 was 2.56 L.<br />
Interpretation of Exercise Test<br />After a 1-minute warm-up, he walked for 7 minutes with his HR and ventilation within their respective target ranges. <br />The treadmill resistance was decreased slightly during the final minute to prevent his HR from exceeding 90% of predicted and to allow him to continue.<br />
Exercise and challenge Flow volume loops<br />
Interpretation of Exercise Challenge and Flow Volume Loops<br />Flow volume loops were recorded every 2 minutes during the exercise and superimposed on the maximal flow volume curve (shown in the first panel above).<br /> All of the tidal breathing loops show expiratory flows are very near the maximal flow the subject could generate. <br />There is very little ventilatory reserve on expiration or inspiration. The patient demonstrates significant flow limitation during exercise.<br />
Interpretation to Exercise changes with Spirometry<br />Post exercise spirometry show a marked fall in FVC, FEV1, and PEF after 5 minutes. <br />This pattern is consistent with significant exercise-induced bronchospasm. <br />The induced obstruction was rapidly reversed with inhaled bronchodilators.<br />
Cause of symptoms<br />This patient's symptoms appear to be directly related to the results of his exercise test. The patient complained of chest pain and cough; both of these symptoms can be caused by hyperreactive airways.<br /> Chest pain is often associated with cardiac disease but may actually be "chest tightness" or "chest discomfort" upon further investigation. The patient did have moderate airway obstruction at rest.<br />
Cause of symptoms<br />Normally an EIA test would not be indicated in a patient with documented reversible airway obstruction. In this case the exercise evaluation quantified the extent of the hyperreactivity by demonstrating an even further decrease in FEV1 following exertion. <br />The patient displayed flow limitation in his tidal breathing, which explains dyspnea during exertion. Exercise-induced bronchospasm typically occurs immediately after exertion. The marked decrease in flows upon completing exercise documents the rather severe nature of the response in this particular patient's airways.<br />
Treatment<br />The patient was started on a combination of inhaled corticosteroids and long-acting -agonists, with fasting-acting -agonists for emergency relief. <br />Unfortunately, he had to leave his job as a welder because of the continued exposure to dust and fumes and because of the level of exertion required by the occupation.<br />
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