Exercise Testing in Clinical Settings

Transcription

1 Exercise Testing in Clinical Settings The purpose of this lab is to gain appreciation and learn to become proficient in the process, modes, and procedures for clinical exercise testing. During this lab, the class as a whole will test at least one class member, using both the treadmill and the cycle ergometer as your modes of testing. You will then use this information to formulate an exercise prescription for that person based on treadmill and cycle ergometer results. Below, are skills you will need in order to perform these tests properly. You will find these skills especially useful when testing those at increased risk for events or death or in those with know disease. While you may know all the tools needed to run a test in order to obtain adequate information, order, timing, and confidence in measurement skills are imperative for reassuring the client being tested and creating a safe environment. The first portion of the lab lists measurements and procedures important in completing at the GXT from start to finish. The second section covers specific duties to be covered by each of those conducting the GXT. You will be responsible for turning in the last section of this lab #3 - where you will report on heart rate, blood pressure, rate pressure product, MET levels, and prognostic scores for the persons tested. Procedures for Conducting the GXT I. Pre-GXT Obtain resting measurements for ECG, HR, and BP after prepping has been completed. a. Supine Position lead ECG 2. Heart rate 3. Blood pressure you should check both arms b. Standing Position lead ECG 2. HR 3. BP c. Exercise Position (if different from Standing position) lead ECG 2. HR 3. BP II. Warm-up a. Treadmill One of the most important procedures, especially for those who have never walked on a treadmill before is to explain how to walk on the treadmill before the person actually attempts to walk. This may mean you will need to demonstrate. At this point, (i.e. while person is walking ~2.0 mph/0% grade, you may want to, take a quick 12-lead and BP, just to see how the client is responding. b. Cycling Mode Again, you will want to explain procedures for getting on and off the cycle. The seat should be set at a height in which there is a slight bend in the knee but also allowing nearly full leg extension at the bottom of the down stroke. Note this seat height on your record sheet. Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 1 of 6

2 III. Exercise Test Protocol After you have obtained a close estimate of what the persons peak capacity will be using the VSAQ (i.e. to reach peak in 8 to 12 minutes), you are ready to start the GXT. a. Record ECG anytime there is an abnormal cardiac response, bring this to the attention for the physician (or Tech#1) immediately; record the event and time of occurrence. i. For arrhythmia, take a rhythm strip in a single lead for at least 15 seconds. ii. For ST changes, take a 12-lead tracing. iii. For changes in conduction, take a 12-lead tracing in addition to a rhythm strip. b. Take BP approximately 1:15 seconds to 1:00 before the end of the current stage. You should have the BP at the very least 15 seconds before the stage ends so that RPE and ECG may follow c. Obtain RPE during the last 15 seconds of the current stage. d. Record ECG during the last seconds of the current stage and record any sign or symptom data at this time as well. Location, quality, and intensity are important to this end. e. Test Termination i. Try to obtain a rhythm strip 10 to 15 seconds before the end of the test. ii. Try to obtain a peak BP before the test is stopped. If this is not possible, do not make the client stand on the treadmill after the test is stopped as this may promote venous pooling and subsequent dizziness or loss of consciousness iii. Stop the test. iv. As soon as the test is terminated (i.e. within 10 seconds) record a 12-lead ECG. v. Record the reason for stopping the test on the record sheet. IV. Post-GXT a. Immediate Post-exercise i. Supine method This is a Dx technique in which you lie the patient down within 10 seconds of terminating the test and immediately record 12-lead ECG and BP ii. Active Recovery Method (Functional GXT) 1. While standing, record 12-lead ECG and start the treadmill or cycle again at warm-up speed for remainder of recovery. 2. Record 12-lead ECG at the 2 and 4 minute mark while walking or cycling. iii. From 4 minutes to the end of recovery have the patient lie in a supine position and continue to record ECG, HR, and BP until the client has reached resting hemodynamic levels. Usually, it is necessary to at least have the HR below 100 before detaching them from any equipment. b. Consider Post-hyperventilation ECG recording, if isolated clinically positive ischemictype ST shift is found AND if respiratory-induced false positive response is suspected. c. Releasing client i. Remove electrodes, BP cuff, provide towel, give shower instructions, and any other special information necessary for the client. ii. Work up data and report results to physician. iii. Have the patient report back to you after showering and before leaving to ensure that recovery was uneventful. Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 2 of 6

3 Exercise Technologist Roles for GXTs Tech #1: Test Supervisor/ ECG Technician This person who is most likely Exercise Specialist SM certified with ACLS certification will be the exercise technician who is primarily responsible for screening the client and running the exercise test from start to finish. The will include but not be limited to the following: 1. Review client records, (medical Hx, physician clearance, old Dx tests, preliminary tests) 2. Check emergency equipment for presence and operation. 3. Greeting and establishing rapport with the patient. 4. Explain procedures and obtain informed consent from the client. 5. Coordinating duties of other staff. 6. Verbal questioning for preliminary screening purposes. 7. Starting and running the GXT. Record all noteworthy events. 8. Modify protocol if needed. Stop test is necessary. 9. Monitor patient during post-exercise and release client. Tech #2: BP/ RPE / ECG prep/ Patient SxS monitoring Tech 1. Greet patient, and explain ECG, BP, and RPE, and pain scale procedures. 2. Place BP cuff on arm; measure BP in both arms 3. Obtain BP in different postures 4. Demonstrate walking on treadmill, cycle, etc. 5. Report BP findings to Tech#1 6. Obtain RPE, and pain scale ratings. 7. As the person most closely observing the client, this person should note any unusual SxS to Tech #1 so that the proper decision whether to continue or not can be made at that time. 8. In recovery, continue to record BP. Tech#3: Note this technician may be for safety monitoring only or may also take some duties of tech #2. If 3 technicians are available, this technician will prep the client for ECG. 1. Prepare patient s skin and affix ECG electrodes in proper position. Explain procedure to patient. 2. Check ECG recorder for operate and standardization of recordings. 3. Obtain 12-lead ECG according to test protocol in the pre-gxt stances. 4. Be available for client safety issues. The best place for this person to be is at the back of the treadmill or behind the cycle. Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 3 of 6

4 Clinical Exercise Research Facility Northern Arizona University Exercise Testing Sheet Name: Age: Date: Supervising MD: Medication/s: Referring MD: Previous Test Results: Date: Pk METs ST Δ Pk RPP (-10) SxS Resting: Ht (in) Wt (kg) Supine HR: Supine BP: Standing HR: Standing BP: Exercise Test: Age-predicted peak HR 85% age-predicted max HR: Time (mph/%grd) METs VO HR (bts min -1 ) BP (mmhg) RPP (-10) RPE Signs/Symptoms Total Test Time: Est. Peak METs Peak RPP ( 10) Reason for Termination: Recovery: Time HR BP Signs/Symptoms IPE Time HR BP Signs/Symptoms Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 4 of 6

5 Exercise Testing Summary Interpretation: Please comment on heart rate and blood pressure responses to exercise, exercise tolerance including peak METs reached any signs or symptoms, ECG responses (resting supine ECG, arrhythmias, ishemia, etc), and complete the Duke Nomogram for this client. Signed Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 5 of 6

6 Questions 1. Compare your VO2 max results from actually oxygen consumption values and ACSM predicted values for the Bruce test. Use Appendix D to help calculate your Bruce VO2 max based on time on treadmill. a. Bruce VO 2 max Actual VO 2 max b. What is the percent difference between the two tests? Use actual VO2max as your criterion test. 2. What is your percentile ranking for: Bruce VO 2 max percentile Actual VO 2 max percentile 3. Did you actually achieve a true VO 2 max? Why or why not? (i.e. you should be able to verify or refute with 3 to 4 explanations). 4. Record your scores from your fitness testing and actual max testing results below. What test, as a percentage difference, was closest to your Actual VO 2 max Predicted VO 2 max from Astrand-Rhyming bike test Predicted VO 2 max from Astrand-Rhyming step test Predicted VO 2 max from single-stage treadmill test Predicted VO 2 max from test Actual VO 2 max Closest test to actual VO 2 max Percent difference. Laboratory Nine, EXS 460 Laboratory, Fall 2004, Northern Arizona University, Page 6 of 6