Principles of Exercise Testing and Interpretation Including Pathophysiology and Clinical Applications

by Wasserman, Karlman; Hansen, James E.; Sue, Darryl Y.; Whipp, Brian J.; Casaburi, Richard

• ISBN13: 9780683306460
• ISBN10: 0683306464
• Edition: 3rd
• Format: Hardcover
• Copyright: 1999-03-17
• Publisher: LWW

Summary

Now in its revised, updated Third Edition, this volume provides both the conceptual basis and the practical tools for using exercise testing as part of the cardiorespiratory workup. Coverage ranges from extensive discussions of the pathophysiology of exercise-limiting disorders, to testing protocols, normal values, principles of interpretation, clinical applications, and case presentations. This edition includes three new clinical chapters: training and exercise rehabilitation; diagnoses uniquely made by cardiopulmonary exercise testing; and clinical applications of cardiopulmonary exercise testing.

Table of Contents

1. Exercise Testing and Interpretation: An Overview	1	(9)
Why Measure Gas Exchange to Evaluate Cardiovascular Function and Cellular Respiration?	2	(1)
Cardiac Stress Test and Pulmonary Stress Test: Nomenclature Fallacies	2	(1)
Cell Respiration and Bioenergetics	3	(1)
Normal Coupling of External to Cellular Respiration	4	(1)
Quantifying State and Time Course of Cellular Respiration from Measurements of External Respiration	4	(2)
Patterns of Change in External Respiration (O(2) Uptake and CO(2) Output) as Related to Function, Fitness and Disease	6	(1)
Factors Limiting Exercise	6	(1)
Fatigue	6	(1)
Dyspnea	7	(1)
Pain	7	(1)
Evidence of Systemic Dysfunction Uniquely Revealed by Integrative Cardiopulmonary Exercise Testing	7	(3)
2. Physiology of Exercise	10	(52)
Skeletal Muscle	11	(6)
Mechanical Properties and Fiber Types	11	(1)
Energetics	12	(5)
Oxygen Cost of Work	17	(2)
Work Efficiency	18	(1)
VO(2) Non-Steady State	19	(1)
Lactate Increase	19	(8)
Lactate Increase as Related to Work Rate	19	(1)
Lactate Increase as Related to Time	19	(1)
Lactate Increase in Response to Increasing Work Rate	20	(1)
Mechanisms of Lactate Increase	21	(6)
Buffering the Exercise-induced Lactic Acidosis	27	(2)
The Anaerobic Threshold (AT) Concept	29	(11)
Identifying AT by Gas Exchange	30	(3)
Altered Physiological Responses to Exercise above the AT	33	(6)
Anaerobic, Lactate and Lactic Acidosis Thresholds	39	(1)
Metabolic-Cardiovascular-Ventilatory Coupling	40	(7)
Cellular Respiration and High Energy Phosphate Regeneration	40	(1)
Cardiovascular Coupling to Metabolism: Muscle O(2) Supply	40	(2)
Ventilatory Coupling to Metabolism	42	(4)
Effect of Dietary Substrate	46	(1)
Control of Breathing	47	(5)
Overview	47	(1)
Acid-Base Regulation	47	(1)
Physical Factors	48	(1)
Reflexes Regulating Breathing During Exercise	48	(4)
Gas Exchange Kinetics	52	(4)
Oxygen Uptake Kinetics	52	(3)
CO(2) Output Kinetics	55	(1)
Summary	56	(6)
3. Measurements During Integrative Cardiopulmonary Exercise Testing	62	(33)
What Is an Integrative Cardiopulmonary Exercise Test?	63	(1)
When Should Integrative Cardiopulmonary Exercise Testing Be Used?	64	(1)
Measurements	64	(23)
Electrocardiogram	64	(1)
Maximal Oxygen Uptake (VO(2) max) Maximum Oxygen Uptake (Peak VO(2))	65	(2)
Oxygen Uptake and Work Rate	67	(1)
Pattern of Work Rate Increase and the VO(2) Response	67	(1)
Upward Displacement of VO(2) as A Function of Work Rate	68	(3)
Cardiac Output and Stroke Volume	71	(2)
Anaerobic (Lactate, Lactic Acidosis) Threshold (AT, LT, LAT)	73	(3)
Heart Rate-Oxygen Uptake Relationship and Heart Rate Reserve	76	(1)
Oxygen Pulse (VO(2)/HR) and Stroke Volume	77	(1)
Arterial Blood Pressure	78	(1)
Breathing Reserve	79	(1)
Expiratory Flow Pattern	79	(1)
Tests of Uneven VA/Q	79	(4)
Arterial Bicarbonate and Acid-Base Response	83	(1)
Tidal Volume/Inspiratory Capacity Ratio (VT/IC)	84	(1)
Measurements Unique to Constant Work Rate Exercise Testing	84	(3)
Data Display and Interpretation	87	(5)
Summary	92	(3)
4. Pathophysiology of Disorders Limiting Exercise	95	(20)
Obesity	96	(2)
Peripheral Arterial Diseases	98	(1)
Heart Diseases	98	(4)
Coronary Artery Disease	99	(1)
Myopathic Heart Disease	100	(1)
Valvular Heart Disease	101	(1)
Congenital Heart Disease	101	(1)
Pulmonary Vascular Diseases	102	(2)
Causes of Increased Ventilation	102	(1)
Causes of Exercise Arterial Hypoxemia	102	(1)
Effect on Systemic Hemodynamics	103	(1)
Ventilatory Disorders	104	(5)
Obstructive Lung Diseases	104	(3)
Restrictive Lung Diseases	107	(2)
Chest Wall (Respiratory Pump) Disorders	109	(1)
Defects in Hemoglobin Content and Quality	109	(1)
Anemia	110	(1)
Left-shifted Oxyhemoglobin Dissociation Curve	110	(1)
Carboxyhemoglobinemia and Cigarette Smoking	110	(1)
Chronic Metabolic Acidosis	110	(1)
Muscle Disorders and Endocrine Abnormalities	111	(1)
Psychogenic Causes of Exercise Limitation and Dyspnea	112	(1)
Anxiety	112	(1)
Poor Effort and Manipulated Exercise Performance	112	(1)
Combinations of Defects	112	(1)
Summary	113	(2)
5. Clinical Exercise Testing	115	(28)
Exercise Laboratory and Equipment	116	(11)
General (Laboratory) Environment	116	(1)
Measuring Gas Exchange	116	(1)
Measurement of Volume, Flow Rate, or Ventilation	117	(2)
Breathing Valves, Mouthpieces, and Masks	119	(1)
Gas Analyzers	119	(2)
Ergometers: Treadmills and Cycle	121	(2)
Electrocardiogram and Systemic Blood Pressure	123	(1)
Oximetry, Blood Sampling, and Arterial Catheters	124	(2)
Data Sampling and Computation	126	(1)
Validation and Maintenance	126	(1)
Preparing for the Exercise Test	127	(2)
Requesting the Test and Notifying the Patient	127	(1)
The Patient in the Exercise Laboratory	128	(1)
Performing the Exercise Test	129	(9)
Incremental Exercise Test to Symptom-Limit Maximum	130	(3)
Constant Work Rate Exercise Tests	133	(2)
Treadmill Test for Detecting Myocardial Ischemia	135	(2)
Arm Ergometry	137	(1)
Other Tests Suitable for Fitness or Serial Evaluations	137	(1)
Preparing the Report	138	(1)
Summary	138	(5)
Normal Values	143	(22)
Peak Oxygen Uptake	144	(6)
Age and Gender	144	(1)
Activity Level	144	(1)
Adults of Normal (Predicted) Body Weight	144	(2)
Overweight Patients	146	(2)
Underweight Patients	148	(1)
Children	148	(1)
Exercise Mode	148	(2)
Maximum Heart Rate and Heart Rate Reserve	150	(1)
Relationship of VO(2) and Heart Rate: The Maximum Oxygen Pulse	151	(1)
Brachial Artery Blood Pressure	152	(1)
Anaerobic (Lactate, Lactic Acidosis) Threshold	153	(1)
Oxygen Uptake-Work Rate Relationship	154	(1)
Breathing Reserve, Tidal Volume, and Breathing Frequency at Maximum Exercise	155	(1)
Maximum Exercise Ventilation and Breathing Reserve	155	(1)
Tidal Volume and Breathing Frequency	156	(1)
Ventilatory Measures at the Anaerobic Threshold: VE/VCO(2), VE/VO(2), and the Breathing Reserve Index	156	(1)
Physiologic Dead Space/Tidal Volume Ratio	157	(2)
Arterial and End-Tidal CO(2) Tensions	159	(1)
Arterial, Alveolar, and End-Tidal Oxygen Tensions and Arterial Oxyhemoglobin Saturation	160	(1)
Femoral and Mixed Venous Values and Estimation of Cardiac Output	161	(1)
Acid-Base Balance	162	(1)
Summary	162	(3)
7. Principles of Interpretation: A Flow Chart Approach	165	(13)
Introduction to Flow Charts	166	(1)
Establishing the Pathophysiologic Basis of Exercise Intolerance	166	(11)
Maximum Exercise Capacity and Anaerobic Threshold (Flow Chart 1)	166	(1)
Exercise Intolerance with Normal Peak VO(2) (Flow Chart 2)	167	(2)
Low Peak VO(2) with Normal AT (Flow Chart 3)	169	(2)
Low Peak VO(2) with Low AT (Flow Chart 4)	171	(4)
Low Peak VO(2) with AT Not Determined (Flow Chart 5)	175	(2)
Summary	177	(1)
8. Clinical Applications of Cardiopulmonary Exercise Testing	178	(37)
Differential Diagnosis of Disorders Causing Exercise Intolerance	179	(1)
Pathophysiological Responses in Common Disorders	179	(9)
O(2) Uptake and CO(2) Output as Related to Work-Rate	179	(1)
Heart Rate and VCO(2) as a Function of VO(2)	180	(5)
Heart Rate and O(2) Pulse as a Function of Work Rate	185	(1)
VT as a Function of VE	185	(1)
VE as a Function of VCO(2)	185	(1)
Ventilatory Equivalents for O(2) and CO(2)	185	(3)
Diagnoses Uniquely Made by Cardiopulmonary Exercise Testing	188	(4)
Development of Myocardial Ischemia with Myocardial Dyskinesis during Exercise	188	(1)
Chronic Heart Failure Due to Diastolic Dysfunction	188	(1)
Pulmonary Vascular Occlusive Disease without Pulmonary Hypertension	189	(1)
Patent Foramen Ovale with Development of a Right to Left Shunt during Exercise	189	(2)
Pulmonary Vascular Disease Limiting Exercise in COPD	191	(1)
Impaired Muscle Bioenergetic Function	191	(1)
Psychogenic Dyspnea and Behavioral (Anxiety or Malingering) Causes of Exercise Intolerance	191	(1)
Grading Severity of Heart Disease	192	(1)
Estimating Peak Cardiac Output During Exercise from O(2) Uptake at Peak VO(2)	192	(2)
Cardiac Output Estimated by the Direct Fick Method	192	(1)
Behavior of Changing Arterial-Venous O(2) Difference during Exercise	193	(1)
Initial and Final Estimate of C(a - v)O(2)	193	(1)
Examples of Estimating C(a - v)O(2)	194	(1)
Short-Cut Estimate of Stroke Volume from O(2) Pulse	194	(1)
Prioritizing Patients for Heart Transplantation	194	(2)
Preoperative Evaluation of Surgical Risk	196	(2)
Thoracotomy	197	(1)
Abdominal Surgery	197	(1)
Analysis	198	(1)
Measuring Impairment for Disability Evaluation	198	(3)
Impairment and Disability	198	(1)
Problems in Assessing Impairment from Resting Measures Only	198	(1)
Exercise Testing and Impairment Evaluation O(2) Cost of Work	199	(1)
O(2) Cost of Work	200	(1)
Analysis	201	(1)
Exercise Rehabilitation	201	(4)
Physiological Basis of Exercise Rehabilitation	201	(3)
Exercise Rehabilitation in Heart Disease	204	(1)
Exercise Rehabilitation in Chronic Obstructive Pulmonary Disease	204	(1)
Assessing Effectiveness of Treatment	205	(3)
Screening for Development of Disease in High Risk Patients	208	(1)
Graded Exercise Testing and the Athlete	209	(1)
Summary	210	(5)
9. Case Presentations	215	(308)
Case 1 Normal Man	218	(3)
Case 2 Normal Athlete	221	(3)
Case 3 Normal Man: Air and Oxygen Breathing	224	(5)
Case 4 Normal Woman: Air and Oxygen Breathing	229	(5)
Case 5 Normal Woman	234	(3)
Case 6 Normal Man	237	(3)
Case 7 Normal Man	240	(3)
Case 8 Normal, with Ventilatory Chemoreflex Insensitivity	243	(3)
Case 9 Exceptionally Fit Man with Mild Lung Disease	246	(3)
Case 10 Normal: Cycle and Treadmill	249	(5)
Case 11 Normal: Pre- and Post-Beta-adrenergic Blockade	254	(5)
Case 12 Normal: Immediate Effects of Cigarette Smoking	259	(5)
Case 13 Cardiologic Misdiagnoses in a Man at Ages 65 and 72	264	(8)
Case 14 Obesity, Hypertension, and Cigarette Smoking	272	(3)
Case 15 Extreme Obesity	275	(3)
Case 16 Coronary Artery Disease	278	(3)
Case 17 Coronary Artery Disease	281	(3)
Case 18 Small Vessel Coronary Artery Disease	284	(3)
Case 19 Coronary Artery Disease Developed Over a 3-year Interval	287	(5)
Case 20 Myocardial Ischemia with Mild Interstitial and Obstructive Airway Disease	292	(3)
Case 21 Silent Myocardial Ischemia, Systemic Hypertension, and Mild Interstitial Lung Disease	295	(3)
Case 22 Ischemic Cardiomyopathy	298	(3)
Case 23 Cardiomyopathy	301	(3)
Case 24 Cardiomyopathy, Hypertrophic Type	304	(4)
Case 25 Chronic Heart Failure: Before and After Therapy	308	(5)
Case 26 Cardiomyopathy with Oscillatory Function	313	(4)
Case 27 Mitral Insufficiency	317	(3)
Case 28 Mitral Stenosis: Pre- and Post-Beta-adrenergic Blockade	320	(5)
Case 29 Congenital Heart Disease	325	(5)
Case 30 Peripheral Arterial Disease	330	(3)
Case 31 Peripheral Arterial Disease with Pulmonary Vascular and Obstructive Airway Disease	333	(3)
Case 32 Heart Failure Dominant Mixed Cardiovascular Disease in an Anemic Smoker	336	(3)
Case 33 Hypertensive Cardiovascular Disease and Carboxyhemoglobinemia	339	(3)
Case 34 Patent Ductus Arteriosus	342	(3)
Case 35 Vasoregulatory Asthenia	345	(4)
Case 36 Chronic Bronchitis, Mild, with Normal Exercise Performance	349	(3)
Case 37 Chronic Bronchitis and Obesity	352	(3)
Case 38 Chronic Bronchitis, Cigarette Smoking, and Obesity	355	(3)
Case 39 Emphysema with Mild Airway Obstruction	358	(3)
Case 40 Emphysema, Severe	361	(3)
Case 41 Emphysema with Pulmonary Vascular Disease	364	(3)
Case 42 Emphysema and Bronchitis, Severe: Air and Oxygen Breathing	367	(5)
Case 43 Lung Cancer and Chronic Bronchitis: Preoperative Evaluation	372	(3)
Case 44 Bullous Emphysema: Pre- and Post-bullectomy	375	(5)
Case 45 Obstructive Airway Disease: Before and After Rehabilitation	380	(5)
Case 46 Early Asbestosis and Chronic Bronchitis	385	(3)
Case 47 Asbestosis, Mild	388	(3)
Case 48 Restrictive Lung Disease (Asbestosis)	391	(3)
Case 49 Idiopathic Interstitial Lung Disease	394	(3)
Case 50 Mixed Connective Tissue Disease with Interstitial and Pulmonary Vascular Disease	397	(3)
Case 51 Interstitial Lung Disease	400	(3)
Case 52 Sarcoidosis	403	(3)
Case 53 Sarcoidosis, Severe: Air and Oxygen Breathing	406	(5)
Case 54 Interstitial Pneumonitis: Pre- and Post-corticosteroid Therapy	411	(5)
Case 55 Interstitial Pulmonary Fibrosis: Air and Oxygen Breathing	416	(5)
Case 56 Pulmonary Alveolar Proteinosis: Air and Oxygen Breathing	421	(5)
Case 57 Alveolar Proteinosis: Pre- and Post-whole Lung Lavage	426	(5)
Case 58 Pulmonary Microlithiasis: Air and Oxygen Breathing	431	(5)
Case 59 Pulmonary Vascular Disease, Thromboembolic	436	(3)
Case 60 Pulmonary Vasculitis: Air and Oxygen Breathing	439	(5)
Case 61 Pulmonary Hypertension with Patent Foramen Ovale	444	(5)
Case 62 Left Ventricular Failure with Accompanying Lung Function Changes	449	(3)
Case 63 Pulmonary Vascular Disease, Secondary to Interstitial and Obstructive Lung Disease	452	(3)
Case 64 Pulmonary Arterio-venous Fistulae	455	(4)
Case 65 Poor Effort	459	(4)
Case 66 Poor Effort	463	(3)
Case 67 Acute Hyperventilation and Anxiety in a Moderately Obese Man	466	(3)
Case 68 Skeletal Disease Limiting Exercise	469	(3)
Case 69 Ankylosing Spondylitis	472	(3)
Case 70 Myasthenia Gravis	475	(3)
Case 71 Aortic and Mitral Stenosis and Obstructive Airway Disease	478	(3)
Case 72 Left Ventricular Failure and Mild Obstructive Airway Disease: Cycle and Treadmill	481	(5)
Case 73 Beta-adrenergic Blockade, Systemic Hypertension, Pulmonary Vascular Disease, and Mild Chronic Bronchitis	486	(3)
Case 74 Beta-adrenergic Blockade, Obesity, and Asbestosis	489	(3)
Case 75 Pulmonary Vascular Disease, Chronic Bronchitis, Asbestosis, and Myocardial Ischemia	492	(3)
Case 76 "Asthma", Obesity, and Anemia	495	(3)
Case 77 Mild Obstructive Airway Disease Complicated by Pulmonary Vascular Disease, with a Patent Foramen Ovale and Systemic Hypertension	498	(4)
Case 78 Pulmonary Vascular Disease, Obstructive Airway Disease, and Talc Pneumoconiosis	502	(3)
Case 79 Systemic Sclerosis and Primary Lung Cancer: Preoperative Evaluation	505	(3)
Case 80 Primary Pulmonary Hypertension	508	(3)
Case 81 Cardiomyopathy Due to Diastolic Dysfunction	511	(4)
Case 82 Transition from Normal to Left Ventricular Failure	515	(5)
Case 83 Psychogenic Dyspnea	520	(3)
Appendices A. Symbols and Abbreviations	523	(2)
B. Glossary	525	(6)
C. Calculations, Formulae, and Examples	531	(10)
D. Placement of a Brachial Artery Catheter	541	(2)
E. Tables and Nomogram	543	(3)
Index	546