CARDIOPULMONARY EXERCISE TESTING
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1 CARDIOPULMONARY EXERCISE TESTING JOSEPHINE B. BLANCO-RAMOS, M.D., FPCP,FPCCP,FACCP MEDICAL HEAD PULMONARY DIAGNOSTIC & THERAPEUTIC CENTER THE MEDICAL CITY
2 OUTLINE Description of CPET Who should and who should not get CPET When to terminate CPET Exercise physiology Define terms: respiratory exchange ratio, ventilatory equivalent, heart rate reserve, breathing reserve, oxygen pulse Patterns of CPET results
3 Karlman Wasserman, MD
4 SOURCES OF ENERGY FOR ATP
5 Derangements of gas exchange in disease. Milani R V et al. Circulation. 2004;110:e27-e31 Copyright American Heart Association, Inc. All rights reserved.
6 Coupling of External Ventilation and Cellular Metabolism
7 WHY EXERCISE? The goal of CARDIO-PULMONARY exercise testing is to evaluate the physiologic response of the heart lungs and muscles to an increase in physical stress.
8 CASE 50 year old, male, computer technician retired 10 years ago because of progressive dyspnea was a heavy cigarette smoker, but denies cough/phlegm/wheezing/che st pains recurrent pneumothorax secondary to multiple bullous disease
9 Predicted Measured %Pred FVC FEV
10 QUESTION 1: WOULD YOU CLEAR THIS PATIENT FOR PNEUMONECTOMY? A. YES B. NO
11
12 Predicted Post -Operative FEV1 PPO FEV1 = Pre-Op FEV1 x (1-a/b) a= number of unobstructed segments to be removed b= total number of unobstructed segments PPO FEV1 = 1480 ml ( 1-9/19) = 778 ml
13 QUESTION 2: WHAT IS THE NEXT MOST APPROPRIATE DIAGNOSTIC PROCEDURE TO CONFIRM WHETHER THIS PATIENY CAN UNDERGO PNEUMONECTOMY? A. STAIR CLIMBING B. DIFFUSION CAPACITY C. VENTILATION-PERFUSION SCANNING D. CARDIOPULMONARY EXERCISE TESTING
14 Use of CPX in the clinical evaluation of chronic dyspnea. Balady G J et al. Circulation. 2010;122: Copyright American Heart Association, Inc. All rights reserved.
15 INDICATIONS FOR CPET Evaluation of dyspnea distinguish cardiac vs pulmonary vs peripheral limitation vs others detection of exercise-induced bronchoconstriction detection of exertional desaturation Pulmonary rehabilitation exercise intensity/prescription response to participation Pre-op evaluation and risk stratification Prognostication of life expectancy
16 INDICATIONS Disability determination Fitness evaluation Confirm the diagnosis Assess response to therapy
17 ABSOLUTE CONTRAINDICATIONS TO CPET Acute MI Unstable angina Unstable arrhythmia Acute endocarditis, myocarditis, pericarditis Syncope Severe, symptomatic Atrial Stenosis Uncontrolled CHF
18 ABSOLUTE CONTRA Acute PE, DVT Respiratory failure Uncontrolled asthma SpO 2 <88% on RA Acute significant non-cardiopulmonary disorder that may affect or be adversely affected by exercise Significant psychiatric/cognitive impairment limiting cooperation
19 RELATIVE CONTRAINDICATIONS Left main or 3-V CAD Severe arterial HTN (>200/120) Significant pulmonary HTN Tachyarrhythmia, bradyarrhythmia High degree AV block
20 RELATIVE CONTRA Hypertrophic cardiomyopathy Electrolyte abnormality Moderate stenotic valvular heart disease Advanced or complicated pregnancy Orthopedic impairment
21 INITIAL EVALUATION HISTORY: tobacco use, medications, tolerance to normal physical activities, any distress symptoms, contraindicated illnesses PHYSICAL EXAM: height, weight, assessment of heart, lungs, peripheral pulses, blood pressure EKG PULMONARY FUNCTION TESTS: spirometry, lung volumes, diffusing capacity, arterial blood gases
22 PRIOR TO THE TEST Wear loose fitting clothes, low-heeled or athletic shoes Abstain from coffee and cigarettes at least 2 hours before the test Continue maintenance medications May eat a light meal at least 2 hours before the test
23 CARDIOPULMONARY EXERCISE TEST (CPET) symptom-limited exercise test measures airflow, SpO 2, and expired oxygen and carbon dioxide allows calculation of peak oxygen consumption, anaerobic threshold
24 EXERCISE MODALITIES Advantages of cycle ergometer cheaper safer Less danger of fall/injury Can stop anytime direct power calculation Independent of weight Holding bars has no effect little training needed easier BP recording, blood draw requires less space less noise Advantages of treadmill attain higher VO 2 more functional
25 COMPARISON OF CYCLE VS TREADMILL CYCLE TREADMILL VO2 MAX LOWER HIGHR LEG MUSCLE FATIGUE OFTEN LIMITING LESS LIMITING WORK RATE QUANTIFICATION YES ESTIMATION WEIGHT BEARING IN OBESE LESS MORE NOISE & ARTIFACTS LESS MORE SAFETY ISSUES LESS MORE
26 EXERCISE TEST PROTOCOLS INCREMENTAL RAMP WORK WORK TIME TIME
27 INDICATIONS TO EXERCISE TERMINATION Patient s request: fatigue, dyspnea, pain Ischemic ECG changes 2 mm ST depression Chest pain suggestive of ischemia Significant ectopy 2 nd or 3 rd degree heart block Bp sys > , Bp dias >
28 INDICATIONS TO TERMINATION Fall in BP sys >20 mmhg SpO 2 <81-85% Dizziness, faintness Onset of confusion Onset of pallor
29 General Mechanisms of Exercise Limitation Pulmonary Ventilatory impairment Respiratory muscle dysfunction Impaired gas exchange Cardiovascular Reduced stroke volume Abnormal HR response Circulatory abnormality Blood abnormality Peripheral Inactivity Atrophy Neuromuscular dysfunction Reduced oxidative capacity of skeletal muscle Malnutrition Perceptual Motivational Environmental
30 CPET Measurements Work RR VO 2 SpO 2 VCO 2 ABG AT Lactate HR Dyspnea ECG Leg fatigue BP
31 Metabolic endpoint to evaluate results of therapeutic interventions. Milani R V et al. Circulation. 2004;110:e27-e31 Copyright American Heart Association, Inc. All rights reserved.
32 PULMONARY PARAMETERS 1. MINUTE VENTILATION NORMAL = 5 6 liters/ min AT EXERCISE = 100 liters/min increase is due to stimulation of the respiratory centers by brain motor cortex, joint propioceptors and chemoreceptors ANAEROBIC THRESHOLD (AT) the minute ventilation increases more than the workload
33 PULMONARY 2. TIDAL VOLUME NORMAL = 500 ml DURING EXERCISE = liters increases early in the exercise increases ventilation
34 PULMONARY 3. BREATHING RATE NORMAL = / min AT EXERCISE = / min responsible for the increase in minute ventilation
35 PULMONARY 4. DEAD SPACE / TIDAL VOLUME ratio NORMAL = AT EXERCISE = decrease is due to increased tidal volume with constant dead space
36 PULMONARY 5. PULMONARY CAPILLARY BLOOD TRANSIT TIME NORMAL = 0.75 second AT EXERCISE = 0.38 second the decrease is due to increased cardiac output 6. ALVEOLAR-ARTERIAL OXYGEN DIFFERENCE NORMAL = 10 mm Hg AT EXERCISE = mm Hg changes very little until a heavy workload is achieved
37 PULMONARY 7. OXYGEN TRANSPORT increase in temperature, PCO2 and relative acidosis in the muscles -> increase in release of Oxygen by blood for use by the tissues for metabolism
38 CARDIOVASCULAR PARAMETERS 1. CARDIAC OUTPUT NORMAL = 4 6 liters / min AT EXERCISE = 20 liters / min increase is linear with increase in workload during exercise until the point of exhaustion first half of exercise capacity, the increase is due to increase in Heart Rate and Stroke Volume later, due to increase in Heart Rate alone
39 CARDIOVASCULAR 2. STROKE VOLUME NORMAL = ml AT EXERCISE = double increase is linear with increase in workload after a Heart Rate of > 120/ min, there is little increase in Stroke Volume
40 CARDIOVASCULAR 3. HEART RATE NORMAL = /min AT EXERCISE = times the resting HR HR max is achieved just prior to total exhaustion, physiologic endpoint of an individual HR max = 220 age HR max = 210 (0.65 x age)
41 CARDIOVASCULAR 4. OXYGEN PULSE NORMAL = ml O2 / heartbeat AT EXERCISE = ml With increasing muscle work during exercise, each heart contraction must deliver a greater quantity of oxygen out to the body O2 PULSE = VO2/ HR
42 CARDIOVASCULAR 5. BLOOD PRESSURE DURING EXERCISE: Systolic BP increases (to 200 mm Hg) Diastolic BP is relatively stable (up to 90 mmhg) increase in Pulse Pressure (difference between Systolic and Diastolic pressures)
43 CARDIOVASCULAR 5. ARTERIAL VENOUS OXYGEN CONTENT DIFFERENCE ml of O2 / 100 ml of blood NORMAL = 5 vol % AT EXERCISE = times higher the increase is due to the greater amounts of Oxygen that are extracted by the working muscle tissue
44 METABOLIC PARAMETERS 1. OXYGEN CONSUMPTION NORMAL = 250 ml / min ml / min / kg increases directly with the level of muscular work increases until exhaustion occurs and until individual reaches. VO2max = maximum level of oxygen consumption definite indicator of muscular work capacity NORMAL RANGE = 1,700 5,800 ml / min
45 METABOLIC 2. CARBON DIOXIDE PRODUCTION NORMAL = 200 ml / min AT EXERCISE 2.8 ml / min / kg initial phase, increases at same rate as VO2 once Anaerobic Threshold (AT) is reached, increases at a faster rate than VO2 increase is due to increased acid production
46 Lactic Acid is Buffered by Bicarbonate Lactic acid + HCO 3 H 2 CO 3 + Lactate H 2 O + CO 2
47 METABOLIC 3. ANAEROBIC THERSHOLD (AT) NORMAL: occurs at about 60% of VO2 max followed by breathlessness, burning sensation begins in working muscles
48 METABOLIC 4. RESPIRATORY QUOTIENT (RQ) RESTING LEVEL = 0.8 AT = 1.0 or more may exercise for a short time on 1.5 RER = CO 2 produced / O 2 consumed = VCO 2 / VO 2 5. BLOOD ph relatively unchanged until AT is reached the body becomes less able to buffer the excessive acid produced by anaerobic metabolism
49 INCREASES DURING EXERCISE Heart rate Oxygen extraction Cardiac output Oxygen uptake Carbon dioxide output Minute ventilation Alveolar ventilation Oxygen pulse RQ and RER METS Arterial blood pressure
50 DECREASES DURING EXERCISE During exercise, there are decreases in: VD/ VT
51 Ventilatory Equivalents Ventilatory equivalent for carbon dioxide = Minute ventilation / VCO 2 Efficiency of ventilation Liters of ventilation to eliminate 1 L of CO 2 Ventilatory equivalent for oxygen = Minute ventilation / VO 2 Liters of ventilation per L of oxygen uptake
52 Relationship of AT to RER and Ventilatory Equiv for O 2 Below the anaerobic threshold, with carbohydrate metabolism, RER=1 (CO 2 production = O 2 consumption). Above the anaerobic threshold, lactic acid is generated. Lactic acid is buffered by bicarbonate to produce lactate, water, and carbon dioxide. Above the anaerobic threshold, RER >1 (CO 2 production > O 2 consumption). Carbon dioxide regulates ventilation. Ventilation will disproportionately increase at lactate threshold to eliminate excess CO 2. Increase in ventilatory equivalent for oxygen demarcates the anaerobic threshold.
53 Lactate Threshold
54 Determination of AT from Ventilatory Equivalent Plot
55 Wasserman 9-Panel Plot
56 Interpretation of CPET Peak oxygen consumption Peak HR Peak work Peak ventilation Anaerobic threshold Heart rate reserve Breathing reserve
57 Estimation of Predicted Peak HR 220 age For age 40: = 180 For age 70: = (age x 0.65) For age 40: (40 x 0.65) = 184 For age 70: (70 x 0.65) = 164
58 Heart Rate Reserve Comparison of actual peak HR and predicted peak HR = (1 Actual/Predicted) x 100% Normal <15%
59 Flow chart for the differential diagnosis of exertional dyspnea and fatigue. Milani R V et al. Circulation. 2004;110:e27-e31 Copyright American Heart Association, Inc. All rights reserved.
60 Abnormal patterns of responses from CPX characteristic of disorders that cause dyspnea Balady G J et al. Circulation. 2010;122: Copyright American Heart Association, Inc. All rights reserved.
61
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63 Estimation of Predicted Peak HR 220 age For age 40: = 180 For age 70: = (age x 0.65) For age 40: (40 x 0.65) = 184 For age 70: (70 x 0.65) = 164
64 Breathing Reserve Comparison of actual peak ventilation and predicted peak ventilation Predicted peak ventilation = MVV, or FEV 1 x 35 = (1 Actual/Predicted) x 100% Normal >30%
65 Comparison CPET results Normal CHF COPD Predicted Peak HR Peak HR MVV Peak VO AT Peak VE Breathing Reserve 40% 60% 2% HR Reserve 0% 7% 20% Borg Breathlessness Borg Leg Discomfort 8 8 5
66 CPET Interpretation Peak VO 2 HRR BR AT/VO 2 max A-a Normal >80% <15% >30% >40% normal Heart disease <80% <15% >30% <40% normal Pulm vasc dis <80% <15% >30% <40% increased Pulm mech dis <80% >15% <30% >40% increased Deconditioning <80% >15% >30% >40% normal
67 Cardiac vs Pulmonary Limitation Heart Disease Breathing reserve >30% Heart rate reserve <15% Pulmonary Disease Breathing reserve <30% Heart rate reserve >15%
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70 QUESTION 3: WOULD YOU CLEAR THIS PATIENT FOR PNEUMONECTOMY? A. YES B. NO
71 CPET to Predict Risk of Lung Resection in Lung Cancer Lim et al; Thorax 65:iii1, 2010 Alberts et al; Chest 132:1s, 2007 Balady et al; Circulation 122:191, 2010 Peak VO 2 >15 ml/kg/min No significant increased risk of complications or death Peak VO 2 <15 ml/kg/min Increased risk of complications and death Peak VO 2 <10 ml/kg/min 40-50% mortality Consider non-surgical management
72 SUMMARY Cardiopulmonary measurements obtained at rest may not estimate functional capacity reliably. CPET includes the measurement of expired oxygen and carbon dioxide. CPET may assist in pre-op evaluation and risk stratification, prognostication of life expectancy, and disability determination. Cycle ergometer permits direct power calculation. Peak VO 2 is higher on treadmill than cycle ergometer
73 SUMMARY Peak VO 2 may be lower than VO 2 max. Absolute contraindications to CPET include unstable cardiac disease and SpO 2 <88% on RA. Fall in BP sys >20 mmhg is an indication to terminate CPET. 1 glucose yields 36 ATP in slow twitch fiber, and 2 ATP + 2 lactic acid in fast twitch fiber. RER= CO 2 produced / O 2 consumed
74 SUMMARY Above the anaerobic threshold, CO 2 production exceeds O 2 consumption. Ventilation will disproportionately increase at lactate threshold to eliminate excess CO 2. AT may be determined graphically from V slope method or from ventilatory equivalent for CO 2. Derived from the Fick equation, Oxygen Pulse = VO 2 / HR, and is proportional to stroke volume. In pure heart disease, BR is >30% and HRR <15%. In pure pulmonary disease, BR is <30% and HRR >15%.
75 REFERENCES Principles of Exercise Testing and Interpretation, 5 th edition, Dr. Karl Wasserman Cardiopulmonary Exercise TestingHow Do We Differentiate the Cause of Dyspnea? Milani, RV, Lavie CJ, Mehra MR., Circulation.2004; 110: e27-e31 Clinician s Guide to Cardiopulmonary Exercise Testing in Adults, A Scientific Statement From the American Heart Association, Circulation.2010; 122:
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