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Tables of Contents for Principles of Exercise Testing & Interpretation
Chapter/Section Title
Page #
Page Count
1. Exercise Testing and Interpretation: An Overview
1
9
Why Measure Gas Exchange to Evaluate Cardiovascular Function and Cellular Respiration?
2
1
Cardiac Stress Test and Pulmonary Stress Test: Nomenclature Fallacies
2
1
Cell Respiration and Bioenergetics
3
1
Normal Coupling of External to Cellular Respiration
4
1
Quantifying State and Time Course of Cellular Respiration from Measurements of External Respiration
4
2
Patterns of Change in External Respiration (O(2) Uptake and CO(2) Output) as Related to Function, Fitness and Disease
6
1
Factors Limiting Exercise
6
1
Fatigue
6
1
Dyspnea
7
1
Pain
7
1
Evidence of Systemic Dysfunction Uniquely Revealed by Integrative Cardiopulmonary Exercise Testing
7
3
2. Physiology of Exercise
10
52
Skeletal Muscle
11
6
Mechanical Properties and Fiber Types
11
1
Energetics
12
5
Oxygen Cost of Work
17
2
Work Efficiency
18
1
VO(2) Non-Steady State
19
1
Lactate Increase
19
8
Lactate Increase as Related to Work Rate
19
1
Lactate Increase as Related to Time
19
1
Lactate Increase in Response to Increasing Work Rate
20
1
Mechanisms of Lactate Increase
21
6
Buffering the Exercise-induced Lactic Acidosis
27
2
The Anaerobic Threshold (AT) Concept
29
11
Identifying AT by Gas Exchange
30
3
Altered Physiological Responses to Exercise above the AT
33
6
Anaerobic, Lactate and Lactic Acidosis Thresholds
39
1
Metabolic-Cardiovascular-Ventilatory Coupling
40
7
Cellular Respiration and High Energy Phosphate Regeneration
40
1
Cardiovascular Coupling to Metabolism: Muscle O(2) Supply
40
2
Ventilatory Coupling to Metabolism
42
4
Effect of Dietary Substrate
46
1
Control of Breathing
47
5
Overview
47
1
Acid-Base Regulation
47
1
Physical Factors
48
1
Reflexes Regulating Breathing During Exercise
48
4
Gas Exchange Kinetics
52
4
Oxygen Uptake Kinetics
52
3
CO(2) Output Kinetics
55
1
Summary
56
6
3. Measurements During Integrative Cardiopulmonary Exercise Testing
62
33
What Is an Integrative Cardiopulmonary Exercise Test?
63
1
When Should Integrative Cardiopulmonary Exercise Testing Be Used?
64
1
Measurements
64
23
Electrocardiogram
64
1
Maximal Oxygen Uptake (VO(2) max) Maximum Oxygen Uptake (Peak VO(2))
65
2
Oxygen Uptake and Work Rate
67
1
Pattern of Work Rate Increase and the VO(2) Response
67
1
Upward Displacement of VO(2) as A Function of Work Rate
68
3
Cardiac Output and Stroke Volume
71
2
Anaerobic (Lactate, Lactic Acidosis) Threshold (AT, LT, LAT)
73
3
Heart Rate-Oxygen Uptake Relationship and Heart Rate Reserve
76
1
Oxygen Pulse (VO(2)/HR) and Stroke Volume
77
1
Arterial Blood Pressure
78
1
Breathing Reserve
79
1
Expiratory Flow Pattern
79
1
Tests of Uneven VA/Q
79
4
Arterial Bicarbonate and Acid-Base Response
83
1
Tidal Volume/Inspiratory Capacity Ratio (VT/IC)
84
1
Measurements Unique to Constant Work Rate Exercise Testing
84
3
Data Display and Interpretation
87
5
Summary
92
3
4. Pathophysiology of Disorders Limiting Exercise
95
20
Obesity
96
2
Peripheral Arterial Diseases
98
1
Heart Diseases
98
4
Coronary Artery Disease
99
1
Myopathic Heart Disease
100
1
Valvular Heart Disease
101
1
Congenital Heart Disease
101
1
Pulmonary Vascular Diseases
102
2
Causes of Increased Ventilation
102
1
Causes of Exercise Arterial Hypoxemia
102
1
Effect on Systemic Hemodynamics
103
1
Ventilatory Disorders
104
5
Obstructive Lung Diseases
104
3
Restrictive Lung Diseases
107
2
Chest Wall (Respiratory Pump) Disorders
109
1
Defects in Hemoglobin Content and Quality
109
1
Anemia
110
1
Left-shifted Oxyhemoglobin Dissociation Curve
110
1
Carboxyhemoglobinemia and Cigarette Smoking
110
1
Chronic Metabolic Acidosis
110
1
Muscle Disorders and Endocrine Abnormalities
111
1
Psychogenic Causes of Exercise Limitation and Dyspnea
112
1
Anxiety
112
1
Poor Effort and Manipulated Exercise Performance
112
1
Combinations of Defects
112
1
Summary
113
2
5. Clinical Exercise Testing
115
28
Exercise Laboratory and Equipment
116
11
General (Laboratory) Environment
116
1
Measuring Gas Exchange
116
1
Measurement of Volume, Flow Rate, or Ventilation
117
2
Breathing Valves, Mouthpieces, and Masks
119
1
Gas Analyzers
119
2
Ergometers: Treadmills and Cycle
121
2
Electrocardiogram and Systemic Blood Pressure
123
1
Oximetry, Blood Sampling, and Arterial Catheters
124
2
Data Sampling and Computation
126
1
Validation and Maintenance
126
1
Preparing for the Exercise Test
127
2
Requesting the Test and Notifying the Patient
127
1
The Patient in the Exercise Laboratory
128
1
Performing the Exercise Test
129
9
Incremental Exercise Test to Symptom-Limit Maximum
130
3
Constant Work Rate Exercise Tests
133
2
Treadmill Test for Detecting Myocardial Ischemia
135
2
Arm Ergometry
137
1
Other Tests Suitable for Fitness or Serial Evaluations
137
1
Preparing the Report
138
1
Summary
138
5
Normal Values
143
22
Peak Oxygen Uptake
144
6
Age and Gender
144
1
Activity Level
144
1
Adults of Normal (Predicted) Body Weight
144
2
Overweight Patients
146
2
Underweight Patients
148
1
Children
148
1
Exercise Mode
148
2
Maximum Heart Rate and Heart Rate Reserve
150
1
Relationship of VO(2) and Heart Rate: The Maximum Oxygen Pulse
151
1
Brachial Artery Blood Pressure
152
1
Anaerobic (Lactate, Lactic Acidosis) Threshold
153
1
Oxygen Uptake-Work Rate Relationship
154
1
Breathing Reserve, Tidal Volume, and Breathing Frequency at Maximum Exercise
155
1
Maximum Exercise Ventilation and Breathing Reserve
155
1
Tidal Volume and Breathing Frequency
156
1
Ventilatory Measures at the Anaerobic Threshold: VE/VCO(2), VE/VO(2), and the Breathing Reserve Index
156
1
Physiologic Dead Space/Tidal Volume Ratio
157
2
Arterial and End-Tidal CO(2) Tensions
159
1
Arterial, Alveolar, and End-Tidal Oxygen Tensions and Arterial Oxyhemoglobin Saturation
160
1
Femoral and Mixed Venous Values and Estimation of Cardiac Output
161
1
Acid-Base Balance
162
1
Summary
162
3
7. Principles of Interpretation: A Flow Chart Approach
165
13
Introduction to Flow Charts
166
1
Establishing the Pathophysiologic Basis of Exercise Intolerance
166
11
Maximum Exercise Capacity and Anaerobic Threshold (Flow Chart 1)
166
1
Exercise Intolerance with Normal Peak VO(2) (Flow Chart 2)
167
2
Low Peak VO(2) with Normal AT (Flow Chart 3)
169
2
Low Peak VO(2) with Low AT (Flow Chart 4)
171
4
Low Peak VO(2) with AT Not Determined (Flow Chart 5)
175
2
Summary
177
1
8. Clinical Applications of Cardiopulmonary Exercise Testing
178
37
Differential Diagnosis of Disorders Causing Exercise Intolerance
179
1
Pathophysiological Responses in Common Disorders
179
9
O(2) Uptake and CO(2) Output as Related to Work-Rate
179
1
Heart Rate and VCO(2) as a Function of VO(2)
180
5
Heart Rate and O(2) Pulse as a Function of Work Rate
185
1
VT as a Function of VE
185
1
VE as a Function of VCO(2)
185
1
Ventilatory Equivalents for O(2) and CO(2)
185
3
Diagnoses Uniquely Made by Cardiopulmonary Exercise Testing
188
4
Development of Myocardial Ischemia with Myocardial Dyskinesis during Exercise
188
1
Chronic Heart Failure Due to Diastolic Dysfunction
188
1
Pulmonary Vascular Occlusive Disease without Pulmonary Hypertension
189
1
Patent Foramen Ovale with Development of a Right to Left Shunt during Exercise
189
2
Pulmonary Vascular Disease Limiting Exercise in COPD
191
1
Impaired Muscle Bioenergetic Function
191
1
Psychogenic Dyspnea and Behavioral (Anxiety or Malingering) Causes of Exercise Intolerance
191
1
Grading Severity of Heart Disease
192
1
Estimating Peak Cardiac Output During Exercise from O(2) Uptake at Peak VO(2)
192
2
Cardiac Output Estimated by the Direct Fick Method
192
1
Behavior of Changing Arterial-Venous O(2) Difference during Exercise
193
1
Initial and Final Estimate of C(a - v)O(2)
193
1
Examples of Estimating C(a - v)O(2)
194
1
Short-Cut Estimate of Stroke Volume from O(2) Pulse
194
1
Prioritizing Patients for Heart Transplantation
194
2
Preoperative Evaluation of Surgical Risk
196
2
Thoracotomy
197
1
Abdominal Surgery
197
1
Analysis
198
1
Measuring Impairment for Disability Evaluation
198
3
Impairment and Disability
198
1
Problems in Assessing Impairment from Resting Measures Only
198
1
Exercise Testing and Impairment Evaluation O(2) Cost of Work
199
1
O(2) Cost of Work
200
1
Analysis
201
1
Exercise Rehabilitation
201
4
Physiological Basis of Exercise Rehabilitation
201
3
Exercise Rehabilitation in Heart Disease
204
1
Exercise Rehabilitation in Chronic Obstructive Pulmonary Disease
204
1
Assessing Effectiveness of Treatment
205
3
Screening for Development of Disease in High Risk Patients
208
1
Graded Exercise Testing and the Athlete
209
1
Summary
210
5
9. Case Presentations
215
308
Case 1 Normal Man
218
3
Case 2 Normal Athlete
221
3
Case 3 Normal Man: Air and Oxygen Breathing
224
5
Case 4 Normal Woman: Air and Oxygen Breathing
229
5
Case 5 Normal Woman
234
3
Case 6 Normal Man
237
3
Case 7 Normal Man
240
3
Case 8 Normal, with Ventilatory Chemoreflex Insensitivity
243
3
Case 9 Exceptionally Fit Man with Mild Lung Disease
246
3
Case 10 Normal: Cycle and Treadmill
249
5
Case 11 Normal: Pre- and Post-Beta-adrenergic Blockade
254
5
Case 12 Normal: Immediate Effects of Cigarette Smoking
259
5
Case 13 Cardiologic Misdiagnoses in a Man at Ages 65 and 72
264
8
Case 14 Obesity, Hypertension, and Cigarette Smoking
272
3
Case 15 Extreme Obesity
275
3
Case 16 Coronary Artery Disease
278
3
Case 17 Coronary Artery Disease
281
3
Case 18 Small Vessel Coronary Artery Disease
284
3
Case 19 Coronary Artery Disease Developed Over a 3-year Interval
287
5
Case 20 Myocardial Ischemia with Mild Interstitial and Obstructive Airway Disease
292
3
Case 21 Silent Myocardial Ischemia, Systemic Hypertension, and Mild Interstitial Lung Disease
295
3
Case 22 Ischemic Cardiomyopathy
298
3
Case 23 Cardiomyopathy
301
3
Case 24 Cardiomyopathy, Hypertrophic Type
304
4
Case 25 Chronic Heart Failure: Before and After Therapy
308
5
Case 26 Cardiomyopathy with Oscillatory Function
313
4
Case 27 Mitral Insufficiency
317
3
Case 28 Mitral Stenosis: Pre- and Post-Beta-adrenergic Blockade
320
5
Case 29 Congenital Heart Disease
325
5
Case 30 Peripheral Arterial Disease
330
3
Case 31 Peripheral Arterial Disease with Pulmonary Vascular and Obstructive Airway Disease
333
3
Case 32 Heart Failure Dominant Mixed Cardiovascular Disease in an Anemic Smoker
336
3
Case 33 Hypertensive Cardiovascular Disease and Carboxyhemoglobinemia
339
3
Case 34 Patent Ductus Arteriosus
342
3
Case 35 Vasoregulatory Asthenia
345
4
Case 36 Chronic Bronchitis, Mild, with Normal Exercise Performance
349
3
Case 37 Chronic Bronchitis and Obesity
352
3
Case 38 Chronic Bronchitis, Cigarette Smoking, and Obesity
355
3
Case 39 Emphysema with Mild Airway Obstruction
358
3
Case 40 Emphysema, Severe
361
3
Case 41 Emphysema with Pulmonary Vascular Disease
364
3
Case 42 Emphysema and Bronchitis, Severe: Air and Oxygen Breathing
367
5
Case 43 Lung Cancer and Chronic Bronchitis: Preoperative Evaluation
372
3
Case 44 Bullous Emphysema: Pre- and Post-bullectomy
375
5
Case 45 Obstructive Airway Disease: Before and After Rehabilitation
380
5
Case 46 Early Asbestosis and Chronic Bronchitis
385
3
Case 47 Asbestosis, Mild
388
3
Case 48 Restrictive Lung Disease (Asbestosis)
391
3
Case 49 Idiopathic Interstitial Lung Disease
394
3
Case 50 Mixed Connective Tissue Disease with Interstitial and Pulmonary Vascular Disease
397
3
Case 51 Interstitial Lung Disease
400
3
Case 52 Sarcoidosis
403
3
Case 53 Sarcoidosis, Severe: Air and Oxygen Breathing
406
5
Case 54 Interstitial Pneumonitis: Pre- and Post-corticosteroid Therapy
411
5
Case 55 Interstitial Pulmonary Fibrosis: Air and Oxygen Breathing
416
5
Case 56 Pulmonary Alveolar Proteinosis: Air and Oxygen Breathing
421
5
Case 57 Alveolar Proteinosis: Pre- and Post-whole Lung Lavage
426
5
Case 58 Pulmonary Microlithiasis: Air and Oxygen Breathing
431
5
Case 59 Pulmonary Vascular Disease, Thromboembolic
436
3
Case 60 Pulmonary Vasculitis: Air and Oxygen Breathing
439
5
Case 61 Pulmonary Hypertension with Patent Foramen Ovale
444
5
Case 62 Left Ventricular Failure with Accompanying Lung Function Changes
449
3
Case 63 Pulmonary Vascular Disease, Secondary to Interstitial and Obstructive Lung Disease
452
3
Case 64 Pulmonary Arterio-venous Fistulae
455
4
Case 65 Poor Effort
459
4
Case 66 Poor Effort
463
3
Case 67 Acute Hyperventilation and Anxiety in a Moderately Obese Man
466
3
Case 68 Skeletal Disease Limiting Exercise
469
3
Case 69 Ankylosing Spondylitis
472
3
Case 70 Myasthenia Gravis
475
3
Case 71 Aortic and Mitral Stenosis and Obstructive Airway Disease
478
3
Case 72 Left Ventricular Failure and Mild Obstructive Airway Disease: Cycle and Treadmill
481
5
Case 73 Beta-adrenergic Blockade, Systemic Hypertension, Pulmonary Vascular Disease, and Mild Chronic Bronchitis
486
3
Case 74 Beta-adrenergic Blockade, Obesity, and Asbestosis
489
3
Case 75 Pulmonary Vascular Disease, Chronic Bronchitis, Asbestosis, and Myocardial Ischemia
492
3
Case 76 "Asthma", Obesity, and Anemia
495
3
Case 77 Mild Obstructive Airway Disease Complicated by Pulmonary Vascular Disease, with a Patent Foramen Ovale and Systemic Hypertension
498
4
Case 78 Pulmonary Vascular Disease, Obstructive Airway Disease, and Talc Pneumoconiosis
502
3
Case 79 Systemic Sclerosis and Primary Lung Cancer: Preoperative Evaluation
505
3
Case 80 Primary Pulmonary Hypertension
508
3
Case 81 Cardiomyopathy Due to Diastolic Dysfunction
511
4
Case 82 Transition from Normal to Left Ventricular Failure
515
5
Case 83 Psychogenic Dyspnea
520
3
Appendices A. Symbols and Abbreviations
523
2
B. Glossary
525
6
C. Calculations, Formulae, and Examples
531
10
D. Placement of a Brachial Artery Catheter
541
2
E. Tables and Nomogram
543
3
Index
546