Cardiopulmonary Exercise Testing (CPET):

Practical Issues and Case Examples for the Clinician

Dr. Scotty Butcher, University of Saskatchewan, Dr. Dennis Jensen, McGill University, Dr. Michael Stickland, University of Alberta

A straight path never leads anywhere except to the objective. ~Andr Gide

Learning Objectives
1. Describe the appropriate methods of determining if a CPET should be considered maximal or submaximal and address the importance of doing so.
2. Discuss critical issues related to the evaluation of peak oxygen consumption and CPET performance.

Learning Objectives
3. Comprehend how to determine a ventilatory limitation to exercise. 4. Determine the nature and source(s) of exertional symptoms, in particular dyspnea.
5. Understand how to prescribe exercise using data derived from a CPET.

What is maximal test performance and why does it matter?

Dr. Scotty Butcher, PhD, BSc(PT), CSCS, ACSM-RCEP University of Saskatchewan scotty.butcher@usask.ca
(no conflict of interest declared)

The Bible

Questions to be addressed
1. Why do we care about the difference between submaximal and maximal patient effort? 2. For the determination of maximal patient effort, how and why is the ATS/ACCP document wrong? Why does it matter?

why are the Respirology Residents / Fellows who interpret the ATS/ACCP document wrong?

Purposes of CPET
Evaluation of:
1. 2. 3. 4. 5. 6. 7. exercise tolerance undiagnosed exercise intolerance patients with CVD/resp disease/symptoms preoperative patients exercise prescription parameters and safety Impairment/disability candidates for transplantation

What is the main outcome measure?

MAXIMAL AEROBIC POWER (VO2max)

2000 1660

Oxygen Consumption (mL.min-1)

1330

1000

660

330

0
0

40

80

120

160

200

Power Output (Watts)

Typical VO2max values

Population Elite x-country skier Elite distance runner Varsity ice hockey Firefighter rookie Sedentary (young) Sedentary (middle-age) Post-MI patient Severe COPD Male 84 83 55 49 38 30 22 13 (7) Female 72 62 45 44 33 27 18 13 (5)

All values expressed in ml/kg/min

Why do we care about the difference between submaximal and maximal patient effort?
Submaximal efforts may interfere with the interpretation of CPET results and, in turn, patient management. (ATS/ACCP) when VO2peak is reduced and physiological limitation is not achieved,was the patient symptom limited, was it poor patient effort, or possibly some other factor(s)? (ATS/ACCP)

Why do we care about the difference between submaximal and maximal patient effort?
What CANT we do with a submaximal test?
Determine true maximum heart rate Determine vigorous to maximal intensity exercise responses and safety of heavy exercise Determine any physiological exercise limitation Make claims about a patients exercise tolerance or a cause(s) of limitation Make claims about the cardiovascular fitness of a patient (VO2max or maximal work rate)

What is a maximal test?

Physiological reason(s) for exercise cessation
Normal responses and limitations Abnormal or pathophysiological limitations

Symptom limitation?
Highly subjective and needs to be correlated with physiological findings

Criteria for maximum patient effort (ATS/ACCP)

One or more of:

MAXIMAL AEROBIC POWER (VO2max)

2000 1660

Oxygen Consumption (mL.min-1)

1330

1000

660

330

0
0

40

80

120

160

200

Power Output (Watts)

Criteria for maximum patient performance (VO2max)

One or more of:
HR > 90% of predicted max Evidence of a ventilatory exercise limitation

Additional criteria to support the above:

RER > 1.15 Borg > 9 / 10

Patient #1
47 yr old male with sarcoidosis

104

Patient #2
69 yr old male with COPD

120