（参考课件）CPET 心肺运动试验.ppt

MitchellHOROWitz,CardiopulmonaryExerciseTesting,1,Outline,DescriptionofCPETWhoshouldandwhoshouldnotgetCPETWhentoterminateCPETExercisephysiologyDefineterms:respiratoryexchangeratio,ventilatoryequivalent,heartratereserve,breathingreserve,oxygenpulsePatternofCPETresultsCOPDvsCHF,2,RationaleforExerciseTesting,Cardiopulmonarymeasurementsobtainedatrestmaynotestimatefunctionalcapacityreliably,3,ClinicalExerciseTests,6-minwalktestSubmaximalShuttlewalktestIncremental,maximal,symptom-limitedExercisebronchoprovocationExertionaloximetryCardiacstresstestCPET,4,KarlmanWasserman,5,CouplingofExternalVentilationandCellularMetabolism,6,AdaptationsofWassermansGears,7,GeneralMechanismsofExerciseLimitation,PulmonaryVentilatoryRespiratorymuscledysfunctionImpairedgasexchangeCardiovascularReducedstrokevolumeAbnormalHRresponseCirculatoryabnormalityBloodabnormality,PeripheralInactivityAtrophyNeuromusculardysfunctionReducedoxidativecapacityofskeletalmuscleMalnutritionPerceptualMotivationalEnvironmental,8,WhatisCPET?,Symptom-limitedexercisetestMeasureairflow,SpO2,andexpiredoxygenandcarbondioxideAllowscalculationofpeakoxygenconsumption,anaerobicthreshold,9,ComponentsofIntegratedCPET,Symptom-limitedECGHRMeasureexpiredgasOxygenconsumptionCO2productionMinuteventilationSpO2orPO2PerceptualresponsesBreathlessnessLegdiscomfort,10,ModifiedBorgCR-10Scale,11,IndicationsforCPET,EvaluationofdyspneaDistinguishcardiacvspulmonaryvsperipherallimitationvsotherDetectionofexercise-inducedbronchoconstrictionDetectionofexertionaldesaturationPulmonaryrehabilitationExerciseintensity/prescriptionResponsetoparticipationPre-opevaluationandriskstratificationPrognosticationoflifeexpectancyDisabilitydeterminationFitnessevaluationDiagnosisAssessresponsetotherapy,12,MortalityinCFPatients,Nixonetal;NEJM327:1785;1992.Followed109patientswithCFfor8yrsfromCPETPeakVO281%predicted:83%survivalPeakVO259-81%predicted:51%survivalPeakVO214ml/kg/min:1-yrsurvival94%2-yrsurvival84%PeakVO214ml/kg/min:1-yrsurvival47%2-yrsurvival32%,14,CPETtoPredictRiskofLungResectioninLungCancer,Limetal;Thorax65:iii1,2010Albertsetal;Chest132:1s,2007Baladyetal;Circulation122:191,2010PeakVO215ml/kg/minNosignificantincreasedriskofcomplicationsordeathPeakVO215ml/kg/minIncreasedriskofcomplicationsanddeathPeakVO2240-250,Bpdias110-120FallinBPsys20mmHgSpO21(CO2productionO2consumption).Carbondioxideregulatesventilation.VentilationwilldisproportionatelyincreaseatlactatethresholdtoeliminateexcessCO2.Increaseinventilatoryequivalentforoxygendemarcatestheanaerobicthreshold.,27,LactateThreshold,28,DeterminationofATfromRERPlot(VSlopeMethod),29,DeterminationofATfromVentilatoryEquivalentPlot,30,Wasserman9-PanelPlot,31,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),32,OxygenPulse,OxygenPulse:“.theamountofoxygenconsumedbythebodyfromthebloodofonesystolicdischargeoftheheart.”HendersonandPrinceAmJPhysiol35:106,1914OxygenPulse=VO2/HRFickEquation:VO2=SVxHRxC(a-v)O2VO2/HR=SVxC(a-v)O2OxygenPulseSV,33,InterpretationofCPET,PeakoxygenconsumptionPeakHRPeakworkPeakventilationAnaerobicthresholdHeartratereserveBreathingreserve,34,HeartRateReserve,ComparisonofactualpeakHRandpredictedpeakHR=(1Actual/Predicted)x100%Normal30%,37,ComparisonCPETresults,NormalCHFCOPDPredictedPeakHR150150150PeakHR150140120MVV10010050PeakVO22.01.21.2AT1.00.61.0PeakVE604049BreathingReserve40%60%2%HRReserve0%7%20%BorgBreathlessness548BorgLegDiscomfort885,38,CardiacvsPulmonaryLimitation,HeartDiseaseBreathingreserve30%Heartratereserve15%,39,CPETInterpretation,PeakVO2HRRBRAT/VO2maxA-aNormal80%30%40%normalHeartdisease30%30%15%40%increasedDeconditioning15%30%40%normal,40,SUMMARY,Cardiopulmonarymeasurementsobtainedatrestmaynotestimatefunctionalcapacityreliably.CPETincludesthemeasurementofexpiredoxygenandcarbondioxide.TheBorgscaleisavalidatedinstrumentformeasurementofperceptualresponses.CPETmayassistinpre-opevaluationandriskstratification,prognosticationoflifeexpectancy,anddisabilitydetermination.,41,SUMMARY,Cycleergometerpermitsdirectpowercalculation.PeakVO2ishigherontreadmillthancycleergometer.PeakVO2maybelowerthanVO2max.AbsolutecontraindicationstoCPETincludeunstablecardiacdiseaseandSpO220mmHgisanindicationtoterminateCPET.1glucoseyields36ATPinslowtwitchfiber,and2ATP+2lacticacidinfasttwitchfiber.RER=CO2produced/O2consumed,42,SUMMARY,Abovetheanaerobicthreshold,CO2productionexceedsO2consumption.Ventilationwilldisproportionatelyinc