CARDIOPULMONARY EXERCISE TESTING CPET

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CARDIOPULMONARY EXERCISE TESTING (CPET)

• E.N. Kosmas, MD, FCCP
• Chest Diseases Hospital
• Athens, Hellas

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Q.1. Your level of knowledge on CPET (voting)

• I have a good level of theoretical knowledge and
  practical experience in conducting and
  interpreting the CPET
• I have only theoretical background
• I have only practical skills
• I do not have a clue and I am here to learn the
  basics

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CONTENTS

• Basic exercise physiology
• Diagnostic utility of CPET
• Exercise system responses
• Clinical cases
• 4 patterns of abnormal CPET
• Elements for unfitness, psychogenic dyspnea,
  exercise-induced asthma

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Basic Exercise Physiology
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Q.2. Choose the wrong statement (voting)

• ATP is the main energy storage for the muscular
  contraction
• Carbohydrate and fatty acid oxidation is the
  main, but not the only, biochemical process for
  ATP production
• The muscle mitochondrial inner surface is the
  site of oxidative ATP production
• Muscle fibers IIb possess high oxidative capacity
  and are fatigue-resistant

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EXERCISE SYSTEM COOPERATION
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EXERCISE SYSTEM COOPERATION

• Muscle fibers
• Tissue gas exchange between systemic capillaries
  and muscle fibers
• Mitochondria
• Aerobic ATP synthesis
• Substrate oxidation
• Cytoplasm
• Anaerobic ATP synthesis
• PCr breakdown
• Anaerobic glycolysis
• Sarcomeres
• ATP utilization muscle contraction
• Oxidative phosphorylation

• Heart - Circulation
• O2 CO2 transport between lungs and muscles
• ?Q SV x HR
• Q distribution to exercising muscles
• Lungs
• O2 uptake (VO2) CO2 output (VCO2)
• ?VE Vt x f
• VE distribution to capillary-alveolar surface
  (VA)
• Respiratory gas exchange between alveoli and
  pulmonary capillaries

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AIMS FOR SYSTEM COOPERATION

• Muscular work exercise performance
• With preservation of homeostasis in gas exchange
  and acid-base balance
• Without the appearance of exercise-limiting
  symptoms (dyspnea, muscle fatigue)

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Q.2. Choose the wrong statement

• ATP is the main energy storage for the muscular
  contraction
• Carbohydrate and fatty acid oxidation is the
  main, but not the only, biochemical process for
  ATP production
• The muscle mitochondrial inner surface is the
  site of oxidative ATP production
• Muscle fibers IIb possess high oxidative capacity
  and are fatigue-resistant

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Diagnostic Utility of CPET
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Q.3. About CPET diagnostics(voting)

• It is the immediate test of choice for evaluating
  the symptom of exertional dyspnea
• CPET is helpful to differentiate among various
  diseases, such as COPD, IPF, CHF etc.
• CPET should be done after detailed evaluation
  (history, clinical exams, X-ray, PFT, ABG, ECG,
  cardiac echo, hematology, biochemistry etc.) has
  failed to prove the cause of dyspnea
• It can be conducted by an ergophysiologist

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WHERE CPET IS USEFUL..

• CPET is not a routine test, it should be
  performed after an initial CL evaluation
• It has specific indications, contraindications
  and complications (some are emergencies, e.g.
  angina, hypertension, hypotension, ST elevation,
  A-V block etc.)
• It should be conducted in a hospital setting and
  supervised by an experienced MD
• Safety measures (O2, monitor, medications,
  equipment)

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WHAT IS THE DIAGNOSTIC AID OF CPET

• It recognizes the system that contributes
  inefficiently to exercise demands
• ?exercise capacity and/or premature termination
  of exercise due to
• Symptom (dyspnea, angina, muscle fatigue)
• Abnormal finding (ECG ischemia, ??BP, HbO2
  desaturation etc)
• Abnormal response of a system
• Normal exercise capacity but with an abnormal
  response (no reserve) of a system

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IT SHOULD BE UNDERLINED THAT

• CPET usually points out the dysfunctioning
  system and not a specific disease
• Exceptions Psychogenic dyspnea Exercise
  induced asthma

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INDICATIONS FOR CPET

• Exertional dyspnea
• Respiratory ?
• Cardiovascular ?
• Muscular ?
• Mixed ?
• Psychogenic ?

• Pre-op evaluation
• Post-op evaluation
• Drug intervention
• Rehab
• EIA
• Ambulatory O2 treatment
• Disability
• Athletics

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WHY CPET IS USEFUL IN THE DIAGNOSTIC APPROACH OF
EXERTIONAL DYSPNEA ?

• Stimulus for dyspnea
• Systems function under stress conditions
• Dyspnea attributed to dysfunction or decreased
  reserves of a specific system

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Q.3. About CPET diagnostics

• It is the immediate test of choice for evaluating
  the symptom of exertional dyspnea
• CPET is helpful to differentiate among various
  diseases, such as COPD, IPF, CHF etc.
• CPET should be done after detailed evaluation
  (history, clinical exams, X-ray, PFT, ABG, ECG,
  cardiac echo, hematology, biochemistry etc.) has
  failed to prove the cause of dyspnea
• It can be conducted by an ergophysiologist

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Exercise System Responses
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Q.4. Which statement is not true(voting)

• CV system is the limiting system for a healthy
  person conducting a maximal CPET
• Normally, respiratory system has adequate
  ventilatory reserve at the termination of CPET
• Anaerobic threshold (AT) is important only for
  determining athletic performance
• AaDO2 increases during exercise

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QUESTIONS TO BE ANSWERED

• Did the patient perform a maximal or a submaximal
  CPET ?
• Which was the cause of CPET termination ?
• Normal or low exercise capacity ?
• Respiratory system responses (ventilation-breathin
  g pattern-gas exchange) ?
• CV system responses ?
• Muscular system responses ?

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CPET MAXIMALITY CRITERIA

• WRmax gt 90 pred
• VO2max plateau despite the WR increase (fit
  athletes)
• HRmaxgt90 pred
• VEmax/MVV gt60-70
• VCO2max/VO2max (RER) gt 1.15
• Exhaustion - Fatigue
• Blood lactate gt 4 mM

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SYMPTOM AT CPET TERMINATION

• Dyspnea
• Leg fatigue
• Borg scale

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EXERCISE CAPACITY / TOLERANCEVO2-WR, AT
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EXERCISE CAPACITY / TOLERANCEVO2-WR, AT
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SYSTEM EXERCISE BASIC RESPONSESVE, Q, La
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RESPIRATORY SYSTEM RESPONSESVENTILATORY (VE, Vt,
FR)
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OPERATIONAL LUNG VOLUMES
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RESPIRATORY SYSTEM RESPONSEGAS EXCHANGE (SpO2,
Vd/Vt, VE/VO2, VE/VCO2)
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CV SYSTEM RESPONSEHR, O2pulse (VO2/HR), BP, ECG
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NORMAL VALUES
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Q.4. Which statement is not true

• CV system is the limiting system for a healthy
  person conducting a maximal CPET
• Normally, respiratory system has adequate
  ventilatory reserve at the termination of CPET
• Anaerobic threshold (AT) is important only for
  determining athletic performance
• AaDO2 increases during exercise

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PATIENT 1

• Female
• 49 yrs old
• Height 1.63
• Weight 53
• Indications Low exercise capacity, dyspnea,
  fatigue

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FINDINGS
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INTERPRETATION

• CV limitation
• Cardiomyopathy

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PATIENT 2

• Male
• 66 yrs
• Height 1.75
• Weight 61
• Indications dyspnea, muscular fatigue

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OPERATIONAL LUNG VOLUMES
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FINDINGS
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INTERPRETATION

• Respiratory limitation, both ventilatory gas
  exchange
• COPD

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PATIENT 3

• Male
• 72 yrs
• Height 1.70
• Weight 80
• Indication Exertional dyspnea

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FINDINGS
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INTERPRETATION

• Respiratory limitation (mainly gas exchange)
• IPF

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PATIENT 4

• Male
• 22 yrs
• Height 1.85
• Weight 77
• Indications Dyspnea, exertional dizziness

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FINDINGS
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INTERPRETATION

• Both CV respiratory (mostly gas exchange)
  limitation
• PAH

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KEY-POINTS FOR CPET INTERPRETATION

• COPD
• Ventilation
• Gas exchange
• RESTRICTIVE LUNG DISEASE
• Gas exchange
• Ventilation
• CHF
• CV response
• PVD
• CV response
• Gas exchange
• PSYCHOGENIC DYSPNEA
• Profound dyspnea
• Normal VO2max
• Normal exercise responses

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• EIA exercise-induced asthma
• Or
• EIB exercise-induced bronchoconstriction

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