CARDIOPULMONARY EXERCISE TESTING (CPET) Epameinondas N. Kosmas, MD, PhD, FCCP Director, Dept. of Pulmonary Medicine, Rehabilitation & Sleep Disordered Breathing Lab METROPOLITAN Hospital, Neo Faliro, Greece
CPET: How it is conducted Ergometric bicycle (WR) connected with a PC Subject breathes through mouthpiece or a mask (with a saliva trap) which is Connected to pneumotach (real me flow signal Vt, RR, VE) Connected to O2 & CO2 analyzers (real time VO2 & VCO2, RQ = VCO2/VO2 ratio) External connections: 12 lead ECG (HR, arrhythmias, Q wave, ST segment) Blood pressure sphygmomanometer (BP) Pulse oximeter (SpO2) Optional (interventional): arterial line (ABGs) SG catheter (PAP, Q etc)
TREADMILL DISADVANTAGES 1. Space 2. Subject s safety 3. No workload (watts) measurement
CPET: How it is conducted Subject away from heavy meal and interfering medications Performs ECG and spirometry prior to CPET, in order to get a maximal F V loop & to calculate MVV (= pred. VEmax = FEV1 x 35) Sits comfortably with adjusted height of the seat (not to stretch & not to bend a lot the legs when pedalling) Instructed about the Borg scale (for breathing & leg discomfort) Getting data at rest Familiarization with breathing through mouthpiece or mask Usual protocol : maximal, symptom limited CPET with gradually increasing (incremental) workload by 5 30 watts/min (no less, no more than 10 12 min) Data collection at recovery When to stop : maximal test exhausted subject symptoms(sob, angina, legs, dizziness) ECG abnormalities BP problems desaturation
Safety measures Most dangerous adverse effects : CV Other common: hypoxaemia, bronchospasm, hypoglycemia Detailed medical history Weigh the need for CPET (risk/benefit ratio) Continuous CV and Resp. monitoring Physician supervised test (+cardiologist) Sufficient experienced personnel (physicians, nurse) Oxygen source Drugs (aspirin, nitroglycerine, antiarrhythmics, antihypertensives, N/S, bronchodilators etc) Availability for venous catheter, intubation, defibrillator etc Immediate access to ward or CCU/ICU In a hospital environment SAE rate : healthy (0.2%) patients(2%) Death rate : 9% of SAE (in hospital CPET)
HOW SYSTEMS INTEGRATE DURING EXERCISE Muscles + mitochondria Muscle contraction Energy production/consumption (ΑΤΡ, oxidative phosphorylation) Need Ο2, overproduce CO2 & lactate Respiratory system ventilation (VE=VT*RR) Gas exchange balance O2 uptake(vo2) &CO2 output (VCO2) Cardiovascular Blood cardiac output (Q=SV*HR) O2 & CO2 transport to & from periphery Optimal CO (and O2) delivery & distribution to exercising muscles Acid base balance
BASIC PARAMETERS OF SYSTEMS INTEGRATIONAL FUNCTION DURING EXERCISE VE, Q, La (Lactate threshold, LT)
DIAGNOSTIC UTILITY OF CPET
DIAGNOSTIC UTILITY OF CPET The diseased system contributes inefficiently to the demands of exercise exercise capacity & premature CPET termination due to Symptom (SOB, angina, leg fatigue) Abnormal finding (ECG ischemia, arrythmia, BP, O2 desat etc) Abnormal system response to exercise Still normal exercise capacity but with abnormal response of a system (early disease with decreased reserves)
SHOULD BE UNDERLINED THAT Rule: Usually CPET unmasks & points to the diseased system and not to the disease itself Exceptions (to the rule): Psychogenic SOB Exercise induced asthma Very often (in chronic diseases, such as COPD) more than 1 system suffer
INDICATIONS FOR CPET Functional evaluation of subjects with unexplained exertional dyspnoea and/or exercise intolerance and normal resting lung and heart function To recognise specific disease exercise response patterns that may help in the differential diagnosis of ventilatory vs. circulatory causes of exercise limitation Detection of exercise induced bronchoconstriction Detection of exercise induced arterial oxygen desaturation Functional and prognostic evaluation of patients with COPD, ILD, PAH, CF, CHF Evaluation of preoperative risk for lung resection Evaluation of therapeutic interventions (drugs, rehab, LVRS) Prescription of exercise training Evaluation of disability Assessment of athletic performance
PROGNOSTIC UTILITY OF CPET Disease staging BODE Index (COPD) Outcomes of treatment modalities Survival Rehabilitation Lung resection LVRS Transplantation COPD PAH CHF
COPD: Kaplan Meier survival curves using quartiles of peak oxygen uptake (V O2,peak ). V O2,peak >995 ml min 1 V O2,peak 793 995 ml min 1 V O2,peak 654 792 ml min 1 V O2,peak : <654 ml min 1 Oga T, Nishimura K, Tsukino M, Sato S, Hajiro T. Analysis of the factors related to mortality in chronic obstructive pulmonary disease: role of exercise capacity and health status. Am J Respir Crit Care Med 2003;167:544 549.
Kaplan Meier cumulative survival curves for 3 yr survival of 70 patients with pulmonary arterial hypertension (PAH). (V O2,peak ) >10.4 ml kg 1 min 1 (V O2,peak ) 10.4 ml kg 1 min 1 Wensel R, Opitz CF, Anker SD, et al. Assessment of survival in patients with primary pulmonary hypertension: importance of cardiopulmonary exercise testing. Circulation 2002;106:319 324.
From: Oscillatory Breathing and Exercise Gas Exchange Abnormalities Prognosticate Early Mortality and Morbidity in Heart Failure J Am Coll Cardiol. 2010;55(17):1814 1823. doi:10.1016/j.jacc.2009.10.075 Figure Legend: Kaplan Meier Survival Curves of Lowest V e/v co 2 and OB, Singly and Combined, for 6 Month Mortality and Morbidity in CHF (A) 1 mortality and (B) 1 morbidity (i.e., hospitaliza on free rate). The numbers of patients at risk for each curve are given at 60 day intervals. Top panels compare the lowest V e/v co 2 ratio <155%pred versus 155%pred (p < 0.001). Middle panels compare posi ve (+OB) versus nega ve OB ( OB) (p < 0.05). Bottom panels compare the lowest V e/v co 2 ratio <155%pred and OB (blue); V e/v co 2 155%pred or +OB (brown); and lowest V e/v co 2 155%pred and +OB (red). The p values of red versus both of blue and brown are <0.0001. Abbreviations as in Figures 1 and 2. Date of download: Copyright The American College of Cardiology. 2/11/2013 All rights reserved.
Preoperative risk assessment for lung resection (pneumonectomy, lobectomy) in patients with lung cancer
ΑΣΘΜΑ ΜΕΤΑ ΑΠΌ ΑΣΚΗΣΗ EIA: exercise induced asthma Or EIB: exercise induced bronchoconstriction
CPET INTERPRETATION
MAXIMAL CPET CRITERIA WRmax > 90% pred VO2max plateau despite increase in WR HRmax>90% pred VEmax/MVV >60 70% VCO2max/VO2max (RQ) > 1.15 Subject s exhaustion Blood lactate > 4 mm
EXERCISE CAPACITY (TOLERANCE) VO2 WR, AT (ANAEROBIC THRESHOLD)
EXERCISE CAPACITY (TOLERANCE) VO2 WR, AT (ANAEROBIC THRESHOLD)
NORMAL VALUES
VENTILATORY RESPONSE VE, Vt, fr
50 watts 120 watts
OPERATIONAL LUNG VOLUMES DURING EXERCISE
NORMAL VALUES
GAS EXCHANGE RESPONSE SpO2, Vd/Vt, VE/VO2, VE/VCO2
NORMAL VALUES
CARDIOVASCULAR RESPONSE HR, O2pulse (=VO2/HR), BP, ECG
NORMAL VALUES
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ΙΑΤΡΙΚΗ ΓΝΩΜΑΤΕΥΣΗ
ΦΥΣΙΟΛΟΓΙΚΕΣ ΤΙΜΕΣ
Determination of the anaerobic threshold, using the V slope method
ΑςΘΕΝΗς 1
Ικανότητα άσκησης Καρδιαγγειακό Αερισμός Ανταλλαγή αερίων ΟΒ ισορρ ΕΥΡΗΜΑΤΑ VO2max VO2/WR, AT, HR, κλίση HR-VO2, O2p, ECG, BP VE max/mvv, BR, VT, fr, VT/VC SpO2, Vd/Vt, VE/VCO2 (AT) PCO2, ph, HCO3, La Ελαττωμένη Παθολογική απόκριση κφ απόκριση ± Σύμπτωμα Borg Κόπωση άκρων ύσπνοια
ΙΑΓΝΩΣΗ Καρδιαγγειακός περιορισμός στην άσκηση Μυοκαρδιοπάθεια
ΑςΘΕΝΗς 2.
2 2 1 1 NEP NEP Flow, l/s 0 0 Exp -1-1 Patient #12 Patient #21-2 -1 0-1 0 Volume, l Volume, l -2
ΜΕΤΑΒΟΛΗ ΠΝΕΥΜΟΝΙΚΩΝ ΟΓΚΩΝ ΣΤΗΝ ΑΣΚΗΣΗ
Ικανότητα άσκησης Καρδιαγγειακό Αερισμός Ανταλλαγή αερίων ΟΒ ισορρ ΕΥΡΗΜΑΤΑ VO2max VO2/WR, AT, HR, κλίση HR-VO2, O2p, ECG, BP VE max/mvv, BR, VT, fr, VT/VC, FL SpO2, Vd/Vt, VE/VCO2 (AT) PCO2, ph, HCO3, La Ελαττωμένη Χωρίς διαταραχές Παθολογική απόκριση Παθολογική απόκριση Σύμπτωμα Borg ύσπνοια
ΙΑΓΝΩΣΗ Αναπνευστικός περιορισμός στην άσκηση (κυρίως αερισμός, δυναμική υπερδιάταση) ΧΑΠ
ΑςΘΕΝΗς 3.
Ικανότητα άσκησης Καρδιαγγειακό Αερισμός Ανταλλαγή αερίων ΟΒ ισορρ ΕΥΡΗΜΑΤΑ VO2max VO2/WR, AT, HR, κλίση HR-VO2, O2p, ECG, BP VE max/mvv, BR, VT, fr, VT/VC, FL SpO2, Vd/Vt, VE/VCO2 (AT) PCO2, ph, HCO3, La Ελαττωμένη Χωρίς διαταραχές Παθολογική απόκριση Παθολογική απόκριση Σύμπτωμα Borg ύσπνοια Κόπωση άκρων
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ΑςΘΕΝΗς 4.
Ικανότητα άσκησης Καρδιαγγειακό Αερισμός Ανταλλαγή αερίων ΟΒ ισορρ ΕΥΡΗΜΑΤΑ VO2max VO2/WR, AT, HR, κλίση HR-VO2, O2p, ECG, BP VE max/mvv, BR, VT, fr, VT/VC, FL SpO2, Vd/Vt, VE/VCO2 (AT) PCO2, ph, HCO3, La Ελαττωμένη Παθολογική απόκριση ± Παθολογική απόκριση Σύμπτωμα Borg ύσπνοια
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FITNESS vs UNFITNESS
ΣΗΜΕΙΑ-ΚΛΕΙ ΙΑ ΓΝΩΜΑΤΕΥΣΗΣ ΑΠΟΦΡ.ΠΝΕΥΜΟΝΟΠΑΘΕΙΑ Αερισμός Ανταλλαγή αερίων ΠΕΡΙΟΡ.ΠΝΕΥΜΟΝΟΠΑΘΕΙΑ Ανταλλαγή αερίων Αερισμός ΚΑΡ ΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ Καρδιαγγειακή απόκριση ΠΝΕΥΜΟΝ.ΑΓΓΕΙΑΚΗ ΝΟΣΟΣ Καρδιαγγειακή απόκριση Ανταλλαγή αερίων ΨΥΧΟΓΕΝΗΣ ΥΣΠΝΟΙΑ Έντονη δύσπνοια κφ VO2max κφ αποκρίσεις συστημάτων
ΕΥΡΗΜΑΤΑ ΝΟΣΟΛΟΓΙΚΩΝ ΠΡΟΤΥΠΩΝ (N U: NORMAL UNDETERMINED) COPD ILD CHF PVD Dec. AT Ν-U Ν-U VE/MVV N- N N N Br.patt. Te, FL RS, Ti N N N VE/VCO2 @AT N- N- N SpO2 Vd/Vt N- N N- N N HRmax N- N- -steep -steep N-steep O2pulse N- N- plateau plateau
ΕΡΓΟΣΠΙΡΟΜΕΤΡΙΑ Ολοκληρωμένος λειτουργικός έλεγχος 3 συστημάτων (αναπνευστικό καρδιαγγειακό περιφερικό μυϊκό) σε ακραίες συνθήκες stress Συνθήκες αναπαραγωγής συμπτώματος (πχ δύσπνοια, κάματος άκρων, άλγος) Αναδεικνύει το πάσχον σύστημα Συγκεκριμένα νοσολογικά πρότυπα