cardiopulmonary exercise testing historical perspective, principles & applications
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CARDIOPULMONARY EXERCISE TESTING Historical Perspective, Principles & Applications. JOSEPH PRIESTLY (1733-1804) Discovers Oxygen. LAVOISIER’S EXPERIMENTS ON OXYGEN IN THE ATMOSPHERE. ANTOINE & MADAME LAVOISIER. ADOLPH FICK (1829-1901) AND CARDIAC OUTPUT. - PowerPoint PPT PresentationTRANSCRIPT
CARDIOPULMONARY EXERCISE TESTING
Historical Perspective, Principles & Applications
JOSEPH PRIESTLY (1733-1804)
Discovers Oxygen
LAVOISIER’S EXPERIMENTS ON OXYGEN IN THE ATMOSPHERE
ANTOINE & MADAME LAVOISIER
ADOLPH FICK (1829-1901) AND CARDIAC
OUTPUT
NATHAN ZUNTZ (1847-1920) COLLECTING
EXPIRED AIR
CARDIOPULMONARY EXERCISE LAB AT THE UNIVERSITY OF PENNSYLVANIA
Collecting Expired Air
DICKINSON RICHARDS AND THE CARDIOPULMONARY UNIT
“The foundation upon which the work of Dr. Cournand and myself chiefly rests is that of Laurence J. Henderson…he was a general physiologist in the broadest sense.
It was from Henderson that we derived the simple but essential concept that lungs, heart, and circulation should be thought of as one single apparatus for the transfer of respiratory gases between outside atmosphere and working tissues.”
THE GAS TRANSPORT SYSTEM
CARDIO-PULMONARY EXERCISE TESTING
Breath-by-Breath Respiratory Gas Exchange
Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986
CARDIO-PULMONARY EXERCISE (CPX)
Modified Naughton Protocol for Incremental Treadmill Exercise
Stage(2 min)
Speed(mph)
Grade(%)
standing
0 0
1 1.0 02 1.5 03 2.0 3.54 2.0 7.05 2.0 10.56 3.0 7.57 3.0 10.08 3.0 12.59 3.0 15.010 3.4 14.0
Patterson JA, et al. Am J Cardiol 1972;30:757
THE PRINCIPLE OF ADOLPH FICK
O2 Uptake (VO2)
Arterio-Venous O2 difference
= Cardiac Output
VO2 = cardiac output • A−VO2 difference
OXYGEN UPTAKE AND INCREMENTAL MUSCULAR
WORK
Maximal O2 Uptake
MAXIMAL O2 UPTAKE
Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986
CLASSIFICATION OF FUNCTIONAL IMPAIRMENT FOR PATIENTS WITH CARDIAC OR CIRCULATORY
FAILURE
ClassVO2max
(mL/min/kg)
A >20
B 16 to 20
C 10 to 16
D <10
Weber KT, et al. N Engl J Med 1980;303:242
RESPONSE IN ARTERIO-VENOUS O2 DIFFERENCE TO UPRIGHT ISOTONIC
EXERCISE
Weber KT & Janicki JS. Am J Cardol 1985;55:22A
Weber KT & Janicki JS. Am J Cardol 1985;55:22A
CARDIAC OUTPUT RESPONSE TO UPRIGHT ISOTONIC EXERCISE
Weber KT & Janicki JS. Am J Cardol 1985;55:22A
RELATIONSHIP BETWEEN CARDIAC OUTPUT AND LEFT VENTRICULAR FILLING PRESSURE
DURING UPRIGHT ISOTONIC EXERCISE
RESPONSE IN MIXED VENOUS LACTATE TO UPRIGHT ISOTONIC EXERCISE
Weber KT & Janicki JS. Am J Cardol 1985;55:22A
CARDIO-PULMONARY EXERCISE
Anaerobic Threshold
Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986
CARDIO-PULMONARY EXERCISE
Gas Exchange, VE and HR
CPX AND GRADING THE SEVERITY OF IMPAIRED AEROBIC CAPACITY
Weber KT, et al. Clin Chest Med 1984;5:173
Class Severity
Maximum Oxygen Uptake
(mL/min/kg)
Maximum Cardiac Output
(L/min/m2)
Anaerobic Threshold(mL/min/
kg)
A none to mild >20 >8 >14
B mild to moderate 16 to 20 6 to 8 11 to 14
Cmoderate to severe
10 to 15 4 to 6 8 to 11
D severe 6 to 9 2 to 4 5 to 8
AEROBIC CAPACITY AND SYMPTOMATIC STATUS
• Patients with cardiac disease begin to experience limiting symptoms when VO2 is <22 mL/kg/min
• They consider themselves severely limited with VO2 <16 mL/kg/min
Patterson JA, et al. Am J Cardiol 1972;30:757
Pardy RL, et al. Clin Chest Med 1984;5:35
NORMAL VENTILATORY RESPONSE TO INCREMENTAL ISOTONIC EXERCISE
Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986
CARDIO-PULMONARY EXERCISE
Predicting Cardiac Index and VE
Class
VO2max
(mL/min/kg)
Anaerobic Threshold (mL/min/kg)
Predicted CI(L/min/m2)
Predicted VE
(L/min)
A >20 >14 >8 >60
B 16 to 20 11 to 14 6 to 8 50 to 60
C 10 to 16 8 to 11 4 to 6 40 to 50
D 6 to 10 5 to 8 <4 <40
THE PROPORTION OF THE MAXIMUM VOLUNTARY VENTILATION (VENTILATORY RESERVE) USED DURING INCREMENTAL ISOTONIC EXERCISE BY PATIENTS WITH
CHRONIC CARDIAC FAILURE
Weber KT, et al. Circulation 1982;65:1213
Class B
52%
Class A
43%
Class C
34%
Class D
37%VE max
MVV
MVV=FEV1×35
EXERCISE VE AND VENTILATORY RESERVE (MVV)
Cardiac vs. Ventilatory Limitation
ARTERIAL O2 IN EMPHYSEMA AND
BRONCHITIS
Jones NL. Clin Sci 1966;31:39
CRITERIA USED TO IDENTIFY CARDIAC FROM VENTILATORY CAUSE OF
EXERTIONAL DYSPNEA
• Achieve anaerobic threshold and VO2max
• Exercise VE is <50% of MVV
• Do not develop arterial O2 desaturation
Cardiac
• Do not achieve anaerobic threshold or VO2max
• Exercise VE is >50% of MVV
• Propensity to develop arterial O2 desaturation
Ventilatory
Weber KT. In: Fishman’s Pulmonary Diseases and Disorders. New York: McGraw-Hill. 1998
INDICATIONS FOR CPX TESTING IN THE EVALUATION AND MANAGEMENT OF
CARDIOPULMONARY DISEASE
• Identify the nature of the disease
• Identify the severity of the disease
• Monitor the natural course of the disease
• Select therapy
• Monitor response to therapy
ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By CXR
ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By CXR, Hemodynamic Data, and Ejection Fraction
Resting RestingCI (L/min/M2) 1.80 1.85PCW (mmHg) 28 27EF (%) 24 26
ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By Response to Exercise
Resting Exercise Resting ExerciseCI (L/min/M2) 1.80 3.43 1.85 6.00PCW (mmHg) 28 42 27 40EF (%) 24 -- 26 --Exerc. capac. (sec) -- 492 -- 924
SIX- AND 12-MONTH SURVIVAL
Chronic Cardiac Failure
Likoff MJ, et al. Am J Cardiol 1987;59:634