CPET心肺运动试验.ppt

MitchellHOROWitz CardiopulmonaryExerciseTesting Outline DescriptionofCPETWhoshouldandwhoshouldnotgetCPETWhentoterminateCPETExercisephysiologyDefineterms respiratoryexchangeratio ventilatoryequivalent heartratereserve breathingreserve oxygenpulsePatternofCPETresultsCOPDvsCHF RationaleforExerciseTesting Cardiopulmonarymeasurementsobtainedatrestmaynotestimatefunctionalcapacityreliably ClinicalExerciseTests 6 minwalktestSubmaximalShuttlewalktestIncremental maximal symptom limitedExercisebronchoprovocationExertionaloximetryCardiacstresstestCPET KarlmanWasserman CouplingofExternalVentilationandCellularMetabolism AdaptationsofWasserman sGears GeneralMechanismsofExerciseLimitation PulmonaryVentilatoryRespiratorymuscledysfunctionImpairedgasexchangeCardiovascularReducedstrokevolumeAbnormalHRresponseCirculatoryabnormalityBloodabnormality PeripheralInactivityAtrophyNeuromusculardysfunctionReducedoxidativecapacityofskeletalmuscleMalnutritionPerceptualMotivationalEnvironmental WhatisCPET Symptom limitedexercisetestMeasureairflow SpO2 andexpiredoxygenandcarbondioxideAllowscalculationofpeakoxygenconsumption anaerobicthreshold ComponentsofIntegratedCPET Symptom limitedECGHRMeasureexpiredgasOxygenconsumptionCO2productionMinuteventilationSpO2orPO2PerceptualresponsesBreathlessnessLegdiscomfort ModifiedBorgCR 10Scale IndicationsforCPET EvaluationofdyspneaDistinguishcardiacvspulmonaryvsperipherallimitationvsotherDetectionofexercise inducedbronchoconstrictionDetectionofexertionaldesaturationPulmonaryrehabilitationExerciseintensity prescriptionResponsetoparticipationPre opevaluationandriskstratificationPrognosticationoflifeexpectancyDisabilitydeterminationFitnessevaluationDiagnosisAssessresponsetotherapy MortalityinCFPatients Nixonetal NEJM327 1785 1992 Followed109patientswithCFfor8yrsfromCPETPeakVO2 81 predicted 83 survivalPeakVO259 81 predicted 51 survivalPeakVO2 59 predicted 28 survival MortalityinCHFPatients Mancinietal Circulation83 778 1991 PeakVO2 14ml kg min 1 yrsurvival94 2 yrsurvival84 PeakVO2 14ml kg min 1 yrsurvival47 2 yrsurvival32 CPETtoPredictRiskofLungResectioninLungCancer Limetal Thorax65 iii1 2010Albertsetal Chest132 1s 2007Baladyetal Circulation122 191 2010PeakVO2 15ml kg minNosignificantincreasedriskofcomplicationsordeathPeakVO2 15ml kg minIncreasedriskofcomplicationsanddeathPeakVO2 10ml kg min40 50 mortalityConsidernon surgicalmanagement AbsoluteContraindicationstoCPET AcuteMIUnstableanginaUnstablearrhythmiaAcuteendocarditis myocarditis pericarditisSyncopeSevere symptomaticASUncontrolledCHFAcutePE DVTRespiratoryfailureUncontrolledasthmaSpO2 88 onRAAcutesignificantnon cardiopulmonarydisorderthatmayaffectorbeadverselyaffectedbyexerciseSignificantpsychiatric cognitiveimpairmentlimitingcooperation RelativeContraindicationstoCPET Leftmainor3 VCADSeverearterialHTN 200 120 SignificantpulmonaryHTNTachyarrhythmia bradyarrhythmiaHighdegreeAVblockHypertrophiccardiomyopathyElectrolyteabnormalityModeratestenoticvalvularheartdiseaseAdvancedorcomplicatedpregnancyOrthopedicimpairment IndicationsforEarlyExerciseTermination PatientrequestIschemicECGchanges2mmSTdepressionChestpainsuggestiveofischemiaSignificantectopy2ndor3rddegreeheartblockBpsys 240 250 Bpdias 110 120FallinBPsys 20mmHgSpO2 81 85 Dizziness faintnessOnsetconfusionOnsetpallor CPETMeasurements WorkVO2VCO2ATHRECGBP RSpO2ABGLactateCPDyspneaLegfatigue ExerciseModality AdvantagesofcycleergometerCheaperSaferLessdangeroffall injuryCanstopanytimeDirectpowercalculationIndependentofweightHoldingbarshasnoeffectLittletrainingneededEasierBPrecording blooddrawRequireslessspaceLessnoiseAdvantagesoftreadmillAttainhigherVO2Morefunctional IncrementalvsRampExerciseTestProtocol INCREMENTAL RAMP WORK TIME TIME WORK PhysiologyandChemistry SlowvsfasttwitchfibersBufferingoflacticacidbybicarbonateCO2productionfromcarbonicacidRespiratoryexchangeratioVentilatoryequivalentofoxygenVentilatoryequivalentofcarbondioxideGraphicaldeterminationofATFickEquationOxygenpulse PropertiesofSkeletalMuscleFibers Red Slowtwitch TypeISustainedactivityHighmitochondrialdensityMetabolizeglucoseaerobically1glucoseyields36ATPRapidrecovery White Fasttwitch TypeIIRapidburstexerciseFewmitochondriaMetabolizeglucoseanaerobically1glucoseyields2ATPand2lacticacidSlowrecovery LacticAcidisBufferedbyBicarbonate Lacticacid HCO3 H2CO3 Lactate H2O CO2 RespiratoryExchangeRatio RER CO2produced O2consumed VCO2 VO2 VentilatoryEquivalents Ventilatoryequivalentforcarbondioxide Minuteventilation VCO2EfficiencyofventilationLitersofventilationtoeliminate1LofCO2Ventilatoryequivalentforoxygen Minuteventilation VO2LitersofventilationperLofoxygenuptake RelationshipofATtoRERandVentilatoryEquivforO2 Belowtheanaerobicthreshold withcarbohydratemetabolism RER 1 CO2production O2consumption Abovetheanaerobicthreshold lacticacidisgenerated Lacticacidisbufferedbybicarbonatetoproducelactate water andcarbondioxide Abovetheanaerobicthreshold RER 1 CO2production O2consumption Carbondioxideregulatesventilation VentilationwilldisproportionatelyincreaseatlactatethresholdtoeliminateexcessCO2 Increaseinventilatoryequivalentforoxygendemarcatestheanaerobicthreshold LactateThreshold DeterminationofATfromRERPlot VSlopeMethod DeterminationofATfromVentilatoryEquivalentPlot Wasserman9 PanelPlot OxygenConsumption FickEquation FickEquation Q VO2 C a v O2VO2 QxC a v O2VO2 SVxHRxC a v O2 Heartdisease HeartdiseaseLungdiseaseMusclediseaseDeconditioning AnemiaLungdisease lowSaO2 Arterialoxygencontent 1 34 SaO2 Hgb Venousoxygencontent 1 34 SvO2 Hgb OxygenPulse OxygenPulse theamountofoxygenconsumedbythebodyfromthebloodofonesystolicdischargeoftheheart HendersonandPrinceAmJPhysiol35 106 1914OxygenPulse VO2 HRFickEquation VO2 SVxHRxC a v O2VO2 HR SVxC a v O2OxygenPulse SV InterpretationofCPET PeakoxygenconsumptionPeakHRPeakworkPeakventilationAnaerobicthresholdHeartratereserveBreathingreserve HeartRateReserve ComparisonofactualpeakHRandpredictedpeakHR 1 Actual Predicted x100 Normal 15 EstimationofPredictedPeakHR 220 ageForage40 220 40 180Forage70 220 70 150210 agex0 65 Forage40 210 40 x0 65 184Forage70 210 70 x0 65 164 BreathingReserve ComparisonofactualpeakventilationandpredictedpeakventilationPredictedpeakventilation MVV orFEV1x35 1 Actual Predicted x100 Normal 30 ComparisonCPETresults NormalCHFCOPDPredictedPeakHR150150150PeakHR150140120MVV10010050PeakVO22 01 21 2AT1 00 61 0PeakVE604049BreathingReserve40 60 2 HRReserve0 7 20 BorgBreathlessness548BorgLegDiscomfort885 CardiacvsPulmonaryLimitation HeartDiseaseBreathingreserve 30 Heartratereserve15 CPETInterpretation PeakVO2HRRBRAT VO2maxA aNormal 80 30 40 normalHeartdisease30 30 15 40 increasedDeconditioning15 30 40 normal SUMMARY Cardiopulmonarymeasurementsobtainedatrestmaynotestimatefunctionalcapacityreliably CPETincludesthemeasurementofexpiredoxygenandcarbondioxide TheBorgscaleisavalidatedinstrumentformeasurementofperceptualresponses CPETmayassistinpre opevaluationandriskstratification prognosticationoflifeexpectancy anddisabilitydetermination SUMMARY Cycleergometerpermitsdirectpowercalculation PeakVO2ishigherontreadmillthancycleergometer PeakVO2maybelowerthanVO2max AbsolutecontraindicationstoCPETincludeunstablecardiacdiseaseandSpO220mmHgisanindicationtoterminateCPET 1glucoseyields36ATPinslowtwitchfiber and2ATP 2lacticacidinfasttwitchfiber RER CO2produced O2consumed SUMMARY Abovetheanaerobicthreshold CO2productionexceedsO2consumption VentilationwilldisproportionatelyincreaseatlactatethresholdtoeliminateexcessCO2 ATmaybedeterminedgraphicallyfromVslopemethodorfromventilatoryequivalentforCO2 DerivedfromtheFickequation OxygenPulse VO2 HR andisproportionaltostrokevolume Inpureheartdisease BRis 30 andHRR15