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1 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Subject Index ACE inhibitors, see Angiotensin-converting enzyme inhibitors Aging muscle effects 63 respiratory system changes advanced age effects 97 breathing pattern 91 demand scaling to capacity 97 end expiratory lung volume regulation 91, 92 expiratory flow and pressure development 92, 93 inspiratory flow and pressure development 93 overview 89, 90 pulmonary gas exchange alveolar to arterial gas exchange 95 dead space and alveolar ventilation 94 lung diffusion 94, 95 pulmonary vasculature 95, 97 ventilatory demand 90 work and cost of breathing during exercise 93 Alveolar ventilation equation 1 Angiotensin-converting enzyme inhibitors, evaluation of congestive heart failure patients 104, 105 Antileukotrienes, exercise-induced asthma management 214 Arrhythmia, pediatric evaluation 293, 294 Asbestosis, pulmonary dysfunction 225 Asthma, exercise-induced bronchospasm features and testing 38 clinical features 206, 214 diagnosis bronchodilator response 206 differential diagnosis 207 exercise testing bronchial provocation challenge comparison 211, 212 cycle ergometer 211 exercise protocol 208, 209 hyperventilation 211 precautions 208 treadmill testing metacholine challenge testing 207, 208 epidemiology 205 pathophysiology 205, 206 pediatric exercise testing 289 prevention 214 treatment antileukotrienes 214 athletes 212, 213 bronchodilators 213, 214 cromolyn 213, 214 inhaled heparin 214 nonpharmacologic therapy 212 AT 1 receptor blockers, cardiopulmonary exercise test evaluation of congestive heart failure patients 105 ß-agonists, see Bronchodilator therapy ß-blockers, evaluation of congestive heart failure patients 105 Blood pressure measurement 51, 52 pediatric response to exercise 292, 293 Breathing retraining biofeedback 170 overview 169 postural changes 170 pursed lip breathing 170, 171 yoga 170 Bronchodilator therapy exercise performance effects 152 exercise-induced asthma 213, 214 exertional dyspnea effects 78 Bronchopulmonary dysplasia, pediatric exercise testing 291 Bullectomy, exertional dyspnea studies 79 Cardiac output exercise response 9 heart transplant recipients pregnancy 274 Cardiac rehabilitation, see Congestive heart failure, Heart transplant Cardiac stress test exercise treadmill test, see Exercise treadmill test stages of Bruce protocol 38 stress echocardiography, see Stress echocardiography stress myocardial perfusion imaging, see Stress myocardial perfusion imaging test selection factors 117 Cardiopulmonary exercise test applications 30, 31, 39 children, see Pediatric exercise testing chronic fatigue syndrome 269, 270 contraindications 53, 54 diabetes 267 dyspnea evaluation, see Dyspnea equipment 43 exercise protocol cycle ergometer vs treadmill 43, 44, 49 cycle ergometry constant work protocols 50, 51 incremental or ramp protocols 49, 50

2 treadmill protocols 51 heart failure assessment, see Congestive heart failure impairment and disability assessment, see Impairment and disability interpretation, integrative approach case studies chronic obstructive pulmonary disease dilated cardiomyopathy with chronic obstructive pulmonary disease exertional dyspnea clinical status evaluation 301 exercise cessation reasons 301 exercise limitation analysis cardiovascular disease 305, 306 chronic obstructive pulmonary disease 307 deconditioning 306, 307 interstitial lung disease 307 mechanisms 305 obesity 307 pulmonary vascular disease 306 test result evaluation 305 measurements and graphic interrelationships clinical signs and symptoms 305 gas exchange 304, 305 heart rate 304 lactic acid threshold 303, 304 ventilatory reserve 304 V O2max 302, 303 overview 307, 308 patient effort assessment 301 rationale 301 reasons for testing 301 reference values 302 interstitial lung disease, see Interstitial lung disease lung resection candidates, see Lung resection lung transplant patients, see Lung transplant measurements 38, 219, 220 blood pressure 51, 52 electrocardiography 51, 54 expiratory flow and volume 44, 45 gas concentration arterial blood gas 52, 63 expiration 45, 46 invasive vs noninvasive testing 51 metabolic measurement comparison of techniques 46, 47 concepts 45, 46 power output 43, 44 pulse oximetry 52 muscle disorders, see Muscle obesity 265, 266 pregnancy, see Pregnancy preliminary requirements 53, 54 protocol overview pulmonary arterial hypertension, see Pulmonary arterial hypertension quality control and validation ergometer validation 48 metabolic measurement quality control 48, 49 reproducibility of measurements 47, 48 rationale 38, 39 safety 55 thyroid disorders 268, 269 ventilatory limitation evaluation Carnitine deficiency, clinical features 246, 247 Carnitine palmitoyltransferase deficiency, clinical features 247 Chest pain, pediatric exercise testing 295 Children, see Pediatric exercise testing Chronic fatigue syndrome findings 270 physiological effects 269 definition 269 Chronic obstructive pulmonary disease bronchodilator therapy effects on exercise performance 152, integrative 307, deconditioning 63, 68 dilated cardiomyopathy with chronic obstructive pulmonary disease exercise intolerance findings 139, 141, 142 cardiovascular factors 151 dynamic hyperinflation dyspnea 146 inspiratory muscle function 144, 145 inspiratory muscle fatigue 149 weakness 148, 149 management 153, 154 overview 138 peripheral muscle dysfunction 150, 151 tidal volume restriction 143, 144 ventilatory constraints 142 ventilatory demand 148 ventilatory limitation and gas exchange abnormalities ventilatory mechanics 143 ventilatory-locomotor muscle competition during exercise 151 exercise performance prediction from resting pulmonary function 224, 225 muscular alterations energy metabolism fiber type distribution 20 mechanisms disuse 24 hypoxia 22, 23 oxidative stress 23, 24 weight loss and altered substrate metabolism 24, 25 morphology 19 overview 18 performance 18, 19 oxygen therapy effects on exercise performance 152, 153 pulmonary rehabilitation, see Pulmonary rehabilitation Congestive heart failure evaluation cardiac surgery patients 105 exercise modalities 99, 100 heart transplant patient selection and follow-up 101, 102 integrative measurements 100, 101 overview 99 pacemaker patients 106 pharmacotherapy evaluation angiotensin-converting enzyme inhibitors 104, 105 AT 1 receptor blockers 105 ß-blockers 105 hormones 105 vasodilators 104 protocols 100 typical response 104 ultrafiltration patients 105, 106 dilated cardiomyopathy with chronic obstructive pulmonary disease exercise intolerance mechanisms baroreflex desensitization and sympathetic activation 121, 122 left ventricular function impairment 121 neurohormonal activation 122 pulmonary abnormalities 122, 123 skeletal muscle abnormalities 103, 122 vasodilation impairment 122 exercise-limiting factors circulation 103 heart 102, 103 lungs 103, 104 muscle fibers 103 sympathetic neuroendocrine system 103 Subject Index 325

3 Congestive heart failure (continued) exercise training adaptations baroreflex and sympathetic activation 123 clinical outcomes 125 myocardial remodeling 123 neurohormonal systems 123, 124 overview 125 skeletal muscle metabolism 124, 125 vasodilatory capacity 124 V O2peak 123 initial intensity 126 progression of program 126, 127 prospects 135 risk stratification and patient screening 125, 126 heart transplant outcomes 120, 121 muscular alterations energy metabolism 20 22, 122 fiber type distribution 20 mechanisms disuse 24 hypoxia 22, 23 oxidative stress 23, 24 weight loss and altered substrate metabolism 24, 25 morphology 19 overview 18 performance 18, 19 socioeconomic impact 120 Coronary artery disease, integrative 305, 306 exercise treadmill test electrocardiography 110, 111, 113 indications 110 interpretation 111, 112 limitations 113 popularity 110 premature ventricular complexes 111, 112 prognostic assessment 112, 113 protocol 110, 111 safety 110 sensitivity and specificity 112 special cases 113 termination indications 111 pediatric myocardial ischemia evaluation 293 risk stratification 109 stress echocardiography dobutamine echocardiography 115, 116 exercise echocardiography 115 interpretation 116 prognostic assessment 117 sensitivity and specificity 116 special cases 117 stress myocardial perfusion imaging dobutamine infusion 114 exercise protocol 114 imaging techniques 114 interpretation 114 prognostic assessment 115 radiotracers 113, 114 sensitivity and specificity 115 special cases 115 vasodilation 114 Cromolyn, exercise-induced asthma management 213, 214 Cystic fibrosis and lung transplantation 260, 261 pediatric exercise testing Deconditioning, integrative 306, 307 impact 63, 68 definition 60, 61 lung volume reduction surgery patients 178 prevention 68 skeletal muscle abnormalities atrophy mechanisms 62, 63 bed rest studies 61, 62 treatment with exercise training aerobic exercise endurance training implementation 66 muscle impact 66 principles 64 rationale 63, 64 resistance/strength training implementation 67 modalities 67 muscle impact 67, 68 Diabetes 267 pediatric exercise testing 294 Disability, see Impairment and disability Dyspnea of unexplained dyspnea differential diagnosis popularity of use 85 specificity 87 causes 81, 82 chronic dyspnea evaluation chest film 84 medical history 82 physical examination pulmonary function testing 84, 85 routine laboratory testing 84 definition 82 dynamic hyperinflation in chronic obstructive pulmonary disease 146 exercise induction, see Exertional dyspnea interstitial lung disease 188 pediatric exercise testing 295 Echocardiography, see Stress echocardiography Electrocardiography 51, 54 exercise treadmill test 110, 111, 113 End expiratory lung volume 139, 141, 143 regulation 91, 92 Endurance training, respiratory system effects 14, 15 Exercise aging effects on capacity, see Aging cardiorespiratory interactions 10, 11 cardiovascular system response 9, 10 pulmonary gas exchange 6 9 respiratory limitations to performance Exercise hyperpnea breathing mechanics during exercise 4 6 neurochemical control 1 4 Exercise-induced arterial hypoxemia causes 11 performance limitations Exercise-induced asthma, see Asthma, exercise-induced Exercise-induced bronchospasm, see also Asthma, exercise-induced features 38 testing methodology 38 Exercise intolerance, see specific conditions Exercise treadmill test electrocardiography 110, 111, 113 indications 110 interpretation 111, 112 limitations 113 popularity 110 premature ventricular complexes 111, 112 prognostic assessment 112, 113 protocol 110, 111 safety 110 sensitivity and specificity 112 special cases 113 termination indications 111 Exertional dyspnea bronchodilator therapy effects 78 bullectomy studies 79, integrative Subject Index

4 central mechanisms 6, 72 definition 72 lung volume reduction surgery studies 79 measurement continuous computerized measurement continuum of ratings 76 CR-10 74, 75 global vs local psychophysical methods 74 peak values 75, 76 VAS 74 oxygen therapy effects 79 pulmonary rehabilitation studies 79 receptors in sensation chemoreceptors 73 lung receptors 73, 74 mechanoreceptors 73 stimuli 74 Expiratory flow limitation, chronic obstructive pulmonary disease 141, 142 FEV 1 lung resection candidates 234 respiratory impairment 222, 223 Fick s law oxygen diffusion in lung 7 V O2max 11 Gas analysis breath-by-breath method 46 arterial blood gas 52, 63 expiration 45, 46 comparison of techniques 46, 47 mixing chamber technique 46 standard temperature and pressure conversion 46 water vapor effects 46 Gas exchange aging effects alveolar to arterial gas exchange 95 dead space and alveolar ventilation 94 lung diffusion 94, , 305 abnormalities exercise dynamics 6 9 interstitial lung disease impairment 187, 188 lung volume reduction surgery response 176, 178 measurement 221 ventilatory requirement relationship 222 Heart failure, see Congestive heart failure Heart rate 304 heart transplant recipients 127, 128 pediatric response to exercise 292 reserve and exercise capacity 221 Heart transplant for patient selection and follow-up 101, 102 congestive heart failure outcomes 120, 121 exercise intolerance factors in recipients cardiac output glucocorticoid-induced osteoporosis and resistance exercise therapy 133, 134 heart rate 127, 128 hemodynamics 130 peripheral circulation 133 pulmonary diffusion 130 pulmonary spirometry 130 skeletal muscle metabolism 130, 131 resistance exercise therapy 132, 133 strength 132 exercise program design 134 initial intensity and progression 135 prospects 135 safety precautions 135 Hypoxia high altitude hypoxia exercise limitations 14 muscle alterations in chronic obstructive pulmonary disease or congestive heart failure 22, 23 Impairment and disability American Thoracic Society Recommendations for Respiratory Impairment 222 decision making on impairment 226, 227 principles 219, 220 quantification of impairment 227, 228 rationale 218, 219, 221 recommendations 228, 229 definitions 219 exercise performance prediction from resting pulmonary function nonventilatory limitation during exercise 225, 226 occupational disease 217, 218 ventilatory capacity 222, 223 Interstitial lung disease indications 190 integrative 307 interpretation 192 measurements 191, 192 normal subject comparisons 192, 193, 195 patient management impact 197 protocol 190, 191 disease-specific differences in exercise responses 189 etiology 186 exercise intolerance factors cardiovascular dysfunction 189 dynamic ventilatory mechanics 188 dyspnea 188 gas exchange impairment 187, 188 overview 187 pulmonary hypertension 189 respiratory muscle function 188, 189 exercise performance prediction from resting pulmonary function 225 tidal flow-volume relationships 193, 195, 197 ventilatory mechanics and lung volumes during exercise 197 Ischemia, see Coronary artery disease Lactic acid exercise hyperpnea feedback 3 threshold 303, 304 sustained exercise capacity 220, 221 Lung resection complications cardiac 233 pulmonary 233 indications 231 preoperative evaluation algorithm maximal tests 235, 236 minimal achievement tests 235 rationale 232, 234 submaximal tests 235 cardiopulmonary risk index 238, 239 computed tomography 238 exercise-limited patients 238 ideal parameter for evaluation 231, 232 pulmonary function testing 234 smokers 233 split function studies 234, 239 tumor type and staging 232 Subject Index 327

5 Lung transplant exercise response and limitations posttransplantation cardiac response 257 exercise-induced hypoxemia 257 skeletal muscle dysfunction 257, 258 ventilation 257 historical perspective 254, 255 outcome measurements cystic fibrosis 260, 261 idiopathic pulmonary fibrosis incremental testing 256, 257 obstructive lung disease 260 pulmonary hypertension 261 rationale 258 functional class 255, 256 lung function 255 six-minute walk test 256 survival 255 Lung volume reduction surgery controversies 173, 174 exercise testing parameters preoperative assessment and prognosis 182, 183 rationale 174 trials 178, 179 walk distance improvement 179, 180 exertional dyspnea studies 79 indications 239 physiological responses gas exchange 176, 178 lung and chest wall mechanics peripheral muscle conditioning 178 pulmonary vascular function 178 McArdle disease, clinical features 245, 246 Master two-step test applications 32 methodology 33 Maximum flow volume loop, ventilatory limitation analysis 56, 57 Maximum ventilatory capacity 142 interstitial lung disease 195 Maximum voluntary ventilation chronic dyspnea evaluation 84 estimation 56, 304 interstitial lung disease 188, 195, 197 Methacholine challenge test chronic dyspnea evaluation 84 exercise-indued asthma diagnosis 207, 208 Mitochondrial myopathy clinical features 247, 248 diagnosis 248 exercise testing pediatric exercise testing 294 pulmonary function testing 248 respiratory muscle function 248 Mitral valve repair, cardiopulmonary exercise test evaluation of congestive heart failure patients 105 Multiple inter gas elimination technique, P O2 alveolar to arterial difference in exercise 8, 9 Muscle, see also Deconditioning aging effects 63 or congestive heart failure alterations energy metabolism fiber type distribution 20 mechanisms disuse 24 hypoxia 22, 23 oxidative stress 23, 24 weight loss and altered substrate metabolism 24, 25 morphology 19 overview 18 performance 18, 19 training adaptations 124, 125 congestive heart failure effects 103, 122 disorders carnitine deficiency 246, 247 carnitine palmitoyltransferase deficiency 247 metabolic pathways 243 mitochondrial myopathy clinical features 247, 248 diagnosis 248 exercise testing pediatric exercise testing 294 pulmonary function testing 248 respiratory muscle function 248 muscle bulk disorders and exercise testing 251, 252 overview 242, 243 phosphofructokinase deficiency 246 phosphorylase deficiency 245, 246 endurance training effects 66 fatiguing of respiratory muscle in performance limitation heart transplant recipients metabolism 130, 131 resistance exercise therapy 132, 133 strength 132 lung transplant recipient dysfunction 257, 258 resistance/strength training effects 67, 68 sympathetic nervous system flow during exercise 10 Negative expiratory pressure testing 142 ventilatory limitation analysis 56, 57, 304 Nitric oxide synthase, endothelial enzyme response to endurance training 15 Obesity findings 265, 266 integrative 307 physiological effects of obesity 265 definition 264, 265 Osteoporosis, heart transplant recipient glucocorticoid-induced osteoporosis and resistance exercise therapy 133, 134 Oxidative stress, muscle alterations in or congestive heart failure 23, 24 Oxygen therapy exercise performance effects 152, 153 interstitial lung disease 197 Pacemaker, evaluation of congestive heart failure patients 106 Pediatric exercise testing approaches 283 bronchopulmonary dysplasia 291 cardiology referrals arrhythmia evaluation 293, 294 blood pressure response to exercise 292, 293 exercise limitation and sports evaluation 294 heart diseases 292 heart rate response to exercise 292 myocardial ischemia evaluation 293 chest pain 295 contraindications and test termination 295, 296 cystic fibrosis diabetes 294 dyspnea 295 exercise-induced asthma 289 healthy child responses to exercise 282, 283 indications 288, 289 maturation of physiological responses to exercise 284, 285 measurements 285 mitochondrial myopathy 294 protocols Balke protocol 288 brief constant work rate tests 286 Bruce protocol 287, Subject Index

6 cycles vs treadmills 286, 287 maximum exercise testing 285, 286 stress tests 286 renal hypertension 294 safety 296 syncope 295 upper airway obstruction 291, 292 Phosphofructokinase deficiency, clinical features 246 P O2aging effects 95 alveolar to arterial difference in exercise 6 9, 11, 12, 95 Pregnancy anatomic and physiological changes 274 exercise testing indications 273 contraindications 274, 275 maximum exercise tests expected responses 278, 279 protocol selection 276, 277 safety 277 postpartum testing 280 rationale 275, 276 submaximum exercise tests expected responses 279, 280 protocol selection 279 weight-bearing exercise 276 weight-supported exercise 276 postpartum exercise prescription 280 Primary pulmonary hypertension, see Pulmonary arterial hypertension Pulmonary arterial hypertension diagnosis 202, 203 grading 203 therapeutic response assessment 203 definition 200 primary pulmonary hypertension 201 pulmonary circulatory response to exercise abnormal response 202 normal response 201, 202 secondary precapillary hypertension 200, 201 Pulmonary rehabilitation breathing retraining biofeedback 170 overview 169 postural changes 170 pursed lip breathing 170, 171 yoga 170 lower extremity exercise reconditioning principles 159, 160 training adaptation 160, 161 upper extremity exercise ventilatory muscle strength endurance training 167 flow resistive and threshold loading 167, 168 intensive care patient training 169 strength training 167 ventilatory isocapneic hyperpnea 168, 169 Pulse oximetry, cardiopulmonary exercise test 52 Reconditioning, see Cardiac rehabilitation, Pulmonary rehabilitation Renal hypertension, pediatric exercise testing 294 Shuttle-walking test comparison with other tests 37 constant work shuttle-walking test 37 Single photon emission computed tomography, see Stress myocardial perfusion imaging Six-minute walk test comparison with other functional capacity tests 36, 37 development 33 indications 31, 33 lung transplant recipients 256 methodology measurements 35 monitor 35 patient preparation 34 practice test 35 protocol 35 standardization 34 track 34 outcome factors course length and shape 33, 34 encouragement 34 medications 34 supplemental oxygen 34 training effect 34 reference values and clinical significance 36 reproducibility 36 safety 35, 36 treadmill test 37 Skeletal muscle, see Muscle Stair climbing test applications 31, 32 methodology 31, 32 Standard temperature and pressure, conversions for gas analysis 46 Stress echocardiography dobutamine echocardiography 115, 116 exercise echocardiography 115 interpretation 116 prognostic assessment 117 sensitivity and specificity 116 special cases 117 Stress myocardial perfusion imaging dobutamine infusion 114 exercise protocol 114 imaging techniques 114 interpretation 114 prognostic assessment 115 radiotracers 113, 114 sensitivity and specificity 115 special cases 115 vasodilation 114 Syncope, pediatric exercise testing 295 Thyroid disorders, cardiopulmonary exercise testing 268, 269 Tidal volume restrictions 143, 144 interstitial lung disease 188 tidal flow-volume relationships in interstitial lung disease 193, 195, 197 Upper airway obstruction, pediatric exercise testing 291, 292 Vasodilation congestive heart failure impairment 122 exercise response 9, 10 Vasodilators evaluation of congestive heart failure patients 104 stress myocardial perfusion imaging 114 V CO2, measurement 45, 46, 101 Ventilatory muscle threshold training intensive care patients 169 pulmonary rehabilitation 167, 168 V O2cardiopulmonary exercise test measurement 45, 46, 100, 101 obesity 265, 266 PaCO 2 relationship 193 submaximal exercise changes 220 thyroid disorders 269 V O2max 302, 303 congestive heart failure patients 100, 101 Fick equation 11 respiratory limitations to exercise performance V O2peak 220, 302, 303 diabetes 267 exercise adaptation in congestive heart failure 123 Water vapor, effects on gas measurement 46 chronic fatigue syndrome 270 thyroid disorders 268, 269 Subject Index 329