CARDIOPULMONARY EXERCISE TESTING

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CARDIOPULMONARY EXERCISE TESTING Historical
Perspective, Principles Applications
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JOSEPH PRIESTLY (1733-1804) Discovers Oxygen
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LAVOISIERS EXPERIMENTS ON OXYGEN IN THE
ATMOSPHERE
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ANTOINE MADAME LAVOISIER
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ADOLPH FICK (1829-1901) AND CARDIAC OUTPUT
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NATHAN ZUNTZ (1847-1920) COLLECTING EXPIRED AIR
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CARDIOPULMONARY EXERCISE LAB AT THE UNIVERSITY OF
PENNSYLVANIA Collecting Expired Air
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DICKINSON RICHARDS AND THE CARDIOPULMONARY UNIT
The foundation upon which the work of Dr.
Cournand and myself chiefly rests is that of
Laurence J. Hendersonhe 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.
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THE GAS TRANSPORT SYSTEM
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CARDIO-PULMONARY EXERCISE TESTING Breath-by-Breath
Respiratory Gas Exchange
Weber KT Janicki JS. In Cardiopulmonary
Exercise Testing. Philadelphia Saunders. 1986
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CARDIO-PULMONARY EXERCISE (CPX) Modified Naughton
Protocol for Incremental Treadmill Exercise
Patterson JA, et al. Am J Cardiol 197230757
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THE PRINCIPLE OF ADOLPH FICK
O2 Uptake (VO2) Arterio-Venous O2 difference
Cardiac Output
VO2 cardiac output A-VO2 difference
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OXYGEN UPTAKE AND INCREMENTAL MUSCULAR
WORK Maximal O2 Uptake
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MAXIMAL O2 UPTAKE
Weber KT Janicki JS. In Cardiopulmonary
Exercise Testing. Philadelphia Saunders. 1986
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CLASSIFICATION OF FUNCTIONAL IMPAIRMENT FOR
PATIENTS WITH CARDIAC OR CIRCULATORY FAILURE
Weber KT, et al. N Engl J Med 1980303242
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RESPONSE IN ARTERIO-VENOUS O2 DIFFERENCE TO
UPRIGHT ISOTONIC EXERCISE
Weber KT Janicki JS. Am J Cardol 19855522A
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CARDIAC OUTPUT RESPONSE TO UPRIGHT ISOTONIC
EXERCISE
Weber KT Janicki JS. Am J Cardol 19855522A
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RELATIONSHIP BETWEEN CARDIAC OUTPUT AND LEFT
VENTRICULAR FILLING PRESSURE DURING UPRIGHT
ISOTONIC EXERCISE
Weber KT Janicki JS. Am J Cardol 19855522A
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RESPONSE IN MIXED VENOUS LACTATE TO UPRIGHT
ISOTONIC EXERCISE
Weber KT Janicki JS. Am J Cardol 19855522A
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CARDIO-PULMONARY EXERCISE Anaerobic Threshold
Weber KT Janicki JS. In Cardiopulmonary
Exercise Testing. Philadelphia Saunders. 1986
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CARDIO-PULMONARY EXERCISE Gas Exchange, VE and HR
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CPX AND GRADING THE SEVERITY OF IMPAIRED AEROBIC
CAPACITY
Weber KT, et al. Clin Chest Med 19845173
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AEROBIC CAPACITY AND SYMPTOMATIC STATUS

• Patients with cardiac disease begin to experience
  limiting symptoms when VO2 is lt22 mL/kg/min
• They consider themselves severely limited with
  VO2 lt16 mL/kg/min

Patterson JA, et al. Am J Cardiol 197230757
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NORMAL VENTILATORY RESPONSE TO INCREMENTAL
ISOTONIC EXERCISE
Pardy RL, et al. Clin Chest Med 1984535
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CARDIO-PULMONARY EXERCISE Predicting Cardiac
Index and VE
Weber KT Janicki JS. In Cardiopulmonary
Exercise Testing. Philadelphia Saunders. 1986
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THE PROPORTION OF THE MAXIMUM VOLUNTARY
VENTILATION (VENTILATORY RESERVE) USED DURING
INCREMENTAL ISOTONIC EXERCISE BY PATIENTS WITH
CHRONIC CARDIAC FAILURE
Class B 52
Class A 43
Class C 34
Class D 37
VE max MVV
MVVFEV135
Weber KT, et al. Circulation 1982651213
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EXERCISE VE AND VENTILATORY RESERVE (MVV) Cardiac
vs. Ventilatory Limitation
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ARTERIAL O2 IN EMPHYSEMA AND BRONCHITIS
Jones NL. Clin Sci 19663139
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CRITERIA USED TO IDENTIFY CARDIAC FROM
VENTILATORY CAUSE OF EXERTIONAL DYSPNEA
Cardiac

• Achieve anaerobic threshold and VO2max
• Exercise VE is lt50 of MVV
• Do not develop arterial O2 desaturation

Ventilatory

• Do not achieve anaerobic threshold or VO2max
• Exercise VE is gt50 of MVV
• Propensity to develop arterial O2 desaturation

Weber KT. In Fishmans Pulmonary Diseases and
Disorders. New York McGraw-Hill. 1998
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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

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ASSESSING THE SEVERITY OF CHRONIC CARDIAC
FAILURE By CXR
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ASSESSING THE SEVERITY OF CHRONIC CARDIAC
FAILURE By CXR, Hemodynamic Data, and Ejection
Fraction
Resting Resting CI (L/min/M2) 1.80 1.85 PCW
(mmHg) 28 27 EF () 24 26
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ASSESSING THE SEVERITY OF CHRONIC CARDIAC
FAILURE By Response to Exercise
Resting Exercise Resting Exercise CI
(L/min/M2) 1.80 3.43 1.85 6.00 PCW
(mmHg) 28 42 27 40 EF () 24 -- 26 -- Exerc.
capac. (sec) -- 492 -- 924
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SIX- AND 12-MONTH SURVIVAL Chronic Cardiac Failure
Likoff MJ, et al. Am J Cardiol 198759634