Introduction to Cardiopulmonary Exercise Testing

150 Pages·3.17 MB·english

by  Luks A.W.

Andrew M. Luks
Robb W. Glenny
H. Thomas Robertson
Introduction to
Cardiopulmonary
Exercise Testing
123
Introduction
to Cardiopulmonary
Exercise Testing

Introduction

to Cardiopulmonary
Exercise Testing
Andrew M. Luks, MD
University of Washington School of Medicine,
Seattle, WA, USA
Robb W. Glenny, MD
University of Washington School of Medicine,
Seattle, WA, USA
H. Thomas Robertson, MD
University of Washington School of Medicine,
Seattle, WA, USA
Andrew M. Luks, MD
University of Washington School of Medicine
Seattle, WA, USA
Robb W. Glenny, MD
University of Washington School of Medicine
Seattle, WA, USA
H. Thomas Robertson, MD
University of Washington School of Medicine
Seattle, WA, USA
ISBN 978-1-4614-6282-8 ISBN 978-1-4614-6283-5 (eBook)
DOI 10.1007/978-1-4614-6283-5
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013930552
© Springer Science+Business Media New York 2013
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Acknowledgements
The authors would like to thank John Smith, the lead technologist in
our exercise laboratory, for his assistance in collecting data for inclu-
sion in the cases in this primer and, most importantly, for his dili-
gence and dedication in keeping our cardiopulmonary exercise testing
program running as well as it has for many years.
The authors would also like to thank Brownie Schoene, Bruce
Culver, Erik Swenson, and other faculty and fellows who have regu-
larly attended our weekly exercise conference since its inception over
30 years ago and helped make it one of the most stimulating parts of
our week.
v

Contents
Acknowledgements .............................................................. v
1 Introduction to the Primer ............................................. 1
2 Glossary of Terms ........................................................... 7
3 Cardiac and Respiratory Responses to Exercise
in Health and Disease ..................................................... 13
4 Conducting a Cardiopulmonary Exercise Test ............. 37
5 Interpreting the Results of Cardiopulmonary
Exercise Tests .................................................................. 53
6 Sample Cases Demonstrating Basic Patterns
of Exercise Limitation .................................................... 77
7 Self-Assessment Cases .................................................... 99
About the Authors ................................................................ 141
Index ..................................................................................... 143
vii
Chapter 1
Introduction to the Primer

Keywords Adenosine triphosphate (ATP) (cid:129) C ardiomyopathy (cid:129)
Cardiopulmonary exercise test (cid:129) Chronic obstructive pulmonary
disease (COPD) (cid:129) Exercise limitation
EXERCISE: A MULTISYSTEM
PROCESS
Most activities of daily living, such as rising from a chair, opening a
jar, lifting a box, or walking at a slow pace, require only a modest
amount of muscle strength or endurance, and do not involve signifi cant
demands on the respiratory or cardiovascular systems. However, vig-
orous aerobic exercises, such as running or sustained stair climbing,
require tight integration of multiple systems in the body including the
respiratory, cardiovascular, and neuromuscular systems (Fig. 1 .1 ).
Each of these systems has important functions. The respiratory
system, for example, is a ventilatory pump, moving oxygen from the
atmosphere to the alveoli and carbon dioxide from the alveoli to the
atmosphere. It must also provide an effective means of exchanging
oxygen and carbon dioxide across the thin alveolar walls. The heart is
responsible for pumping oxygenated blood to the exercising muscles
as well as returning oxygen-poor and carbon dioxide-rich blood to the
gas-exchanging surfaces of the lungs. Finally, the nervous system
must transmit signals to the exercising muscles through upper and
lower motor neurons while the muscles must extract oxygen from the
blood, generate adenosine triphosphate (ATP) in the mitochondria,
and contract with force suffi cient to support the intended activity.
The systems do not work independently but rather in a highly coor-
dinated manner. The most signifi cant interdependence is the delivery
A.M. Luks et al., Introduction to Cardiopulmonary 1
Exercise Testing, DOI 10.1007/978-1-4614-6283-5_1,
© Springer Science+Business Media New York 2013
2 INTRODUCTION TO CARDIOPULMONARY EXERCISE TESTING

Fig. 1.1 Multiple systems including the lungs at t op , right , and left side of the
heart, denoted in blue and red , respectively, and the neuromuscular system
work together to generate sustained high-level exercise. Problems in one or
several of these systems can lead to diminished exercise capacity
of oxygen to the working muscles. The lungs must ef fi ciently oxygen-
ate blood returning from the venous system, and the left heart must
then distribute this oxygenated blood to skeletal, cardiac, and respira-
tory muscles in proportion to the amount of work being done by the
individual muscles. All of this coordination must occur in proportion
to the amount of work being performed, whether it is mild, moderate,
or extreme exercise.
Pathology in any of the important systems noted above can lead to
limitations in an individual’s exercise tolerance. In patients with car-
diomyopathy, for example, delivery of oxygen to the exercising mus-
cles is insuffi cient to support mitochondrial ATP generation and, as a
result, muscle contraction. Similarly, in patients with severe chronic
obstructive pulmonary disease (COPD), altered respiratory system