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TABLE OF CONTENTS
1.
EXERCISE TESTING AND INTERPRETATION: AN OVERVIEW 1
Why Measure Gas Exchange to Evaluate Cardiovascular
Function and Cellular Respiration? 2
Cardiac Stress Test and Pulmonary Stress Test:
Nomenclature Fallacies 2
Cell Respiration and Bioenergetics 3
Normal Coupling of External to Cellular Respiration 4
Quantifying State and Time Course of Cellular
Respiration from Measurements of External
Respiration 4
Patterns of Change in External Respiration
(02 Uptake and CO2 Output) as Related to
Function, Fitness and Disease 6
Factors Limiting Exercise 6
Fatigue 6
Dyspnea 7
Pain 7
Evidence of Systemic Dysfunction Uniquely Revealed
by Integrative Cardiopulmonary Exercise Testing 7
2.
PHYSIOLOGY OF EXERCISE 10
Skeletal Muscle 11
Mechanical Properties and Fiber Types 11
Energetics 12
Oxygen Cost of Work 17
Work Efficiency 18
Vo2 Non-Steady State 19
Lactate Increase 19
Lactate Increase as Related to Work Rate 19
Lactate Increase as Related to Time 19
Lactate Increase in Response to Increasing
Work Rate 20
Mechanisms of Lactate Increase 21
Buffering the Exercise-induced Lactic Acidosis 27
The Anaerobic Threshold (AT) Concept 29
Identifying AT by Gas Exchange 30
Altered Physiological Responses to Exercise
above the AT 33
Anaerobic, Lactate and Lactic Acidosis
Thresholds 39
Metabolic-Cardiovascular-Ventilatory Coupling 40
Cellular Respiration and High Energy Phosphate
Regeneration 40
Cardiovascular Coupling to Metabolism:
Muscle O2 Supply 40
Ventilatory Coupling to Metabolism 42
Effect of Dietary Substrate 46
Control of Breathing 47
Overview 47
Acid-Base Regulation 47
Physical Factors 48
Reflexes Regulating Breathing During
Exercise 48
Gas Exchange Kinetics 52
Oxygen Uptake Kinetics 52
CO2 Output Kinetics 55
Summary 56
3.
MEASUREMENTS DURING INTEGRATIVE CARDIOPULMONARY
EXERCISE TESTING 62
What Is an Integrative Cardiopulmonary Exercise
Test? 63
When Should Integrative Cardiopulmonary Exercise
Testing Be Used? 64
Measurements 64
Electrocardiogram 64
Maximal Oxygen Uptake (Vo2max) Maximum Oxygen
Uptake (Peak Vo2) 65
Oxygen Uptake and Work Rate 67
Pattern of Work Rate Increase and the Vo2
Response 67
Upward Displacement of Vo2 as A Function of
Work Rate 68
Cardiac Output and Stroke Volume 71
Anaerobic (Lactate, Lactic Acidosis) Threshold
(AT, LT, LAT) 73
Heart Rate-Oxygen Uptake Relationship and Heart
Rate Reserve 76
Oxygen Pulse (Vo2/HR) and Stroke Volume 77
Arterial Blood Pressure 78
Breathing Reserve 79
Expiratory Flow Pattern 79
Tests of Uneven VA/Q 79
Arterial Bicarbonate and Acid-Base Response 83
Tidal Volume/Inspiratory Capacity Ratio
(Vt/IC) 84
Measurements Unique to Constant Work Rate
Exercise Testing 84
Data Display and Interpretation 87
Summary 92
4.
PATHOPHYSIOLOGY OF DISORDERS LIMITING EXERCISE 95
Obesity 96
Peripheral Arterial Diseases 98
Heart Diseases 98
Coronary Artery Disease 99
Myopathic Heart Disease 100
Valvular Heart Disease 101
Congenital Heart Disease 101
Pulmonary Vascular Diseases 102
Causes of Increased Ventilation 102
Causes of Exercise Arterial Hypoxemia 102
Effect on Systemic Hemodynamics 103
Ventilatory Disorders 104
Obstructive Lung Diseases 104
Restrictive Lung Diseases 107
Chest Wall (Respiratory Pump) Disorders 109
Defects in Hemoglobin Content and Quality 109
Anemia 110
Left-shifted Oxyhemoglobin Dissociation Curve 110
Carboxyhemoglobinemia and Cigarette Smoking 110
Chronic Metabolic Acidosis 110
Muscle Disorders and Endocrine Abnormalities 111
Psychogenic Causes of Exercise Limitation
and Dyspnea 112
Anxiety 112
Poor Effort and Manipulated Exercise
Performance 112
Combinations of Defects 112
Summary 113
5.
CLINICAL EXERCISE TESTING 115
Exercise Laboratory and Equipment 116
General (Laboratory) Environment 116
Measuring Gas Exchange 116
Measurement of Volume, Flow Rate, or Ventilation 117
Breathing Valves, Mouthpieces, and Masks 119
Gas Analyzers 119
Ergometers: Treadmills and Cycle 121
Electrocardiogram and Systemic Blood Pressure 123
Oximetry, Blood Sampling, and Arterial Catheters 124
Data Sampling and Computation 126
Validation and Maintenance 126
Preparing for the Exercise Test 127
Requesting the Test and Notifying the Patient 127
The Patient in the Exercise Laboratory 128
Performing the Exercise Test 129
Incremental Exercise Test to Symptom-Limit
Maximum 130
Constant Work Rate Exercise Tests 133
Treadmill Test for Detecting Myocardial
Ischemia 135
Arm Ergometry 137
Other Tests Suitable for Fitness or Serial
Evaluations 137
Preparing the Report 138
Summary 138
6.
NORMAL VALUES 143
Peak Oxygen Uptake 144
Age and Gender 144
Activity Level 144
Adults of Normal (Predicted) Body Weight 144
Overweight Patients 146
Underweight Patients 148
Children 148
Exercise Mode 148
Maximum Heart Rate and Heart Rate Reserve 150
Relationship of Vo2 and Heart Rate: The Maximum
Oxygen Pulse 151
Brachial Artery Blood Pressure 152
Anaerobic (Lactate, Lactic Acidosis) Threshold 153
Oxygen Uptake-Work Rate Relationship 154
Breathing Reserve, Tidal Volume, and Breathing
Frequency at Maximum Exercise 155
Maximum Exercise Ventilation and Breathing Reserve 155
Tidal Volume and Breathing Frequency 156
Ventilatory Measures at the Anaerobic Threshold:
VE/Vco2, VE/Vo2, and the Breathing Reserve Index 156
Physiologic Dead Space/Tidal Volume Ratio 157
Arterial and End-Tidal CO2 Tensions 159
Arterial, Alveolar, and End-Tidal Oxygen Tensions
and Arterial Oxyhemoglobin Saturation 160
Femoral and Mixed Venous Values and Estimation of
Cardiac Output 161
Acid-Base Balance 162
Summary 162
7.
PRINCIPLES OF INTERPRETATION: A FLOW CHART APPROACH 165
Introduction to Flow Charts 166
Establishing the Pathophysiologic Basis of Exercise
Intolerance 166
Maximum Exercise Capacity and Anaerobic Threshold
(Flow Chart 1) 166
Exercise Intolerance with Normal Peak Vo2
(Flow Chart 2) 167
Low Peak Vo2 with Normal AT
(Flow Chart 3) 169
Low Peak Vo2 with Low AT
(Flow Chart 4) 171
Low Peak Vo2 with AT Not Determined
(Flow Chart 5) 175
Summary 177
8.
CLINICAL APPLICATIONS OF CARDIOPULMONARY EXERCISE TESTING 178
Differential Diagnosis of Disorders Causing Exercise
Intolerance 179
Pathophysiological Responses in Common Disorders 179
CO2 Uptake and CO2 Output as Related to
Work-Rate 179
Heart Rate and Vco2 as a Function of Vo2 180
Heart Rate and O2 Pulse as a Function of
Work Rate 185
VT as a Function of Ve 185
BE as a Function of Vco2 185
Ventilatory Equivalents for O2 and CO2 185
Diagnoses Uniquely Made by
Cardiopulmonary Exercise Testing 188
Development of Myocardial Ischemia with
Myocardial Dyskinesis during Exercise 188
Chronic Heart Failure Due to Diastolic
Dysfunction 188
Pulmonary Vascular Occlusive Disease without
Pulmonary Hypertension 189
Patent Foramen Ovale with Development of
a Right to Left Shunt during Exercise 189
Pulmonary Vascular Disease Limiting Exercise
in COPD 191
Impaired Muscle Bioenergetic Function 191
Psychogenic Dyspnea and Behavioral (Anxiety
or Malingering) Causes of Exercise
Intolerance 191
Grading Severity of Heart Disease 192
Estimating Peak Cardiac Output During Exercise from
CO2 Uptake at Peak Vo2 192
Cardiac Output Estimated by the Direct Fick
Method 192
Behavior of Changing Arterial-Venous 02
Difference during Exercise 193
Initial and Final Estimate of C(a - v)o2 193
Examples of Estimating C(a - v)o2 194
Short-Cut Estimate of Stroke Volume from
O2 Pulse 194
Prioritizing Patients for Heart Transplantation 194
Preoperative Evaluation of Surgical Risk 196
Thoracotomy 197
Abdominal Surgery 197
Analysis 198
Measuring Impairment for Disability Evaluation 198
Impairment and Disability 198
Problems in Assessing Impairment from Resting
Measures Only 198
Exercise Testing and Impairment Evaluation 199
02 Cost of Work 200
Analysis 201
Exercise Rehabilitation 201
Physiological Basis of Exercise Rehabilitation 201
Exercise Rehabilitation in Heart Disease 204
Exercise Rehabilitation in Chronic Obstructive
Pulmonary Disease 204
Assessing Effectiveness of Treatment 205
Screening for Development of Disease in High Risk
Patients 208
Graded Exercise Testing and the Athlete 209
Summary 210
9.
CASE PRESENTATIONS 215
Case 1 Normal Man 218
Case 2 Normal Athlete 221
Case 3 Normal Man: Air and Oxygen Breathing 224
Case 4 Normal Woman: Air and Oxygen Breathing 229
Case 5 Normal Woman 234
Case 6 Normal Man 237
Case 7 Normal Man 240
Case 8 Normal, with Ventilatory Chemoreflex
Insensitivity 243
Case 9 Exceptionally Fit Man with Mild Lung
Disease 246
Case 10 Normal: Cycle and Treadmill 249
Case 11 Normal: Pre- and Post-B-adrenergic
Blockade 254
Case 12 Normal: Immediate Effects of Cigarette
Smoking 259
Case 13 Cardiologic Misdiagnoses in a Man at
Ages 65 and 72 264
Case 14 Obesity, Hypertension, and Cigarette
Smoking 272
Case 15 Extreme Obesity 275
Case 16 Coronary Artery Disease 278
Case 17 Coronary Artery Disease 281
Case 18 Small Vessel Coronary Artery Disease 284
Case 19 Coronary Artery Disease Developed Over a
3-year Interval 287
Case 20 Myocardial Ischemia with Mild Interstitial
and Obstructive Airway Disease 292
Case 21 Silent Myocardial Ischemia, Systemic
Hypertension, and Mild Interstitial
Lung Disease 295
Case 22 Ischemic Cardiomyopathy 298
Case 23 Cardiomyopathy 301
Case 24 Cardiomyopathy, Hypertrophic Type 304
Case 25 Chronic Heart Failure: Before and After
Therapy 308
Case 26 Cardiomyopathy with Oscillatory Function 313
Case 27 Mitral Insufficiency 317
Case 28 Mitral Stenosis: Pre- and Post-B-adrenergic
Blockade 320
Case 29 Congenital Heart Disease 325
Case 30 Peripheral Arterial Disease 330
Case 31 Peripheral Arterial Disease with Pulmonary
Vascular and Obstructive Airway Disease 333
Case 32 Heart Failure Dominant Mixed Cardiovascular
Disease in an Anemic Smoker 336
Case 33 Hypertensive Cardiovascular Disease and
Carboxyhemoglobinemia 339
Case 34 Patent Ductus Arteriosus 342
Case 35 Vasoregulatory Asthenia 345
Case 36 Chronic Bronchitis, Mild, with Normal
Exercise Performance 349
Case 37 Chronic Bronchitis and Obesity 352
Case 38 Chronic Bronchitis, Cigarette Smoking,
and Obesity 355
Case 39 Emphysema with Mild Airway Obstruction 358
Case 40 Emphysema, Severe 361
Case 41 Emphysema with Pulmonary Vascular Disease 364
Case 42 Emphysema and Bronchitis, Severe: Air
and Oxygen Breathing 367
Case 43 Lung Cancer and Chronic Bronchitis:
Preoperative Evaluation 372
Case 44 Bullous Emphysema: Pre- and
Post-bullectomy 375
Case 45 Obstructive Airway Disease: Before and
After Rehabilitation 380
Case 46 Early Asbestosis and Chronic Bronchitis 385
Case 47 Asbestosis, Mild 388
Case 48 Restrictive Lung Disease (Asbestosis) 391
Case 49 Idiopathic Interstitial Lung Disease 394
Case 50 Mixed Connective Tissue Disease with
Interstitial and Pulmonary Vascular
Disease 397
Case 51 Interstitial Lung Disease 400
Case 52 Sarcoidosis 403
Case 53 Sarcoidosis, Severe: Air and Oxygen
Breathing 406
Case 54 Interstitial Pneumonitis: Pre- and
Post-corticosteroid Therapy 411
Case 55 Interstitial Pulmonary Fibrosis:
Air and Oxygen Breathing 416
Case 56 Pulmonary Alveolar Proteinosis:
Air and Oxygen Breathing 421
Case 57 Alveolar Proteinosis: Pre- and
Post-whole Lung Lavage 426
Case 58 Pulmonary Microlithiasis: Air and
Oxygen Breathing 431
Case 59 Pulmonary Vascular Disease, Thromboembolic 436
Case 60 Pulmonary Vasculitis: Air and Oxygen
Breathing 439
Case 61 Pulmonary Hypertension with Patent
Foramen Ovale 444
Case 62 Left Ventricular Failure with Accompanying
Lung Function Changes 449
Case 63 Pulmonary Vascular Disease, Secondary
to Interstitial and Obstructive Lung
Disease 452
Case 64 Pulmonary Arterio-venous Fistulae 455
Case 65 Poor Effort 459
Case 66 Poor Effort 463
Case 67 Acute Hyperventilation and Anxiety
in a Moderately Obese Man 466
Case 68 Skeletal Disease Limiting Exercise 469
Case 69 Ankylosing Spondylitis 472
Case 70 Myasthenia Gravis 475
Case 71 Aortic and Mitral Stenosis and Obstructive
Airway Disease 478
Case 72 Left Ventricular Failure and Mild
Obstructive Airway Disease: Cycle
and Treadmill 481
Case 73 B-adrenergic Blockade, Systemic Hypertension,
Pulmonary Vascular Disease, and Mild
Chronic Bronchitis 486
Case 74 B-adrenergic Blockade, Obesity,
and Asbestosis 489
Case 75 Pulmonary Vascular Disease, Chronic
Bronchitis, Asbestosis, and Myocardial
Ischemia 492
Case 76 "Asthma," Obesity, and Anemia 495
Case 77 Mild Obstructive Airway Disease Complicated
by Pulmonary Vascular Disease, with a
Patent Foramen Ovale and Systemic
Hypertension 498
Case 78 Pulmonary Vascular Disease, Obstructive
Airway Disease, and Talc Pneumoconiosis 502
Case 79 Systemic Sclerosis and Primary Lung Cancer:
Preoperative Evaluation 505
Case 80 Primary Pulmonary Hypertension 508
Case 81 Cardiomyopathy Due to Diastolic Dysfunction 511
Case 82 Transition from Normal to Left Ventricular
Failure 515
Case 83 Psychogenic Dyspnea 520
APPENDICES
A. Symbols and Abbreviations 523
B. Glossary 525
C. Calculations, Formulae, and Examples 531
D. Placement of a Brachial Artery Catheter 541
E. Tables and Nomogram 543
INDEX 546
END
