American Thoracic Society/ American College of Chest Physicians ATS/ACCP Statement on Cardiopulmonary Exercise Testing This Joint Statement of the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) was adopted by the ATS Board of Directors,March 1, 2002 and by the ACCP Health Science Policy Committee, November 1, 2001 CONTENTS 3.2 Maximal Incremental Treadmill Protocols 3.3 Constant Work Rate Protocol Executive Summary 4. Conducting the Test . .......................226 I. Introduction 4.1 Preliminary Requirements for Exercise Testing Idelle M. Weisman 4.2 Day of the Test Purpose and Scope ............................212 4.3 Patient Safety 5. Personnel Qualifications . ..................227 II. Indications for Cardiopulmonary Exercise Testing Idelle M. Weisman, Darcy Marciniuk, Fernando J. Martinez, IV. Conceptual and Physiologic Basis of Cardiopulmonary Frank Sciurba, Darryl Sue, Jonathan Myers Exercise Testing Measurements 1. Evaluation of Exercise Intolerance ..............214 Bruce Johnson, Brian Whipp, Jorge Zeballos, Idelle M. Weisman, 2. Unexplained Dyspnea ........................215 Ken Beck, Donald Mahler, John Cotes, Kathy Sietsema, 3. Evaluation of Patients with Cardiovascular Disease. 215 Kieran Killian 4. Evaluation of Patients with Respiratory Disease . 216 1. Oxygen Uptake . .............228 4.1 Chronic Obstructive Pulmonary Disease (COPD) 1.1 V˙ o2 Work Rate Relationship 4.2 Interstitial Lung Disease (ILD) 1.2 V˙ o2 max–V˙ o2 peak 4.3 Chronic Pulmonary Vascular Disease (PVD) 2. CO2 Output . .....229 4.4 Cystic Fibrosis 3. Respiratory Exchange Ratio . ......230 4.5 Exercise Induced Broncospasm (EIB) 4. Anaerobic Threshold . .....230 5. Preoperative Evaluation ......................216 4.1Clinical Applications of the Anaerobic Threshold 5.1 Preoperative Evaluation for Lung Cancer Resectional 4.2 Determination of the Anaerobic Threshold Surgery 4.3 Noninvasive Determinations 5.2 Lung Volume Reduction Surgery (LVRS) 5. Cardiac Output . .............232 5.3 Evaluation for Lung or Heart-Lung Transplantation 5.1 Heart Rate, HR-V˙ o2 Relationship 5.4 Preoperative Evaluation of Other Procedures 5.2 O2 Pulse 6. Exercise Prescription for Pulmonary Rehabilitation. 217 6. Blood Pressure Response ....................233 7. Evaluation of Impairment/Disability .............217 7. Ventilation . ....................233 7.1 Breathing Pattern and Ventilatory Timing III. Methodology Richard Casaburi, Darcy Marciniuk, Ken Beck, Jorge Zeballos, 7.2 Ventilatory Demand/Capacity 7.3 Ventilatory Reserve George Swanson, Jonathan Myers, Frank Sciurba ˙ ˙ ˙ ˙ 1. Equipment and Methodology . ..............218 7.4 Relationship of Ve vs. Vo2 and Ve vs. Vco2 ˙ ˙ 1.1 Exercise Equipment 7.5 Ventilatory Equivalents for Vo2 and Vco2 1.2 Airflow or Volume Transducers 7.6 End-Tidal Po2 and Pco2 1.3 Gas Analyzers 8. Emerging Techniques to Evaluate Ventilatory 1.4 Gas Exchange Measurements (V˙ o and V˙ co ) Limitation . ........235 2 2 ˙ 1.5 Electrocardiograph 8.1 Maximal Exercise Ventilation (Vecap) 1.6 Non Invasive Blood Pressure 8.2 Negative Expiratory Pressure (NEP) 1.7 Intraarterial Blood Pressure 9. Respiratory Muscle Evaluation . ......237 1.8 Pulse Oximetry 10. Pulmonary Gas Exchange . ........237 1.9 Calibration Procedures/Quality Control 10.1 Alveolar-Arterial Po2 Pressure difference 1.10 Reproducibility of the Measurements (PaO2–PaO2) and PaO2 2. Exercise Test with Arterial Blood Sampling .......224 10.2 Physiological Dead Space-to-Tidal Volume Ratio 3. Exercise Testing Protocols ....................224 (Vd/Vt) 3.1 Maximal Incremental Cycle Ergometry Protocols 11. Perceptual Assessment—Symptoms . .......238 (IET) V. Reference Values Jorge Zeballos, John Cotes, Mary S. Fairbarn, Robert O. Crapo 1. Requirements for an Optimal Set of Normal Reference This version of the Statement contains the corrections outlined in the May 15 Values . ..................239 Erratum Letter to the Editor (Am J Respir Crit Care Med 2003;167:1451–1452) 1.1 Population Characteristics Am J Respir Crit Care Med Vol 167. pp 211–277, 2003 DOI: 10.1164/rccm.167.2.211 1.2 Sample Size Internet address: www.atsjournals.org 1.3 Randomization 212 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 167 2003 1.4 Quality Assurance EXECUTIVE SUMMARY 1.5 CPET Protocols 1.6 Treatment of the Data Cardiopulmonary exercise testing (CPET) provides a global as- 1.7 Validation sessment of the integrative exercise responses involving the pul- 1.8 Statistical Treatment of the Data monary, cardiovascular, hematopoietic, neuropsychological, and 2. Alternative Approach to Obtain Normal Reference skeletal muscle systems, which are not adequately reflected Values ...................................239 through the measurement of individual organ system function. 3. Evaluation and Critique of the Most Current This relatively noninvasive, dynamic physiologic overview per- Reference Values ...........................239 mits the evaluation of both submaximal and peak exercise re- 4. Reference Values for Submaximal Levels sponses, providing the physician with relevant information for of Exercise ................................240 clinical decision making. Once the exclusive province of research 5. Reference Values for Arterial Blood Gases, physiologists and specialized centers, CPET is increasingly being P(a–a)O2, and Vd/Vt during CPET. ............241 used in a wide spectrum of clinical applications for the evaluation 6. Practical Approach for the Selection of of undiagnosed exercise intolerance and exercise-related symp- Reference Values ...........................242 toms, and for the objective determination of functional capacity and impairment. The use of CPET in patient management is VI. Normal Integrative Exercise Response increasing with the understanding that resting pulmonary and Bruce Johnson, Peter D. Wagner, Jerome Dempsey cardiac function testing cannot reliably predict exercise perfor- Normal Exercise Limitation mance and functional capacity and that, furthermore, overall VII. Exercise Limitation in Cardiopulmonary Patients health status correlates better with exercise tolerance rather than Bruce Johnson, Peter D. Wagner, Jorge Zeballos, Idelle M. with resting measurements. Weisman Introduction VIII. Interpretation The purpose of this Joint American Thoracic Society/American Idelle M. Weisman, Charles G. Gallagher, Fernando J. College of Chest Physicians (ATS/ACCP) statement is to pro- Martinez, Jonathan Myers, Darcy Marciniuk vide a comprehensive, conceptually balanced document on 1. Introduction ...............................243 CPET, which formulates guidelines and recommendations to 2. Interpretative Strategies . ................243 facilitate interpretation and clinical application on the basis of 3. Integrative Approach: Important Issues to the current best scientific knowledge and technical advances. The Be Addressed ..............................244 focus of this document is on clinical indications, standardization 3.1 Reason(s) for CPET 3.2 Clinical Status Evaluation issues, and interpretative strategies for CPET in adults. The 3.3 Compare Results with Appropriate Reference scope of issues includes (1) indications for CPET; (2) methodol- Values ogy—equipment, modality, protocols, conduct of the test, moni- 3.4 Measurements and Graphic Interrelationships toring, safety, and personnel issues; (3) measurements and 3.5 Symptoms graphic interrelationships, the physiologic response to exercise 3.6 Data Presentation in “normal” subjects, and the consequences of pathophysiologic 3.7 Assessment of Patient Effort derangements on exercise performance; (4) normal reference 3.8 Reasons for Stopping values; (5) interpretation, including case study analysis; and (6) 4. Patterns of Exercise Response in Different future recommendations for research. The intended audience Clinical Entities ............................246 for this document includes those who perform clinical CPET, 4.1 Heart Failure and also those who use these results to assist in the clinical 4.2 Pulmonary Vascular Disease decision-making process. 4.3 Deconditioning The Joint ATS/ACCP Ad Hoc Committee on Cardiopulmo- 4.4 COPD nary Exercise Testing included an international group of ac- 4.5 ILD knowledged experts with a broad range of clinical and research 4.6 Obesity expertise and conceptual orientations. A comprehensive litera- 4.7 Psychogenic (Anxiety, Hyperventilation Syndrome) ture search using Medline from 1970 through 2002, and relevant 4.8 Poor Effort and Malingering publications selected by the committee members, were used. In 5. Important Questions .........................251 this document, recommendations are based on best available 5.1 Is Exercise Capacity (V˙ o2 peak) normal? evidence, current prevailing scientific knowledge, and expert 5.2 Is Metabolic Rate Appropriate During Exercise? opinion. The committee attempted to identify areas of contro- 5.3 Does Cardiovascular Function Contribute to versy and to note clearly those areas where recommendations Exercise Limitation? did not achieve clear consensus, and where alternative ap- 5.4 Does Ventilatory Function Contribute to Exercise proaches were possible. Limitation? 5.5 Does Pulmonary Gas Exchange Contribute to Indications for Cardiopulmonary Exercise Testing Exercise Limitation? There are a number of specific indications for CPET (see Table 5.6 Is There Premature Metabolic Acidosis? 1). These include the following: 6. Putting It All Together . ...................253 7. Case Studies ...............................253