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Exercise Testing for Evaluation of Hypoxemia And/Or Desaturation: 2001 Revision & Update

Exercise Testing for Evaluation of Hypoxemia And/Or Desaturation: 2001 Revision & Update

AARC GUIDELINE: EXERCISE TESTING FOR EVALUATION OF HYPOXEMIA AND/OR DESATURATION: 2001 REVISION & UPDATE

AARC Clinical Practice Guideline

Exercise Testing for Evaluation of Hypoxemia and/or Desaturation: 2001 Revision & Update

ETD 1.0 PROCEDURE: cation skills of the patient being served, Exercise testing for evaluation of hypoxemia should be taken into consideration when and/or desaturation. performing these tests. 2.5.2 The neonatal population is not ETD 2.0 DESCRIPTION/DEFINITION: served by this guideline. Exercise testing may be performed to determine the degree of desaturation and/or hypoxemia ETD 3.0 SETTINGS: that occurs on exertion. Desaturation is defined as a Exercise testing may be performed by trained valid decrease in arterial oxygenation as measured personnel in a variety of settings including by CO-oximetry saturation, (SaO2) of 2% (based on 3.1 pulmonary function laboratories the reproducibility of HbO measurement at ±1%),1 2 3.2 cardiopulmonary exercise laboratories an S 2 < 88%,2,3 and/or a blood gas P 2 ≤ 55 torr.4 aO aO 3.3 clinics 2.1 Exercise testing may also be performed to 3.4 facilities optimize titration of supplemental oxygen for 3.5 physicians’ offices the correction of hypoxemia. An SpO2 of 93% should be used as a target.3 ETD 4.0 INDICATIONS: 2.2 It is preferable that this procedure be per- Indications for exercise testing include formed using a method that allows quantitation 4.1 the need to assess and quantify the adequa- of workload and achieved (as % pre- cy of arterial oxyhemoglobin saturation during dicted). exercise in patients who are clinically suspect- 2.2.1 This evaluation can be incorporated ed of desaturation (eg, those who manifest dys- into other more complex test protocols pnea on exertion, decreased DLCO, decreased (eg, cardiac stress testing). PaO2 at rest, or documented pulmonary dis- 2.2.2 Continuous noninvasive measure- ease);2,7,15-18 ment of arterial oxyhemoglobin saturation 4.2 the need to quantitate the response to thera- by oximetry can provide qualitative peutic intervention (eg, oxygen prescription, information and an approximation of oxy- medications, smoking cessation, or to reassess saturation,RETIRED with a 4% de- the need for continued supplemental oxy- 4 2,7,15,19-21 crease in SpO2 considered significant, but gen); evaluation of desaturation on exertion re- 4.3 the need to titrate the optimal amount of quires analysis of arterial samples supplemental oxygen to treat hypoxemia or de- drawn with the subject at rest and at peak saturation during activity;2,7,21,22 exercise.3,5-12 4.4 the need for preoperative assessment for 2.3 specimens may be obtained resection or transplant;23 by single puncture or by arterial cannulation.13,14 4.5 the need to assess the degree of impairment 2.4 Exercise testing performed with exhaled gas for disability evaluation (eg, pneumoconiosis, analysis is addressed in a separate guideline. asbestosis).24 2.5 This guideline is appropriate for pediatric, adult, and geriatric patients who are capable of ETD 5.0 CONTRAINDICATIONS: following test instructions and techniques. 5.1 Absolute contraindications include 2.5.1 The learning ability and communi- 5.1.1 acute electrocardiographic changes

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suggesting myocardial ischemia or seri- by exercise;25,26 ous cardiac dysrhythmias including 5.2.8 uncontrolled metabolic disease (eg, bradydysrhythmias, tachydysrhythmias, diabetes, thyrotoxicosis, or myxede- sick sinus syndrome, and multifocal pre- ma;25,26 26 mature ventricular contractions (PVCs), 5.2.9 SaO2 or SpO2 < 85% on room air; causing symptoms or hemodynamic com- 5.2.10 complicated or advanced pregnan- promise (occasional PVCs are not a con- cy;25 traindication);25-29 5.2.11 hypertrophic cardiomyopathy or 5.1.2 unstable angina;24,25,27 other forms of outflow tract obstruction;26 5.1.3 recent myocardial infarction (within 5.2.12 patient’s inability to cooperate or the previous 4 weeks) or myocarditis;25,26 follow directions for testing. 5.1.4 aneurysm of the heart or aorta;25,26 5.1.5 uncontrolled systemic hyperten- ETD 6.0 PRECAUTIONS AND/OR POSSIBLE sion;25,26 COMPLICATIONS: 5.1.6 acute thrombophlebitis or deep ve- 6.1 Indications for immediate termination of nous thrombosis;25,26 testing include 5.1.7 second- or third-degree heart 6.1.1 electrocardiographic abnormalities block;25,26 (eg, dangerous dysrhythmias, ventricular 5.1.8 recent systemic or pulmonary embo- tachycardia, ST-T wave changes);25,26 lus;25,26 6.1.2 severe desaturation as indicated by 25,26 5.1.9 acute pericarditis; an SaO2 ≤80% or SpO2 ≤83% (A number of 5.1.10 symptomatic severe aortic steno- pulse oximeters have been found to over- 3,12,33-36 sis; estimate SpO2 ) and/or a 10% fall 5.1.11 uncontrolled heart failure;25 from baseline values; (Underestimation of 5.1.12 uncontrolled or untreated ; saturation has been noted to occur with 5.1.13 pulmonary edema;25 certain pulse oximeter models.33,34) 5.1.14 respiratory failure;25 6.1.3 angina;25,26 5.1.15 acute non-cardiopulmonary disor- 6.1.4 hypotensive responses; ders affected by exercise. 6.1.4.1 a fall of > 20 torr in systolic 5.2 Relative contraindications include pressure, occurring after the normal ex- 5.2.1 situations in which ercise rise;37 may provide invalid data (eg, elevated 6.1.4.2 a fall in systolic blood pressure HbCO, HbMet, or decreased ). below the pre-exercise level;36 (See AARC Pulse Oximetry Guidelines.30) 6.1.5 lightheadedness;25,26 5.2.2 situations in which arterial puncture 6.1.6 request from patient to terminate and/or arterial cannulation may be con- test. traindicated;31,32 RETIRED6.2 Abnormal responses that may require dis- 5.2.3 a non-compliant patient or one who continuation of exercise include is not capable of performing the test be- 6.2.1 a rise in systolic blood pressure to > cause of weakness, pain, fever, dyspnea, 250 torr or of diastolic pressure to > 120 incoordination, or psychosis;25,26 torr,25,26 or a rise in systolic pressure of < 5.2.4 severe pulmonary hypertension (cor 20 torr from resting level; pulmonale);25,26 6.2.2 mental confusion or headache;25,26 5.2.5 known electrolyte disturbances (hy- 6.2.3 cyanosis;25,26 pokalemia, hypomagnesemia);25,26 6.2.4 nausea or vomiting; 5.2.6 resting diastolic blood pressure > 6.2.5 muscle cramping.25,26 110 torr or resting systolic blood pressure 6.3 Hazards associated with arterial puncture, > 200 torr;25,26 arterial cannulation, and pulse oximetry:30-32 5.2.7 neuromuscular, musculoskeletal, or Pulse oximetry is a noninvasive safe procedure, rheumatoid disorders that are exacerbated but because of device limitations, false-nega-

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tive results for hypoxemia11 and/or false-posi- 7.1.1.7 Pulse oximeter response time tive results for normoxemia or hyperoxemia may be inadequate to describe rapid may lead to inappropriate treatment of the pa- changes in saturation.7,16,45 tient. Although it is rare, tissue injury may 7.1.1.8 Skin pigmentation should, in occur at the measuring site as a result of probe theory, not affect pulse oximeter read- misuse, such as pressure sores from prolonged ings, but various studies report con- application or electrical shock and burns from flicting data depending on the manu- the substitution of incompatible probes be- facturer and model.3,45 tween instruments.30,38-42 7.1.1.9 Hemoglobin disorders may af- fect the accuracy of the pulse oximeter ETD 7.0 LIMITATIONS OF PROCEDURE/ reading.16,33,45 Important underestima- VALIDATION OF RESULTS: tion of arterial saturation may result 7.1 Limitations of equipment: from pulse oximetry in subjects with 7.1.1 Because of possible limitations of total hemoglobin levels of ≤8 g/dL.53 pulse oximetry with exercise and at rest, 7.1.1.10 Pulse oximetry is less useful measurements may read falsely low or over the range in which large changes falsely high and should be validated by in PaO2 are associated with small 16 comparison with baseline arterial samples changes in SaO2 (ie, PaO2 ≥60 torr). analyzed by CO-oximetry.30,33,43 7.1.1.11 Ambient light during testing 7.1.1.1 Only a limited number of pulse may interfere with measurements of oximeters have been validated with re- pulse oximetry.45 sults of concurrent arterial blood gas 7.1.1.12 Exercise testing in which oxy- analysis in diseased subjects under ex- hemoglobin saturation by pulse oxime- ercise conditions.16 try is the only variable measured pro- 7.1.1.2 Overestimation of oxygen satu- vides limited information. ration may occur with carboxyhe- 7.1.2 Limitations related to the patient: moglobin saturations (> 4 %).2,44,45 7.1.2.1 Additional limitations common 7.1.1.3 Decreasing accuracy in SpO2 to arterial sampling and analysis under has been reported with desaturations to resting conditions should be consid- < 83%. This is assumed to be the result ered.31,32 of limitations of in vivo calibration to 7.1.2.2 Patient cooperation level or 85% with extrapolation of the calibra- physical condition may limit the sub- tion curve below that value.13,45 ject’s ability to exercise at a workload 7.1.1.4 Decreased perfusion with car- sufficient to evoke a response.25,26 Vari- diovascular disease, , ables that are not adequately monitored or hypothermia may result in false- (eg, free walking) have limited applica- positive results or noRETIRED valid data in tion. some pulse oximeter models.11,46 7.2 Validation of results: Use of an alternative site should be 7.2.1 Arterial blood gas samples should evaluated (eg, ear, finger, forehead). be obtained at rest and at peak exercise. Alternative handwarming methods Samples from single arterial punctures may be used to increase circulation. have been shown to be equivalent to sam- 7.1.1.5 Reduced ear perfusion associat- ples drawn from indwelling cannulas.15,54 ed with heavy exercise has been shown 7.2.2 In the unlikely event that a single to affect SpO2 in some models of pulse puncture at peak exercise is unsuccessful oximeters.11,47-49 in an uncannulated patient, a sample 7.1.1.6 Motion artifact may appear drawn within 10-15 seconds of the termi- with exercise.16,50 Some pulse oxime- nation of exercise will suffice unless anal- ters are better then others at rejecting ysis shows a decrease from the resting motion artifact.51,52 values, in which case quantitation of de-

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saturation requires a peak exercise sample ETD 8.0 ASSESSMENT OF NEED: obtained by cannula.15 Exercise testing for evaluation of hypoxemia and/or 7.2.3 Arterial blood gas results should be desaturation may be indicated (see section ETD 4.0 obtained according to the Guidelines for INDICATIONS) in the presence of arterial blood gas sampling and for arteri- 8.1 a history and physical indicators suggesting al blood gas analysis.31,32,54 hypoxemia and/or desaturation (eg, dyspnea, 7.2.4 Validity of pulse oximetry results is pulmonary disease); verified by comparison with the results of 8.2 abnormal diagnostic test results (eg, DLCO, 30,51 analysis by CO-oximetry, preferably FEV1, resting arterial blood gases including di- at rest and at end of exercise. rectly measured HbO2, HbCO, and HbMet); 7.2.4.1 SpO2 may be used to assess re- 8.3 the need to titrate or adjust a therapy (eg, sponse to supplemental oxygen. If ad- supplemental oxygen). ministration of supplemental oxygen does not improve a low SpO2, arterial ETD 9.0 ASSESSMENT OF QUALITY OF blood analysis may be warranted. TEST AND VALIDITY OF RESULTS: 7.2.4.2 Testing should be performed in The consensus of the committee is that all diag- compliance with the AARC Pulse nostic procedures should follow the quality model Oximetry Clinical Practice Guideline.30 described in the NCCLS GP26-A A Quality Sys- 7.2.4.3 Correlation between pulse tem Model for Health Care.55 (Fig. 1) The docu- oximetry heart rate and palpated pulse ment describes a laboratory path of workflow rate and/or electrocardiogram should model that incorporates all the steps of the proce- be established.45 dure. This process begins with patient assessment 7.2.4.4 Pulse oximetry with pulse and the generation of a clinical indication for test- waveform display may be desirable. ing through the application of the test results to For patients with normal adult patient care. The quality system essentials de- hemoglobin, the highest accuracy and fined for all health care services provide the best performance is attained when the framework for managing the path of workflow. A probe is attached to the patient in such continuation of this model for respiratory care a way that the arterial signal has the services is further described in NCCLS HS4-A A largest possible amplitude, which is Quality System Model for Respiratory Care.56 In only available with systems that yield a both quality models the patient is the central plethysmographic tracing.45 focus.

Pulmonary Diagnostics Path of Workflow

Pretest Testing Session Post-test Quality PatientRETIRED Assessment Patient Training Results Report Test Request Test Performance Interpretation System Patient Preparation Results Review and Selection Clinical Consult Essentials Equipment Preparation Patient Assessment for Further Testing Organization Personnel Information Management Equipment Information System Purchasing/ Inventory Process control Documents/ Records Occurence management Quality system essentials Internal apply to all operations assessment in the path of workflow Process improvement Service and Satisfaction

Fig. 1. Structure for a Quality System Model for a Pulmonary Diagnostics Service (From Reference 55, with permission)

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9.1 General considerations include: 9.2.2 Treadmills and bicycle ergometers 9.1.1 As part of any quality assurance pro- should be calibrated according to the gram, indicators must be developed to manufacturer’s recommendations, with monitor areas addressed in the path of periodic re-verification. (One reference workflow. suggests every 3-6 months.42) 9.1.2 Each laboratory should standardize 9.2.3 Pulse oximeters monitors should be procedures and demonstrate intertechnol- maintained as described under quality as- ogist reliability. Test results can be con- surance in the manufacturer’s manual. sidered valid only if they are derived ac- 9.2.4 Biological controls should be tested cording to and conform to established lab- regularly (self-testing of normal laborato- oratory quality control, quality assurance, ry staff).58 and protocols. 9.3 Test quality: Results of arterial blood gas 9.1.3 Documentation of results, therapeu- analysis and/or SpO2 should confirm or rule out tic intervention (or lack of) and/or clinical oxygen desaturation during exercise to validate decisions based on the exercise testing the patient’s clinical condition. should be placed in the patient’s medical 9.4 Test results:The exercise should have a record. symptom-limited or physiologic end point docu- Report of test results should contain a mented (eg, heart rate or onset of dyspnea). statement by the technician performing the test regarding test quality (includ- ETD 10.0 RESOURCES: ing patient understanding of directions 10.1 Equipment: and effort expended) and, if appropri- 10.1.1 Treadmill, cycle ergometer, or ate, which recommendations were not equivalent equipment, adaptable to pa- met. tients who may be severely limited (eg, 9.1.4 The type of medications, dose, and low-speed treadmill, low-watt ergometer, time taken prior to testing and the results arm crank ergometer).25,26,59Ð61 Other of the pretest assessment should be docu- forms of exercise may be utilized (stair mented. climbing, step test, timed walking); how- 9.1.5 Test results should be interpreted by ever, such modes do not eliminate the ne- a physician, taking into consideration the cessity for adequate monitoring as de- clinical question to be answered.57 scribed in Sections 7 and 9 and the neces- 9.1.6 A technologist who has not met an- sity for adequate documentation of nual competency requirements or whose procedure and patient response. competency is deemed unacceptable as 10.1.2 Arterial blood sampling equipment documented in an occurrence report for single puncture or arterial cannulation should not be allowed to participate, until and analyzers that have been properly cal- he has received remedialRETIRED instruction and ibrated and for which multilevel controls has been re-evaluated. indicate proper function31,32,54 9.1.7 There must be evidence of active re- 10.1.3 Pulse oximeter monitor and related view of quality control, proficiency test- accessories.30 ing, and physician alert, or ‘panic’ values, 10.1.4 Electrocardiographic monitor with on a level commensurate with the number the capacity to monitor heart rate to a pre- of tests performed dicted maximum and accurately display 9.2 Calibration and quality control measures cardiac rhythm during exercise. (Multiple specific to equipment used in exercise testing leads are preferred.)25,26 for desaturation include: 10.1.5 Resuscitation equipment including 9.2.1 Calibration procedures as defined oxygen with various delivery devices, by the laboratory protocols and manufac- such as nasal cannula and mask.25,26 turer’s specifications should be adhered 10.1.6 An easily accessible cardiac arrest to.42 cart and defibrillator with resuscitation

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equipment25,26,59 ETD 11.0 MONITORING: 10.1.7 Blood pressure monitoring device, 11.1 Recommended monitoring of patient dur- manual or automatic. (If an automated ing testing: system is used, a manual blood pressure 11.1.1 Electrocardiograph with strip cuff and stethoscope should be available recorder, preferably screened in real-time as a backup.)25,26 to check for displaced leads. 10.1.8 Visual aids (eg, Borg scales for 11.1.2 Oxygen delivery devices with doc- dyspnea and fatigue) that are large, easy umented FDO2 to read, and in clear view.59,62,63 11.1.3 Physical assessment (chest pain, 10.1.9 Blood gas sampling and analysis leg cramps, color, perceived exertion, equipment.31,32,54 dyspnea)25,26 10.2 Background history and data: 11.1.4 Respiratory rate25,26 10.2.1 Results of appropriate baseline di- 11.1.5 Patient cooperation and effort level agnostic tests and patient history (eg, 11.1.6 Borg, modified Borg, or visual ana- electrocardiogram, chest radiograph, and log dyspnea or symptom scales64, 65 pulmonary function test results) should be 11.1.7 Blood gas sampling using site and available.25,26,29 technique consistent with the AARC 10.2.2 The need for written consent Clinical Practice Guideline for blood gas should be determined within the specific sampling,31 and NCCLS Guidelines54 institution.26,27 11.1.8 Continuous monitoring of oxy- 10.2.3 A list of the patient’s current medi- genation status (SpO2) cations and any pharmacologic allergies 11.1.9 Heart rate, rhythm, and ST-T wave should be included. changes25,26 10.3 Personnel: 11.1.10 Blood pressure25,26 10.3.1 The presence of a physician trained 11.2 Recommended equipment monitoring dur- in exercise testing may be required de- ing testing: Pulse waveforms of SpO2 and/or pending on patient condition and hospital SaO2 should be analyzed to assure adequate sig- policy.25,26,59 nal acquisition for reliable readings. 10.3.2 Personnel administering the test should possess experience and knowl- ETD 12.0 FREQUENCY: edge in exercise physiology and testing, The frequency of testing depends on the patient’s including arterial blood gas sampling clinical condition and the need for changes in ther- and analysis; cardiopulmonary resusci- apy. Exercise may be repeated for certification of tation (certified in Basic Cardiac Life supplemental oxygen needs. Support, or BCLS. Qualification in Ad- vanced Cardiac Life Support, or ACLS, ETD 13.0 INFECTION CONTROL: is recommended); ECGRETIRED abnormality 13.1 The staff, supervisors, and physician-di- recognition; ; blood pres- rectors associated with the pulmonary laborato- sure monitoring; and application and ry should be conversant with “Guideline for limitations of pulse oximeters.28 Train- Isolation Precautions in Hospitals” made by the ing and demonstrated competency must Centers for Disease Control and the Hospital be documented for all testing person- Infection Control Practices Advisory Commit- nel.56 tee (HICPAC),66 and develop and implement 10.3.3 Testing personnel should have the policies and procedures for the laboratory that knowledge and skills to respond to ad- comply with its recommendations for Standard verse situations with the patient and to Precautions and Transmission-Based Precau- know when cessation of further testing is tions. indicated (versus coaching the patient to 13.2. The laboratory’s manager and its medical continue).28, 57-59 director should maintain communication and

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cooperation with the institution’s infection con- The current Pulmonary Diagnostic Clinical Practice trol service and the personnel health service to Guidelines Committee updated an earlier version help assure consistency and thoroughness in (Exercise testing for evaluation of hypoxemia complying with the institution’s policies related and/or desaturation. Respir Care 1992;37(8):907- to immunizations, post-exposure prophylaxis, 912) and gratefully acknowledges the contribution and job- and community-related illnesses and of those individuals who provided input to that ear- exposures.67 lier version: Kevin Shrake, Robert Brown, and 13.3 Primary considerations include: Michael Kochansky. 13.3.1 adequate handwashing,68 13.3.2 provision of prescribed ventilation REFERENCES with adequate air exchanges,69 13.3.3 careful handling and thorough 1. Mohler JG, Collier CR, Brandt W, Abramson J, Kerkaik G, cleaning and processing of equipment.66 Yates S. Blood gases. In: Clausen JL, editor. Pulmonary Procedure-specific considerations include: function testing guidelines and controversies: equipment, 13.3.3.1 disposable items are for single methods, and normal values. New York: Academic Press; 1982: 251. patient use; 2. American Thoracic Society. Standards for the diagnosis 13.3.3.2 disposable electrodes should and care of patients with chronic obstructive pulmonary be used for electrocardiographic moni- disease: official statement. Am J Respir Crit Care Med toring with Standard Precautions ob- 152(3):S77-S120. served during patient skin preparation. 3. Carone M, Patessio A, Appendini L, Purro A, Czernicka E, Cables and equipment that touch the Zanaboni S, Donner CF. Comparison of invasive and non- invasive saturation monitoring in prescribing oxygen dur- patient should be wiped down with a ing exercise in COPD patients. Eur Respir J, disinfectant after each use; 1997;10(2):446Ð451. 13.3.3.3 reusable pulse oximeter 4. Tobin M. Respiratory monitoring. JAMA 1990;264:244- probes should be cleaned between pa- 251. tient use, following the manufacturer’s 5. Zeballos RJ, Weisman IM. Reliability of noninvasive guidelines. oximetry in black subjects during exercise and . Am Rev Respir Dis 1991;144:1240-1244. 13.3.4 the exercise of particular care in 6. Schnapp LM, Cohen NH. Pulse oximetry uses and abuses. scheduling and interfacing with the pa- Chest 1990;98(5):1244-1250. tient in whom a diagnosis has not been es- 7. Escourrou PJL, Delaperche MF, Visseaux A. Reliability of tablished. pulse oximetry during exercise in pulmonary patients. Chest 1990;97(3):635-638. ETD 14.0 AGE SPECIFIC ISSUES 8. Powers SK, Dodd S, Freeman J, Ayers GD, Samson H, McKnight T. Accuracy of pulse oximetry to estimate HbO2 14.1 This guideline does not apply to the fraction of total Hb during exercise. J Appl Physiol neonatal population. 1989;67(1):300-304. 14.2 This CPG document applies to pediatric, 9. Douglas NJ, Brash HM, Wraith PK, Calverley PM, adolescent, adult, and geriatric RETIREDpopulations. Leggett RJ, McElderry L, Flenley DC. Accuracy sensitivi- 14.3 Test instructions and techniques should be ty to , and speed of response of the given in a manner that takes into consideration Hewlett-Packard 47201A ear oximeter. Am Rev Respir Dis 1979;119(2):311-313. the learning ability, communication skills, and 10. Hansen JE, Casaburi R. Validity of ear oximetry in clinical age of the patient being served. exercise testing. Chest 1987;91(3):333-337. 11. Powers SK, Dodd S, Woodyard J, Beadle RE. Cardiopulmonary Diagnostics Guidelines Com- Haemoglobin saturation during incremental arm and leg mittee (the principal author is listed first): exercise. Br J Sports Med 1984;18(3):212-216. Catherine M Foss BS RRT RPFT, Ann Arbor MI 12. Smyth RJ, D’Urzo AD, Slutsky AS, Galko BM, Rebuck AS. Ear oximetry during combined hypoxia and exercise. J Susan Blonshine BS RRT RPFT, Mason MI Appl Physiol 1986;60(2):716-719. Carl Mottram BA RRT RPFT, Chair, Rochester MN 13. Ries AL, Fedullo PF, Clausen JL. Rapid changes in arterial Gregg Ruppel MEd RRT RPFT, St Louis MO blood gas levels after exercise in pulmonary patients. Chest Jack Wanger MS RRT RPFT, Lenexa KS 1983;83(3):454-56. 14. Frye M, DiBenedetto R, Lain D, Morgan K. Single arterial

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