Exercise Testing in Laryngectomized Patients | 227 9 Similar results to ours were found in a group of hemato-oncological patients during treatment: CPET (without breathing gas analysis) was found to be feasible and safe, but only a minority of patients reached maximal effort28. The researchers concluded that the protocol used might not be fitting for this low-fit and vulnerable group and suggested the use of an endurance protocol at fixed workload as a possible alternative. Although fixed-workload tests cannot be used to determine VO2 peak, they can be useful to evaluate changes in exercise capacity over time in individuals, and for evaluation of intervention effects in comparative studies. The advantage of our current set-up is that it still enables breath-gas-analysis during such submaximal testing. As suggested by others, it would be an option to first train patients, before applying maximal CPET testing. For this purpose, muscle strength training, as well as aerobic training, have been suggested28,38–40. In the context of rehabilitation, the question remains whether reaching maximal capacity should be a testing goal, or whether individual testing goals should be set to match the patient’s treatment goals, wishes and possibilities. Further research is warranted to determine the best approach to exercise testing in low-fit cancer survivors, including those after TL. What stood out in the results of the patients reaching an RER>1.1 is the low relative peak VO2 (mean 19.3 ml/kg/min), especially considering their self-reported level of regular physical activity. As a reference: the minimum level of maximal oxygen uptake compatible with continued independence is about 15–18 ml/kg/min, normally reached at 80-85 years in sedentary elderly people38. In this sample, participants using the 0.3 hPa HME as regular HME had poorer exercise performance than participants using the 0.6 hPa HME. This is not likely the result of the HME used, but probably reflects that patients with a poorer general health or pulmonary condition choose a lower resistance HME for comfort. In this sample, we found that lowering the HME resistance level did not lead to improved exercise capacity. Non-laryngectomized people tend to lower the breathing resistance during exercise by mouth breathing. So, we anticipated that a lower resistance would increase exercise capacity, but our data indicates otherwise. Of note; the resistance of the 0.6 hPa HME is still lower than that of nose breathing (1.9 - 3.9 hPa41). Those who are comfortable wearing a regular HME under non-exercise conditions likely will not benefit from a lower resistance HME during exercise. In addition, they must be aware that using low-resistance HMEs may feel more comfortable, but comes at the cost of reduced health benefits due to poorer performance of the HME in terms of heat and moisture retainment, and reduced training stimulus to the respiratory muscles.
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