Version May 2024
| Patients who require this level of testing for undiagnosed dyspnea may benefit from referral to a pulmonary or cardiology specialist | ||
| Test | Rationale | Further testing |
| Revisit description of dyspnea; Consider upper airway contribution (including nasal obstruction), muscle weakness, or fatigue being interpreted as dyspnea | Conditioning program with reassessment of symptoms and PFTs at 6 to 12 month intervals. | Further testing as described below if no response to conditioning program or patient prefers more immediate answers. |
| Exercise echocardiography | Wall motion and Doppler parameters are monitored during treadmill or cycle exercise to elicit exercise related PH, identify segmental wall motion abnormalities suggestive of CAD, or unmask mitral or aortic valvular disease that is hemodynamically significant during exercise. | Exercise-related pulmonary hypertension may need further evaluation with invasive CPET, if clinically significant dyspnea. CAD and valvular disease will need appropriate evaluation and treatment. |
| Obtain CPET | CPET can help identify nonrespiratory causes of exercise limitation, mitochondrial disease, and can help distinguish whether cardiac or respiratory problems are causing the patient's limitation in cases in which more than one disease is present. | Patients with normal testing including a normal CPET are likely to have deconditioning or a perceptual or psychological cause for dyspnea. |
| Serum lactate (rest and exercise) | Plasma lactate level at rest and fasting >2.5 mmol/L may suggest mitochondrial disease. | Further correlation needed with CPET, creatine kinase, and possibly muscle biopsy. |
| Invasive CPET (with arterial line and/or pulmonary artery catheter in place) | Depending on the level of suspicion and availability of testing, iCPET may be performed directly or based on exercise echocardiogram findings. | iCPET is largely used to identify or exclude exercise-related PH, HFpEF, and preload dependent limitations to cardiac output. |
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