cardiopulmonary exercise testing historical perspective, principles & applications

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