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CARDIOPULMONARY EXERCISE TESTING Historical Perspective, Principles & Applications. JOSEPH PRIESTLY (1733-1804) Discovers Oxygen. LAVOISIER’S EXPERIMENTS ON OXYGEN IN THE ATMOSPHERE. ANTOINE & MADAME LAVOISIER. ADOLPH FICK (1829-1901) AND CARDIAC OUTPUT.

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slide1

CARDIOPULMONARY EXERCISE TESTING

Historical Perspective, Principles & Applications

slide7

CARDIOPULMONARY EXERCISE LAB AT THE UNIVERSITY OF PENNSYLVANIA

Collecting Expired Air

slide8

DICKINSON RICHARDS AND THE CARDIOPULMONARY UNIT

“The foundation upon which the work of Dr. Cournand and myself chiefly rests is that of Laurence J. Henderson…he 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.”

slide10

CARDIO-PULMONARY EXERCISE TESTING

Breath-by-Breath Respiratory Gas Exchange

Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

slide11

CARDIO-PULMONARY EXERCISE (CPX)

Modified Naughton Protocol for Incremental Treadmill Exercise

Patterson JA, et al. Am J Cardiol 1972;30:757

slide12

THE PRINCIPLE OF ADOLPH FICK

O2 Uptake (VO2)

Arterio-Venous O2 difference

= Cardiac Output

VO2 = cardiac output • A−VO2 difference

slide14

MAXIMAL O2 UPTAKE

Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

slide15

CLASSIFICATION OF FUNCTIONAL IMPAIRMENT FOR PATIENTS WITH CARDIAC OR CIRCULATORY FAILURE

Weber KT, et al. N Engl J Med 1980;303:242

slide16

RESPONSE IN ARTERIO-VENOUS O2 DIFFERENCE TO UPRIGHT ISOTONIC EXERCISE

Weber KT & Janicki JS. Am J Cardol 1985;55:22A

slide17

CARDIAC OUTPUT RESPONSE TO UPRIGHT ISOTONIC EXERCISE

Weber KT & Janicki JS. Am J Cardol 1985;55:22A

slide18

RELATIONSHIP BETWEEN CARDIAC OUTPUT AND LEFT VENTRICULAR FILLING PRESSURE DURING UPRIGHT ISOTONIC EXERCISE

Weber KT & Janicki JS. Am J Cardol 1985;55:22A

slide19

RESPONSE IN MIXED VENOUS LACTATE TO UPRIGHT ISOTONIC EXERCISE

Weber KT & Janicki JS. Am J Cardol 1985;55:22A

slide20

CARDIO-PULMONARY EXERCISE

Anaerobic Threshold

Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

slide21

CARDIO-PULMONARY EXERCISE

Gas Exchange, VE and HR

slide22

CPX AND GRADING THE SEVERITY OF IMPAIRED AEROBIC CAPACITY

Weber KT, et al. Clin Chest Med 1984;5:173

slide23

AEROBIC CAPACITY AND SYMPTOMATIC STATUS

  • Patients with cardiac disease begin to experience limiting symptoms when VO2 is <22 mL/kg/min
  • They consider themselves severely limited with VO2 <16 mL/kg/min

Patterson JA, et al. Am J Cardiol 1972;30:757

slide24

NORMAL VENTILATORY RESPONSE TO INCREMENTAL ISOTONIC EXERCISE

Pardy RL, et al. Clin Chest Med 1984;5:35

slide25

CARDIO-PULMONARY EXERCISE

Predicting Cardiac Index and VE

Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

slide26

THE PROPORTION OF THE MAXIMUM VOLUNTARY VENTILATION (VENTILATORY RESERVE) USED DURING INCREMENTAL ISOTONIC EXERCISE BY PATIENTS WITH CHRONIC CARDIAC FAILURE

Class A

43%

Class B

52%

Class C

34%

Class D

37%

VE max

MVV

MVV=FEV1×35

Weber KT, et al. Circulation 1982;65:1213

slide27

EXERCISE VE AND VENTILATORY RESERVE (MVV)

Cardiac vs. Ventilatory Limitation

slide28

ARTERIAL O2 IN EMPHYSEMA AND BRONCHITIS

Jones NL. Clin Sci 1966;31:39

slide29

CRITERIA USED TO IDENTIFY CARDIAC FROM VENTILATORY CAUSE OF EXERTIONAL DYSPNEA

Cardiac

  • Achieve anaerobic threshold and VO2max
  • Exercise VE is <50% of MVV
  • Do not develop arterial O2 desaturation

Ventilatory

  • Do not achieve anaerobic threshold or VO2max
  • Exercise VE is >50% of MVV
  • Propensity to develop arterial O2 desaturation

Weber KT. In: Fishman’s Pulmonary Diseases and Disorders. New York: McGraw-Hill. 1998

slide30

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
slide32

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

slide33

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

slide35

SIX- AND 12-MONTH SURVIVAL

Chronic Cardiac Failure

Likoff MJ, et al. Am J Cardiol 1987;59:634