Table Of ContentComputerized Cardiopulmonary Exercise Testing
U. J. Winter, K. Wasserman,
N. Treese, H. W. H6pp (Eds.)
Computerized Cardiopulmonary
Exercise Testing
,f.
!
Steinkopff Verlag Darmstadt
~ ~
Springer-Verlag New York
The Editors: Prof. Dr. K. Wasserman
PD Dr. U. J. Winter Harbor UCLA
Klinik III fUr 1000 W. Carson Street
Innere Medizin Torrance, CA 90509
UniversiHit Koln USA
J oseph-Stelzmann-Str. 9
5000 KOin 41 Prof. Dr. N. Treese
II. Medizinische Klinik
Prof. Dr. H. W. Hopp und Poliklinik
Klinik III fUr Universitat Mainz
Innere Medizin LangenbeckstraBe 1
Universitat Koln 6500 Mainz
Joseph-Stelzmann-Str.9
5000 KOin 41
Die Deutschen Bibliothek - CIP-Einheitsaufnahme
Computerized cardiopulmonary exercise testing / U. J. Winter
... (ed.) - Darmstadt: Steinkopf; New York: Springer, 1991
ISBN-13 :978-3-642-85406-4 e-ISBN-13 :978-3-642-85404-0
DOl: 10.1007/978-3-642-85404-0
NE: Winter, Ulrich J. [Hrsg.]
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Foreword
The measurement of cardio-circulatory and gas-exchange parameters during phy
sical exercise - the so-called ergo spirometry or cardiopulmonary exercise testing
(CPX) - as a basis of pathophysiological and clinical research has a long tradition
in Cologne. Knipping and his coworkers, especially Hollmann, performed basic re
search work in healthy subjects. In the area of sports medicine, bicycle or treadmill
exercise testing with parallel serial lactate determinations has gained increasing im
portance for the assessment of cardiac functional capacity. Also, in other medical
disciplines, ergospirometry lost its importance. K. Wasserman in Los Angeles is to
be credited for having further improved the method to its present standard, a
computerized, on-line measuring and practicable cardiopulmonary exercise testing
procedure. The prerequisites were technical innovations, such as continuously
measuring gas analyzers and personal computers. Thereby, the knowledge about
physiology, pathophysiology, and clinical circumstances of cardiocirculatory and re
spiratory regulation during exercise were significantly extended. The working groups
of W. Hollmann, Cologne, and K. Wasserman, Los Angeles, determined normal
values for the gas-exchange parameters and derived values for healthy normals in
large populations. Wasserman and coworkers were able to introduce a differential
diagnostic concept for patients suffering from various cardiovascular and cardio
pulmonary diseases. Many cardiologists, working, for example in myocardial failure
or with rate-adaptive pacemakers, belong to those who recommended the modem,
computerized ergo spirometry. Furthermore, this method is controversely discussed·
by colleagues working in sports medicine and pulmonary function.
The main topic of the first Cologne CPX Workshop (which was organized by my
coworker Priv.-Doz. Dr. U. J. Winter) was the interdisciplinary discussion of clinical
and diagnostic values of modem cardiopulmonary exercise testing. This meeting
brought together all the experience gained in different medical disciplines. The re
sults of this workshop and these discussions are collected in this book. The active
participation ofW. Hollmann, pillar of German sports medicine, and ofK. Wasser
man, the "father" of modem computerized ergospirometry at this meeting was of
special benefit for all who attended. I therefore hope for a widespread distribution
of this book and a good acceptance by the readers. It is an important source of
current information on modem cardiopulmonary exercise testing.
Cologne, FRG Prof. Dr. H. H. Hilger
v
Contents
Foreword
v
Hilger, Ho Ho
Introduction
The editors IX
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1. Historical and Methodological Aspects
On the History of Spiroergometry
Hollmann, Wo, Po Prinz 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Dynamic coupling of External to Cellular Respiration During Exercise
Wasserman, K., Ao Koike, K. Sietsema, R. Casaburi, Harbor-UCLA Medical
Center 19
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Determination ofV0 Kinetics by Means of Spectral Analysis: A New Method
2
for Evaluation of Endurance Capacity
Stegemann, Jo, Uo Hoffmann, Do E13feld 35
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The Importance of Lactate Measurement for the Determination of the Anae-
robic Threshold
Heck, Ho 41
0000000000000000000000000000000000000000000000000000 0 0 0
The Significance of Spiroergometry from the Viewpoint of Sports Cardiology
Rost, Ro, Ho Heck 57
00000000000000000000000000000000000000000000000
Thoracic Electrical Bioimpedance - Alternative or Complement in Cardio
pulmonary Exercise Testing?
Klocke, R. K., Ao Kux, Go Mager, Uo Winter, Jo Kliippelberg, Ho W. Hopp,
Ho Ho Hilger 63
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2. Clinical Value in Coronary Heart Disease and Myocardial
Failure
Role of Spiroergometry in Clinical Excercise Testing
Lollgen, Ho, Po Dirschedl, Uo Fahrenkrog 73
00000000000000000000000000000
Evaluation of the Cardiopulmonary Exercise Tolerance in Patients with Co
ronary Artery Disease (CAD) and Chronic Heart Failure (CHF)
Winter, Uo Jo, Ao K. Gitt, Go Mager, R. Klocke, Go Pothoff, Mo Sedlak,
Ho W. Hopp, Ho Ho Hilger 85
00000000000000000000000000000000000000000
Respiratory Gas Analysis in Patients with Chronic Heart Failure
Drexler, Ho 95
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Influence of Phosphodiesterase Inhibitors on Aerobic Capacity in Chronic
Heart Failure
Treese, No, Mo Coutinho, Ao Werneyer, So Rhein, R. Erbel, Jo Meyer 103
0000000
Effect of a Single Oral Dose of the PDE Inhibitor Milrinone on Exercise
Tolerance of Chronic Heart Failure Patients - CPX in Advanced Heart Failure
Mager, Go, R. K. Klocke, Uo Jo Winter, Ao Gitt, Go Rommert, Ho W. Hopp,
Ho Ho Hilger 111
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VII
Spiroergometry in Post Myocardial Infarction Patients with Compromised Left
Ventricular Function
Kleber, F. Xo, L. Niem611er, F. WeiBthanner, W. Doering 119
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3. Clinical Value in Pacemaker Therapy
Evaluation of Algorithms for Rate Adaptive Pacing by Gas Exchange Mea
surements
MacCarter, Do Jo, Jo Millerhagen 131
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Influence of Rate Responsive Pacing on Aerobic Capacity in Patients with
Chronotropic Incompetence
Treese, No, Mo Coutinho, Ao Stegmeier, So Jungfleisch, Ao Werneyer,
Uo Nixdorf, No Ophoff, Jo Meyer 139
00000000000000000000000000000000000
Cardiopulmonary Exercise Testing in Rate-Modulated Cardiac Pacing Based
on Minute Ventilation and QT-Interval
van Erckelens, F., Mo Sigmund, Cho Renpcke, B. Heiermann, Po Hanrath 147
000
Evaluation of Temperature- and Activity-Controlled Rate-Adaptive Cardiac
Pacemakers by Spiroergometry
Alt, Eo, Ho Theres, Mo Heinz 159
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4. Clinical Value in Pulmonary Diseases
Effects of Inhaled Salbutamol and Oxitropium Bromide on Cardiopulmonary
Exercise Capacity in Patients with Chronic Obstructive Pulmonary Disease
and Coronary Artery Disease
van Erckelens, F., Tho HUrter, Tho Eitelberg, Uo Krobok, Cho Reupcke, Eo
Schmitz, Mo Sigmund, Po Hanrath 173
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Cardiopulmonary Exercise Testing in the Diagnosis of HIV-Infected Patients
Pothoff, Go, K. Wasserman, Ao Gitt, H. Ostmann, Uo Jo Winter, Ho Wo H6pp,
Ho Ho Hilger 183
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Respiratory Parameters after Systemic Corticotropin-Releasing
Hormone Administration
Nink, Mo, Uo Krause, Mo Coutinho, No Treese, Eo Salomon, Ho Lehnert,
Jo Beyer 189
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VIII
Introduction
Cardiopulmonary exercise testing (CPX) has been proposed to examine the integrity
of the heart, lung, and circulation during exercise. This approach is based on the
classical view that pulmonary gas exchange, gas transport by the circulatory system,
and the cellular gas exchange are functioning together to maintain the "internal
milieu" both at rest and during exercise. The analysis of the respiratory gas exchange
may provide some insight in possible disorders of this integrated unit. Modern
computerized technology has facilitated the analysis of expired gases on breath to
breath basis. Therefore interest in this unique tool is growing to readily identify
mechanisms of exercise intolerance.
The problem with cardiopulmonary exercise testing today is that this technique
originally developed and extensively used in sportsmedicine has now been more and
more employed in patients with severely limited excercise capacity. Whereas in
sportsmedicine serial lactate determinations have almost resplaced the respiratory
gas analysis, cardiologists discover the value of simultaneous assessment of venti
latory and circulatory reserve in their patients.
The first Cologne CPX symposium 1990 was focused on the different views on
how to assess cardiopulmonary function. The controversy between sportmedicine
using the lactate approach and cardiology employing gas exchange analysis was ex
tensively discussed:
Hollmann gave an unique historical view about the development of ergo spiro
metric devices and experiences with this method since the early beginnings. Fun
damental studies from the Deutsche Sporthochschule in Cologne had stimulated the
research in this field over a long period of time before switching over to the more
metabolic approach using serial lactic acid determination. Heck demonstrated the
different concepts and definitions of the anaerobic threshold, based upon serial
lactate determinations. Stegemann reported upon a new method with possible appli
cation for low exercise capacity. Serial lactate determination as a tool to assess exer
cise capacity also in patients with cardiopulmonary disorder was appraised by Rost.
A critical review of exercise testing in clinical medicine was given by L611gen, who
discussed the possible role of cardiopulmonary exercise testing compared to con
current methods.
The outstanding contribution of Wasserman and his group from Harbor-UCLA,
Torrance in California to the development of respiratory gas analysis during exercise
has been appreciated for many years. Their research on the dynamic coupling of
external to cellular respiration during exercise has contributed fundamental insight
into exercise physiology and presented evidence that the respiratory anaerobic thres
hold is truly the lactic acidosis threshold. Wasserman discussed his approach to
cardiopulmonary exercise testing with the V-Slope Method during an incremental
work rate test which allows the non-invasive determination of the anaerobic thres
hold. It is his methodology which is mostly used by the clinicians today.
While in the United States cardiopulmonary exercise testing has gained wide
acceptance, the clinical experience with this technique in our country is still limited
to a small number of patients. The first CPX symposium therefore tried to bring
together different groups which have alrady gained some clinical experience with
respiratory gas exchange analysis during exercise:
IX
Several groups have independently used CPX to assess exercise capacity in rate
response pacing. Alt reported on CPX to compare activity controlled and tempe
rature controlled pacing systems. Treese pointed out that this technique allows to
optimize pacemaker programming in these patients.
Winter and his group discussed his experience with CPX in patients with coronary
heart disease and chronic heart failure. Most interesting was their observation of an
oscillatory ventilation pattern in the very severly limited patients. Drexler reviewed
clinical studies using cardiopulmonary exercise testing in chronic heart failure. In
his own studies a good correlation was found between serial lactate determinations
and oxygen uptake at the anaerobic threshold. Kleber reported early results on exer
cise testing to assess the efficacy of long-term treatment with captopril after myo
cardial infarction.
The use of cardiopulmonary exercise testing in patients with chronic obstructive
pulmonary disease was reported by van Erkelens. The increase of exercise capacity
improvement after bronchodilative medication could be demonstrated. Interesting
the use of CPX to assess pulmonary function in HIV infected patients as presented
by Pothoff.
This first German CPX symposium was thought to encourage further use of car
diopulmonary exercise testing in patients with exercise limitation of various reasons.
However, it became also quite clear that a concerted interdisciplinary effort is ne
cessary towards more standardized guidelines for testing and interpretation. A com
mon method is necessary to collect data in larger patient populations and to finally
establish the potential diagnostic power and limitations of this interesting technique.
The different papers of this symposium express quite controversial views on how
to ideally exercise, however, they demonstrate the increasing importance of exercise
as part of the quality of life of many of our patients. We therefore hope that these
proceedings will stimulate the interest in cardiopulmonary exercise testing and
speed its further application.
K6ln, Mainz 1991 The editors
x
1. Historical and Methodological Aspects
On the History of Spiroergometryl)
W. Hollmann, P. Prinz
Institute for Cardiology and Sports Medicine, German Sports University,
Cologne
Spiroergometry is a diagnostic procedure for the assessment Qf the performance
capacity of the cardiovascular system, respiration, and metabolism. As far as term
and content are concerned, spiroergometry includes two components: spirometry
and ergometry. The goal of spirometry is the continuous measurement of respiratory
gas metabolism and the continuous registration of respiration (spirography). Here,
the measurement of oxygen consumption - which is synonymous with oxygen up
take - is much more important than that of CO expiration. Ergometry constitutes
2
a method for the exact dose of physical work and its precise reproduction at any
time. The history of science shows that, initially, spirometry and ergometry were
used sporadically and later more systemically in the experimental arrangements of
research scientists. H. W. Knipping was the first in the 1920s to unite both elements
into a standardized clinical procedure [60, 61]. The following historical overview
describes milestones in the joining of ergometry and spirometry.
The first attempts to measure human gas metabolism during quantified physical
work were made in 1790 by the versatile French scientist Antoine Laurent Lavoisier
and his assistant Armand Seguin [99]. Lavoisier measured his assistant's oxygen
consumption under different experimental conditions, e.g. at rest and during phy
sical exercise. Apparently the exercise consisted of weightlifting. It appears that the
workload was not preset, but that at the end of the experiment it was calculated as
the total height of lift of the weight per unit of time. Two mutually corroborative
illustrations of these experiments show that the gas metabolism examinations were
based on the attachment method using a face mask. The investigators absorbed the
expired carbon dioxide by means of a solution of alkali hydroxydes; the oxygen
content of the inhaled air was presumably measured eudiometrically [49], which
means that the oxygen was led into a water-soluble compound. The measured oxy
gen consumption per hour was between 24 liters (sober, at rest, and at 32.5 0c) and
91 liters (exercise during digestion) [99].
Further investigations into the gas metabolism of exercising humans were con
ducted by the English physician William Prout in 1813. He is particularly known
to chemists as the creator of the "Prout Hypothesis" (chemical elements are integral
multiples of hydrogen) [17]. During and after walks, Prout collected his own exhaled
air in a bag and later analyzed its carbon dioxide content. By varying the walking
distance and velocity, he distinguished between moderate and! intensive physical
exercise. However, Prout obtained no conclusive results [90].
In 1856 a handy method of measuring the amount of inspired air and expired
carbon dioxide during exercise was developed by the English physician and hygienist
Edward Smith [19]. While wearing a face mask he inhaled ambient air through a
I) Supported by the Federal Institute for Sports Science, Cologne
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