Summary:
Thoroughly updated for its Fourth Edition, this volume is the most comprehensive, current text on exercise physiology and pathophysiology. It provides an organized method for evaluating causes of exercise limitation and includes flow charts and over 80 case studies.

FEATURES:
Comprehensively presents metabolic, cardiovascular and respiratory physiologic and pathophysiologic responses to exercise
Provides normal values for different patient groups
Contains more than 80 case histories and exercise physiology studies on patients with a wide variety of diseases
This is the only book that describes disorders, which can only be diagnosed by cardiopulmonary exercise testing
Includes chapter on clinical applications

NEW TO THIS EDITION:
Chapter on regulation or arterial and mixed venous blood gases
New 9-panel graphic array
Updated and more efficient flow charts, now including more diagnoses recognised by cardiopulmonary exercise testing

Contents

1. Exercise Testing and Interpretation: An Overview
Why Measure Gas Exchange to Evaluate
Cardiovascular Function and Cellular Respiration?
Cardiac Stress Test and Pulmonary Stress
Test: Nomenclature and Fallacies
Cell Respiration and Bioenergetics
Normal Coupling of External to Cellular Respiration
Quantifying State and Time Course of Cellular Respiration from Measurements Of External Respiration
Patterns of Change in External Respiration (O2 Uptake and CO2 Output) as Related to Function, Fitness and Disease
Factors Limiting Exercise
Fatigue
Dyspnea
Pain
Evidence of Systemic Dysfunction Uniquely Revealed by Integrative Cardiopulmonary Exercise Testing

2. Physiology of Exercise
Skeletal Muscle
Mechanical Properties and Fiber Types
Energetics
Oxygen Cost of Work
Work Efficiency
VO2 Non-Steady State
Lactate Increase
Lactate Increase as Related to Work Rate
Lactate Increase as Related to Time
Lactate Increase in Response to Increasing Work Rate
Mechanisms of Lactate Increase
Buffering the Exercise-induced Lactic Acidosis
The Anaerobic Threshold (AT) Concept
Identifying AT by Gas Exchange
Altered Physiological Responses to Exercise Above the AT
Anaerobic, Lactate and Lactic Acidosis Thresholds
Metabolic-Cardiovascular-Ventilatory Coupling
Cellular Respiration and High Energy Phosphate Regeneration
Cardiovascular Coupling to Metabolism: Muscle O2 Supply
Ventilatory Coupling to Metabolism
Effect of Dietary Substrate
Control of Breathing
Overview
Acid-Base Regulation
Physical Factors
Reflexes Regulating Breathing During Exercise
Gas Exchange Kinetics
Oxygen Uptake Kinetics
CO2 Output Kinetics

3. Measurements During Integrative Cardiopulmonary Exercise Testing
What is an Integrative Cardiopulmonary Exercise Test?
When Should Integrative Cardiopulmonary Exercise Testing Be Used?
Measurements
Electrocardiogram
Maximal Oxygen Uptake (VO2max) Maximum
Oxygen Uptake (Peak VO2)
Oxygen Uptake and Work Rate
Pattern of Work Rate Increase and the VO2 Response
Upward Displacement of VO2 as A Function of Work Rate
Cardiac Output and Stroke Volume
Anaerobic (Lactate, Lactic Acidosis) Threshold (AT, LT, LAT) Heart Rate-Oxygen Uptake Relationship and Heart Rate Reserve Oxygen Pulse (VO2/HR) and Stroke Volume
Arterial Blood Pressure
Breathing Reserve
Expiratory Flow Pattern
Tests of Uneven VA/Q
Arterial Bicarbonate and Acid-Base Response
Tidal Volume/Inspiratory Capacity Ratio (VT/IC)
Measurements Unique to Constant Work Rate Exercise Testing
Data Display and Interpretation

4. Pathophysiology of Disorders Limiting Exercise
Obesity
Peripheral Arterial Diseases
Heart Disease
Coronary Artery Disease
Myopathic Heart Disease
Valvular Heart Disease
Congenital Heart Disease
Pulmonary Vascular Diseases
Causes of Increased Ventilation
Causes of Exercise Arterial Hypoxemia
Effect on Systemic Hemodynamics
Ventilatory Disorders
Obstructive Lung Diseases
Restrictive Lung Diseases
Chest Wall (Respiratory Pump) Disorders
Defects in Hemoglobin Content and Quality
Anemia
Left-shifted Oxyhemoglobin Dissociation Curve
Carboxyhemoglobinemia and Cigarette Smoking
Chronic Metabolic Acidosis
Muscle Disorders and Endocrine Abnormalities
Psychogenic Causes of Exercise Limitation and Dyspnea
Anxiety
Poor Effort and Manipulated Exercise Performance
Combinations of Defects

5. Clinical Exercise Testing
Exercise Laboratory and Equipment
General (Laboratory) Environment
Measuring Gas Exchange
Measurement of Volume, Flow Rate, or Ventilation
Breathing Valves, Mouthpieces, and Masks
Gas Analyzers
Ergometers: Treadmills and Cycle
Electrocardiogram and Systemic Blood Pressure
Oximetry, Blood Sampling, and Arterial Catheters
Data Sampling and Computation
Validation and Maintenance
Preparing for the Exercise Test
Requesting the Test and Notifying the Patient
The Patient in the Exercise Laboratory
Performing the Exercise Test
Incremental Exercise Test to Symptom-Limit Maximum
Constant Work Rate Exercise Tests
Treadmill Test for Detecting Myocardial Ischemia
Arm Ergometry
Other Tests Suitable for Fitness or Serial Evaluations
Preparing the Report

6. Normal Values
Peak Oxygen Uptake
Age and Gender
Activity Level
Adults of Normal (Predicted) Body Weight
Overweight Patients
Underweight Patients
Children
Exercise Mode
Maximum Heart Rate and Heart Rate Reserve
Relationship of VO2 and Heart Rate: The Maximum Oxygen Pulse
Brachial Artery Blood Pressure
Anaerobic (Lactate, Lactic Acidosis) Threshold
Oxygen Uptake-Work Rate Relationship
Breathing Reserve, Tidal Volume, and Breathing Frequency at Maximum Exercise
Maximum Exercise Ventilation and Breathing Reserve
Tidal Volume and Breathing Frequency
Ventilatory Measures at Anaerobic Threshold: VE/VCO2, VE/VO2, and the Breathing Reserve Index
Physiologic Dead Space/Tidal Volume Ratio
Arterial and End-Tidal CO2 Tensions
Arterial, Alveolar, and End-Tidal Oxygen Tensions
Femoral and Mixed Venous Values and Estimation of Cardiac Output
Acid-Base Balance

7. Principles of Interpretation: A Flow Chart Approach
Introduction to Flow Charts
Establishing the Pathophysiologic Basis of Exercise Intolerance
Maximum Exercise Capacity and Anaerobic Threshold (Flow Chart 1)
Exercise Intolerance with Normal Peak VO2 (Flow Chart 2)
Low Peak VO2 with Normal AT (Flow Chart 3)
Low Peak VO2 with Low AT (Flow Chart 4)
Low Peak VO2 with AT Not Determined (Flow Chart 5)

8. Clinical Applications of Cardiopulmonary Exercise Testing
Differential Diagnosis of Disorders Causing Exercise Intolerance
Pathophysiological Responses in Common Disorders
O2 Uptake and CO2 Output as Related to Work-Rate
Heart Rate and VCO2 as a Function of VO2
Heart Rate and O2 Pulse as a Function of Work Rate
VT as a Function of VE
VE as a Function of VCO2
Ventilatory Equivalents of O2 and CO2
Diagnoses Uniquely Made by Cardiopulmonary Exercise Testing
Development of Myocardial Ischemia with Myocardial Dyskinesis during Exercise
Chronic Heart Failure Due to Diastolic Dysfunction
Pulmonary Vascular Occlusive Disease without Pulmonary Hypertension
Patent Foramen Ovale with Development of a Right to Left Shunt during Exercise
Pulmonary Vascular Disease Limiting Exercise in COPD
Impaired Muscle Bioenergetic Function
Psychogenic Dyspnea and Behavioral (Anxiety or Malingering) Causes of Exercise Intolerance
Grading Severity of Heart Disease Estimating Peak Cardiac Output During Exercise from O2 Uptake to Peak VO2
Cardiac Output Estimated by the Direct Fick Method
Behavior of Changing Arterial-Venous O2 Difference during Exercise
Initial and Final Estimate of C(a-v)O2
Examples of Estimating C(a-v)O2
Short-Cut Estimate of Stroke Volume from O2 Pulse
Prioritizing Patients for Heart Transplantation
Preoperative Evaluation of Surgical Risk
Thoracotomy
Abdominal Surgery
Analysis
Measuring Impairment for Disability Evaluation
Impairment and Disability
Problems in Assessing Impairment from Resting Measures Only
Exercise Testing and Impairment Evaluation O2
Cost of Work Analysis
Exercise Rehabilitation
Physiological Basis of Exercise Rehabilitation
Exercise Rehabilitation in Heart Disease
Exercise Rehabilitation in Chronic Obstructive Pulmonary Disease
Assessing Effectiveness of Treatment
Screening for Development of Disease in High Risk Patients
Graded Exercise Testing and the Athlete
Regulation of Arterial and Mixed Venous Blood Gases During Exercise.
Summary

9. Case Presentations (83 cases)

Appendices A. Symbols and Abbreviations

B. Glossary

C. Calculations, Formulae, and Examples

D. Placement of a Brachial Artery Catheter

E. Tables and Nomogram

Index