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

2. JOSEPH PRIESTLY ( )
Discovers Oxygen

3. LAVOISIER’S EXPERIMENTS ON OXYGEN IN THE ATMOSPHERE

4. ANTOINE & MADAME LAVOISIER

5. ADOLPH FICK (1829-1901) AND CARDIAC OUTPUT

6. NATHAN ZUNTZ (1847-1920) COLLECTING EXPIRED AIR

7. CARDIOPULMONARY EXERCISE LAB AT THE UNIVERSITY OF PENNSYLVANIA
Collecting Expired Air

8. 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.”

9. THE GAS TRANSPORT SYSTEM

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

11. 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

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

13. OXYGEN UPTAKE AND INCREMENTAL MUSCULAR WORK
Maximal O2 Uptake

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

15. 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

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

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

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

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

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

21. CARDIO-PULMONARY EXERCISE
Gas Exchange, VE and HR

22. 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

23. 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

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

25. 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

26. 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

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

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

29. 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

30. 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

31. ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By CXR

32. ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By CXR, Hemodynamic Data, and Ejection Fraction
Resting Resting
CI (L/min/M2)
PCW (mmHg) 28 27
EF (%) 24 26

33. ASSESSING THE SEVERITY OF CHRONIC CARDIAC FAILURE
By Response to Exercise
Resting Exercise Resting Exercise
CI (L/min/M2)
PCW (mmHg)
EF (%)
Exerc. capac. (sec)

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