Cardiopulmonary Exercise Testing in Children and Adolescents

288 Pages·2017·4.77 MB·English

by  Thomas Rowland

Cardiopulmonary
Exercise Testing
in Children and
Adolescents
Thomas W. Rowland, MD
Baystate Medical Center
American College of Sports Medicine
North American Society
for Pediatric Exercise Medicine
Editors
Human Kinetics
Library of Congress Cataloging-in-Publication Data
Names: Rowland, Thomas W., editor. | American College of Sports Medicine,
editor. | North American Society for Pediatric Exercise Medicine, editor.
Title: Cardiopulmonary exercise testing in children and adolescents / Thomas
W. Rowland, American College of Sports Medicine, North American Society
for Pediatric Exercise Medicine, editors.
Description: Champaign, IL : Human Kinetics, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2016050870 (print) | LCCN 2016051582 (ebook) | ISBN
9781492544470 (print) | ISBN 9781492544487 (e-book)
Subjects: | MESH: Exercise Test | Child | Adolescent
Classification: LCC RC669 (ebook) | LCC RC669 (print) | NLM WG 141.5.F9 | DDC
616.1/062--dc23
LC record available at https://lccn.loc.gov/2016050870
ISBN: 978-1-4925-4447-0 (print)
Copyright © 2018 by Thomas W. Rowland, American College of Sports Medicine, and North American Society for Pediatric
Exercise Medicine
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Contents
Preface ix
Notice and Disclaimer xi
Part I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1 Clinical Applicability of the Pediatric Exercise Test . . . . . . 3
Thomas W. Rowland
Development of Pediatric Exercise Testing 4
Unique Features of Exercise Testing in Children 7
Normative Values 8
Adjusting Values for Body Size 8
Tyranny of “Maximal” Testing 9
Safety of Clinical Exercise Testing 10
Conclusion 11
Chapter 2 Conducting the Pediatric Exercise Test . . . . . . . . . . . . . . 13
Amy Lynne Taylor
Pediatric Exercise Laboratory Environment and Equipment 13
Optimizing Safety 14
Preparing the Child for an Exercise Test 16
Test Communication 17
Conclusion 19
Part II Exercise Testing Methodology . . . . . . . . . . . . . . 21
Chapter 3 Exercise Testing Protocols . . . . . . . . . . . . . . . . . . . . . . . . 23
Richard J. Sabath III, David A. White, and Kelli M. Teson
Exercise Testing Modality 24
Protocol Design 25
Treadmill Protocols 26
Cycle Ergometer Protocols 28
Multistage Versus Ramp Protocols 32
Six-Minute Walk Test 35
Maximal Test Criteria 36
Scope of Pediatric Exercise Testing 37
Conclusion 38
iii
iv Contents
Chapter 4 Normal Cardiovascular Responses
to Progressive Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Thomas W. Rowland
Reductionist’s Disclaimer 41
Historical Context 42
Empirical Evidence 43
Synthesis 46
Physiological Basis of Cardiovascular Fitness 47
Conclusion 49
Chapter 5 Exercise Electrocardiography . . . . . . . . . . . . . . . . . . . . . 51
Thomas W. Rowland
Effects of Exercise on the Cardiac Conduction System 52
ECG Setup and Monitoring 54
Measuring Heart Rate 55
Identifying Heart Block 57
Detecting Arrhythmias 58
Detecting Ischemia 60
Evaluation of Prolonged QT Interval 62
Risk Stratification With Ventricular Pre-Excitation 63
Conclusion 63
Chapter 6 Blood Pressure Response to Dynamic Exercise . . . . . . . . 65
Bruce Alpert and Ranjit Philip
Basic Physiology of Exercise Blood Pressure 65
Technical Aspects of Blood Pressure Measurement 66
Normal Blood Pressure Response to Dynamic Exercise in Healthy Children 67
When to Terminate Exercise Testing Based on Blood Pressure Response 72
Prognostic Value of Exercise BP Testing 72
Special Conditions 73
Interpretation of Results 77
Conclusion 77
Chapter 7 Maximal Oxygen Uptake . . . . . . . . . . . . . . . . . . . . . . . . . 79
Ali M. McManus and Neil Armstrong
Physiological Responses to Aerobic Exercise 80
Measuring Maximal Oxygen Uptake in Children 83
Developmental Patterns in Maximal Oxygen Uptake 87
Normal Values 91
Conclusion 93
Contents v
Chapter 8 Other Measures of Aerobic Fitness . . . . . . . . . . . . . . . . . 95
Robert P. Garofano
Peak Workload 95
Ventilatory Anaerobic Threshold 97
Submaximal Testing Protocols 101
Oxygen Uptake Efficiency Slope 102
Conclusion 104
Chapter 9 Cardiac Output Measurement Techniques . . . . . . . . . . 107
Darren E.R. Warburton and Shannon S.D. Bredin
Invasive Versus Noninvasive Techniques 107
Direct Fick Method 108
Dye-Dilution Method 110
Thermodilution Method 111
Lithium Dilution Method 111
Foreign Gas Rebreathing Techniques 112
Doppler Echocardiography 115
Impedance Cardiography 116
Arterial Pulse Contour Method 117
Conclusion 118
Chapter 10 Assessing Myocardial Function . . . . . . . . . . . . . . . . . . . 119
Thomas W. Rowland
Systolic Time Intervals 120
Radionuclide Exercise Testing 120
Pattern of Stroke Volume Response 120
Oxygen Pulse 121
Doppler Echocardiographic Techniques During Exercise 122
Stress Echocardiography 124
Conclusion 125
Chapter 11 Pulmonary Function . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Patricia A. Nixon
Protocols 127
Pulmonary Function at Rest and During Exercise 127
Asthma 136
Cystic Fibrosis 137
Conclusion 138
vi Contents
Part III Exertion-Based Applications . . . . . . . . . . . . . . . 139
Chapter 12 Congenital and Acquired Heart Disease . . . . . . . . . . . . 141
Michael G. McBride and Stephen M. Paridon
Factors Affecting Exercise Performance 141
Exercise Testing 142
Simple Two-Ventricle Defects 143
Obstructive Lesions 146
Complex Two-Ventricle Defects 148
Single-Ventricle Physiology 151
Primary Arrhythmias and Channelopathies 153
Acquired Heart Disease and Cardiomyopathies 153
Conclusion 156
Chapter 13 Exercise-Induced Dyspnea . . . . . . . . . . . . . . . . . . . . . . 157
Steven R. Boas
Differential Diagnosis 157
Evaluation 162
Exercise Testing 164
Conclusion 166
Chapter 14 Chest Pain With Exercise . . . . . . . . . . . . . . . . . . . . . . . . 167
Julie Brothers
Differential Diagnosis 167
Evaluation 170
Exercise Testing 172
Conclusion 173
Chapter 15 Presyncope and Syncope With Exercise . . . . . . . . . . . . . 175
Julie Brothers
Differential Diagnosis 175
Evaluation 179
Exercise Testing 180
Conclusion 182
Chapter 16 Exercise Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Thomas W. Rowland
Differential Diagnosis 183
Evaluation 186
Exercise Testing 188
Conclusion 188
Contents vii
Part IV Testing Special Populations . . . . . . . . . . . . . . . 189
Chapter 17 Pectus Excavatum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Thomas W. Rowland
Physiological Implications 191
Surgical Results 193
Cardiopulmonary Testing 193
Conclusion 194
Chapter 18 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Laura Banks and Brian W. McCrindle
Quantifying Childhood Obesity 195
Physiological Adaptations 198
Effects of Obesity on Physiologic Measures 198
Cardiopulmonary Exercise Testing Modifications 202
Conclusion 203
Chapter 19 Intellectual Disability . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Bo Fernhall and Tracy Baynard
Physiological Implications 206
Exercise Testing 208
Conclusion 213
Chapter 20 Neuromuscular Disease . . . . . . . . . . . . . . . . . . . . . . . . 215
Olaf Verschuren, Janke de Groot, and Tim Takken
Cerebral Palsy 215
Duchenne and Becker Muscular Dystrophy 216
Conclusion 219
References 221
Index 263
About the Editors 274
About the Contributors 275
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Preface
The pediatric exercise testing laboratory is playing clinical laboratory setting. Appropriately, then,
an increasingly important role in the diagnosis and the consideration of testing methods will take into
assessment of children and adolescents with—or account the typical wide variety of ages, sizes,
suspected of having—heart or lung disease. This levels of physical fitness, and body composition of
text represents an effort to consolidate informa- patients as well as states of cardiac and pulmonary
tion about our growing experience with exercise health. Still, those involved in exercise testing of
testing in young persons so that those who con- youth for research purposes will undoubtedly find
duct these tests can have a guide and a reference useful material in these pages.
book. Recent scientific statements (1) and review A practical guidebook such as this one is obli-
articles (2, 4) about clinical exercise testing of gated to present normative data for exercise test-
children have given us new material since the ing variables. While such published norms will be
publication of my earlier book, Pediatric Labora- included in these chapters, one must—as will be
tory Exercise Testing: Clinical Guidelines (3). It is repeatedly emphasized—accept such information
the goal of this text to extend coverage of the topic with a high level of caution. Normative data for
in order to one laboratory often differ from those of another
because of variability in types of measuring equip-
• provide up-to-date guidance for the perfor-
ment, subject population, testing protocols, and
mance of exercise stress testing in youth,
staff characteristics. There are few data that can
and
be confidently considered normal for a general
• document our current knowledge about pediatric population. Consequently, normal values
interpreting the physiological variables for variables measured during exercise testing are
measured during these tests. best established for one’s own laboratory.
As much as possible, the discussions in these
The extent of the knowledge and experience
chapters will be based on published, evidence-
shared in this book, compared to its much thin-
based observations of youth during exercise test-
ner predecessor published over 20 years ago, is a
ing. In some cases, however, the authors of these
testament to the growing importance of pediatric
chapters will draw observations and recommen-
exercise testing.
dations from their own professional experience.
The central theme of this text is that clinical
These authors all have a high level of expertise
exercise testing in children differs from that con-
and extensive experience in
ducted in the adult stress testing laboratory. The
exercise testing of children
clinical questions being addressed in these two
and adolescents; they each
populations reflect obvious differences in forms
represent established pediat-
of cardiopulmonary disease, and the protocols
ric clinical testing laboratories
for testing adults must be modified to satisfy the
in major medical centers.
requirements of a wide range of subject sizes and
The authors expect that this book will prove
degrees of physical development as well as the
useful to physicians and exercise scientists as a
intellectual and emotional immaturity of the child.
source of current testing information and practi-
The first part of this book outlines the testing
cal guidelines for performing exercise testing in
procedure and its measurement variables, fol-
young patients. Beyond this, we hope that this
lowed by chapters that offer practical approaches
book will serve as a means of focusing and unify-
to patient complaints that are commonly
ing approaches to such testing and that it will
encountered in the exercise testing laboratory.
serve as a foundation for the future development
Throughout these discussions, we emphasize the
of innovative approaches to exercise testing in the
value of determining gas exchange variables to
health care of children and adolescents.
supplement the traditional measurement of blood
pressure and electrocardiogram.
Thomas W . Rowland, MD
This book is directed toward those who conduct
Editor
exercise testing of children and adolescents in the
ix
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