Correlation of anthropometric index and cardiopulmonary exercise testing in children with pectus excavatum
Introduction
Cardiopulmonary exercise testing (CPET) is a method that helps clinicians understand the root of cardiorespiratory impairment in various diseases. The use of breath-by-breath analysis of exhaled air in a stress test helps clinicians understand the cause and pathophysiology of pathological patterns causing clinical symptomatology. Pectus excavatum (PE) is a congenital deformity of the chest of unknown aetiology, in which an abnormal formation of bone-cartilaginous joints of the ribs and sternum occurs, creating a concave depression of the chest wall (Jaroszewski et al., 2010). Frequently present symptoms are lack of endurance, shortness of breath during exercise and chest pain (Rowland and American College of Sports Medicine, 2017). Symptoms often vary in severity and their effect on normal daily activities (Krystofová et al., 2011). The severity of the deformity does not necessarily correlate with the severity of the symptoms. Many patients are asymptomatic at a younger age but begin to experience the first symptoms during puberty and adolescence. This can be caused by a growth spurt or an increase in physical activity. The most common symptoms are dyspnoea during exercise and loss of stamina (Krystofová et al., 2011). In addition to somatic problems, patients with PE often have psychological problems based on the perception of physical deformity. Exercise intolerance might be a secondary sequela to psychologically escalated fear of physical activity to which the body might be exposed (showering, changing clothes), and so it might be manifested by subsequent hypoactivity (Kelly et al., 2008).
Examination of patients with PE includes a careful anatomical description, evaluation of the extent of cardiac compression, measurement of lung function and echocardiography (ECG) to detect the presence of mitral valve prolapse or reduced right ventricular volume. The extent of the chest deformity is based on chest computed tomography (CT) and determination of the so-called Haller index (HI; Jaroszewski et al., 2010). Indications for surgical treatment include two or more of the following: severe symptomatic deformity; deformity progression; paradoxical chest movement with breathing; HI greater than 3.25; cardiac compression and/or pulmonary compression; finding a restrictive ventilation disorder; mitral valve prolapse, right bundle branch block; or other cardiological pathology secondary to cardiac compression (Kelly, 2008).
To monitor non-invasively patients with PE who are not candidates for surgery, a proposal was submitted to assess the severity of PE, the so-called anthropometric index (AI). For PE, this index is defined as the B measurement divided by the A measurement (AI = B/A) (Rebeis et al., 2007). The A and B clinical measurements are carried out with the patient in a horizontal supine position on a flat table parallel to the floor during deep inhalation. The A measurement is defined as the largest anteroposterior diameter at the level of the distal third of the sternum, and the B measurement is the greatest depth at the same level (Rebeis et al., 2007). A cut-off value for determining the severity of PE was determined to be 0.12 based on measurements and comparisons with the HI. Patients with a value greater than 0.12 are those in whom surgery is indicated in the presence of the auxiliary criteria listed above (Saxena, 2017).
Patients without the need for surgery or not wanting to undergo surgery are treated conservatively with physiotherapy and suitable candidates are also treated with vacuum bell. In those patients, measuring the HI is an unnecessary risk and the search for a non-invasive, X-ray-free measurement is ongoing. Because it has only been proved that the HI correlates with the physical abilities of patients with PE, and it appears that the HI correlates with the AI, we hypothesise that the AI is a suitable observatory index for patients not undergoing surgery due to its low cost, repeatability and lack of X-ray.
Section snippets
Methods
The study was performed from December 2017 to December 2020 and included children aged 8–19 years with a diagnosis of PE. The project protocol was approved by the Ethics Committee of the Jessenius Faculty of Medicine in Martin. All patients and their legal representatives were informed of the nature and purpose of the examination and had signed informed consent. The work was carried out at the Centre for the Diagnosis of Functional Disorders in Childhood at the Clinic for Children and
Results
We included 32 patients (28 males) in our study. Based on the severity of the deformity, the patients in our cohort were divided into two groups: a group of patients with PE and an AI < 0.12 and a group of patients with PE and an AI ≥ 0.12. A total of 17 patients (15 males) were enrolled in the AI < 0.12 group, with a mean AI of 0.09 ± 0.02. A total of 15 patients (13 males) were enrolled in the AI ≥ 0.12 group, with a mean AI of 0.17 ± 0.05. There were no statistically significant differences
Discussion
The most objective method to measure exercise capacity is CPET, which measures peak oxygen consumption (Leclerc, 2017). Non-invasive examination methods without exposure to radiation are preferred in assessing the health status of paediatric patients (Jurko et al., 2016). PE is the most common deformity of the child’s chest; it can have a major impact on the quality of life of the child not only by reducing physical condition, but also by the psychological effect that hinders their full
Conclusion
CPET is a valid, accessible, non-invasive and easily repeatable method of functional diagnostics that is applicable in childhood to determine the functional capacity of the subject and to detect the causes of reduced exercise tolerance. PE is a frequent deformity of the chest (especially in the male population) and the functional obstacles in the tolerance of physical exertion are frequently attributed to people with this deformity. Understanding the pathophysiological context in patients with
Ethics statement
The studies involving human participants were reviewed and approved by the Ethics Committee of Jessenius Medical Faculty in Martin, Commenius University, Bratislava, Slovakia. Written informed consent to participate in this study was provided by the patient’s legal guardian or next to kin.
Author contributions
OF, SB, PD, MG, KT, MM and MD managed the patients and contributed to the conception of the study. OF, SB, AD and KT drafted the manuscript. All authors have read and approved the final manuscript.
Declaration of Competing Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgement
This work was supported by VEGA grant 1/0310/18.
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