Triage assessment of cardiorespiratory risk status based on measurement of the anaerobic threshold, and estimation by activity limitation in patients with pulmonary arteriovenous malformations and hereditary haemorrhagic telangiectasia
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Abstract
B ackground
Rapid triaging, as in the current COVID-19 pandemic, focuses on age and pre-existing medical conditions. In contrast, preoperative assessments use cardiopulmonary exercise testing (CPET) to categorise patients to higher and lower risk independent of diagnostic labels. Since CPET is not feasible in population-based settings, our aims included evaluation of a triage/screening tool for cardiorespiratory risk.
M ethods
CPET-derived anaerobic thresholds were evaluated retrospectively in 26 patients with pulmonary arteriovenous malformations (AVMs) who represent a challenging group to risk-categorise. Pulmonary AVM-induced hypoxaemia secondary to intrapulmonary right-to-left shunts, anaemia from underlying hereditary haemorrhagic telangiectasia and metabolic equivalents derived from the 13-point Veterans Specific Activity Questionnaire (VSAQ) were evaluated as part of routine clinical care. Pre-planned analyses evaluated associations and modelling of the anaerobic threshold and patient-specific variables.
R esults
In the 26 patients (aged 21-77, median 57 years), anaerobic threshold ranged from 7.6-24.5 (median 12.35) ml.min -1 kg -1 and placed more than half of the patients (15, 57.7%) in the >11 ml.min -1 kg -1 category suggested as “lower-risk” for intra-abdominal surgeries. Neither age nor baseline SpO 2 predicted anaerobic threshold, or lower/higher risk categories, either alone or in multivariate analyses, despite baseline oxygen saturation (SpO 2 ) ranging from 79 to 99 (median 92)%, haemoglobin from 108 to 183 (median 156)g.L -1 . However, lower haemoglobin, and particularly, arterial oxygen content and oxygen pulse were associated with increased cardiorespiratory risk: Modelling a haemoglobin increase of 25g.L -1 placed a further 7/26 (26.9%) patients in a lower risk category. For patients completing the VSAQ, derived metabolic equivalents were strongly associated with anaerobic threshold enabling risk evaluations through a simple questionnaire.
C onclusions
Baseline exercise tolerance may override age and diagnostic labels in triage settings. These data support approaches to risk reduction by aerobic conditioning and attention to anaemia. The VSAQ is suggested as a rapid screening tool for cardiorespiratory risk assessment to implement during triage/screening.
Key Messages
What is already known
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Alongside age, pre-existing medical conditions are perceived negatively during triage assessments, particularly if rare, and/or theoretically expected to influence cardiorespiratory risk;
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Anaesthetists use cardiopulmonary exercise testing to categorise patients to higher and lower risk independently to diagnostic labels, but this is not feasible in acute settings;
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Pulmonary arteriovenous malformations are an exemplar of a condition where, due to expected or measured abnormalities (hypoxaemia-low PaO 2 SpO 2 ), poor physiological capacity might be predicted.
What this study adds
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Neither age nor usual SpO 2 predicted lower/higher risk categories by anaerobic threshold, but haemoglobin-dependent indices of oxygen delivery to the tissues were associated with higher risk, offering opportunities for improvement by attention to anaemia and aerobic conditioning;
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Baseline exercise tolerance may override age and diagnostic labels in triage settings: the 13-point VSAQ Veterans Specific Activity Questionnaire (VSAQ) is suggested as a rapid screening tool for cardiorespiratory risk assessment.
Article activity feed
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SciScore for 10.1101/2020.03.27.20045203: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: General patient evaluations: With ethical approvals (Hammersmith and Queen Charlotte’s and Chelsea Research Ethics Committee (LREC 2000/5792), patient indices derived as part of the clinical assessment process in a pulmonary AVM service at a single centre were examined as described elsewhere [14,15,17,18].
Consent: Written informed consent had been obtained from all participants.Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
Software and Algorithms Sentences Resources Metabolic equivalents (METs) were calculated from the VSAQ as in the original protocol,[5] and subsequent … SciScore for 10.1101/2020.03.27.20045203: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: General patient evaluations: With ethical approvals (Hammersmith and Queen Charlotte’s and Chelsea Research Ethics Committee (LREC 2000/5792), patient indices derived as part of the clinical assessment process in a pulmonary AVM service at a single centre were examined as described elsewhere [14,15,17,18].
Consent: Written informed consent had been obtained from all participants.Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
Software and Algorithms Sentences Resources Metabolic equivalents (METs) were calculated from the VSAQ as in the original protocol,[5] and subsequent validations [6-10], by the formula: Data Analysis: Statistical analyses were performed in Microsoft Excel and Stata IC versions 14 and 15 (Statacorp, Texas).
Microsoft Excelsuggested: (Microsoft Excel, RRID:SCR_016137)Statacorpsuggested: NoneResults from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: An explicit section about the limitations of the techniques employed in this study was not found. We encourage authors to address study limitations.Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a protocol registration statement.
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