به نام خدا

1. به نام خدا

2. دكتر محمد اماميفوق تخصص ريه عضوهيات علمي دانشگاه علوم پزشكي اصفهان

4. CardiopulmonaryExercise Testing

5. JOSEPH PRIESTLY (1733-1804) Discovers Oxygen

6. Exercise requires the coordinated function of several integrated systems: 1-Heart 2-Lung 3-Blood 4-Muscle

7. Oxygen content • The arterial oxygen content (CaO2) is the amount of oxygen bound to hemoglobin plus the amount of oxygen dissolved in arterial blood •  CaO2 (mL O2/dL) = (1.34 x hemoglobin concentration x SaO2) + (0.0031 x PaO2) • Normal CaO2 is approximately 20 mL O2/dL.

8. the mixed venous blood oxygen content (CvO2) is the amount of oxygen bound to hemoglobin plus the amount of oxygen dissolved in mixed venous blood •  CvO2 (mL O2/dL) = (1.34 x hemoglobin concentration x SvO2) + (0.0031 x PvO2) • Normal CvO2 is approximately 15 mL O2/dL

9. Oxygen delivery • Oxygen delivery (DO2) is the rate at which oxygen is transported from the lungs to the microcirculation • DO2 (mL/min) = Q x CaO2 • Normal DO2 is approximately 1000 mL/min • AV oxygen difference (mL O2/dL) = CaO2 - CvO2

10. Oxygen consumption (VO2) • Oxygen consumption (VO2) is the rate at which oxygen is removed from the blood for use by the tissues • Normal VO2 in a conscious, resting person is approximately 250 mL O2/min •  VO2 (mL O2/min) = Q x (CaO2 - CvO2)

11. Oxygen extraction • Oxygen extraction is the slope of the relationship between oxygen delivery (DO2) and oxygen consumption (VO2) • O2 Extraction Ratio = (CaO2 - CvO2)/CaO2 • Normal O2 extraction ratios range from 0.25 to 0.30

12. NORMAL PHYSIOLOGY • Oxygen consumption (VO2) is proportional to oxygen delivery (DO2) and oxygen extraction • DO2 and oxygen extraction are inversely proportional to one another • At rest, VO2 remains constant over a wide range of oxygen delivery (DO2) because changes in DO2 are balanced by reciprocal changes in oxygen extraction

14. VO2 decreases if DO2 declines to such a degree that it cannot be balanced by increasing oxygen extraction • The threshold value of DO2 below which VO2 will fall is called the "critical DO2"

16.  PATHOPHYSIOLOGY • Decreased oxygen delivery or increased metabolic demand are common sequelae of medical illness

17. Decreased oxygen delivery • Oxygen delivery (DO2) will decrease if cardiac output falls or arterial oxygen content (CaO2) declines • Cardiac output can decrease due to cardiac disease or hypovolemia • CaO2 can decrease due to anemia or poor oxygenation. The latter can be caused by lung disease (eg, ventilation-perfusion mismatch, diffusion limitation), a right-to-left shunt, diminished inspired oxygen, or hypoventilation

18. Increased metabolic demand • Metabolic demand is elevated in critically ill patients (eg, acute respiratory distress syndrome, sepsis, or septic shock)

19. Cardiac Pump CO=HRxSV • The predicted maximum HR is 220 minus age in years (alternate: 210 - [0.65 x age in years])

22. O2 Pulse • O2 pulse is Vo2/HR, obtained by dividing these two simultaneous measurements taken during exercise

24. AT • Most of the metabolic work performed by the muscles during exercise is done via aerobic mechanisms • There is workload above which a given person his or her or her physiologic capability to do most of the work aerobically, and incremental work rates result in progressive lactic acidosis in the blood due to anaerobic metabolism in muscle

26. The Ventilatory Pump VE=TVxRR • Early in exercise, VE increases mostly due to increases in TV • As TV reaches approximately 50 to 60% of vital capacity (VC), it begins to plateau, and further increases in VE are mostly due to increases in RR

27. Gas Exchange in the Lung • Total VE=VA+VD • VD/VT Ratio=0.3 at rest • VD/VT Ratio=0.18 during maximum exercise • VD/VT=Paco2-pEco2/Paco2

28. O2 Transfer • During exercise, P(A-a)O2 increases due V/Q mismatching, O2 diffusion limitation, and low Svo2

29. Exercise physiology • Skeletal muscle metabolism can rise quickly to fifty times its resting rate during heavy exercise. • VO2 increases linearly versus work rate with a slope of approximately 10 mL/min per watt in normal subjects • A true maximal VO2, identified by a plateau of VO2 versus work, occurs only in a small subset of normal subjects and patients • normal VO2max is greater than 20 mL/kg per min, and can be predicted from age, gender, height, and lean body weight.

31. The VO2max increases as a function of training and decreases with age • A young, world-class endurance athlete may have a VO2max greater than 80 mL/kg per minute

32. Minute ventilation (VE) normally rises during incremental exercise as a result of a linear increase in breathing frequency (up to about 50 breaths/minute in normal adults) and a hyperbolic increase in tidal volume (Vt)

33. During exercise, the partial pressure of oxygen in arterial blood (PaO2) remains near resting values despite marked reductions in mixed venous oxygen tension (PvO2) and an abbreviated red cell transit time through the pulmonary capillaries

34. External and Internal Measurementsof Work • During an incremental exercise test, there is a steady, linear increase in external work rate performed by the patient. This is expressed in watts. • Internal metabolic work performed by the muscles is generally represented by the linear increase in Vo2 with increasing work

35. The shift into increasing anaerobic metabolism is a reflection of limitations in O2 delivery or in muscle oxidative capacity, or both

37. Equipment • Bicycle • treadmill

38. Patient Safety • a relatively safe procedure • The risk of complications is related to the underlying disease • Rate of death is between 2 and 5 per 100,000 tests

39. Primary Measurements • ECG: The ECG is used for heart rate (HR), Stsegmentdepression, and arrhythmia detection • Collection of Expired Gases • Pulse Oximetry • Arterial Catheterization • BP

40. Indications for CPET • Unexplained Exertional Intolerance: Dyspnea or Fatigue • Objective Assessment of Capacity/Impairment • Establish Organ System-Limiting ExerciseWhen Multiple Diagnoses Are Present • Preoperative Assessment Before Lung Resection • Diagnose Exercise-Induced Asthma

41. Identify Gas Exchange Abnormalities • Titrate O2 Flow During Exercise • Pulmonary Rehabilitation Prescription and Assessment of Response • Transplant Referral and Prognosis • Assess Response to Therapy

42. Absolute Contraindications to CPETs • 1-acute myocardial infarction (prior 3 to 5 days) • 2-unstable angina • 3-uncontrolled, symptomatic arrhythmias • 4-syncope • 5-active endocarditis; acute myocarditis or pericarditis • 6-symptomatic severe aortic stenosis • 7-uncontrolled heart failure

43. 8-thrombosis of lower extremities • 9-suspected dissecting aneurysm • 10-uncontrolled asthma • 11-pulmonary edema • 12-room air saturation ,85% (can exercise with supplemental O2); • 13-respiratory failure • 14-mental impairment leading to inability to cooperate

44. Relative Contraindications to CPETs • left main coronary stenosis or equivalent • moderate stenoticvalvular heart disease • severe untreated arterial hypertension at rest (.200 mm Hg systolic, .120 mm Hg diastolic) • tachyarrhythmias or bradyarrhythmias • high-degree atrioventricular block • Hypertrophic cardiomyopathy • significant pulmonary hypertension (although this can be done safely) • advanced or complicated pregnancy • electrolyte abnormalities • orthopedic impairment that compromises exercise performance

45. Indications for Exercise Termination • chest pain suggestive of ischemia • ischemic ECG changes • complex ectopy • Second or third-degree heart block • fall in systolic BP> 20 mm Hg • hypertension (>250 mm Hg systolic, >120 mm Hg diastolic) • desaturation (Spo2<80% when accompanied by symptoms and signs of severe hypoxemia) • sudden pallor • loss of coordination • mental confusion; dizziness or faintness • signs of respiratory failure