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PRE-OPERATIVE CARDIO-PULMONARY EXERCISE TESTING (CPET)

PRE-OPERATIVE CARDIO-PULMONARY EXERCISE TESTING (CPET)

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Published by: Suresh Kumar on Sep 16, 2012
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11/07/2013

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PRE-OPERATIVE CARDIO-PULMONARY EXERCISE TESTING(CPET)
ByDr.B.V.Mahesh Babu M.D,R.M.C,KAKINADA
ACCP (AMERICAN COLLEGE OF CHEST PHYSICIANS )
 
ATS (AMERICAN THORACIC SOCIETY)gave a joint statement on CPET in 2001 & 2002 respectively.
 
Cardio Pulmonary Exercise Testing (CPET)
is increasingly being used in a wide spectrum of clinical applications for the evaluation of undiagnosed exercise intolerance, exercise-relatedsymptoms, and, uniquely, for the objective determination of functional capacity andimpairment. Cardiopulmonary exercise testing (CPET) provides a global assessment of theintegrative exercise responses involving the pulmonary, cardiovascular, hematopoietic, neuro- psychological, and skeletal muscle systems, which are not adequately reflected throughthe measurement of individual organ system function.
1
 The use of CPET in patient management is increasing with the understanding that resting
 pulmonary and cardiac function testing cannot reliably predict exercise performance and  functional capacity 
and that, furthermore, overall health status correlates better withexercise tolerance rather than with resting measurements.
Indications for Cardiopulmonary Exercise Testing
These include the following:1. Evaluation of exercise tolerance2. Evaluation of undiagnosed exercise intolerance3. Evaluation of patients with cardiovascular disease4. Evaluation of patients with respiratory diseases/symptoms5. Preoperative evaluation6. Exercise evaluation and prescription for pulmonary rehabilitation7. Evaluation of impairment/disability8. Evaluation for lung, heart, and heart
 –
lung transplantation
2
 In practice, CPET should be considered when specific questions remain un-answered afterconsideration of basic clinical data including history, physical
 
examination, chestradiographs,,resting pulmonary function tests, and resting electrocardiogram(ECG).
 
 
CPET
involves the measurement of respiratory
gas exchange: oxygen uptake (V˙ o2),carbon
dioxid
e output (V˙co
2
) and minute ventilation (V˙E), in
addition to monitoringElectrocardiography, blood pressure, and pulse oximetry typically during symptom-limitedmaximal progressive exercise tolerance test; When appropriate, arterial sampling is alsoperformed and provides more detailed, important information about pulmonary gasexchange.
 
Equipment & Methodology
 Two modes of exercise are commonly employed in Cardiopulmonary Exercise Tests: 1)
Treadmill
and 2)
Cycle Ergometer
. In most clinical Circumstances,Cycle ergometry is the preferable mode of exercise. However, depending on the reasons forwhich CPET is requested and equipment availability, a Treadmill may be an acceptablealternative
.
Cycle ergometry is comparatively cheaper and requires less space than Treadmill.The motor-driven treadmill imposes progressively increasing exercise stress through acombination of speed and grade (elevation) increases.There are two types of cycle ergometers- Mechanically braked & Electricallybraked.Mechanically braked cycles regulate external work by adjustable frictional bands.Electrically braked cycles increase resistance to pedaling electro-magnetically
.
Electricallybraked cycle ergometer allows direct quantification of the work rate performed and can becomputer controlled.
5
 
EXERCISE EQUIPMENT: CYCLE ERGOMETRY VERSUS TREADMILLCycle Treadmill
VO2max lower higherWork rate measurement yes noNoise and artifacts less moreSafety safer less safe?Weight bearing in obese less moreDegree of leg muscle training less moreMore appropriate for : patients active normal
.
 
The goal of cardiopulmonary exercise testing is to evaluate organs and systems involved inthe exercise response under conditions of progressively intense physical stress. Thereforeexercise testing involves large muscle groups, usually the lower extremity muscles as inrunning on the treadmill or pedaling on a cycle ergometer. It is usually most efficient toemploy a progressively increasing work rate protocol so that a range of exercise intensitiescan be studied in a short period of time. Some patients may be unable to perform lower
 
extremity exercise. For such patients, arm crank ergometers can be adapted for incrementalexercise testing.
OVERVIEW OF CARDIOPULMONARY EXERCISE TESTING
1
 Clinical Status Evaluation
Clinical diagnosis and reason(s) for CPETHealth questionnaire (cardiopulmonary); physical activity profileMedical and occupational history and physical examinationPFTs, CXR, ECG, and other appropriate laboratory testsDetermination of indications and contraindications for CPET
.
Pretest Procedures
Abstain from smoking for at least 8 h before the testRefrain from exercise on the day of the testMedications as instructedConsent form
 
CONDUCT of CPET
Laboratory proceduresQuality controlEquipment calibrationProtocol SelectionIncremental versus constant work rate; invasive versus noninvasivePatient preparationFamiliarization

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