CARDIOPULMONARY EXERCISE TESTING April 16, 2017 CARDIOPULMONARY EXERCISE TESTING Historical Perspective, Principles & Applications CPX with Historical Perspective

JOSEPH PRIESTLY (1733-1804) Discovers Oxygen

LAVOISIER’S EXPERIMENTS ON OXYGEN IN THE ATMOSPHERE

ANTOINE & MADAME LAVOISIER

ADOLPH FICK (1829-1901) AND CARDIAC OUTPUT

NATHAN ZUNTZ (1847-1920) COLLECTING EXPIRED AIR

CARDIOPULMONARY EXERCISE LAB AT THE UNIVERSITY OF PENNSYLVANIA Collecting Expired Air

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.”

THE GAS TRANSPORT SYSTEM

CARDIO-PULMONARY EXERCISE TESTING Breath-by-Breath Respiratory Gas Exchange Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

CARDIO-PULMONARY EXERCISE (CPX) Modified Naughton Protocol for Incremental Treadmill Exercise Stage (2 min) Speed (mph) Grade (%) standing 1 1.0 2 1.5 3 2.0 3.5 4 7.0 5 10.5 6 3.0 7.5 7 10.0 8 12.5 9 15.0 10 3.4 14.0 Patterson JA, et al. Am J Cardiol 1972;30:757

THE PRINCIPLE OF ADOLPH FICK O2 Uptake (VO2) Arterio-Venous O2 difference = Cardiac Output VO2 = cardiac output • A−VO2 difference

OXYGEN UPTAKE AND INCREMENTAL MUSCULAR WORK Maximal O2 Uptake

MAXIMAL O2 UPTAKE Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

CLASSIFICATION OF FUNCTIONAL IMPAIRMENT FOR PATIENTS WITH CARDIAC OR CIRCULATORY FAILURE VO2max (mL/min/kg) A >20 B 16 to 20 C 10 to 16 D <10 Weber KT, et al. N Engl J Med 1980;303:242

RESPONSE IN ARTERIO-VENOUS O2 DIFFERENCE TO UPRIGHT ISOTONIC EXERCISE Weber KT & Janicki JS. Am J Cardol 1985;55:22A

CARDIAC OUTPUT RESPONSE TO UPRIGHT ISOTONIC EXERCISE Weber KT & Janicki JS. Am J Cardol 1985;55:22A

RELATIONSHIP BETWEEN CARDIAC OUTPUT AND LEFT VENTRICULAR FILLING PRESSURE DURING UPRIGHT ISOTONIC EXERCISE Weber KT & Janicki JS. Am J Cardol 1985;55:22A

RESPONSE IN MIXED VENOUS LACTATE TO UPRIGHT ISOTONIC EXERCISE Weber KT & Janicki JS. Am J Cardol 1985;55:22A

CARDIO-PULMONARY EXERCISE Anaerobic Threshold Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

CARDIO-PULMONARY EXERCISE Gas Exchange, VE and HR

CPX AND GRADING THE SEVERITY OF IMPAIRED AEROBIC CAPACITY Class Severity Maximum Oxygen Uptake (mL/min/kg) Maximum Cardiac Output (L/min/m2) Anaerobic Threshold A none to mild >20 >8 >14 B mild to moderate 16 to 20 6 to 8 11 to 14 C moderate to severe 10 to 15 4 to 6 8 to 11 D severe 6 to 9 2 to 4 5 to 8 Weber KT, et al. Clin Chest Med 1984;5:173

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

NORMAL VENTILATORY RESPONSE TO INCREMENTAL ISOTONIC EXERCISE Pardy RL, et al. Clin Chest Med 1984;5:35

CARDIO-PULMONARY EXERCISE Predicting Cardiac Index and VE Class VO2max (mL/min/kg) Anaerobic Threshold (mL/min/kg) Predicted CI (L/min/m2) Predicted VE (L/min) A >20 >14 >8 >60 B 16 to 20 11 to 14 6 to 8 50 to 60 C 10 to 16 8 to 11 4 to 6 40 to 50 D 6 to 10 5 to 8 <4 <40 Weber KT & Janicki JS. In: Cardiopulmonary Exercise Testing. Philadelphia: Saunders. 1986

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

EXERCISE VE AND VENTILATORY RESERVE (MVV) Cardiac vs. Ventilatory Limitation

ARTERIAL O2 IN EMPHYSEMA AND BRONCHITIS Jones NL. Clin Sci 1966;31:39

CRITERIA USED TO IDENTIFY CARDIAC FROM VENTILATORY CAUSE OF EXERTIONAL DYSPNEA 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

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

ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE By CXR

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

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

SIX- AND 12-MONTH SURVIVAL Chronic Cardiac Failure Likoff MJ, et al. Am J Cardiol 1987;59:634