Principles of Exercise Testing and Interpretation Including Pathophysiology and Clinical Applications

by Wasserman, Karlman; Hansen, James E.; Sue, Darryl Y.; Stringer, William W.; Whipp, Brian J.

• ISBN13: 9780781748766
• ISBN10: 0781748763
• Edition: 4th
• Format: Hardcover
• Copyright: 2004-10-25
• Publisher: LWW

Summary

Thoroughly updated in its Fourth Edition, this exceptional resource is the most comprehensive, current text on the physiology and pathophysiology of exercise testing available. It is the only reference to address those disorders that can be diagnosed only through cardiopulmonary exercise testing. Readers will find... . Comprehensive presentation addressing cardiovascular, metabolic, and respiratory responses to exercise--in both health and disease states. . Principles and rationale behind exercise testing, commonly used testing protocols, guidelines for normal and abnormal values, and tips for accurate interpretation of test results. . Normal test values for a range of patient groups--including children, over- and underweight patients, and the elderly. . More than 80 case histories, each accompanied by exercise physiology results, highlight differential diagnosis by applying basic physiological concepts to real-world examples. . Coverage of disorders that can be diagnosed only through cardiopulmonary exercise testing. NEW to the Fourth Edition... . New chapter covering regulation of arterial and mixed venous blood gases . New nine-panel graphic array illustrating critical aspects of exercise testing . Updated flow charts to help with clinical interpretation and differential diagnosis

Table of Contents

Exercise Testing and Interpretation: An Overview	1	(9)
Cell Respiration and Bioenergetics	2	(1)
What Is Cardiopulmonary Exercise Testing?	3	(1)
Why Measure Gas Exchange to Evaluate Cardiovascular Function and Cellular Respiration?	3	(1)
Cardiac Stress Test and Pulmonary Stress Test: Nomenclature Fallacies	4	(1)
Normal Coupling of External to Cellular Respiration	4	(1)
Patterns of Change in External Respiration (Oxygen Uptake and Carbon Dioxide Output) as Related to Function, Fitness, and Disease	5	(1)
Factors Limiting Exercise	6	(1)
Fatigue	6	(1)
Dyspnea	6	(1)
Pain	6	(1)
Evidence of Systemic Dysfunction Uniquely Revealed by Integrative Cardiopulmonary Exercise Testing	7	(3)
Physiology of Exercise	10	(56)
Skeletal Muscle	11	(7)
Mechanical Properties and Fiber Types	11	(1)
Energetics	12	(6)
Oxygen Cost of Work	18	(1)
Work Efficiency	18	(1)
VO2 Non--Steady State	19	(1)
Lactate Increase	19	(9)
Lactate Increase as Related to Work Rate	19	(1)
Lactate Increase as Related to Time	20	(1)
Lactate Increase in Response to Increasing Work Rate	21	(1)
Mechanisms of Lactate Increase	22	(1)
Oxygen Supply, Critical Capillary PO2, and Lactate Increase	23	(5)
Buffering the Exercise-Induced Lactic Acidosis	28	(2)
The Anaerobic Threshold Concept	30	(12)
The Oxygen Flow-Independent and Oxygen Flow-Dependent Work Rate Zones and the Anaerobic Threshold	31	(1)
Identifying the Anaerobic Threshold by Gas Exchange	32	(3)
Altered Physiological Responses to Exercise Above the Anaerobic Threshold	35	(6)
Anaerobic, Lactate, and Lactic Acidosis Thresholds	41	(1)
Metabolic-Cardiovascular-Ventilatory Coupling	42	(8)
Cellular Respiration and High-Energy Phosphate Regeneration	42	(1)
Cardiovascular Coupling to Metabolism: Muscle Oxygen Supply	43	(2)
Ventilatory Coupling to Metabolism	45	(3)
Effect of Dietary Substrate	48	(2)
Control of Breathing	50	(5)
Acid--Base Regulation	50	(1)
Physical Factors	50	(1)
Reflexes Regulating Breathing During Exercise	51	(4)
Gas Exchange Kinetics	55	(4)
Oxygen Uptake Kinetics	56	(2)
Carbon Dioxide Output Kinetics	58	(1)
Summary	59	(7)
Changes in Blood Gases and pH During Exercise	66	(10)
Oxygen, Carbon Dioxide, and H+ Ion Transport	67	(2)
PO2	67	(1)
PCO2	68	(1)
H+ Ion	68	(1)
The Relation Between Cardiac Output and Oxygen Uptake During Exercise	69	(2)
Estimating Cardiac Output	71	(1)
Carbon Dioxide Transport	71	(3)
Summary	74	(2)
Measurements During Integrative Cardiopulmonary Exercise Testing	76	(35)
What Is an Integrative Cardiopulmonary Exercise Test?	77	(1)
When Should Cardiopulmonary Exercise Testing Be Used?	77	(1)
Measurements	78	(26)
Electrocardiogram	78	(2)
Maximal Oxygen Uptake (VO2max) and Maximum Oxygen Uptake (Peak VO2)	80	(1)
Oxygen Uptake and Work Rate	81	(1)
Pattern of Work Rate Increase and the VO2 Response	81	(3)
Cardiac Output and Stroke Volume	84	(2)
Anaerobic, Lactate, and Lactic Acidosis Thresholds	86	(4)
Heart Rate--Oxygen Uptake Relationship and Heart Rate Reserve	90	(1)
Oxygen Pulse and Stroke Volume	91	(1)
Arterial Blood Pressure	92	(1)
Breathing Reserve	92	(1)
Expiratory Flow Pattern	92	(1)
Tests of Uneven VA/Q	93	(5)
Arterial Bicarbonate and Acid--Base Response	98	(1)
Tidal Volume/Inspiratory Capacity Ratio	99	(1)
Measurements Unique to Constant Work Rate Exercise Testing	99	(5)
Data Display and Interpretation	104	(2)
Evaluation of Systemic Function from the Nine-Panel Graphical Array	104	(2)
Factors Confounding Interpretation of Cardiopulmonary Exercise Testing	106	(1)
Summary	106	(5)
Pathophysiology of Disorders Limiting Exercise	111	(22)
Obesity	112	(2)
Peripheral Arterial Diseases	114	(1)
Heart Diseases	114	(4)
Coronary Artery Disease	115	(1)
Myopathic Heart Disease	116	(1)
Valvular Heart Disease	117	(1)
Congenital Heart Disease	118	(1)
Pulmonary Vascular Diseases	118	(2)
Causes of Increased Ventilation	118	(1)
Causes of Exercise Arterial Hypoxemia	119	(1)
Effect on Systemic Hemodynamics	119	(1)
Ventilatory Disorders	120	(6)
Obstructive Lung Diseases	120	(4)
Restrictive Lung Diseases	124	(1)
Chest Wall (Respiratory Pump) Disorders	125	(1)
Defects in Hemoglobin Content and Quality	126	(1)
Anemia	126	(1)
Left-shifted Oxyhemoglobin Dissociation Curve	127	(1)
Carboxyhemoglobinemia and Cigarette Smoking	127	(1)
Chronic Metabolic Acidosis	127	(1)
Muscle Disorders and Endocrine Abnormalities	128	(1)
Psychogenic Causes of Exercise Limitation and Dyspnea	128	(1)
Anxiety Reactions	128	(1)
Poor Effort and Manipulated Exercise Performance	129	(1)
Combinations of Defects	129	(1)
Summary	129	(4)
Clinical Exercise Testing	133	(27)
Exercise Laboratory and Equipment	134	(10)
General Laboratory Environment	134	(1)
Gas Exchange Measurement	134	(1)
Measurement of Volume, Flow Rate, or Ventilation	135	(1)
Breathing Valves, Mouthpieces, and Masks	136	(1)
Gas Analyzers	136	(1)
Ergometers: Treadmills and Cycles	137	(2)
Electrocardiogram and Systemic Blood Pressure	139	(1)
Oximetry, Blood Sampling, and Arterial Catheters	140	(2)
Data Sampling and Computation	142	(1)
Quality Control, Validation, and Maintenance	142	(2)
Preparing for the Exercise Test	144	(2)
Requesting the Test and Notifying the Patient	144	(1)
The Patient in the Exercise Laboratory	144	(2)
Performing the Exercise Test	146	(10)
Incremental Exercise Test to Symptom-Limited Maximum	146	(4)
Constant Work Rate Exercise Tests	150	(2)
Treadmill Test for Detecting Myocardial Ischemia	152	(1)
Arm Ergometry	153	(1)
Other Tests Suitable for Fitness or Serial Evaluations	154	(2)
Preparing the Report	156	(1)
Summary	156	(4)
Normal Values	160	(23)
Peak Oxygen Uptake	161	(7)
Age and Gender	161	(1)
Activity Level	161	(1)
Adults of Normal (Predicted) Body Weight	161	(2)
Overweight Patients	163	(3)
Underweight Patients	166	(1)
Children	166	(1)
Exercise Mode	166	(1)
Recommendations	167	(1)
Peak Heart Rate and Heart Rate Reserve	168	(1)
Relationship of Oxygen Uptake and Heart Rate: The Peak Oxygen Pulse	168	(2)
Brachial Artery Blood Pressure	170	(1)
Anaerobic Threshold	171	(1)
Oxygen Uptake--Work Rate Relationship	172	(1)
Breathing Reserve, Tidal Volume, and Breathing Frequency at Maximum Exercise	172	(2)
Exercise Ventilation and Breathing Reserve	172	(1)
Tidal Volume and Breathing Frequency	173	(1)
Recommendations	174	(1)
Ventilatory Efficiency	174	(1)
Physiological Dead Space--Tidal Volume Ratio	175	(1)
Arterial and End-Tidal Carbon Dioxide Tensions	176	(1)
Arterial, Alveolar, and End-Tidal Oxygen Tensions and Arterial Oxyhemoglobin Saturation	177	(1)
Femoral and Mixed Venous Values and Estimation of Cardiac Output	178	(1)
Acid--Base Balance	179	(1)
Summary	180	(3)
Principles of Interpretation: A Flowchart Approach	183	(15)
Introduction to Flowcharts	184	(1)
Establishing the Pathophysiological Basis of Exercise Intolerance	184	(1)
Maximum Exercise Capacity and Anaerobic Threshold (Flowchart 1)	184	(2)
Exercise Intolerance with Normal Peak Oxygen Uptake (Flowchart 2)	186	(4)
Low Peak Oxygen Uptake with Normal Anaerobic Threshold (Flowchart 3)	190	(1)
Low Peak Oxygen Uptake with Low Anaerobic Threshold (Flowchart 4)	191	(4)
Low Peak Oxygen Uptake with Anaerobic Threshold Not Determined (Flowchart 5)	195	(1)
Summary	196	(2)
Clinical Applications of Cardiopulmonary Exercise Testing	198	(44)
Differential Diagnosis of Disorders Causing Exercise Intolerance	199	(1)
Pathophysiological Responses in Common Disorders	200	(10)
Oxygen Uptake and Carbon Dioxide Output as Related to Work Rate	200	(2)
Heart Rate and Carbon Dioxide Output as a Function of Oxygen Uptake	202	(1)
Heart Rate and Oxygen Pulse as a Function of Work Rate	202	(1)
Tidal Volume as a Function of Exercise Minute Ventilation	202	(4)
Exercise Minute Ventilation as a Function of Carbon Dioxide Output	206	(1)
Ventilatory Equivalents for Oxygen and Carbon Dioxide	206	(1)
End-Tidal Oxygen and Carbon Dioxide	206	(4)
Diagnoses Uniquely Made by Cardiopulmonary Exercise Testing	210	(4)
Development of Myocardial Dyskinesis with Myocardial Ischemia During Exercise	210	(1)
Chronic Heart Failure Due to Diastolic Dysfunction	210	(1)
Pulmonary Vascular Occlusive Disease Without Pulmonary Hypertension (Pulmonary Vasculopathy)	211	(1)
Patent Foramen Ovale with Development of a Right-to-Left Shunt During Exercise	211	(1)
Pulmonary Vascular Disease Limiting Exercise in Chronic Obstructive Pulmonary Disease	212	(2)
Impaired Muscle Bioenergetic Function	214	(1)
Psychogenic Dyspnea and Behavioral Causes of Exercise Intolerance	214	(1)
Grading Severity of Heart Disease	214	(1)
Estimating Peak Cardiac Output During Exercise from Oxygen Uptake at Peak Work Rate	215	(3)
Cardiac Output Estimated from Oxygen Uptake Applying the Fick Principle	215	(1)
Behavior of Changing Arterial--Venous Oxygen Difference During Exercise	216	(1)
Estimating Arterial--Venous Oxygen Difference	216	(1)
Shortcut Estimate of Stroke Volume from Oxygen Pulse	217	(1)
Cardiopulmonary Exercise Testing for Prognostic Evaluation	218	(4)
Prognosis in Heart Failure and Prioritizing Patients for Heart Transplantation	218	(2)
Prognosis in Primary Pulmonary Hypertension and Prioritizing Patients for Lung Transplantation	220	(1)
Prognosis in Chronic Obstructive Pulmonary Disease and Prioritizing Emphysema Patients for Lung Reduction Surgery	221	(1)
Preoperative Evaluation of Surgical Risk	222	(1)
Thoracic Surgery	222	(1)
Abdominal Surgery	223	(1)
Who Should Undergo Cardiopulmonary Exercise Testing Preoperatively?	223	(1)
Measuring Impairment for Disability Evaluation	223	(3)
Impairment and Disability	224	(1)
Problems in Assessing Impairment from Only Resting Measures	224	(1)
Exercise Testing and Impairment Evaluation	225	(1)
Oxygen Cost of Work	226	(1)
Exercise Rehabilitation	226	(6)
Physiological Basis of Exercise Rehabilitation	226	(2)
Exercise Rehabilitation in Heart Disease	228	(2)
Exercise Rehabilitation in Chronic Obstructive Pulmonary Disease	230	(2)
Assessing the Effectiveness of Treatment	232	(3)
Screening for Development of Disease in High-Risk Patients	235	(1)
Graded Exercise Testing and the Athlete	235	(1)
Summary	235	(7)
Case Presentations	242	(329)
Case 1 Normal Man	245	(3)
Case 2 Normal Athlete	248	(3)
Case 3 Normal Man: Air and Oxygen Breathing Studies	251	(5)
Case 4 Normal Woman: Air and Oxygen Breathing Studies	256	(5)
Case 5 Normal Woman	261	(3)
Case 6 Normal Man	264	(3)
Case 7 Normal Man	267	(3)
Case 8 Normal Man with Ventilatory Chemoreflex Insensitivity	270	(3)
Case 9 Exceptionally Fit Man with Mild Lung Disease	273	(3)
Case 10 Normal Subject: Cycle and Treadmill Studies	276	(4)
Case 11 Normal Subject: Before and After β-Adrenergic Blockade	280	(5)
Case 12 Normal Subject: Immediate Effects of Cigarette Smoking	285	(5)
Case 13 Cardiologic Misdiagnoses in a Man at Ages 65 and 72	290	(7)
Case 14 Obesity, Hypertension, and Cigarette Smoking	297	(3)
Case 15 Extreme Obesity	300	(3)
Case 16 Coronary Artery Disease	303	(3)
Case 17 Coronary Artery Disease	306	(3)
Case 18 Small Vessel Coronary Artery Disease	309	(3)
Case 19 Coronary Artery Disease Developed Over a Three-Year Interval	312	(5)
Case 20 Myocardial Ischemia with Mild Interstitial and Obstructive Airway Disease	317	(3)
Case 21 Silent Myocardial Ischemia, Systemic Hypertension, and Mild Interstitial Lung Disease	320	(3)
Case 22 Ischemic Cardiomyopathy	323	(3)
Case 23 Cardiomyopathy	326	(3)
Case 24 Cardiomyopathy, Hypertrophic Type	329	(4)
Case 25 Chronic Heart Failure: Before and After Therapy	333	(5)
Case 26 Cardiomyopathy with Oscillatory Function	338	(4)
Case 27 Mitral Insufficiency	342	(3)
Case 28 Mitral Stenosis: Before and After β-Adrenergic Blockade	345	(4)
Case 29 Congenital Heart Disease	349	(5)
Case 30 Peripheral Arterial Disease	354	(3)
Case 31 Peripheral Arterial Disease with Pulmonary Vascular and Obstructive Airway Disease	357	(3)
Case 32 Heart Failure--Dominant Mixed Cardiovascular Disease in an Anemic Smoker	360	(3)
Case 33 Hypertensive Cardiovascular Disease and Carboxyhemoglobinemia	363	(3)
Case 34 Patent Ductus Arteriosus	366	(3)
Case 35 Vasoregulatory Asthenia	369	(3)
Case 36 Mild Chronic Bronchitis with Normal Exercise Performance	372	(3)
Case 37 Chronic Bronchitis and Obesity	375	(3)
Case 38 Chronic Bronchitis, Cigarette Smoking, and Obesity	378	(3)
Case 39 Emphysema with Mild Airway Obstruction	381	(3)
Case 40 Severe Emphysema	384	(3)
Case 41 Emphysema with Pulmonary Vascular Disease	387	(3)
Case 42 Severe Emphysema and Bronchitis: Air and Oxygen Breathing Studies	390	(5)
Case 43 Lung Cancer and Chronic Bronchitis: Preoperative Evaluation	395	(3)
Case 44 Bullous Emphysema: Before and After Bullectomy	398	(5)
Case 45 Obstructive Airway Disease: Before and After Rehabilitation	403	(5)
Case 46 Early Asbestosis and Chronic Bronchitis	408	(3)
Case 47 Mild Asbestosis	411	(3)
Case 48 Restrictive Lung Disease (Asbestosis)	414	(3)
Case 49 Idiopathic Interstitial Lung Disease	417	(3)
Case 50 Mixed Connective Tissue Disease with Interstitial and Pulmonary Vascular Disease	420	(3)
Case 51 Interstitial Lung Disease	423	(3)
Case 52 Sarcoidosis	426	(3)
Case 53 Severe Sarcoidosis: Air and Oxygen Breathing Studies	429	(4)
Case 54 Interstitial Pneumonitis: Before and After Corticosteroid Therapy	433	(5)
Case 55 Interstitial Pulmonary Fibrosis: Air and Oxygen Breathing Studies	438	(5)
Case 56 Pulmonary Alveolar Proteinosis: Air and Oxygen Breathing Studies	443	(4)
Case 57 Alveolar Proteinosis: Before and After Whole-Lung Lavage	447	(5)
Case 58 Pulmonary Microlithiasis: Air and Oxygen Breathing Studies	452	(4)
Case 59 Thromboembolic Pulmonary Vascular Disease	456	(3)
Case 60 Pulmonary Vasculitis: Air and Oxygen Breathing Studies	459	(5)
Case 61 Pulmonary Hypertension with Patent Foramen Ovale	464	(4)
Case 62 Left Ventricular Failure with Accompanying Lung Function Changes	468	(3)
Case 63 Pulmonary Vascular Disease Secondary to Interstitial and Obstructive Lung Disease	471	(3)
Case 64 Pulmonary Arteriovenous Fistulae	474	(3)
Case 65 Poor Effort	477	(3)
Case 66 Poor Effort	480	(3)
Case 67 Acute Hyperventilation and Anxiety in a Moderately Obese Man	483	(3)
Case 68 Skeletal Disease Limiting Exercise	486	(3)
Case 69 Ankylosing Spondylitis	489	(3)
Case 70 Myasthenia Gravis	492	(3)
Case 71 Aortic and Mitral Stenosis and Obstructive Airway Disease	495	(3)
Case 72 Left Ventricular Failure and Mild Obstructive Airway Disease: Cycle and Treadmill Studies	498	(4)
Case 73 β-Adrenergic Blockade, Systemic Hypertension, Pulmonary Vascular Disease, and Mild Chronic Bronchitis	502	(3)
Case 74 β-Adrenergic Blockade, Obesity, and Asbestosis	505	(3)
Case 75 Pulmonary Vascular Disease, Chronic Bronchitis, Asbestosis, and Myocardial Ischemia	508	(3)
Case 76 ``CHF,'' ``COPD,'' Obesity, and Anemia	511	(3)
Case 77 Mild Obstructive Airway Disease Complicated by Systemic Hypertension and Pulmonary Vascular Disease	514	(3)
Case 78 Pulmonary Vascular Disease, Obstructive Airway Disease, and Talc Pneumoconiosis	517	(3)
Case 79 Systemic Sclerosis and Primary Lung Cancer: Preoperative Evaluation	520	(3)
Case 80 Primary Pulmonary Hypertension Before and After Treatment	523	(5)
Case 81 Cardiomyopathy Due to Diastolic Dysfunction	528	(4)
Case 82 Transition from Normal to Left Ventricular Failure	532	(5)
Case 83 Psychogenic Dyspnea	537	(3)
Case 84 Hypertension Treated with β-Adrenergic Blockade	540	(5)
Case 85 Ischemic Cardiomyopathy, Restrictive Lung Disease, and β-Adrenergic Blockade	545	(3)
Appendices
A. Symbols and Abbreviations	548	(2)
B. Glossary	550	(6)
C. Calculations, Formulas, and Examples	556	(10)
D. Placement of a Brachial Artery Catheter	566	(2)
E. Tables and Nomogram	568	(3)
Index	571