Elsevier

Clinics in Chest Medicine

Volume 22, Issue 4, 1 December 2001, Pages 679-701
Clinics in Chest Medicine

Clinical Exercise Testing

https://doi.org/10.1016/S0272-5231(05)70060-5Get rights and content

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TYPES OF CLINICAL EXERCISE TESTING

Clinical exercise testing increasingly is being used in clinical practice for two main reasons—its impact in the clinical decision-making process and a growing awareness that resting cardiopulmonary measurements do not provide a reliable estimate of functional capacity. Several modalities of clinical exercise testing are used in clinical practice. Some provide basic information, have low technical requirements, and are simple to perform; others provide a more complete assessment of all the

CARDIOPULMONARY EXERCISE TEST

Cardiopulmonary exercise testing involves measuring oxygen uptake (

o2), carbon dioxide output (
co2), minute ventilation (
e), and other variables in addition to monitoring 12-lead ECG, blood pressure, and pulse oximetry (Spo2) during a maximal symptom-limited incremental exercise test on the cycle ergometer or treadmill. When appropriate, the additional measurement of arterial blood gases provides important information on pulmonary gas exchange.

REASONS TO PERFORM CARDIOPULMONARY EXERCISE TESTING

Cardiopulmonary exercise testing (CPET) provides information not available from the previously described clinical exercise testing modalities. Cardiopulmonary exercise testing permits: (1) objective determination (

o2max) of functional capacity and impairment, (2) evaluation of the mechanisms of exercise limitation, such as the contribution of different organ systems involved in exercise (i.e., heart, lungs, blood, skeletal muscles), (3) differentiation between heart and lung disease, (4)

CLINICAL INDICATIONS

Comprehensive CPET is useful in a wide spectrum of clinical settings125: Evaluation of exercise intolerance and unexplained dyspnea

  1. Functional impairment (

    o2 peak)

  2. Exercise limitation: determination of factors and pathophysiologic mechanisms

  3. Assessing contribution of cardiac and pulmonary causes in coexisting disease

  4. Symptoms disproportionate to resting pulmonary and cardiac tests

  5. When initial resting cardiopulmonary testing is nondiagnostic

Evaluation of patients with cardiovascular disease
  1. Heart failure

  2. Selection for cardiac transplantation

  3. Exercise prescription and monitoring response to cardiac

METHODOLOGY AND PROTOCOLS

Conventional equipment used for the measurement of cardiopulmonary variables uses automated systems that provide on-line breath-by-breath analysis of respiratory gas exchange. The subject breathes through a mouthpiece connected to a flow measurement device (pneumotachograph, mass flow sensor, pitot apparatus, and so forth); oxygen and carbon dioxide fractions are measured by a fuel cell (zirconium oxide) and infrared analyzer, respectively, or both by a mass spectrometer, and heart rate by an

MEASUREMENTS

Computerized exercise systems permit an impressive number of variables to be measured during CPET (Table 1). A list of selected peak CPET measurements and suggested normal guidelines for interpretation (Table 2) also is included.126

NORMAL CARDIOPULMONARY EXERCISE TEST RESPONSE

The graphic representation of the normal cardiopulmonary response of a healthy, physically active, young person to a symptom-limited maximal incremental exercise test appears in Figure 4.

The upper panel shows oxygen uptake (

o2), carbon dioxide output (
co2), and minute ventilation (
e) increasing as work rate increases. The increase in
o2 is linear with increases in work rate. During the early stages of exercise,
co2 and
e also increase linearly with
o2, until approximately 50% to 60% of
o2max,

EXERCISE LIMITATION

Clinically, it is increasingly appreciated that exercise limitation or low

o2max achieved is multifactorial and, as such, is not limited by any single component of the oxygen transport or use process, but, rather, by their collective quantitative interaction.34, 58, 118 Although several factors may be involved, one factor often predominates, with variable contributions to exercise intolerance from the other factors. Exercise in normal subjects is limited mainly by the cardiovascular system. The

Interpretative Strategies

Several approaches to interpretation of CPET results should be considered because there is no consensus on any one interpretative strategy. Approaches that emphasize the mechanism for exercise limitation (i.e., ventilatory limitation to exercise) are limited by their lack of “gold standard” definition and the realization that exercise limitation is often multifactorial. Algorithms based on key measurements and conceptual framework39, 85, 121 are limited by excessive reliance on single

PUTTING IT ALL TOGETHER

The integrative approach to CPET interpretation involves analyzing the quality of the test and the consistency of results; comparing results with appropriate reference values57, 121; identifying physiologic limitations and patterns of exercise responses; considering which clinical entities may be associated with these patterns (Fig. 5 and Table 3); and correlating these results with other available studies, important patient information, and reasons for which CPET was requested. Accurate

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References (135)

  • J.E. Hansen et al.

    Pathophysiology of activity limitation in patients with interstitial lung disease

    Chest

    (1996)
  • D.K. Howard et al.

    The role of cardiopulmonary exercise testing in lung and heart-lung transplantation

    Clin Chest Med

    (1994)
  • B.D. Johnson et al.

    Ventilatory constraints during exercise in patients with chronic heart failure

    Chest

    (2000)
  • B.D. Johnson et al.

    Advances in pulmonary laboratory testing

    Chest

    (1999)
  • B.D. Johnson et al.

    Emerging concepts in the evaluation of ventilatory limitation during exercise. The exercise tidal flow-volume loop

    Chest

    (1999)
  • K.J. Killian et al.

    Mechanisms of exertional dyspnea

    Clin Chest Med

    (1994)
  • D.A. Lewis et al.

    Inaccuracy of non-invasive estimates of VD/VT in clinical exercise testing

    Chest

    (1994)
  • T.J. LoRusso et al.

    Prediction of maximal exercise capacity in obstructive and restrictive pulmonary disease

    Chest

    (1993)
  • D.M. Mancini

    Pulmonary factors limiting exercise capacity in patients with heart failure

    Prog Cardiovasc Dis

    (1995)
  • D.D. Marciniuk et al.

    Clinical exercise testing in chronic airflow limitation

    Med Clin North Am

    (1996)
  • D.D. Marciniuk et al.

    Clinical exercise testing in interstitial lung disease

    Clin Chest Med

    (1994)
  • F.J. Martinez et al.

    Graded comprehensive cardiopulmonary exercise testing in the evaluation of dyspnea unexplained by routine evaluation

    Chest

    (1994)
  • R.C. Morice et al.

    Exercise testing in the evaluation of patients at high risk for complications from lung resection

    Chest

    (1992)
  • J. Myers et al.

    Dangerous curves: A perspective on exercise, lactate, and the anaerobic threshold

    Chest

    (1997)
  • J. Myers et al.

    Can maximal cardiopulmonary capacity be recognized by a plateau in oxygen uptake?

    Chest

    (1989)
  • G.N. Olsen

    The evolving role of exercise testing prior to lung resection

    Chest

    (1989)
  • D. Ramos-Barbon et al.

    Maximal exercise testing for the selection of heart transplantation candidates: Limitation of peak oxygen consumption

    Chest

    (1999)
  • C. Risk et al.

    Exercise alveolar-arterial oxygen pressure difference in interstitial lung disease

    Chest

    (1984)
  • AARC

    Clinical practice guideline: Exercise testing for evaluation of hypoxemia and/or desaturation

    Respir Care

    (1992)
  • ACCP/AACVPR

    Evidence-based guidelines for pulmonary rehabilitation

    Chest

    (1997)
  • ACC/AHA/ACP-ASIM: Guidelines for the management of patients with chronic stable angina: Executive summary and recommendations

    Circulation

    (1999)
  • ACC/AHA guidelines for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing)

    J Am Coll Cardiol

    (1997)
  • P. Agostoni et al.

    Evaluation of breathlessness in asbestos workers

    Am Rev Respir Dis

    (1987)
  • R.C.B. Aitken

    Measurement of feelings using visual analogue scales

    Proc R Soc Med

    (1969)
  • American College of Sports Medicine

    Guidelines for exercise testing and prescription

    (1991)
  • American Heart Association

    Exercise standards. A statement for healthcare professionals

    Circulation

    (1995)
  • American Thoracic Society

    Guidelines for methacholine and exercise challenge testing-1999

    Am J Respir Crit Care Med

    (2000)
  • American Thoracic Society

    Evaluation of impairment/disability secondary to respiratory disorders

    Am Rev Respir Dis

    (1986)
  • American Thoracic Society: Guidelines for the six minute walk test. Am J Respir Crit Care Med 2001; In...
  • American Thoracic Society

    Official Statement. Pulmonary rehabilitation-1999

    Am J Respir Crit Care Med

    (1999)
  • N.R. Anthonisen et al.

    Ventilation: Total, alveolar, and dead space

  • P.O. Astrand et al.

    Textbook of Work Physiology: Physiological Bases of Exercise

    (1986)
  • T.G. Babb

    Mechanical ventilatory constraints in aging, lung disease, and obesity: Perspective and brief review

    Med Sci Sports Exerc

    (1999)
  • T.G. Babb et al.

    Effect of mild-to-moderate airflow limitation on exercise capacity

    J Appl Physiol

    (1991)
  • M. Belman et al.

    Inhaled bronchodilators reduce dynamic hyperinflation during exercise in patients with chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (1996)
  • J.O. Benditt et al.

    Lung volume reduction surgery improves maximal O2 consumption, maximal minute ventilation, O2 pulse, and dead space-to-tidal volume ratio during leg ergometry

    Am J Respir Crit Care Med

    (1997)
  • C.T. Bolliger et al.

    Exercise capacity as a predictor of postoperative complications in lung resection candidates

    Am J Respir Crit Care Med

    (1995)
  • C.T. Bolliger et al.

    Functional evaluation of the lung resection candidate

    Eur Respir J

    (1998)
  • G.A.V. Borg

    Psychophysical bases of perceived exertion

    Med Sci Sports Exerc

    (1982)
  • G.A. Brooks

    Current concepts in lactate exchange

    Med Sci Sports Exerc

    (1991)
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    Address reprint requests to Idelle M. Weisman, MD, Department of Clinical Investigation, William Beaumont Army Medical Center, 5005 N. Piedras St., El Paso, TX 79920–5001, e-mail:weisman@aol.com

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