Principles Of Exercise Testing And Interpretation Wasserman Free Download

Although one might quibble as to which test would hold this distinction, there is little doubt about the importance and usefulness of cardiopulmonary testing. Although traditional cardiology stress testing facilities primarily focus on cardiac response, the popularity of the combined cardiac and respiratory testing is increasing. It makes intuitive sense that the appropriate investigation of exercise intolerance, dyspnea or fatigue needs to incorporate the spectrum of gas exchange from the cell to the environment. The cause(s) for such diagnostic problems may be found in the lungs, heart, pulmonary circulation or the muscles themselves.

The organization is logical and proves the appropriate sequence. The flowchart interpretation and nine-plot montage of exercise data have been developed by Dr Wasserman over the past 20 years. This format has been adopted by major cardiopulmonary metabolic cart manufactures.

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Unexplained exertional dyspnoea or fatigue can arise from a number of underlying disorders and shows only a weak correlation with resting functional or imaging tests. Noninvasive cardiopulmonary exercise testing (CPET) offers a unique, but still under-utilised and unrecognised, opportunity to study cardiopulmonary and metabolic changes simultaneously. CPET can distinguish between a normal and an abnormal exercise response and usually identifies which of multiple pathophysiological conditions alone or in combination is the leading cause of exercise intolerance. Therefore, it improves diagnostic accuracy and patient health care by directing more targeted diagnostics and facilitating treatment decisions. Consequently, CPET should be one of the early tests used to assess exercise intolerance. However, this test requires specific knowledge and there is still a major information gap for those physicians primarily interested in learning how to systematically analyse and interpret CPET findings. This article describes the underlying principles of exercise physiology and provides a practical guide to performing CPET and interpreting the results in adults.

Cardiopulmonary exercise testing (CPET) is a maximal exercise test with concomitant gas exchange analysis that provides an integrative and comprehensive assessment of physiologic responses to exercise and cardiorespiratory fitness. In contrast to exercise ECG, the direct noninvasive determination of minute ventilation, heart rate and expired gases analysis (oxygen uptake and carbon dioxide output) at rest and during exercise provides accurate and reproducible data on the interaction of ventilation, gas exchange, and cardiovascular and musculoskeletal function, and enables determination of deviations from normal.

The objective of this practical introduction is to describe the basic principles of exercise physiology and provide an easy-to-follow approach for those primarily interested in learning how to conduct, analyse and interpret CPET in their clinical practice. For further information, reference is given to the literature [3, 5,6,7, 10, 11, 15,16,17,18,19,20] and the updated reference work [1].

A basic working knowledge of exercise (patho)physiology and gas exchange is fundamental to understanding the pathophysiology of exercise intolerance and to the proper analysis and interpretation of CPET. Figure 1 illustrates characteristic alterations of key physiological parameters as exercise work rate is increased.

The primary objective of the interpretation is to determine whether and to what extent there is impaired exercise capacity and what cause(s) of cardiovascular, pulmonary vascular or pulmonary origin may be primary.

Table 2 shows an example of a CPET interpretation worksheet that can guide structured interpretation of the data and determine the primary pattern of exercise limitation (e.g., cardiocirculatory, pulmonary vascular, pulmonary, deconditioning).

CPET provides an objective and reproducible opportunity to identify why an individual is complaining of exertional dyspnoea and to quantify the limitation of exercise capacity. It can help not only to differentiate between pulmonary, pulmonary vascular and cardiovascular disease but also to unmask the underlying and often complex mechanisms. Accordingly, CPET should be performed before the patient undergoes extensive diagnostic workup that searches in a state of rest for an abnormality that takes place during exercise. CPET probably covers a broader range of potential differential diagnoses than any other test in medicine and is also likely to be cost effective because it directs diagnosis and facilitates treatment decisions [1]. Moreover, many patients regard CPET as being a very useful part of their clinical examination [24]. This all suggests that CPET should be used much more frequently, particularly since the expenditure of time, e.g., compared to exercise ECG, is low in routine use. In addition, the diagnostic value of CPET significantly exceeds that of non-discriminating tests of exercise performance (exercise ECG, 6-min walking test, etc. that provide no information about exercise tolerance), because prognostically important key variables can be determined with the simultaneous measurement of ventilatory gas exchange, even at submaximal exercise levels. However, this global cardiopulmonary reference test is increasingly at risk of disappearing from outpatient specialist medical care for a variety of reasons, such as cost, lack of expertise or reimbursement [15]. This inconsistency is partly explained by the fact that CPET statements may be considered complicated and often fail to provide practical, easy-to-follow guidance [6]. CPET can be seen as a complex test (based on the unique wealth of information it provides) but not necessarily a difficult tool that can be performed well by non-specialists. However, lack of a compact and readily accessible introduction for those interested in learning how to analyze and interpret CPET findings might limit wider use of this powerful reference method. Accordingly, CPET should be promoted in the clinical setting and training should be a mandatory component of respiratory specialist medical training. In this regard, the exemplified CPET standard operating procedure of the German Centre for Cardiovascular Research recommends the initial guided application of 5 CPETs and the subsequent independent performance and interpretation of at least 20 CPETs under supervision [37]. Although this introduction is not intended to be comprehensive, we have attempted to provide a practical guide for those involved in the performance and interpretation of CPET, and to encourage the use of this specialist reference examination much more frequently in indicated cases.

"Exercise testing is valuable for: 1) diagnosing the many causes of exertional dyspnea; 2) evaluating the severity of the impairment of exercise performance; 3) evaluating the effect of medical, surgical, or rehabilitative therapy. This book is designed to provide a guide for exercise physiologists and physicians wishing to set up a laboratory for the purpose of any of the above objectives." [Preface] The chapter headings are: Exercise Testing and Interpretation: An Overview; Physiology of Exercise; Measurement of the Physiological Response to Exercise; Pathophysiology of Disorders Limiting Exercise; Protocols for Exercise Testing; Normal Values; Principles of Interpretation; and Cases Illustrating Pathophysiology. 274 mostly two-column pages, with tables, figures, 6 Appendixes, and Index; plus xiii pages, prefatory matter. Boards show color loss at front lower quarter; name of prior owner inked on front paste-down; text is clean and strong. Seller Inventory # 203015

When Dr Wasserman began to consider the evaluation of patients with heart disease, exercise stress testing with electrocardiogram monitoring was being introduced into clinical medicine. The analysis of pulmonary gas exchange from exhaled breath was in use for quantifying metabolic rate at rest and exercise in research laboratories. Measuring gas exchange was cumbersome, however, and not readily transferable to clinical settings. To more precisely resolve dynamic gas exchange responses to exercise for physiologic research, and ultimately to make the measures accessible for use by clinicians, more facile methods would be needed. After completing fellowship at CVRI and joining the Respiratory Physiology faculty at Stanford University, Dr Wasserman established what would become a long-standing collaboration with Dr William Beaver, a physicist at Varian Industries in Palo Alto. Their work included seminal papers in the field of exercise testing (3,4) and advanced technical and analytic processes for quantifying gas exchange. The development of rapidly responding gas analyzers and expanded capacity of computers for data processing allowed them eventually to realize the goal of measuring pulmonary gas exchange in real time on a breath-by-breath basis (5,6).

By the early 1980s, interest in CPET was expanding more rapidly than facilities and expertise to perform it. In response, Dr Wasserman and colleagues at Harbor-UCLA established a recurring 3-d course for physicians and scientists on the principles of exercise testing, and not long thereafter published a text integrating their foundational research with their experience in clinical CPET (11). The course continues to be conducted regularly and has been replicated around the world (Figure 2); the text has been translated into multiple languages and was recently released in its 6th edition (12).

The Practicum was inaugurated in 1982 by the late Drs. Karlman Wasserman and Brian J. Whipp in response to requests for practical instruction in cardiopulmonary exercise testing (CPET). Course content has evolved to reflect changes in technology and clinical practice, but it continues to have the physiology of exercise as its focus. This Practicum is a two and one half day program which includes in-person didactic presentations, laboratory demonstrations and group discussions. Clinical case examples will be used throughout to illustrate key concepts, the use of CPET, and approach to data summary and interpretation. e24fc04721