COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

SPIROMETRY:

Spirometry is the term given to the basic lung function tests that measure the air that is
expired and inspired. There are three basic related measurements: volume, time and flow.
Spirometry is objective, noninvasive, sensitive to early change and reproducible. With the
availability of portable meters it can be performed almost anywhere and, with the right
training, it can be performed by anybody. It is performed to detect the presence or absence of
lung disease, quantify lung impairment, monitor the effects of occupational/environmental
exposures and determine the effects of medications.

American Thoracic Society (ATS) recommends that the equipment should be such that it
meets the minimum standards.

o Should record 7 litres volume and 12 L/second flow rate

o Should be calibrated with a 3Lsyringe
o Should record minimum FVC and FEV1
o Should record flow volume curve or flow volume loop or both

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

American Thoracic society (ats) recommendations for Performing spirometry

Effort Maximal, smooth and cough-free
Position Sitting
Exhalation time 6 seconds
End of test 2 second volume plateau
Reproducibility FVC within 5% in three acceptable tests
Spirometric measures include the following.

 Forced expiratory volume in 1 s (FEV1)

 Forced vital capacity (FVC), the maximum amount of air that can be exhaled when
blowing out as fast as possible
 Vital capacity (VC), the maximum amount of air that can be exhaled when blowing
out as fast as possible
 FEV1/FVC ratio
 Peak expiratory flow (PEF), the maximal flow that can be exhaled when blowing out
at a steady rate
 Forced expiratory flow, also known as mid-expiratory flow; the rates at 25%, 50%
and 75% FVC are given
 Inspiratory vital capacity (IVC), the maximum amount of air that can be inhaled after
a full expiration

Technique

There are a number of different techniques for performing spirometry.

 Before performing the forced expiration, tidal (normal) breaths can be taken first, then
a deep breath taken in while still using the mouthpiece, followed by a further quick, full
inspiration.
 Alternatively, a deep breath can be taken in then the mouth placed tightly around the
mouthpiece before a full expiration is performed.

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

 The patient can be asked to completely empty their lungs then take in a quick full
inspiration, followed by a full expiration.

The latter technique can be useful in patients who may achieve a larger inspiration following
expiration.

 For FVC and FEV1, the patient takes a deep breath in, as large as possible, and blows
out as hard and as fast as possible and keeps going until there is no air left.
 PEF is obtained from the FEV1 and FVC manoeuvre.
 For VC, the patient takes a deep breath in, as large as possible, and blows steadily for
as long as possible until there is no air left. Nose clips are essential for VC as air can leak out
due to the low flow.
 The IVC manoeuvre is performed at the end of FVC/VC (depending on what type of
equipment is used) by taking a deep, fast breath back in after breathing all the way out.

Encouragement makes a big difference, so don't be afraid to raise your voice to encourage the
patient, particularly near the end of the manoeuvre. The patient needs to keep blowing until
no more air comes out and the volume–time trace reaches a plateau with <50 mL being
exhaled in 2 s . Some patients, particularly those with obstructive disease, may find it difficult
to exhale completely on a forced manoeuvre.

SIX MINUTE WALK TEST:

The 6MWT is a practical simple test that requires a 100-ft hallway but no exercise equipment
or advanced training for technicians. Walking is an activity performed daily by all but the
most severely impaired patients. This test measures the distance that a patient can quickly
walk on a flat, hard surface in a period of 6 minutes (the 6MWD)
The self-paced 6MWT assesses the submaximal level of functional capacity. Most patients do
not achieve maximal exercise capacity during the 6MWT; instead, they choose their own
intensity of exercise and are allowed to stop and rest during the test. However, because most
activities of daily living are performed at submaximal levels of exertion, the 6MWD may
better reflect the functional exercise level for daily physical activities.

Before the 6MWT

 Ensure that you have already obtained a medical history for the patient and have taken
into account any precautions or contraindications to exercise testing.
 Instruct the patient to dress comfortably, wear appropriate footwear and to avoid
eating for at least one hour before the test (where possible or appropriate).
 Any prescribed inhaled bronchodilator medication should be taken within one hour of
testing or when the patient arrives for testing.

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

 The patient should rest for at least 15 minutes before beginning the 6MWT.
 Record:
o Blood pressure.
o Heart rate.
o Oxygen saturation.
o Dyspnoea score.*

* Note: Show the patient the dyspnoea scale (i.e. Borg scale) and give standardised
instructions on how to obtain a score.

Before the Test

The oximeter is to be attached to the patient so it is ready to be checked throughout the test
without interfering with walking pace.
Describe the walking track to the patient and then give the patient the following instructions6:
The aim of this test is to walk as far as possible for 6 minutes. You will walk along this
hallway between the markers, as many times as you can in 6 minutes.
I will let you know as each minute goes past, and then at 6 minutes I will ask you to stop
where you are.
6 minutes is a long time to walk, so you will be exerting yourself. You are permitted to slow
down, to stop, and to rest as necessary, but please resume walking as soon as you are able.
Remember that the objective is to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run
or jog.
Do you have any questions?

During the Test

Monitor the patient for untoward signs and symptoms.
Use the following standard encouragements during the test6:

 1 min “You are doing well. You have 5 minutes to go.”

 2 min “Keep up the good work. You have 4 minutes to go.”
 3 min “You are doing well. You are halfway.”
 4 min “Keep up the good work. You have only 2 minutes left.”
 5 min “You are doing well. You have only 1 minute to go.”
 6 min “Please stop where you are.”

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

If the patient stops during the test, every 30 s once SpO2 is >85% “Please resume walking
whenever you feel able.”
Continuous monitoring of SpO2 and HR should be performed during the test and results
recorded each minute. If the Nadir (lowest) SpO2  is observed at a different time-point then
this should also be recorded as it is an important prognostic indicator
 

At the End of the 6MWT

 Put a marker on the distance walked.

 Seat the patient or, if the patient prefers, allow to the patient to stand.
 Immediately record oxygen saturation (SpO2)%, heart rate and dyspnoea rating on
the 6MWT recording sheet.

It is important to understand the reason for test termination/limitation, so patients

should be asked why they could not walk any further.

 Measure the excess distance with a tape measure and tally up the total distance.
The patient should remain in a clinical area for at least 15 minutes following an
uncomplicated test.

Stop the Test in the Event of Any of the Following

 Chest pain suspicious for angina.

 Evolving mental confusion or lack of coordination.
 Evolving light-headedness.
 Intolerable dyspnoea.
 Leg cramps or extreme leg muscle fatigue.
 Persistent SpO2 < 80%. (In a community setting the test may be stopped if SpO2 <
85%)

Predicted Normal Values for the 6MWT

The following predictive equations use the reference values determined from a study that
performed two 6MWTs according to the above protocol [For further details, see Jenkins, et
al., 20097]

 Predictive equation for males: 6MWD(m) = 867 – (5.71 age, yrs) + (1.03 height, cm)
Predictive equation for females: 6MWD(m) = 525 – (2.86 age, yrs) + (2.71 height,
cm) – (6.22 BMI).

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

INDICATIONS FOR THE SIX-MINUTE WALK TEST

The strongest indication for the 6MWT is for measuring the response to medical
interventions in patients with moderate to severe heart or lung disease. The 6MWT has also
been used as a one-time measure of functional status of patients, as well as a predictor of
morbidity and mortality. Formal cardiopulmonary exercise testing provides a global
assessment of the exercise response, an objective determination of functional capacity and
impairment, determination of the appropriate intensity needed to perform prolonged exercise,
quantification of factors limiting exercise, and a definition of the underlying pathophysiologic
mechanisms such as the contribution of different organ systems involved in exercise. The
information provided by a 6MWT should be considered complementary to cardiopulmonary
exercise testing, not a replacement for it. patients with end-stage lung diseases . In some
clinical situations, the 6MWT provides information that may be a better index of the patient’s
ability to perform daily activities than is peak oxygen uptake; for example, 6MWD correlates
better with formal measures of quality of life . Changes in 6MWD after therapeutic
interventions correlate with subjective improvement in dyspnea
Pre treatment and posttreatment comparison
Lung transplantation
Lung resection
Lung volume reduction surgery
Pulmonary rehabilitation
COPD
Pulmonary hypertension
Heart failure
Functional status (single measurement)
COPD
Cystic fibrosis
Heart failure
Peripheral vascular disease
Fibromyalgia
Older patients
Predictor of morbidity and mortality
Heart failure
COPD

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

Primary pulmonary hypertension

Absolute contraindications for the 6MWT include the following:

unstable angina during the previous month and myocardial infarction during the previous
month.
Relative contraindications include a resting heart rate of more than 120, a systolic blood
pressure of more than 180 mm Hg, and a diastolic blood pressure of more than 100 mm Hg
Patients with any of these findings should be referred to the physician ordering or supervising
the test for individual clinical assessment and a decision about the conduct of the test.
The results from a resting electrocardiogram done during the previous 6 months should also
be reviewed before testing. Stable exertional angina is not an absolute contraindication for a
6MWT, but patients with these symptoms should perform the test after using their anti angina
medication, and rescue nitrate medication should be readily available.
DYSPNEA:
Dyspnea, commonly referred to as shortness of breath, is the subjective sensation of
uncomfortable breathing comprised of various sensations of varying intensity. It is a common
symptom impacting millions of people and maybe the primary manifestation respiratory,
cardiac, neuromuscular,
psychogenic, systemic
illness, or a combination of these.
Dyspnea can be either acute or
chronic with acute occurring over
hours to days and chronic
occurring for more than 4 to 8
weeks.

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Patient Instructions for Borg Dyspnoea Scale:

“This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0
where your breathing is causing you no difficulty at all and progresses through to number 10
where your breathing difficulty is maximal.

The Borg Scale of Perceived Exertion

One way to gauge how hard you are exercising is to use the Borg Scale of Perceived
Exertion. The Borg Scale takes into account your fitness level: It matches how hard you feel
you are working with numbers from 6 to 20; thus, it is a “relative” scale. The scale starts with
“no feeling of exertion,” which rates a 6, and ends with “very, very hard,” which rates a 20.
Moderate activities register 11 to 14 on the Borg scale (“fairly light” to “somewhat hard”),
while vigorous activities usually rate a 15 or higher (“hard” to “very, very hard”). Dr. Gunnar
Borg, who created the scale, set it to run from 6 to 20 as a simple way to estimate heart rate—
multiplying the Borg score by 10 gives an approximate heart rate for a particular level of
activity.

References:

https://breathe.ersjournals.com/content/8/3/232
ATS Statement: Guidelines for the Six-Minute Walk Test
https://www.thoracic.org › statements › resources › pfet › sixminute

https://pulmonaryrehab.com.au › assessing-exercise-capacity › six-minute-

https://www.hsph.harvard.edu/nutritionsource/borg-scale/

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