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Card|opu|monary

Lxerc|se 1est|ng
Darcy D. Marciniuk, MD, FRCP(C), FCCP
Professor, Division of Respirology, Critical Care and Sleep Medicine
Royal University Hospital, University of Saskatchewan
Saskatoon, SK, CANADA
Conf||ct of Interest D|sc|osure
l have no relaLlons wlLh lndusLry or
pharmaceuLlcal/devlce companles LhaL
relaLe Lo Lhe Loplc of Lhls presenLaLlon
Cb[ect|ves
1o provlde a brlef overvlew of normal exerclse
physlology and responses
1o ouLllne Lhe lndlcaLlons, conducL, and
lnLerpreLaLlon of cardlopulmonary exerclse
LesLlng
1o hlghllghL characLerlsLlc responses commonly
demonsLraLed by paLlenLs wlLh varlous dlsorders
!"#$%&'()*&+"#, ./0#1%20 3024%+5
Wh|ch of the fo||ow|ng best
descr|bes me?
a) l currenLly am Lhe ulrecLor of a CL1 LaboraLory
b) I am [ or was just] a Pulmonary Fellow, and know
everyLhlng Lhere ls Lo know abouL Lxerclse 1esLlng
c) l rouLlnely lnLerpreL Lxerclse 1esLs le. 10 or more
sLudles/week
d) l lnfrequenLly lnLerpreL Lxerclse 1esLs
e) 1he only reason l need Lo know abouL Lxerclse 1esLlng ls
because of Lhe [$!~*_] 8oard LxamlnaLlon!
Lxerc|se |n the norma| human |s
typ|ca||y ||m|ted by:
a) ulmonary gas exchange
b) Mechanlcal venLllaLory llmlLaLlon
c) 1he cardlovascular sysLem
d) 1he pulmonary vasculaLure
e) Laziness
8ackground
Lxerclse ln Lhe normal human lnvolves Lhe effecLlve
lnLegraLlon of resplraLory, cardlovascular,
neuromuscular and meLabollc funcLlons
Crgans lnvolved ln Lhese roles have slzeable reserve,
wlLh Lhe consequence LhaL cllnlcal manlfesLaLlons of a
dlsease or abnormallLy may noL become readlly
apparenL unLll Lhe funcLlonal capaclLy of Lhe organ(s) ls
markedly lmpalred
CL1 ls a senslLlve meLhod for Lhe early deLecLlon of
abnormal funcLlon and response(s)
!"#$%&'()*&+"#, ./0#1%20 3024%+5
Norma| Lxerc|se hys|o|ogy
ueLermlnanLs of oxygen upLake (vC
2
) and cardlovascular
responses:
vC
2
= C
1
(CaC
2
- CvC
2
) [LquaLlon 1]
or
vC
2
= (P8
.
Sv) (CaC
2
- CvC
2
) [LquaLlon 2]
where C
1
ls cardlac ouLpuL, Lhe producL of sLroke volume (Sv)
and hearL raLe (P8), and CaC
2
- CvC
2
ls Lhe oxygen conLenL
dlfference beLween sysLemlc arLerlal and mlxed venous blood
!"#$%&'()*&+"#, ./0#1%20 3024%+5
Norma| Lxerc|se hys|o|ogy [contd]
ueLermlnanLs of carbon dloxlde ouLpuL (vCC
2
) and resplraLory
responses:
v
A
= k
.
vCC
2
[LquaLlon 3]
aCC
2
or
v
L
= k
.
vCC
2
[LquaLlon 4]
aCC
2
(1 - v
u
/v
1
)
v
L
ls mlnuLe venLllaLlon, sum of alveolar venLllaLlon (v
A
) and dead space
venLllaLlon (v
u
), v
u
/v
1
ls Lhe physlologlc dead space Lo Lldal volume raLlo
Lhese relaLlonshlps reflecL Lhe venLllaLory response durlng exerclse, as v
L
and v
A
are more closely relaLed Lo vCC
2
Lhan Lo vC
2
!"#$%&'()*&+"#, ./0#1%20 3024%+5
v1
88
vL
V
L
(
L
]
m
|
n
)
VC
2
(|]m|n)
MvC (Maxlmal venLllaLory CapaclLy)
v
C
2
m
a
x

p
r
e
d
l
c
L
e
d
Norma| kesp|ratory kesponses
Norma| Card|ovascu|ar kesponses
P8
Sv
CC
n
e
a
r
t

k
a
t
e


(
m
|
n
-
1
)
VC
2
(|]m|n)
a-v C
2
conLenL dlff.
P8max predlcLed
v
C
2
m
a
x

p
r
e
d
l
c
L
e
d
kest|ng vs Lxerc|se kesponses
!"#$%&'()*&+"#, ./0#1%20 3024%+5
Callagher CC. 60$ !)%+ 7 8* 1990
ract|ca| Ind|cat|ons Ior 1est|ng
unexplalned shorLness of breaLh
unexplalned/dlsproporLlonaLe acLlvlLy llmlLaLlon
esLabllshlng cardlovascular vs resplraLory
ob[ecLlvely assesslng dlsablllLy
or the consequences of impairment
LransplanL assessmenL
lung
cardlac
!"#$%&'()*&+"#, ./0#1%20 3024%+5
FLOW CO
2
O
2
VE
PETCO
2
PETO
2
VCO
2
VO
2
RQ
VE/VCO
2
VE/VO
2
Cycle Ergometer Work Rate, RPM
VO
2
/WR
Pulse Oximetry
SpO
2
Cuff (Sphygmomanometer)
Blood Pressure
Visual Analogue Scale / Borg Scale
Perceived Shortness of Breath
Perceived Leg Fatigue
Reason for Stopping Exercise
ECG
Heart Rate
Rhythm/
Ischemia
O
2
Pulse
P(A-a)O
2
, P(a-ET)CO
2
, VD/VT
Arterial Blood Gases
PaO
2
, PaCO
2
, Hgb,
COHgb, pH, Lactate, SaO
2
VT RR
Ca||brat|on
CL1 equlpmenL sysLems (wheLher mlxlng chamber or
breaLh-by-breaLh) requlre meLlculous callbraLlon
procedures Lo ensure measuremenLs are/remaln
accuraLe and preclse
ln addlLlon Lo dally callbraLlon, regular physlologlc
callbraLlon should be performed
%09 :0")4:, 24";; *0*<0# 0/0#1%202 ;&# =>? *%+(402 "4 @A "+$
BAA C"442 C:%)0 D
.
E DF
G
"+$ D!F
G
*0"2(#0$
values should remaln conslsLenL (less Lhan 3 varlaLlon) wlLh
measuremenLs collecLed prevlously under ldenLlcal
clrcumsLances
!"#$%&'()*&+"#, ./0#1%20 3024%+5
CL1 rotoco|s
lncremenLal roLocol used mosL ofLen, and ls Lhe besL
LesL for mosL cllnlcal seLLlngs (the Gold Standard)
Lndurance roLocol (73-80 consLanL work raLe
proLocol) mosL senslLlve for assesslng a LreaLmenL
effecL
Lxerclse Challenge 1esLlng roLocol speclflcally
deslgned for deLecLlng exerclse-lnduced
bronchoconsLrlcLlon (Ll8)
!"#$%&'()*&+"#, ./0#1%20 3024%+5
A|| of the fo||ow|ng statements
regard|ng card|opu|monary exerc|se
test|ng (CL1) are true except?
a) 8lsk of deaLh wlLh CL1 ls 2-3 per 10,000 LesLs
b) 1esLlng should be sLopped lf Lhe paLlenL
develops 2
o
/3
o
hearL block
c) aLlenLs wlLh sympLomaLlc, severe aorLlc
sLenosls should noL undergo LesLlng
d) 1esLlng should be dlsconLlnued lf Lhe paLlenL
wanLs Lo sLop exerclslng
e) 1esLlng should be LermlnaLed lf sysLollc blood
pressure falls >20 mmPg from hlghesL value
Iundamenta| r|nc|p|es
vC
2
ls Lyplcally presenLed wlLh work raLe, and lncreases
nearly llnearly as exLernal work lncreases
1he slope of Lhls relaLlonshlp reflecLs Lhe efflclency of
meLabollc converslon of energy Lo work, and Lhe
mechanlcal efflclency of Lhe musculoskeleLal sysLem
values of 8.3-11.0 ml/mln/waLL are normal for Lhe
VO
2
/work rate relationship, and are unaffected by age,
helghL or sex
Whlle obese lndlvlduals may have an elevaLed raLlo, Lhe
slope of LhaL relaLlonshlp remalns normal
!"#$%&'()*&+"#, ./0#1%20 3024%+5
Iundamenta| r|nc|p|es [contd]
8educed peak vC
2
ls Lhe sLarLlng polnL for lnLerpreLaLlon
underlylng causes for reduced exerclse capaclLy are
deLermlned by lnspecLlng Lhe paLLern of responses ln oLher
varlables
1he anaeroblc Lhreshold (A1) ls consldered an lndlcaLor of
Lhe onseL of meLabollc acldosls, caused predomlnanLly by
lncreased arLerlal lacLaLe durlng exerclse
A1 should be expressed as a percenLage of Lhe peak vC
2
. ln
healLhy lndlvlduals, Lhe A1 occurs aL 30-60 peak vC
2
, wlLh
Lhe range of normal belng 40-80
!"#$%&'()*&+"#, ./0#1%20 3024%+5
A1
V
C
C
2
(
L
]
m
|
n
)
VC
2
(L]m|n)
A1
V
L
(
L
]
m
|
n
)
VC
2
(L]m|n)
A1
8C
V
L
]

V
C
2
V
L
]

V
C
C
2

VC
2
(L]m|n)
A1
8C

L
1
C
C
2

L
1
C
2
(
m
m
n
g
)
VC
2
(L]m|n)
Card|ovascu|ar kesponses
normal
PearL
ulsease
1ralned
CCu
n
k


(
m
|
n
-
1
)
VC
2
(L]m|n)
v
C
2
m
a
x

p
r
e
d
l
c
L
e
d
Vent||atory kesponses
normal
Lung
ulsease
1ralned
V
L
(
L
]
m
|
n
)
VC
2
(L]m|n)
normal MvC (Maxlmal venLllaLory CapaclLy)
v
C
2
m
a
x

p
r
e
d
l
c
L
e
d
MvC Lung ulsease
I|ow-Vo|ume Curves
rovlde lnformaLlon abouL Lhe overall breaLhlng sLraLegy
adopLed by paLlenLs durlng exerclse
behavlor of operaLlonal lung volumes, lncludlng end-explraLory
lung volume (LLLv) (derlved from 1LC and Lhe lnsplraLory capaclLy
[lC]) and Lhe end-lnsplraLory lung volume (LlLv)
ob[ecLlve assessmenL of Lhe presence/degree of flow llmlLaLlon
1he LLLv, Lhe lnsplraLory reserve volume (l8v), and Lhe
presence/absence of flow llmlLaLlon serve Lo dlsLlngulsh Lhe
varlous dlsease sLaLes from normal
ln addlLlon Lo CCu and lLu, paLlenLs wlLh cenLral alrway
obsLrucLlon and slgnlflcanL obeslLy demonsLraLe
dlsLlngulshlng responses
!"#$%&'()*&+"#, ./0#1%20 3024%+5
I|ow-Vo|ume Curves Dur|ng Lxerc|se
I
|
o
w


(
L
]
s
e
c
)
Vo|ume (L)
Norma|
I
|
o
w


(
L
]
s
e
c
)
Vo|ume (L)
CCD
I
|
o
w


(
L
]
s
e
c
)
Vo|ume (L)
ILD
!
"
#
$
%#"&'(
)*+," ./(,01*23
40 5(60
)*+," ./(,01*23
40 72+ 78(/9*6(
:; 5(60
:; 78(/9*6(
<0,/0
78(/9*6(
!"#$%&' )"*+,&#-.$/&0# =>&,20*0,0*?(@
H%4: I'01%") 3:"+J2 4& K#9 L9 M&+02
Lxerc|se I|ow-Vo|ume Curves |n CCD
1
1
2
3
Lxerc|se I|ow-Vo|ume Curves |n Cbes|ty
Cflr u, eL al. M 8'') N:,2%&) 2007, 102: 2217-2226
Cperat|ona| Vo|umes CCD]Cbes|ty
Cflr u, eL al. M 8'') N:,2%&) 2011, 111:10-19
CCD]Cbes|ty Act|v|ty L|m|tat|on
Cflr u, eL al. 8* M L02' !#%4 !"#0 60$ 2009, 180:964-971
r|nc|p|es of Interpretat|on
Address a number of lmporLanL and fundamenLal
quesLlons when lnLerpreLlng exerclse LesLlng:
Are Lhe resulLs normal or abnormal?
Pow llmlLed ls Lhe paLlenL?
WhaL facLors are responslble for Lhe llmlLaLlon?
WhaL abnormal paLLerns of response are
demonsLraLed?
WhaL cllnlcal dlsorders may resulL ln Lhese paLLerns
of response?
!"#$%&'()*&+"#, ./0#1%20 3024%+5
r|nc|p|es of Interpretat|on [contd]
!"#$%&'()*&+"#, ./0#1%20 3024%+5
ueclde upon conLrlbuLors Lo exerclse llmlLaLlon, and
wheLher Lhey are normal (le. approprlaLe) or abnormal:
Cardlovascular funcLlon
8esplraLory mechanlcs (and/or resplraLory muscle funcLlon)
ArLerlal hypoxemla
uyspnea
unflLness/decondlLlonlng
MusculoskeleLal dlsorders, perlpheral vascular dlsease
CLher facLors le. moLlvaLlon, secondary galn, Lechnlcal
facLors, anxleLy, eLc.
6-M|nute Wa|k 1est
8esponslve Lo lnLervenLlons
Lv8S, pulmonary rehablllLaLlon, alLered lnsplred gases, and
pharmacologlc Lheraples ln varled populaLlons
CorrelaLes wlLh lmporLanL ouLcomes
hosplLallzaLlon, morLallLy, P8CL
uemonsLraLes a celllng effecL
Some uncertainty regarding what is normal, although
ofLen slmple Lo deduce whaL ls abnormal
!"#$%&'()*&+"#, ./0#1%20 3024%+5
1
lrosL AL, eL al. D"21() N:"#*"1&) 2003, 43:36-39.
2
8arsL 8!, eL al. 8ML!!6 2004, 169:441-447.
3
Marclnluk uu, eL al. !:024 2007, 131:1639-1663.
6-M|nute Wa|k 1est red|cted Norma|
8asekaba 1, eL al. O+40#+ 60$ M 2009, 39:493-301.
6-M|nute Wa|k 1est red|cted Norma|
8asekaba 1, eL al. O+40#+ 60$ M 2009, 39:493-301.
What |s the m|n|ma| c||n|ca||y
|mportant d|fference (MCID)
for the d|stance wa|ked |n the 6MW1?
a) 20 meLers
b) 33 meLers
c) 34 meLers
d) 71 meLers
e) All of Lhe above
6-M|nute Wa|k 1est - MCID
CCu: 37-71 m (34 m )
1,2
, 33 m
3
Aglng normals: 20 m (small change), and 30 m
(subsLanLlal change)
4
PearL lallure: 33 m (moderaLe lmprovemenL)
3
ulmonary PyperLenslon: 33 m
6
lLu, CLhers: less well deflned
!"#$%&'()*&+"#, ./0#1%20 3024%+5
1
Cazzola M, eL al. A1S/L8S 1ask lorce. .(# L02'%# M 2008, 31:416-468.
2
8edelmeler uA, eL al. 8ML!!6 1997, 133:1278-1282.
3
uhan MA, eL al. .(# L02'%# M 2008, 32:637-643.
4
erera S, eL al. M 8* P0#%"4# I&1 2006, 34:743-749.
3
SperLus !, eL al. 8* Q0"#4 M 2003, 130:707-713.
6
MaLhal SC, eL al. Am ! 8esp CrlL Care Med 2012, 186:428-433.
Shutt|e Wa|k 1est
Measures dlsLance walked (10 m course)
LxLernally paced by audlo slgnals from a casseLLe
lncremenLal and endurance proLocols
Lxerclse lnLenslLy ls comparable Lo maxlmal LesLs on a
Lreadmlll
8eproduclble, and correlaLes well wlLh peak vC
2
1
noL commonly performed, buL famlllarlLy ls growlng
Cllnlcally lmporLanL dlfferences and reference values are
belng sLudled and reporLed
2,3,4
!"#$%&'()*&+"#, ./0#1%20 3024%+5
1
ArnardoLLlr 8P, eL al. L02'%# L02 2006, 17:127-134.
2
epln v, eL al. 3:&#"/ 2007, 62:291-298.
3
8roulllard C, eL al. .(# L02'%# M 2008, 31:379-384.
4
8evlll SM, eL al. N:,2%&4:0#"', 2009, 93:140.
Shutt|e Wa|k 1est
epln v, eL al. 3:&#"/ 2007, 62:291-298.
Changes |n performance after S00 mcg Ipratrop|um 8rom|de
*p = 0.028, n = 16 sub[ects, ILV
1
S0 pred|cted, 6MW1 d|stance 88 pred|cted
eak VC
2
|s typ|ca||y reduced |n a|| of
the fo||ow|ng cond|t|ons except?
a) Chronlc CbsLrucLlve ulmonary ulsease
b) Lxerclse-AssoclaLed 8ronchoconsLrlcLlon
c) lnLersLlLlal Lung ulsease
d) ulmonary PyperLenslon
e) ue-condlLlonlng
Variable CHF COPD ILD PVD
De-
conditioned
Peak VO
2

AT

V or
indeterminate
or
Peak HR
v or or or
O
2
Pulse
or or
V
E
/MVV
or or
V
E
/VCO
2

V
D
/V
T

PaO
2
v
P
A-a
O
2
v
(= decreased; = unchanged from normal; = increased; v = variable)
Variable CHF COPD ILD PVD
De-
conditioned
Peak VO
2

AT

V or
indeterminate
or
Peak HR
v or or or
O
2
Pulse
or or
V
E
/MVV
or or
V
E
/VCO
2

V
D
/V
T

PaO
2
v
P
A-a
O
2
v
(= decreased; = unchanged from normal; = increased; v = variable)
Variable CHF COPD ILD PVD
De-
conditioned
Peak VO
2

AT

V or
indeterminate
or
Peak HR
v or or or
O
2
Pulse
or or
V
E
/MVV
or or
V
E
/VCO
2

V
D
/V
T

PaO
2
v
P
A-a
O
2
v
(= decreased; = unchanged from normal; = increased; v = variable)
Variable CHF COPD ILD PVD
De-
conditioned
Peak VO
2

AT

V or
indeterminate
or
Peak HR
v or or or
O
2
Pulse
or or
V
E
/MVV
or or
V
E
/VCO
2

V
D
/V
T

PaO
2
v
P
A-a
O
2
v
(= decreased; = unchanged from normal; = increased; v = variable)
1he 8ottom L|ne
lmporLanL Lo focus on Lhe reason(s) for LesLlng
Lnsures a correcL and meanlngful lnLerpreLaLlon
Whlle Lhere ls a mulLlLude of graphlcal and numerlcal
resulLs, an over-dependence on compllcaLed
algorlLhms conLrlbuLes Lo confuslon
locus on cardlnal measuremenLs and relaLlonshlps
no slngle flndlng or measuremenL ls dlagnosLlc of any speclflc
dlsease entity [ almost]
CL1 ls never ordered, nor should lL be lnLerpreLed ln
lsolaLlon
!"#$%&'()*&+"#, ./0#1%20 3024%+5

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