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