Any physical exercise requires interaction of physiological support mechanisms energy that enable of

cardiovascular and respiratory systems to

increased demand contracting muscles, so CPET evaluate that whether the defect in pulmonary system, or cardiovascular system.

It pinpoints the weak link in the chain of

exercise intolerance.

CPET directly measure VO2, VCO2 and air flow

(minute ventilation, respiratory rate and tidal volume) on a breath - by - breath basis. Samples of expired air are typically assessed every 15 seconds.

Indications
a) Evaluation of exercise tolerance: Resting pulmonary and cardiac functions cannot

reliably predict exercise performance and

functional capacity (Peak VO2). B) Differential diagnosis of unexplained

dyspnea, CPET is a useful tool to identify the cause of dyspnea (cardiac, pulmonary, deconditioning)

c) Diagnosis of exercise-induced bronchospasm.

d) Evaluation of patients for cardiac

transplantation based on VO2 max:

- < 10 ml / kg / min - 10-14 ml / kg / min - > 16 ml / kg / min e) Prescription of supervised cardiac

rehabilitation programs.

f) Prognosis of cardiac patients (VO2 max < 50% of the predicted) and risk stratification.

g) Athletics purpose.
h) Evaluation of patients with respiratory

disease:
- COPD - Chronic pulmonary vascular disease. - Cystic fibrosis. - Preoperativally.

Equipment and methodology

a) Equipement [stationary bicycle ergometer or treadmill]
Advantages of stationary bicycle ergometer Advantages of Treadmill

(1)It is patient dependent

(1) independent as the speed, grade

can be varied independently

(1)less work is performed

(2) more work is performed so VO2max is usually higher than using

bicycle.

Advantages of stationary bicycle ergometer (1)Less accurate in measuring workloads as

Advantages of Treadmill (3) the workload are more

the pedaling frequency is the important

determinant of total workload More portable and takes less space. (2)At higher workloads, we can obtain good ECG data without motion artifact. (3)Blood pressure can be easily measured because the upper body motion is reduced. (4)Obese patients are less anxious because they are more in control of their exercise

accurately measured.

performance.
(5)The bicycle ergometer can be positioned for supine leg exercise during catheterization or noninvasive imaging studies as ultrasound or nuclear techniques.

b) exercise testing protocol:

The testing protocol may be

Submaximal symptom limited exercise testing (120 b/min or 5 METS)

Maximal symptom limited exercise testing predicted HRmax

Maximal exercise testing

The load used during the protocol to stress

the cardiopulmonary system may be: Incremental:
Increase 5-25 W/min

In the form of stages (3 minutes)

Ramp protocol (every 1-15 seconds)

- Constant work rate protocol

For monitoring responses after cardiopulmonary rehabilitation, bronchodilators.

Can be also used for diagnosis of exerciseinduced bronchospasm.

Preliminary requirements for exercise

testing:
The following are required:
Spirometry and maximal voluntary

ventilation (MVV) should be measured.

It hypoxemia is clinically suspected, resting

arterial blood gases should be obtained.

Patients who smoke should be asked to stop smoking at least 8 hours.

 For functional evaluation and disability,

patients should be tested with their optimal

medical regimen.

The morning of the test, patient should not

exercise and should have a light breakfast

no less than 2 hours before test.

The patient should be familiarized with the

testing unit, about one week before the test.

Absolute and relative contraindications for CPET:

Absolute Relative Acute myocardial infarction (35-days) Left main coronary stenosis or its equivalent Unstable angina Uncontrolled arrhythmias causing symptoms or hemodynamic compromise Syncope Active endocarditis Acute myocarditis or pericarditis Symptomatic severe aortic stenosis Uncontrolled heart failure Moderate stenotic valvular heart disease Severe untreated arterial hypertension at rest ( > 200 mm Hg systolic, > 120 mm Hg diastolic) Tachyarrhythmias or bradyarrhythmias High-degree atrioventricular block Hypertrophic cardiomyopathy Significant pulmonary hypertension Advanced or complicated pregnancy

Acute pulmonary embolus or pulmonary infarction

Electrolyte abnormalities

Absolute Thrombosis of lower extermitis Suspected dissecting aneurysm Uncontrolled asthma Pulmonary edema Room air desaturation at rest < 85%* Respiratory failure Acute noncardiopulmonary disorder that may affect exercise performance or be aggravated by exercise (i.e. infection, renal failure, thyrotoxicosis) Mental impairment leading to inability to cooperate

Relative Orthopedic impairment that compromises exercise performance

Measurements obtained normal values for each:

Variables
VO2 max or VO2 peak Anaerobic threshold

from

CPET

and

Criteria of Normality
> 84% predicted > 40% VO2 max predicted; wide range of normal (40-80%)

Heart rate (HR)

Heart rate reserve (HRR) Blood pressure O2 pulse (VO2 / HR) Ventilatory reserve (VR) Respiratory frequency (fR) VE/VCO2 (at AT) VD/VT Pao2 P(A-a) O2

HRmax > 90% age predicted

HRR < 15 beats/min < 220 / 90 > 80% MVV-VEmax:> 11 L VEmax/MVV x 100: < 85%. Wide normal range: 72 + 15% < 60% breaths/min < 34 < 0.28; < 0.30 fro age > 40 years > 80 mm Hg < 35 mm Hg

1. VO2 max and Peak VO2

VO2

max

is defined as the greatest amount of

oxygen that a person can extract from inspired

air while performing dynamic exercise.

Criteria for reaching VO2 max includes

Plateau

RER = 1.33

Predicted
HRmax

In the case that the plateau no reached because of symptoms limiting a test a little

increase of about 150 ml/min is noted and the

value obtained called peak VO2 (used as an

estimation of VO2 max). It can be expressed in

L/min, mL/kg/min, or as a percentage of the predicted value.

Factors affecting VO2 max

- Genetic - age (15-30 years, at age of 60 years). - Sex (male has more VO2 max. - Fitness (life style) [12 versus 18 to 24 METs) quantity of exercising muscles. - Cardiovascular clinical status.

The VO2 - work rate relationship

(VO2/WR)

It reflects the rate of change in VO2 divided by

the rate of change in external work.

It reflect metabolic conversion from

Chemical energy

To

Mechanical work

Reduction of normal value (8.5-11 mL/min/watt)

reflects defect in:

O2 transport

and/ or

O2 utilization

HR- VO2 relationship

- Nonlinear at beginning of exercise
- Then relatively linear as near to maximal

- At maximal effort there is little or no heart

rate reserve

HRR = maximum predicted heart rate

achieved peak heart rate during test)

- What is meant by hyperdynamic

cardiovascular response?

2.

O2 Pulse

VO 2 max It equals HR max

HRxSV x (a - v)O 2 difference O2 pulse HR max O2 pulse SV x (a - v) O2 difference

It is defined as the amount of O2 extracted by

the peripheral tissues of body from O2 carried in each stroke volume. - A low flat O2 pulse (early plateau) against increased work rate reflects what ???

3- Respiratory exchange ratio

RER

CO 2 production It equals O 2 consumptio n

It may be less than (1.1) or equal to (1.1) or
more than (1.1)

When

exercising

under

steady

state

conditioning the external respiration = the internal respiration. - In practical testing situations, both lactic acidosis and hyperventilation must be

considered when RER is greater than (1).

4- Anaerobic threshold (AT)

- It is defined as the level of exercise VO2
above which the aerobic energy production is

supplemented by anaerobic metabolism and is

reflected by an increase in lactate and lactate/ pyruvate ratio in the muscle or arterial blood. - It is expressed as percentage of the predicted VO2 max.

Determination of AT

1. Invasive
2. Non invasive

5- Ventilatory reserve or capacity

VE minute ventilati on It equals & 70% MVV maximum voluntary ventilati on
It reflects the relationship of ventilatory

demand to ventilatory capacity. The reserve equals to 30%.

Important points and questions

should be considered during

application of the test:

a)Symptoms: [using of Borg Scale]. Patients are symptom limited rather than physiologically limited. b) when the effort considered to be maximal??

c)Is

metabolic

rate

appropriate

During

exercise? VO2 WR relationship

Does cardiovascular function contribute to

exercise limitation?? Reaching VO2 max + HR max predicted Cardiovascular limitation - Low peak VO2 + predicted HRmax Abnormal cardiovascular, and/or O2 content,

and/or O2 utilization.

Does

ventilatory

function

contribute

to

exercise limitation??

VE 70% and may approach 100% MVV

Pulmonary disorder

or combined disorder

Emerging techniques to evaluate ventilatory limitation

ECG Recording (Picture For Ischemia)