Where should one site a CPET System?

A very good question with no simple answer.  Historically CPET systems were developed for use in Respiratory Medicine but you will find that most Pulmonary Function Laboratories under-utilise the equipment. This is mainly because historically the equipment has been used to differentiate a Respiratory disease after a previous Cardiac referral which proved negative.

In order to take advantage of the potential benefits of CPET, the system would be best sited in a purpose built room in a Pre-Assessment Unit. The room should be well ventilated for obvious reasons with the availability of patient changing facilities.

Importantly, as CPET is both demanding and potentially stressful for the patient, the availability of Resuscitation Equipment is essential.

To extract the true benefits of CPET in the context of preoperative assessment, it has often proved vital that the Anaesthetists have direct control over the use of the system in order that they can perform CPET whenever necessary.

So, who should supervise a CPET session?

Another good question linked to the above. There is no doubt that an Anaesthetist should make him or herself available, in order to both safely guide the patient though and conduct the consultation and CPET processes. One of the important reasons for this is that again the patient needs to be supervised, in case of an emergency, by suitably qualified personnel.

Agreement for support in conducting CPET can often be gained by prior discussion with both the Cardiac & Respiratory Medicine Groups, in order that either a Cardiac or Respiratory Physiologist can assist with the sessions.

Ideally, from a reporting angle, it would be useful to enlist the skills of the Consultant Chest Physician in reaching an objective assessment of both the performance and outcome of the CPET Test.

What do you suggest be done to establish such a service in a hospital?

Firstly, why not assess what services you already have working with your colleagues in Respiratory Medicine and Cardiology? See what facilities exist? Then build your business plan for the number of studies per year and the benefits to be gained by the hospital through this service.

Then it just requires establishing the level of equipment that can support the service at the level you require, plus the clinic space and support or admin staff to deliver the service.

None of these are obstacles that should not be overcome by discussion with hospital management teams, keen to see real savings and improved services.

What might these benefits be?

Estimates show that cardio pulmonary exercise testing will allow Hospitals to reduce surgical patients’ length of stay (LOS) by a minimum of 1 day, as patients can be admitted on the day of surgery. This alone brings considerable savings.

Evidence from other UK centres shows that CPET testing could well save the Hospital Trusts many Intensive Care bed days.

Since some patients may be considered more likely to die from major surgery than from their underlying condition, the surgery may not take place. And if it does, their post-operative care can be better planned for and managed in advance, ensuring the likelihood of unexpected complications setting in several days later is significantly reduced.

How might this service expand and benefit a hospital?

The initial pre-operative assessment itself will allow education of the patient to the very real risks they may be facing.

Or it may give the confidence to proceed to a successful outcome, which thus may avoid un-necessary palliative care.

However, it can also mark the commencement of a programme of fitness assessment, to encourage a patient to adopt a healthier lifestyle or fitness regime that will ultimately permit the intervention with an improved likelihood of a successful outcome.

Post operatively, it can be used to continue monitoring the rehabilitation of a subject.

Finally, it is worth considering that just one single CPET can yield a vast amount of data profiling the patient for a variety of hospital procedures.

The test is relatively inexpensive in consumables and the capital cost can be regained in less than one month’s testing.

So in summary, what might be gained?

The greatest reward is positive outcome from interventions and less need of palliative care.

Patients are better informed, educated and aware of risk and benefit.

What is more, the hospital is more efficient and negative operations are minimised.