essentials cardiopulmonary exercise testing essentials tool abdurahman m. al-howikan specialist in...

Cardiopulmonary Exercise Testing EssentialsEssentials Tool

Abdurahman M. AL-Howikan

Specialist in CPET

(CPET)

Definition :

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

Muscle

LungHeart

non- invasive procedure

►Obstruction►Restriction►Chestwall►infiltrative

►Heart disease - coronary -Valvular►Anemia

►Obisity►airflow obstruction

Other Fields of CPET:

Pulmonary …….

Cardiology ………

Sports medicine

Occupational medicine

Intensive care

Rehabilitation

►physical performance►exercise prescription ►quality of trainning

►occupational exercise tolerance (Air traveler, diving, fireman)

►Risk assessment prior to surgery ►Nutrition

►design of Reh. programs►assessed the improvement

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

abnormal blood pressure response to exercise

poor circulation

exercise capacity and anaerobic threshold of the individual

Follow responses to therapy in patients with cardiopulmonary disease

Information of CPET

Power

symptom intensity

oxygen intake:

At rest 3.5ml/kg = METml/kg = MET

carbon dioxide output

At the begininng of test < 1.0

(0.7 fat), (07-0.1 mix),(>1.0 carbohydrate

heart rate

HRSV= CO

HRmaxfor each 10 yrs

HRmax=220-age

HRmax=194.8-(0.504age

systemic blood pressure

Ventilation

from7 liter at rest to 100 liter

VE 70% of mvv

Arterial O2 saturation

SAFETY OF SAFETY OF EXERCISE TESTINGEXERCISE 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 FITNESSCLASSIFYING FITNESS

Maximal Oxygen Uptake (VO2 -- ml/kg) Maximal Oxygen Uptake (VO2 -- ml/kg)

MENMEN WOMEN WOMEN

AGEAGE LOW FAIR AVG. GOOD HIGHLOW FAIR AVG. GOOD HIGH LOW FAIR AVG. GOOD HIGHLOW FAIR AVG. GOOD HIGH

20-29 20-29 < 25 25-33 34-42 43-52 > 52 < 25 25-33 34-42 43-52 > 52 < 24 24-30 31-37 38-48 > 48 < 24 24-30 31-37 38-48 > 48

30-3930-39 < 23 23-30 31-38 39-48 > 48 < 23 23-30 31-38 39-48 > 48 < 20 20-27 28-33 34-44 > 44 < 20 20-27 28-33 34-44 > 44

40-4940-49 < 20 20-26 27-35 36-44 > 44 < 20 20-26 27-35 36-44 > 44 < 17 17-23 24-30 31-41 > 41 < 17 17-23 24-30 31-41 > 41

50-5950-59 < 18 18-24 25-33 34-42 > 42 < 18 18-24 25-33 34-42 > 42 < 15 15-20 21-27 28-37 > 37 < 15 15-20 21-27 28-37 > 37

60-6960-69 < 16 16-22 23-30 31-40 > 40 < 16 16-22 23-30 31-40 > 40 < 13 13-17 18-23 24-34 > 34 < 13 13-17 18-23 24-34 > 34

** ** **

0

1000

2000

3000

4000سجينك

الى ل

علال

ك االهست

الا

20-29 30-39 40-50

سنة( العمر )بال

تقدير ياس ق

P ‹ 0.01

Comparative between direct measurement VO2 max( ml/min) and estimate according to Wasserman equation

Age (years)

VO

2 m

ax(

ml/

min

) measurement estimate

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

Identification of the clinical problem, Clinical historyPhysical examination, Pulmonary function tests, E C G

Indication for CPET

Ensure quality of results

Select appropriate reference valuesto establish patterns of abnormal response

Compare with characteristic patternsof relevant diseases

Logical strategy to approach cardiopulmonary exercise testing

Cardiopulmonary responseTo 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

►both Vt, fr increase until 70 to 80% of peak exercise

►Vt usually plateaus at 50 to 60% of vital capacity (VC)

►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,

VE=(tidal volume, Vt, time respiratory frequency, fr)

MVV=(FEV1 35–40).healthy adults, peak exercise ventilation approaches 70% of the MVV

►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)

► 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,

► 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˙ o2without hyperventilation

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 DIAGNOSIS

VO2 maxVO2 maxNORMALNORMAL LOWLOW

NORMALNORMALOBESITYOBESITYVO2-ATVO2-AT

NORMALNORMAL LOWLOW

CARDIOVASC. CARDIOVASC. LIMITATIONLIMITATION

BR %BR %NORMALNORMAL

LOWLOWRESPIRATORY RESPIRATORY

LIMITATIONLIMITATION

DECONDITIONEDDECONDITIONED

POOR POOR EFFORTEFFORT

AL

L-C

AU

SE

MO

RT

AL

ITY

HighHigh

<1% <1% /yr/yr

IVIV IIII II FUNCTIONAL FUNCTIONAL CLASSCLASS

5 10 30 25 20 15 35 VO2 ACTUALACTUAL

METSMETS 1 2 3 4 6 5 8 7 10 9

IIIIII

1818

BRUCEBRUCE 1.7 / 10%1.7 / 10% 2.5 / 12%2.5 / 12% 3.4 / 14%3.4 / 14%

SSASSA

WATTS WATTS (70 Kg bwt)(70 Kg bwt) 5050 7575 150150 100100 125125

NON-SPECIALIST MANAGEMENT; TREATMENT OF RISK FACTORS AND SYMPTOMS; IF PATHOLOGY PRESENT, YEARLY VISIT WITH SPECIALIST

SEVERE MODERATE MILD NORMAL

(Impairment) (No Impairment)

Mortality worsened if Angina and ST depression occur during Test

SPECIALIST INPUT NEEDED; CONSIDER INVASIVE INTERVENTIONS; CHRONIC CARE CAN BE DIRECTED BY A SPECIALIST TO A PRACTITIONER

ACCUGRAPHACCUGRAPH

13

A

C

T

P

R

E

D

27

WORKWORK

TREADMILLTREADMILL BIKE BIKE

WORK WORK )Watts( )Watts(

TIME TIME TIMETIME

WORKWORK ) ? () ? (

Patterns of abnormal response to exercise in different diseases

COPD ILD PVD Obesity Deconditioned

Heart 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 or Normal

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

Peak vo2Normal (24.4)

Low

1-Normal

2-Early heart or lung disease

3- Obesity

ECGO2 Pulse

Abnormal

Normal

Obese81kg

167 cm

Normal ( anxiety)

AT (Normal)

(40-50) y (30-39) y (20-29) y Reference

36.1

40.4 46.3 German medical staff

42.3 47.4 51.7 Canadian

Sedentary

23.9 28.88 31.55 Saudi

sedentary

Compare Maximal oxygen consumption with other population

Peak cardiopulmonary function in healthy Saudi males (mean ± SD). (103)

Age (years) Variables

(40-50) (30-39) (20-29)

1.93± 0.27 2.23 ± 0.29 2.22 ±0.32 VO2 peak (L. min-1)

23.9± 3.6 28.9± 5.5 31.6±5.9 VO2 peak (ml. kg.-1

min-1)

172 ± 8 178±8 183 ± 8 HR peak (bpm)

4±9 8 ±8 12±9 HR reserve (bpm)

** **

****

**

Peak cardiopulmonary function in healthy Saudi males (mean ± SD). (103)

Age (years) Variables

(40-50) (30-39) (20-29)

82.3 ± 14.2 90.2±15 89.6±14.6 VE peak

(L. min-1)

1.9 ±0.28 1.9 ± 0.3 1.9 ± 0.26 VT peak (L)

44.5 ± 7.9 47.9 ± 8 48 ± 7.3 fb peak (min)

24.9±17 37.9±17.8 41.2±19 B R (L)

***

Age (years) Variables

(40-50) (30-39) (20-29)

140.8±17.9 156.4± 20 153.7± 19.8 Maximal work load (watts)

12.2 ± 1.6 14.2 ±1.9 14.2 ± 1.9 Exercise time (min)

13.2 ±1.9 14.5 ±3.6 16±3.9 VAT (L.min-1)

%56 %51 %51 VAT

(% VO2 peak)

***

**

Peak cardiopulmonary function in healthy Saudi males) mean ± SD.(( 103)

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

AdvantageAdvantage DisadvantageDisadvantage

Similar to walkingSimilar to walking More cooperation from patients More cooperation from patients

Setting of speed and Setting of speed and graded for all sizegraded for all size

NoisyNoisy

-------------------------------------------- Patient hold handrail Patient hold handrail

--------------------- Patient can not stop in Patient can not stop in emergency case emergency case

TREADMILL

AdvantageAdvantage DisadvantageDisadvantage

Some measurement can be taken

Local muscles fatigue

Less noisy, coast, size, weight

VO2 max less, but AT, VE higher

BIKEBIKE