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Dr Simon Donoghue Product Support Manager VIASYS Healthcare

Cardio-Pulmonary Exercise Testing. Dr Simon Donoghue Product Support Manager VIASYS Healthcare. Schedule. 9.30- 10.30        Methodology in CPET 10.30 – 11.00    Coffee 11.00-12.00       Useful Parameters Defined 12.00-13.00       Lunch 13.00-14.00       Basic Interpretation

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Dr Simon Donoghue Product Support Manager VIASYS Healthcare

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  1. Cardio-PulmonaryExercise Testing Dr Simon Donoghue Product Support Manager VIASYS Healthcare

  2. Schedule • 9.30- 10.30        Methodology in CPET • 10.30 – 11.00    Coffee • 11.00-12.00       Useful Parameters Defined • 12.00-13.00       Lunch • 13.00-14.00       Basic Interpretation • 14.00-14.30       Coffee • 14.30-15.30       Case Examples, flow limitation • 15.30-16.00       Additional Value of CPET

  3. Knipping (1959)

  4. 1964

  5. 1970

  6. 1975

  7. Current Technology

  8. CPET Bike or Treadmill Diffusion & C.O. Psys, Pdia ECG P0.1 Analog channels Cardiac Output SpO2 Calorimetry Mixing chamber Compliance Hypoxia/Hypercapnia (resp. Drive)

  9. Indirect Calorimetry

  10. 25 Watt 50 Watt slow walking VE  18 l/min VO2 750 ml/min quick walking slow step climbing VE  25 l/min VO2 1000 ml/min

  11. 75 Watt 100 Watt quick step climbing (2 steps) VE  42 l/min VO2 1500 ml/min quick step climbing VE  32 l/min VO2 1250 ml/min

  12. 150 Watt 200 Watt swimming (50 m/min) running (15 km/h) VE  84 l/min VO2 2500 ml/min cross-country run bicycling (20 km/h) VE  63 l/min VO2 2000 ml/min

  13. WASSERMAN METABILOSM CIRCULATION VENTILATION PERIPHERAL GAS EXCHANGE PULMONARY GAS EXCHANGE

  14. Indications for CPET I: Provide support in differential diagnosis. (Cardiac, Pulmonary, Peripheral) II: Determine performance limitations. (Chronic lung disease, workplace, pre-operative, insurance) III: Assess therapeutic interventions. (Pulmonary rehab, transplant)

  15. Contra-indications for CPET Absolute Relative Acute myocardial infarction (3-5 days) Left main coronary stenosis Unstable angina Moderate stenotic vascular heart disease Uncontrolled arrhythmia causing symptoms Electrolyte abnormalities Active endocarditis Severe untreated hypertension (>200mmHg Active myocarditis or pericarditis systolic, >120 mmHg diastolic) Symptomatic severe aortic stenosis Significant pulmonary hypertension Uncontrolled heart failure Tachyarrhythmias or bradyarrhythmas Acute pulmonary embolus or pulmonary infarction Hypertrophic cardiomyopathy Acute noncardiac disorder that may affect exercise Mental impairment leading to inability to performance or be aggravated by exercise . cooperate Thrombosis of lower extremities High-degree of atrioventricular block ‘Relative’ contra-indications can be over-ruled if the benefits outweigh the risks of exercise

  16. What Protocol??? Maximal? Bicycle? Steps? Ramp? Warm-up? Workload? Endpoint? Sub-maximal?

  17. What Protocol ??? Max or Sub-max? Bike or Treadmill? Exercise Duration? Ramp or Steps? Workload?

  18. MAX or SUBMAX • For cardio-pulmonary diagnostic purposes, MAXIMAL tests are performed. • We aim to stress the cardio-resp system until we identify the factor which limits exercise capacity • Sub max test are more common in athletics training, rehabilitation etc.

  19. Treadmill vs Cycle FEATURE TREADMILL CYCLE Higher Peak VO2 + Similar Max HR and Max VE + + Familiarity of exercise ++ + Quantitation of external work - - + Freedom from artifact (ECG, BP) - - + + Ease of obtaining blood gases - - + + Safe (less musculoskeletal injuries) + Useful in supine position + Less vertical/horizontal space + Less noise, Less Expensive + Portable - + Wasserman et al. Principles of Exercise Testing and Interpretation. Lea & febiger, 1987.

  20. Ramp or Step?

  21. Ramp, Do Not Step

  22. Ramp Don’t Step

  23. INCLUDE REST and WARMUP

  24. No Rest or Warm-up

  25. Start From Low Workload

  26. Ideal Testing Duration • Exercise portion of test lasts 8-12minutes.

  27. Selecting the Work Rate What is the appropriate work rate increment for each patient?

  28. Calculating the Work Rate • 1. Approximate VO2 for Unloaded Pedaling: • 150+(6 x Weight) • 2. Estimate VO2 max • Height (cm) - Age(yrs) x 20 (Males) • Height (cm) - Age (yrs) x 14 (Females) • Work Rate Increment • VO2 max pred - VO2 Unloaded /100 Example: 50 yr old male, 100 kg and 180 cm 1. VO2 unloaded = [150+(6x100) = 750 ml/min 2. VO2 Pred max = [(180-50) x 20 = 2600 ml/min 3. Work = [2600 - 750] / 100 = 18.5 (round to 20) Wasserman, et al. Principles of Exercise Testing and Interpretation. Lea & Febiger, 1987.

  29. Selecting the Work Rate 5 Watts/min Severe impairment(e.g. patient who is confined to home or walks only short distances) 10 Watts/min Moderate impairment(e.g. patient who walks one or two city blocks before symptoms) 15 Watts/min Mild impairment or sedentary older patient 20 Watts/min Sedentary younger patient 25 Watts/min Active younger patient(regular sports, physical exercise) 30 Watts/min Athletic and fit(competitive sports) 40 Watts/min Extremely fit(highly competitive) Chris Cooper, MD.. Harbor UCLA Medical

  30. Time to exercise…

  31. Maximal - Stop (1) Exercise criteria for exhaustion (1): 1. Cardial • HR: 220 - age (athlets) • HR: 200 - age (patients) • (HR = 210 - 0.65 * age) 2. Ventilation • no breathing reserve (see below) • F/V - limitation

  32. Maximal - Stop (2) Exercise criteria for exhaustion (2): 3. Gas exchange • RER > 1.1 - 1.2 • Breathing equivalent EQO2 > 35 • VO2-plateau 4. Metabolic • Lactate: 6 - 12 mmol/l • pH-value < 7.2 (< 7.0)

  33. Stop Criterias (1) Indications for load-stop: Angina Pectoris ST-decrease more than 0.25 mV(horizontal or descending) Dysrhythmia according to Lown IIIa or IV(polytop extrasystols or volleys) AV block of degree II or III Decrease of O2-uptake, HR, and/or O2-pulse during exercise

  34. Stop Criterias (2) Psys: > 250 mmHg and / or Pdia: > 120 mmHg

  35. Parameters • Breathing Pattern • O2 and CO2 • Heart Rate and ECG • Blood Pressure • SpO2 • Also ABGs, Lactate, Indirect Cardiac Output, Flow Volume loops, indirect calorimetry, P0.100, high FIO2

  36. Respiratory Parameters

  37. Breathing Parameters • Ventilation VE(L/min) • Tidal Volume VT(L) • Respiratory RateRR(Breaths/min) • Breathing ReserveBR(% Max Pred) • Others include Ti, Ttot,

  38. Breathing Reserve • How much Ventilation we have in reserve • Percent of PREDICTED MAX eg Predicted Max Ve = 125 L/min Current Ve = 100 L/min 25 L/min reserve = 20%

  39. Predicted Max Ventilation We need to know if patients reached THEIR ACHIEVABLE MAX VE, not the Ve predicted for a healthy individual. • Should not use prediction from age height etc. • Can measure Max Voluntary Ventilation (MVV) • Best Prediction for Max VE during exercise= 35 x FEV1

  40. Normal Ventilatory Response 160 - Predicted Maximum Ventilation } BR = 20-40% . VE (l/min) 10 | 0 Max Predicted Work

  41. Ventilatory Limitation 160 - BR = 50 % . Individuals Predicted Maximum Ventilation BR = 0 % VE (l/min) 10 | 0 Max Predicted Work

  42. Breathing Pattern 5 - Normal Restrictive Obstructive VT (L) 0 | 0 120 VE

  43. Heart Rate Parameters

  44. Heart Rate Reserve • How much heart rate capacity we have in reserve, expressed as number of beats. • maximum predicted HR is 180 bpm • current HR is 160 bpm • HRR of 20 beats.

  45. VO2 HR = SV * ( Ca - Cv ) O2 According to Fick Heart Rate and Load

  46. Normal Heart Rate Response 200 - Predicted Maximum Heart Rate HRR = 0 HR (b/min) 0 | 0 Work Max Predicted

  47. Cardiac Limitation 200 - Predicted Maximum Heart Rate HRR = 0 HR (b/min) 0 | 0 Work Max Predicted

  48. Ventilation/Heart Rate Summary

  49. Normal HRR = 0 BR = 20-40% Predicted Max Predicted Max . HR b/min VE l/min Work Predicted Max Work Predicted Max

  50. Ventilatory Limitation HRR = ++ BR = 0 % Predicted Max . HR b/min VE l/min Predicted Max Work Predicted Max Work Predicted Max

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