CPET心肺运动试验.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,MITCHELL HOROWITZ,Cardiopulmonary Exercise Testing,Outline,Description of CPET,Who should and who should not get CPET,When to terminate CPET,Exercise physiology,Define terms:respiratory exchange ratio,ventilatory equivalent,heart rate reserve,breathing reserve,oxygen pulse,Pattern of CPET results COPD vs CHF,Rationale for Exercise Testing,Cardiopulmonary measurements obtained at rest may not estimate functional capacity reliably,Clinical Exercise Tests,6-min walk test,Submaximal,Shuttle walk test,Incremental,maximal,symptom-limited,Exercise bronchoprovocation,Exertional oximetry,Cardiac stress test,CPET,Karlman Wasserman,Coupling of External Ventilation and Cellular Metabolism,Adaptations of Wassermans Gears,General Mechanisms of Exercise Limitation,Pulmonary,Ventilatory,Respiratory muscle dysfunction,Impaired gas exchange,Cardiovascular,Reduced stroke volume,Abnormal HR response,Circulatory abnormality,Blood abnormality,Peripheral,Inactivity,Atrophy,Neuromuscular dysfunction,Reduced oxidative capacity of skeletal muscle,Malnutrition,Perceptual,Motivational,Environmental,What is CPET?,Symptom-limited exercise test,Measure airflow,SpO,2,and expired oxygen and carbon dioxide,Allows calculation of peak oxygen consumption,anaerobic threshold,Components of Integrated CPET,Symptom-limited,ECG,HR,Measure expired gas,Oxygen consumption,CO,2,production,Minute ventilation,SpO,2,or PO,2,Perceptual responses,Breathlessness,Leg discomfort,Modified Borg CR-10 Scale,Indications for CPET,Evaluation of dyspnea,Distinguish cardiac vs pulmonary vs peripheral limitation vs other,Detection of exercise-induced bronchoconstriction,Detection of exertional desaturation,Pulmonary rehabilitation,Exercise intensity/prescription,Response to participation,Pre-op evaluation and risk stratification,Prognostication of life expectancy,Disability determination,Fitness evaluation,Diagnosis,Assess response to therapy,Mortality in CF Patients,Nixon et al;NEJM 327:1785;1992.,Followed 109 patients with CF for 8 yrs from CPET,Peak VO,2,81%predicted83%survival,Peak VO,2,59-81%predicted:51%survival,Peak VO,2,14 ml/kg/min:,1-yr survival 94%,2-yr survival 84%,Peak VO,2,14 ml/kg/min:,1-yr survival 47%,2-yr survival 32%,CPET to Predict Risk of Lung Resection in Lung Cancer,Lim et al;Thorax 65:iii1,2023,Alberts et al;Chest 132:1s,2023,Balady et al;Circulation 122:191,2023,Peak VO,2,15 ml/kg/min,No significant increased risk of complications or death,Peak VO,2,15 ml/kg/min,Increased risk of complications and death,Peak VO,2,10 ml/kg/min,40-50%mortality,Consider non-surgical management,Absolute Contraindications to CPET,Acute MI,Unstable anginaUnstable arrhythmia,Acute endocarditis,myocarditis,pericarditis,Syncope,Severe,symptomatic AS,Uncontrolled CHF,Acute PE,DVT,Respiratory failure,Uncontrolled asthma,SpO,2,200/120),Significant pulmonary HTN,Tachyarrhythmia,bradyarrhythmia,High degree AV block,Hypertrophic cardiomyopathy,Electrolyte abnormality,Moderate stenotic valvular heart disease,Advanced or complicated pregnancy,Orthopedic impairment,Indications for Early Exercise Termination,Patient request,Ischemic ECG changes,2 mm ST depression,Chest pain suggestive of ischemia,Significant ectopy,2,nd,or 3,rd,degree heart block,Bp,sys,240-250,Bp,dias,110-120,Fall in BP,sys,20 mmHg,SpO,2,1(CO,2,production O,2,consumption).,Carbon dioxide regulates ventilation.,Ventilation will disproportionately increase at lactate threshold to eliminate excess CO,2,.,Increase in ventilatory equivalent for oxygen demarcates the anaerobic threshold.Lactate Threshold,Determination of AT from RER Plot(V Slope Method),Determination of AT from Ventilatory Equivalent Plot,Wasserman 9-Panel Plot,Oxygen Consumption:Fick Equation,Fick Equation:,Q=V,O,2,/C(a-v),O,2,V,O,2,=Q x C(a-v),O,2,V,O,2,=SV x HR x C(a-v),O,2,Heart disease,Heart disease,Lung disease,Muscle disease,Deconditioning,Anemia,Lung disease(low SaO,2,),Arterial oxygen content=,(1.34)(SaO,2,)(Hgb),Venous oxygen content=,(1.34)(SvO,2,)(Hgb),Oxygen Pulse,Oxygen Pulse:,“.the amount of oxygen consumed by the body from the blood of one systolic discharge of the heart.”,Henderson and Prince,Am J Physiol 35:106,1914,Oxygen Pulse=VO,2,/HR,Fick Equation:,VO,2,=SV x HR x C(a-v)O,2,VO,2,/HR=SV x C(a-v)O,2,Oxygen Pulse,SV,Interpretation of CPET,Peak oxygen consumption,Peak HR,Peak work,Peak ventilation,Anaerobic threshold,Heart rate reserve,Breathing reserve,Heart Rate Reserve,Comparison of actual peak HR and predicted peak HR,=(1 Actual/Predicted)x 100%,Normal 30%,Comparison CPET results,Normal CHF COPD,Predicted Peak HR150150150,Peak HR150140120,MVV10010050,Peak VO,2,2.01.21.2,AT1.00.61.0,Peak VE604049,Breathing Reserve40%60%2%,HR Reserve0%7%20%,Borg Breathlessness548,Borg Leg Discomfort885,Cardiac vs Pulmonary Limitation,Heart Disease,Breathing reserve 30%,Heart rate reserve 15%,Pulmonary Disease,Breathing reserve 15%,CPET Interpretation,Peak V,O,2,HRR BR AT/V,O,2,max A-a,Normal 80%30%40%normal,Heart disease 30%40%normal,Pulm vasc dis 30%30%40%normal,SUMMARY,Cardiopulmonary measurements obtained at rest may not estimate functional capacity reliably.,CPET includes the measurement of expired oxygen and carbon dioxide.,The Borg scale is a validated instrument for measurement of perceptual responses.,CPET may assist in pre-op evaluation and risk stratification,prognostication of life expectancy,and disability determination.,SUMMARY,Cycle ergometer permits direct power calculation.,Peak VO,2,is higher on treadmill than cycle ergometer.,Peak VO,2,may be lower than VO,2,max.,Absolute contraindications to CPET include unstable cardiac disease and SpO,2,20 mmHg is an indication to terminate CPET.,1 glucose yields 36 ATP in slow twitch fiber,and 2 ATP+2 lactic acid in fast twitch fiber.,RER=CO,2,produced/O,2,consumed,SUMMARY,Above the anaerobic threshold,CO,2,production exceeds O,2,consumption.,Ventilation will disproportionately increase at lactate threshold to eliminate excess CO,2,.,AT may be determined graphically from V slope method or from ventilatory equivalent for CO,2,.,Derived from the Fick equation,Oxygen Pulse=VO,2,/HR,and is proportional to stroke volume.,In pure heart disease,BR is 30%and HRR 15%.,In pure pulmonary disease,BR is 15%.,