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Cardiopulmonary Exercise Testing
Essentials Tool
Abdurahman M. AL-Howikan
Specialist in CPET
(CPET)
Definition :
Muscle
Lung
Heart
Cardiopulmonary exercise testing ( CPET ) is defined as diagnostic
procedure that analyzes the responses and cooperation of the heart,
circulation, respiration, and metabolism during continuously increase
muscular stress
 non- invasive procedure
►Obisity
►airflow
obstruction
►Heart disease
- coronary
-Valvular
►Anemia
►Obstruction
►Restriction
►Chestwall
►infiltrative
Other Fields of CPET:
Pulmonary …….
Cardiology ………
Sports medicine
Occupational medicine
Intensive care
Rehabilitation
►design of Reh. programs
►assessed the improvement
►physical performance
►exercise prescription
►quality of trainning
►occupational exercise
tolerance (Air traveler,
diving, fireman)
►Risk assessment prior
to surgery
►Nutrition
Indications for Exercise Testing
Diseases that affect the heart, lungs, circulation, or blood
shortness of breath that otherwise cannot be determined at
rest or through conventional lung function testing
exercise capacity and anaerobic threshold of the individual
abnormal blood pressure response to
exercise
Follow responses to therapy in patients with
cardiopulmonary
disease
poor circulation
Information of CPET
oxygen intake:
Power
At rest 3.5ml/kg = MET
symptom intensity
Ventilation
Arterial O2 saturation
from7 liter at rest
to 100 liter
systemic blood pressure
VE 70% of mvv
carbon dioxide output
At the begininng of test
< 1.0
(0.7 fat), (07-0.1
mix),(>1.0
carbohydrate
heart rate
HRSV= CO
HRmaxfor each 10 yrs
HRmax=220-age
HRmax=194.8-(0.504age
SAFETY OF
EXERCISE TESTING
Complications: 1 per 2,000
Death: 1 per 20,000
Reference: The Safety of Exercise Testing. Gibbons, LW et al. Primary Care (1994) 21; 3; 611-628.
CLASSIFYING FITNESS
Maximal Oxygen Uptake (VO2 -- ml/kg)
MEN
WOMEN
AGE
LOW
20-29
30-39
40-49
50-59
60-69
< 25
25-33
34-42
43-52
> 52
< 24
24-30
31-37
38-48
> 48
< 23
23-30
31-38
39-48
> 48
< 20
20-27
28-33
34-44
> 44
< 20
20-26
27-35
36-44
> 44
< 17
17-23
24-30
31-41
> 41
< 18
18-24
25-33
34-42
> 42
< 15
15-20
21-27
28-37
> 37
< 16
16-22
23-30
31-40
> 40
< 13
13-17
18-23
24-34
> 34
FAIR
AVG.
GOOD
HIGH
LOW
FAIR
AVG.
GOOD
HIGH
Comparative between direct measurement VO2 max( ml/min)
and estimate according to Wasserman equation
estimate
VO2 max( ml/min)
**
-
**
-
Age (years)
measurement
**
-
P ‹ 0.01
AL- Howikan A, AL- Hazzaa H, Al- Mobeireek F, Al- Majed S. peak cardiorespiratory exercise data for healthy Saudi males
(abstract) proceeding of the 12th annual meeting of the Saudi Heart Association. Riyadh (KSA): the Saudi Heart Association; 2002
Logical strategy to approach cardiopulmonary exercise testing
Identification of the clinical problem, Clinical history
Physical examination, Pulmonary function tests, E C G
Indication for CPET
Ensure quality of results
Select appropriate reference values
to establish patterns of abnormal response
Compare with characteristic patterns
of relevant diseases
Cardiopulmonary response
To effort
►the response is linear
►slope (DV’O2/change in work rate
(DWR)) approximately 10 mL·min1·W-1
►oxygen
cost of breathing per unit
ventilation (COPD), (ILD).
►Oxygen
pulse Vo2/HR= SV C(a–v)O2
►reduced SV  low, unchanging or
flatO2 pulse  deconditioning,
cardiovascular disease
►Vt
usually plateaus at 50 to 60% of vital capacity (VC)
►both
Vt, fr increase until 70 to 80% of
peak exercise
MVV=(FEV1 35–40).
healthy adults, peak
exercise ventilation
approaches 70% of the
MVV
VE=(tidal volume, Vt, time respiratory
frequency, fr)
►Lung
disease typically increases both ventilation at
rest and given level of exercise COPD, ILD, PVD
So, an abnormal level of ventilation is required to
maintain normal Pa,CO2,
►good
for monitoring trending phenomenon
but not reliable for determining absolute
magnitude of change in hemoglobin transmit
► less accurate at saturations below about
88%
►Dark skin color can interfere with signal
detection
►Vco2 reaction
between hydrogen ion
(from lactate) and dissolved CO2
► [H] [HCO3 ] ←→ [H2CO3] ←→ [CO2] [H2O]
► hyperventilation producing extra CO2
(aerobically)
► V-slope method, in turn, determines the point of
the change in slope of the relationship of V˙ co2
versus V˙ o2
►V˙ co2 increases faster than V˙ o2
without hyperventilation
► AT increased
rate of rise of arterial [lactate]
during exercise.
► occurs at about 50–60% V˙ o2max
► low 40% ➽ cardiac, pulmonary
(desaturation)
► limitation in O2 supply to the tissues,
(mitochondrial myopathies)
► level of fitness,
As exercise intensity increases
► vasodilatation ➽ metabolic demands.
►vasoconstricted ➽ nonworking muscle
►excessive rise➽abnormal BP control
►BP does not increase ➽ abnormality of
sympathetic
►BP falls ➽ heart failure, ischemi aortic
stenosis, pulmonary vascular disease,
central venous obstruction
DIAGNOSIS
NORMAL
OBESITY
VO2 max
VO2-AT
NORMAL
NORMAL
NORMAL
DECONDITIONED
POOR
EFFORT
LOW
BR %
LOW
CARDIOVASC.
LIMITATION
LOW
RESPIRATORY
LIMITATION
NON-SPECIALIST
MANAGEMENT;
¤
TREATMENT
OF RISK
FACTORS AND SYMPTOMS;
(Impairment)
¤ IF PATHOLOGY PRESENT, YEARLY VISIT WITH
ALL-CAUSE MORTALITY
SEVERE
¤
¤
¤
High
SPECIALIST
MILD
NORMAL
SPECIALIST INPUT NEEDED;
CONSIDER INVASIVE INTERVENTIONS;
CHRONIC CARE CAN BE DIRECTED BY A SPECIALIST
TO A PRACTITIONER
<1%
/yr
VO2
ACTUAL
MODERATE
(No Impairment)
1
METS
BRUCE
WATTS
ACCUGRAPH
18 SSA
Mortality worsened if Angina and ST depression occur during Test
IV
5
III
10
II
FUNCTIONAL
CLASS
I
P
A
20
15
C
25
T
2
3
13
4
5
6
1.7 / 10%
(70 Kg bwt)
50
75
100
7
E
D
27
2.5 / 12%
125
30
R
8
35
9
10
3.4 / 14%
150
WORK
TREADMILL
BIKE
WORK
(Watts)
WORK
(?)
TIME
TIME
Patterns of abnormal response to exercise in different diseases
COPD
ILD
PVD
Obesity
Decondit Heart
ioned
failure
V’O2,peak
Reduced
Reduced
Reduced
Reduced
Normal
Reduced
Reduced
LT
Indeter.
Nor. Low
Normal
Low
Low
Low
Normal
Low
Low
VE,reserve Reduced
or none
Reduced Normal
or Normal
Normal
Normal
Normal
HRR
normal
increased
normal
increased
normal
normal
normal
Reduced
or Normal
O2 pul .pa
Reduced
Reduced
Reduced
normal
Reduced
Reduced
Fall in
SaO2
Present
Absent
Present
Present
Absent
Absent
Absent
Interpretation Case 2
Sex: male
age: 46 years
weight: 81 kg
% of ideal Wt: 64 kg
height: 167 cm
BMI:31.59
BSA:1.93 sm
Start
Normal
(24.4)
Peak vo2
1-Normal
2-Early heart or
lung disease
3- Obesity
Low
Abnormal
ECG
O2 Pulse
Normal
Normal ( anxiety)
AT (Normal)
Obese
81kg
167 cm
Compare Maximal oxygen consumption with other
population
(40-50) y
36.1
(30-39) y
40.4
(20-29) y
46.3
Reference
German
medical staff
42.3
47.4
51.7
Canadian
Sedentary
23.9
28.88
31.55
Saudi
sedentary
Peak cardiopulmonary function in healthy Saudi
males (mean ± SD). (103)
Age (years)
(40-50)
±1.93
0.27
(30-39)
± 2.23
0.29
3.6 ±23.9
5.5 ±28.9
**
**
8 ± 172
8±178
*
**
8± 8
9±4
**
Variables
(20-29)
2.22
0.32±
5.9±31.6
8 ± 183
*
9±12
VO2 peak (L. min-1)
VO2 peak (ml. kg.-1
min-1)
HR peak (bpm)
HR reserve
(bpm)
Peak cardiopulmonary function in healthy Saudi males
(mean ± SD). (103)
Age (years)
Variables
(40-50)
± 82.3
14.2
(30-39)
15±90.2
(20-29)
14.6±89.6
0.28± 1.9
0.3 ± 1.9
0.26 ± 1.9
7.9 ± 44.5
8 ± 47.9
7.3 ± 48
fb peak (min)
17±24.9
17.8±37.9
19±41.2
*
**
B R (L)
VE peak
(L. min-1)
VT peak (L)
Peak cardiopulmonary function in healthy Saudi males
(mean ± SD). (103)
Age (years)
(40-50)
(30-39)
17.9±140.8 20 ±156.4
**
*
1.6 ± 12.2 1.9± 14.2
1.9± 13.2
3.6± 14.5
%56
**
%51
(20-29)
±153.7
19.8
1.9 ± 14.2
3.9±16
%51
Variables
Maximal work
load (watts)
Exercise time
(min)
VAT (L.min-1)
VAT
(% VO2 peak)
SUGGESTED NORMAL GUIDELINES FOR
INTERPRETATION OF CARDIOPULMONARY
EXERCISE TESTING RESULTS
Variables
Criteria of Normality
VO2max or VO2peak
> 84% predicted
Anaerobic threshold
range of normal (40–80%)
Heart rate (HR)
HRmax 90% age predicted
Heart rate reserve (HRR)
HRR <15 beats/min
O2 pulse (VO2/HR)
> 80%
Ventilatory reserve (VR)
MVV -VEmax:11(L )
Respiratory frequency (fR)
< 60 breaths/min
VE/VCO2 (at AT)
< 34
VD/VT
< 0.28; < 0.30 for age > 40 y
P(A–a)O2
< 35 mm Hg
TREADMILL
Advantage
Disadvantage
Similar to walking
More cooperation from patients
Setting of speed and
graded for all size
Noisy
----------------------
Patient hold handrail
---------------------
Patient can not stop in
emergency case
BIKE
Advantage
Disadvantage
Some measurement can
be taken
Local muscles fatigue
Less noisy, coast, size,
weight
VO2 max less, but AT, VE
higher