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Chapter 9

Exercise Testing

THE 6-MIN WALK TEST

The 6MWT is similar to the 12MWT, but the 6MWT is preferred


because it is faster, better tolerated, and more standardized.1,2
The 6MWT is a useful tool for both the clinical and research
fields. Its main indication is to assess the response of patients
with pulmonary or cardiac disorders to certain interventions,
e.g., pulmonary hypertension.1 This test can also be used to
assess the functional status and predict mortality and morbidity
in such patients. Table 9.1 summarizes the indications and con-
traindications to 6MWT. The 6MWT is generally safe.22,2732 The
test should be immediately terminated, however, if the patient
develops chest pain, intolerable dyspnea, leg cramps, unstable
balance, marked diaphoresis, or pale or ashen appearance.1

Technique

The technique and methodology of 6MWT used for prognostic


studies must follow a standardized protocol.
The 6MWT is best performed in a building with unobstructed
level corridors. A distance of 30 m (~100 ft) is considered suitable
and the laps are then counted.1,3235 Under the supervision of
the respiratory therapist, the patient should walk normally,
unassisted in carrying portable O2 cylinder if used.1,36 The
patient is allowed, however, to use any kind of assistance that
he/she normally uses for daily activities, e.g., walker. During
the test, the patient may be encouraged only by standardized
phrases.1,33,37 The patient is allowed to rest whenever needed.

157
A. Altalag et al., Pulmonary Function Tests in Clinical Practice,
DOI: 10.1007/978-1-84882-231-3_9, Springer-Verlag London Limited 2009
158 PULMONARY FUNCTION TESTS IN CLINICAL PRACTICE

TABLE 9.1. Indications & contraindications for the 6MWT


Indications for 6MWT
To assess outcome of therapy (test is done before and after therapy)
Pulmonary hypertension1
Lung transplantation3,4
Lung resection5
Lung volume reduction surgery6,7
Pulmonary rehabilitation8,9
Drug therapy for COPD1012 and heart failure (CHF)13,14
To assess functional status in patients with:
Lung disease (COPD,15,16 CF,17,18 and pulmonary hypertension)
Heart disease (CHF)1921
To predict mortality and morbidity in patients with CHF,22,23 COPD,24,25
and pulmonary hypertension4,26
To assess outcome parameters for research studies
Contraindications1
Absolute
Unstable angina or MI within the past month
Relative
Resting tachycardia (>120/min)
Uncontrolled hypertension (systolic >180 and diastolic >100)

A portable pulse oximeter may be used during the test but more
important is the reporting of SPO2 at the start and the end of
the test.1,38,39
The 6MWT is repeated after a sufficient resting period. It
is usually reproducible and the largest achieved distance is
reported.1,34

Interpretation

Three measurements can be obtained from the 6MWT: the 6-min


walk distance (6MWD), the degree of dyspnea and fatigue, and
the SPO2.1,36
The most important measurement is the 6MWD, which is nor-
mally 580 m in men and 500 m in women.30 A low 6MWD is
nonspecific and nondiagnostic. A low 6MWD may be seen in
patients with lung disease, heart disease, and musculoskeletal
disease (arthritis) or even in normal subjects who perform a
submaximal effort. A significant reduction in the 6MWD, cou-
pled with the appropriate clinical setting is useful to grade
the exercise capacity and to evaluate response to therapy and
predict the overall outcome. An unexplained reduction of the
6MWD should prompt a search for a possible cause.
EXERCISE TESTING 159

The 6MWD varies significantly among normal individuals.


Factors such as age, weight, sex, and height independently
influence the 6MWD in healthy adults.1 Serial measurements
of 6MWD in the same patient, to assess disease progression or
effect of therapy, given the low intrasubject variability, make the
test more useful.
The modified Borg scale, which is a 12-level scale ranging from
no discomfort to maximal discomfort, Figure 9.1, may be
used to grade the degree of dyspnea that the patient experiences
during and at the end of the test.40
SPO2 normally is unchanged with exercise. Any drop of >5%
usually indicates a respiratory or possibly a cardiac disorder.41
Artifacts related to signal recording during walking, however,
may influence the accuracy of the SPO2.1,38,39
Sometimes a walking (exercise) oximetry is done (without meas-
uring the 6MWD) to assess SPO2 to determine the need for, or
to titrate the level of, supplemental O2 during exertion. This is
often referred to as exercise oximetry and has nothing to do with
the 6MWT.

FIGURE 9.1. The modified Borg Scale.

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