Editorial
The Stair-climbing Test. The Quest for Much-needed Simplicity
La prueba de escaleras. En búsqueda de la necesaria simplicidad
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The Quest for Much-needed Simplicity" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "259" "paginaFinal" => "260" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Francisco García-Río" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Francisco" "apellidos" => "García-Río" "email" => array:1 [ 0 => "fgr01m@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La prueba de escaleras. En búsqueda de la necesaria simplicidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">For several decades, exercise capacity has been an essential part of the evaluation of functionality in patients with lung cancer. Exercise tests are used in patients referred for lung resection surgery to more accurately select those capable of supplying tissues with enough oxygen to meet increased demand if a postoperative complication should occur. According, an exercise test is recommended for all patients referred for lung cancer surgery with an FEV<span class="elsevierStyleInf">1</span> or DLCO less than 80% of reference values.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Progressive formal cardiopulmonary exercise testing (CPET) is the procedure of choice, and maximal oxygen consumption (VO<span class="elsevierStyleInf">2</span>max) is the single most important parameter. Planned resection is feasible when predicted post-operative VO<span class="elsevierStyleInf">2</span>max is greater than 35% of the reference value, and 10<span class="elsevierStyleHsp" style=""></span>ml/kg/min.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, compliance with these recommendations is limited. An evaluation of several Spanish hospitals carried out in 2009–2010, found that 26% of patients in whom CPET was indicated did not perform the test, mainly because of lack of availablity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> This situation has led to greater interest in “low-tech” exercise testing that could replace CPET, or at least select patients in whom the test is essential.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The stair-climbing test is one of the most widely used alternatives, since it is simple, accessible, quick and cheap. Indeed, according to one classic approach, patients who can climb 3 floors without stopping are candidates for lobectomy, while those who can climb 5 floors may be considered for pneumonectomy.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The ERS/ESTS consensus document identifies the stair-climbing test as the first-line evaluation in the selection of patients who can be safely accepted for surgery, or for identifying those who need a more precise functional evaluation with CPET, the cut-off point being an ascent of 22<span class="elsevierStyleHsp" style=""></span>m.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However, a recent systematic review of 21 studies<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> found several different stair-climbing procedures used during the test, and notable methodological limitations. The equipment used depends largely on the structural characteristics of the hospital in question. While the Brunelli group uses 8 floors with 16 flights of 11 steps, each measuring 15.5<span class="elsevierStyleHsp" style=""></span>cm, producing an ascent of 27<span class="elsevierStyleHsp" style=""></span>m,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> other authors limit the ascent to 20, 13.8 or 12<span class="elsevierStyleHsp" style=""></span>m, using steps measuring between 15<span class="elsevierStyleHsp" style=""></span>cm and 17.5<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Instructions given to patients also vary widely: some groups ask the patient to climb the most stairs possible, at their own speed, until they are exhausted,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> while others propose climbing a previously established number of stairs in the shortest time possible.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Finally, no consensus exists on which variable should be recorded, with some clinicians using altitude, test duration, speed of ascent, change in oxyhemoglobin saturation or heart rate and power of work performed (body mass times ascent speed)–often estimated using different equations–have all be used.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Hence, efforts aimed at achieving greater standardization of the procedure, such as those presented by Novoa et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in this issue <span class="elsevierStyleItalic">Archivos de Bronconeumología</span>, are of great interest. They compared the estimated power between the stair-walking test limited to 27<span class="elsevierStyleHsp" style=""></span>m and to 12<span class="elsevierStyleHsp" style=""></span>m. They found that the power was similar in both protocols, although patients gained greater speed in the shorter test. It is also interesting to note that while the 33 study subjects completed the 12-m test, 21 were incapable of completing the 27-m test, and 17 did not manage to climb 22<span class="elsevierStyleHsp" style=""></span>m.</p><p id="par0030" class="elsevierStylePara elsevierViewall">These data lead us to ask if the shorter stair-climbing test could be an acceptable alternative, and if so, what the best parameter to evaluate would be. Answers may vary, depending on the objective of the procedure. According to current information, height climbed, test duration and desaturation appear to be the most consistent variables for predicting post-operative complications.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Specifically, an ascent of less than 12<span class="elsevierStyleHsp" style=""></span>m is identified as very high risk, while the cut-off point for low risk may be 14<span class="elsevierStyleHsp" style=""></span>m for lobectomy<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and 22<span class="elsevierStyleHsp" style=""></span>m for pneumonectomy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The principal variable for predicting mortality is height climbed: subjects who only climb 12<span class="elsevierStyleHsp" style=""></span>m have a 13-fold increase in risk of mortality than those who climb 22<span class="elsevierStyleHsp" style=""></span>m,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> with a cut-off point of probably 18<span class="elsevierStyleHsp" style=""></span>m.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Height climbed is also related with post-operative hospital costs,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> while power and speed of ascent are related with length of hospital stay.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">These associations give the stair-climbing test robustness and consistency, compensating for a potential physiological limitation. Because of its short duration, this test probably provides a partial assessment of the patient's aerobic capacity, since metabolism at the beginning of exercise is supported by oxidative phosphorylation, and as such, is not oxygen-dependent.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> For this reason, it is essential to identify variables for the stair-climbing test that are more closely related to VO<span class="elsevierStyleInf">2</span>max, and to establish cut-off points for clinical decision-making. To date, height climbed has shown a reasonable association with VO<span class="elsevierStyleInf">2</span>max.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">International recommendations currently in force suggest that patients who climb less than 12<span class="elsevierStyleHsp" style=""></span>m should be refused surgery, and those who climb more than 22<span class="elsevierStyleHsp" style=""></span>m do not need further evaluation, while the remaining patients require CPET.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,10</span></a> Thus, a 12-m stair-climbing test would not be sufficient to distinguish between these 3 groups of patients. However, speed of ascent has also been proposed as a useful parameter for distinguishing between patients on the basis of VO<span class="elsevierStyleInf">2</span>max, with the recommendation that those who complete the ascent at a speed of less than 15<span class="elsevierStyleHsp" style=""></span>m/min should be referred for CPET.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This would clearly facilitate the use of shorter stair-walking tests; however, there is still much work to be done on standardizing the procedure, and its usefulness in clinical decision-making algorithms needs to be validated.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Río F. La prueba de escaleras. En búsqueda de la necesaria simplicidad. Arch Bronconeumol. 2015;51:259–260.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Brunelli" 1 => "A. Charloux" 2 => "C.T. Bolliger" 3 => "G. Rocco" 4 => "J.P. Sculier" 5 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 23 | 0 | 23 |
| 2024 October | 215 | 21 | 236 |
| 2024 September | 203 | 25 | 228 |
| 2024 August | 132 | 38 | 170 |
| 2024 July | 93 | 19 | 112 |
| 2024 June | 85 | 23 | 108 |
| 2024 May | 110 | 31 | 141 |
| 2024 April | 98 | 29 | 127 |
| 2024 March | 68 | 23 | 91 |
| 2024 February | 60 | 22 | 82 |
| 2023 April | 1 | 0 | 1 |
| 2023 March | 27 | 6 | 33 |
| 2023 February | 191 | 35 | 226 |
| 2023 January | 169 | 46 | 215 |
| 2022 December | 163 | 55 | 218 |
| 2022 November | 255 | 39 | 294 |
| 2022 October | 253 | 51 | 304 |
| 2022 September | 277 | 60 | 337 |
| 2022 August | 204 | 55 | 259 |
| 2022 July | 168 | 64 | 232 |
| 2022 June | 210 | 55 | 265 |
| 2022 May | 225 | 56 | 281 |
| 2022 April | 230 | 49 | 279 |
| 2022 March | 219 | 80 | 299 |
| 2022 February | 235 | 69 | 304 |
| 2022 January | 261 | 66 | 327 |
| 2021 December | 164 | 52 | 216 |
| 2021 November | 205 | 45 | 250 |
| 2021 October | 217 | 62 | 279 |
| 2021 September | 194 | 55 | 249 |
| 2021 August | 159 | 42 | 201 |
| 2021 July | 149 | 40 | 189 |
| 2021 June | 212 | 40 | 252 |
| 2021 May | 228 | 45 | 273 |
| 2021 April | 523 | 123 | 646 |
| 2021 March | 280 | 72 | 352 |
| 2021 February | 200 | 34 | 234 |
| 2021 January | 182 | 25 | 207 |
| 2020 December | 151 | 27 | 178 |
| 2020 November | 248 | 31 | 279 |
| 2020 October | 171 | 24 | 195 |
| 2020 September | 231 | 13 | 244 |
| 2020 August | 171 | 20 | 191 |
| 2020 July | 161 | 33 | 194 |
| 2020 June | 199 | 29 | 228 |
| 2020 May | 315 | 39 | 354 |
| 2020 April | 249 | 43 | 292 |
| 2020 March | 178 | 28 | 206 |
| 2020 February | 186 | 27 | 213 |
| 2020 January | 162 | 37 | 199 |
| 2019 December | 142 | 43 | 185 |
| 2019 November | 165 | 48 | 213 |
| 2019 October | 161 | 29 | 190 |
| 2019 September | 184 | 23 | 207 |
| 2019 August | 154 | 24 | 178 |
| 2019 July | 143 | 29 | 172 |
| 2019 June | 122 | 20 | 142 |
| 2019 May | 136 | 46 | 182 |
| 2019 April | 124 | 30 | 154 |
| 2019 March | 105 | 39 | 144 |
| 2019 February | 143 | 41 | 184 |
| 2019 January | 153 | 33 | 186 |
| 2018 December | 305 | 40 | 345 |
| 2018 November | 165 | 50 | 215 |
| 2018 October | 194 | 43 | 237 |
| 2018 September | 77 | 22 | 99 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 51 | 0 | 51 |
| 2018 April | 99 | 5 | 104 |
| 2018 March | 72 | 10 | 82 |
| 2018 February | 81 | 13 | 94 |
| 2018 January | 54 | 7 | 61 |
| 2017 December | 51 | 8 | 59 |
| 2017 November | 58 | 8 | 66 |
| 2017 October | 65 | 13 | 78 |
| 2017 September | 64 | 26 | 90 |
| 2017 August | 77 | 17 | 94 |
| 2017 July | 54 | 14 | 68 |
| 2017 June | 84 | 33 | 117 |
| 2017 May | 69 | 28 | 97 |
| 2017 April | 46 | 15 | 61 |
| 2017 March | 36 | 19 | 55 |
| 2017 February | 42 | 14 | 56 |
| 2017 January | 44 | 5 | 49 |
| 2016 December | 37 | 16 | 53 |
| 2016 November | 31 | 12 | 43 |
| 2016 October | 29 | 12 | 41 |
| 2016 September | 27 | 18 | 45 |
| 2016 August | 32 | 12 | 44 |
| 2016 July | 26 | 9 | 35 |
| 2016 May | 1 | 0 | 1 |
| 2016 March | 1 | 0 | 1 |
| 2015 December | 4 | 0 | 4 |
| 2015 October | 42 | 2 | 44 |
| 2015 September | 17 | 11 | 28 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 0 | 1 | 1 |
| 2015 June | 0 | 1 | 1 |
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