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Peds Cardiology > 7. Exercise Physiology > Flashcards

7. Exercise Physiology Flashcards

1
Q

How do you index VO2 (maximal oxygen uptake) in exercise testing?

A

Body weight in kg

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2
Q

What 2 things is a higher max VO2 related to?

A
  1. Mass of muscle used (more muscle groups used = higher VO2 max)
  2. Amount of exercise done
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3
Q

What type of exercise will have the highest maximal O2 uptake?

A

Treadmill ergometer

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4
Q

What cardiac index has the smallest increase with exercise when measured in the supine position?

A

Stroke volume

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5
Q

What 2 things is stroke volume dependent on?

A
  1. LVEDV

2. EF

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6
Q

What happens to stroke volume in the supine position?

A

Increases due to increased volume return to heart (increased EDV)

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7
Q

What happens to stroke volume in the supine position with exercise?

A

SV already increased from baseline due to supine position… volume needed to reach max SV is small and limited

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8
Q

How does stroke volume change during exercise?

A

Increases early in exercise and little change thereafter

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9
Q

What happens to CO during exercise?

A

Increases

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10
Q

What happens to HR during exercise?

A

Increases

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11
Q

What happens to EF during exercise?

A

Increases

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12
Q

What happens to total peripheral resistance during exercise?

A

Decreases

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13
Q

Why does total peripheral resistance decrease during exercise?

A

Decreased skeletal muscle vascular resistance allowing more blood flow to muscles

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14
Q

What happens to CVP during exercise?

A

No change

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15
Q

Why doesn’t CVP change during exercise?

A

Compensatory mechanisms of skeletal muscle pump and respiratory pump - Promotes increased venous return, so CVP doesn’t need to increase

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16
Q

Constant muscle length (no change) against a force or tension?

A

Isometric exercise

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17
Q

Examples of isometric exercise?

A
  1. Holding a weight in a fixed position
  2. Pushing against a door frame
  3. Hangrip
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18
Q

What happens to SBP/DBP during isometric exercise?

A

Both increase significantly

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19
Q

What happens to SBP/DBP during isotonic exercise?

A
  1. SBP increases

2. DBP remains relatively unchanged (within 10mmHg of resting DBP)

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20
Q

What is the increase in SBP during isotonic exercise attributable to?

A

Increased CO despite reduction in total systemic resistance

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21
Q

What is the relationship between HR and VO2 max?

A

Linear until max workload achieved

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22
Q

Typical max HR for an adolescent?

A

195-215

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23
Q

Normal VO2 max?

A

35-45

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24
Q

Accepted max HR for patients 5-20 years?

A

195-215bpm

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25
Q

Accepted max HR for patients >20 years?

A

210 - (0.65 * age)

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26
Q

Difference in maximal RR, tidal volume and minute ventilator at peak exercise as child ages?

A
  1. RR decreases
  2. TV increases
  3. MVe increases
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27
Q

How does minute ventilation in exercise increase?

A
  1. Increase in ventilation frequency

2. Increase in tidal volume

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28
Q

Change in SV, resting HR, max HR and CO with improved fitness?

A
  1. Increased SV
  2. Decreased resting HR
  3. No change to max HR
  4. Increase CO
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29
Q

With conditioning, what causes decrease in resting HR?

A
  1. Increased SV

2. Increased vagal tone at rest

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30
Q

True or False: In the same subject, a higher VO2 mx can be achieved with treadmill testing compared to cycle testing?

A

True

-More muscle groups used when exercising on a treadmill versus cycle

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31
Q

What is the standard unit of work?

A

Joule

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32
Q

What is VO2 max?

A

VO2 reached when it plateaus

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33
Q

Do most centers use isotonic or isometric exercise-testing protocols?

A

Isotonic

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34
Q

What conditions are a contraindication for exercise testing?

A
  1. Severe pulmonary HTN
  2. Acute MI (fragile myocardial tissue)
  3. Acute rheumatic fever (fragile myocardial tissue)
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35
Q

True or False: History of MI or rheumatic fever are contraindications to exercise testing?

A

False

-Can’t test in acute period, but history of this should have testing to assess fatigue or exercise intolerance

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36
Q

What happens to resting HR, max HR and VO2 max for someone who is deconditioned?

A
  1. Resting HR increases
  2. VO2 max decreases
  3. Max HR doesn’t change
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37
Q

What does is mean is someone doesn’t achieve max HR during exercise testing?

A
  1. Submaximal effort

2. Patient has chronotropic insufficiency

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38
Q

During incremental exercise, what is ventilator anaerobic threshold reflective of?

A

Onset of anaerobic metabolism

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39
Q

When does ventilator anaerobic threshold occur during exercise?

A

At point where there is disproportionate increase in minute ventilation relative to O2 uptake

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40
Q

What does the disproportionate increase in minute ventilation relative to O2 uptake result in?

A

Increased expiration of mixed oxygen concentration

-Can see disproportionate increase in lactate in adults

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41
Q

When does decompensated acidosis occur during exercise?

A

After the ventilator anaerobic threshold has occurred

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42
Q

A cyanotic patient at peak exercise will have a higher ___ compared to an aycanotic patient?

A

Ventilator equivalent for oxygen

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43
Q

What is minute ventilation divided by oxygen uptake?

A

Ventilator equivalent for oxygen

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44
Q

What is a major determinant of increased ventilator equivalent for oxygen in cyanotic patients?

A

Presence of large R-L shunting

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45
Q

What happens to minute ventilation for cyanotic patients at peak exercise?

A

Increase minute ventilation disproportionately to oxygen uptake

-Results in a higher ventilator equivalent for oxygen than acyanotic patients

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46
Q

True or False: SpO2 and VO2max are lower in cyanotic patients that acyanotic patients?

A

True

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47
Q

Which exercise protocol involves small, frequent increases of workload?

A

Bruce and “modified” bruce

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48
Q

Which protocol involves cycle ergometry with large increments of workload?

A

James

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49
Q

Which treadmill protocol uses a constantly increasing workload?

A

Ramp treadmill protocol

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50
Q

What is a disadvantage of the ramp treadmill protocol?

A

Doesn’t allow assessment of steady-state exercise due to constant change in workload

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51
Q

What happens to Ve/VO2 in early exercise?

A

Decreases

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52
Q

Why does Ve/VO2 decrease in early exercise?

A

Pulmonary blood flow increases and resting V/Q mismatch is reduced- More uniform perfusion of lungs and ventilation

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53
Q

What happens to Ve/VO2 when the ventilator anaerobic threshold is reached?

A

Decreases

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54
Q

What happens to minute ventilation, respiratory rate and tidal volume with increased work?

A
  1. Ve increases
  2. RR increases
  3. TV increases
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55
Q

What happens with age to minute ventilation, max respiratory rate and tidal volume with increased work?

A
  1. Ve increases
  2. Max RR decreases
  3. TV increases
56
Q

What causes normal patients to terminate exercise?

A

CO can no longer increase

-There is typically still ventilator reserve available

57
Q

What is acetylene-helium exercise testing dependent upon?

A

Even distribution of inspired gas in the lung

58
Q

What technique is used to measure CO indirectly by measuring effective pulmonary blood flow in the absence of significant intracardiac shunts?

A

Acetylene-helium rebreating

59
Q

What exercise testing technique isn’t reliable for CO measurement in patients with lung disease that involves mismatching of ventilation and perfusion?

A

Acetylene-helium

60
Q

Sphygmomanometer cuff should have a bladder length that covers what % of the circumference of the upper arm and what % width of the upper arm?

A

80% circumference

40% width

61
Q

What happens to VO2 max and Ve with improved fitness?

A

Both increase

62
Q

Does ability to achieve max HR and BP limit with deconditioning?

A

No

63
Q

When is max voluntary ventilation obtained?

A

At rest

64
Q

What is max voluntary ventilation dependent on?

A

Patient effort

-Use cautiously when suggesting pulmonary limitation

65
Q

What value is max voluntary ventilation?

A

35-40x patient effort

66
Q

At the point of exercise termination in a normal patient, Ve is what % of MVV?

A

60-70%

67
Q

In a patient with lung disease and pulmonary limitation, the achieved Ve is what % of MVV?

A

Can be >70%

-Tap into ventilator reserve

68
Q

What is a more accurate method of assessing pulmonary limitation to exercise besides MVV?

A

Tidal flow-volume loops

69
Q

What testing has the advantage of assessing vocal cord dysfunction?

A

Tidal flow-volume loops

70
Q

True or False: African American children have a higher blood pressure response to exercise when compared to Caucasian children?

A

True

71
Q

True or False: Size of a child has no impact on blood pressure response to exercise

A

False- Larger sized children have a higher blood pressure response when compared to smaller sized children

72
Q

Which gender (if similar sized patient) has a higher blood pressure response to exercise?

A

Boys

73
Q

How does CO increase during exercise?

A

Increases in HR and SV

74
Q

What happens to end-systolic volume during exercise?

A

Decreases

75
Q

What happens to diastolic BP during isotonic exercise?

A

Stable (change <10mmHg)

76
Q

What happens to DBP during isometric exercise?

A

Increases

77
Q

BP increases during exercise predominantly occur by what?

A

Increased CO

78
Q

What happens to total systemic resistance during exercise?

A

Decreases

79
Q

What test is used to measure CO indirectly by measuring effective pulmonary blood flow in the absence of significant intracardiac shunts?

A

Acetylene-helium rebreathing technique

80
Q

What is the acetylene-helium rebreathing technique dependent on?

A

Even distribution of the inspired gas throughout the lung

81
Q

What types of patients is acetylene-helium rebreathing as a measure of CO not reliable in?

A
  1. Lung disease with VQ mismatch

2. Significant intracardiac or intrapulmonary shunts

82
Q

During exercise stress testing, what direct measurement can be determined by using acetylene-helium rebreathing technique?

A

Effective pulmonary blood flow

83
Q

True or False: Acetylene-helium rebreathing is well tolerated by children?

A

True (non-invasive technique)

84
Q

What does the acetylene-helium rebreathing estimate?

A

CO (it directly measures effective pulmonary blood flow)

85
Q

How does acetylene-helium rebreathing work?

A
  • Acetylene diffuses from the alveolus into the pulmonary capillary blood
  • Acetylene concentration declines relative to volume of effective pulmonary blood flow
86
Q

In a healthy, normal child, what organ system is most commonly responsible for limiting maximal achievable workload?

A

Cardiovascular

87
Q

When is maximum CO achieved?

A

When max HR limits ventricular filling during diastole and in turn stroke volume?

88
Q

How long can a well-fit patient exercise at their max HR?

A

1-2 minutes

89
Q

True or False: The pulmonary system in a normal, healthy child won’t limit exercise capacity

A

True

90
Q

Minute ventilation and work have a linear relationship until what is achieved?

A

Ventilator anaerobic threshold

91
Q

What happens to minute ventilation and work at the ventilator anaerobic threshold?

A

Disproportionate increase in Ve relative to VO2

92
Q

At the point of exhaustion, Ve is what % of the maximum ventilation volume?

A

60-70%

93
Q

What is the equation for work?

A

Work = Force * Distance

94
Q

What is the force needed to move a mass a given distance?

A

Work

95
Q

What is the unit for work?

A

Newton-meter or joule (J)

96
Q

What is the equation for Force?

A

Force = Mass * Acceleration

97
Q

What is the equation for Power?

A

Work performed per unit of time

98
Q

For patients ages 5-20, what is the estimated HR max?

A

195-215bpm

99
Q

What happens to the max HR for patients >20?

A

It decreases with increasing age

100
Q

Equation for Max HR?

A

Max HR: 210 - (0.65*age)

101
Q

Why does max HR decrease with age?

A

Unclear… may be due to fibrosis and scarring of the SA node

102
Q

Describe change in SV with exercise?

A

Increases early, then little change thereafter

*HR continues to increase which accounts for increasing CO

103
Q

What happens to total SVR with exercise?

A

Decreases

104
Q

For isotonic exercise, what happens to SBP and DBP?

A

SBP increases, DBP remains unchanged

105
Q

For isometric exercise, what happens to SBP and DBP?

A

Both rise

106
Q

What is VO2 max dependent on?

A 
Age
Sex
Ethnicity
Hgb level
Type of work
107
Q

What happens to Max VO2 with increasing age?

A

Increases

108
Q

Describe relationship between gender for VO2 max

A

Before puberty: Same

After puberty: Males have higher VO2 max

109
Q

What happens to VO2 max in patients with anemia?

A

Lower

110
Q

What type of work results in a higher VO2 max?

A

Highest: Treadmill ergometry
Cycle ergometry
Arm crank ergometry
Lowest: Hand grip ergometry

*More muscle groups involved = Higher VO2 max

111
Q

Describe HR, SV, LVEDD and LVESD for a well-trained athlete

A

HR decreases
SV increases at rest and max HR
Increased LVEDD
Decreased LVESD

112
Q

True or False: Severe AS is an absolute contraindication to exercise testing?

A

True

113
Q

Describe pros/cons of treadmill v. cycle ergometry

A
  • Neither treadmill nor cycle ergometry is superior to the other
  • Treadmill allows higher VO2 max (more muscle groups during exercise)
  • Most people can walk efficiently but not everyone can cycle efficiently
  • Treadmill is potentially more dangerous due to potential of falling
  • Treadmill with more noise and artifact
  • More accurate and controlled measurement of work can be obtained with cycle
114
Q

In aortic stenosis, what is the relationship between work performed and transaortic pressure gradient?

A

Total work performed has an inverse relationship with transaortic pressure gradient

115
Q

What can exercise testing be helpful to determine in mild-mod AS?

A
  1. Significant ST segment changes

2. Distinguish between chest wall pain or more concerning cause

116
Q

True or False: Patients with more severe AS (higher transaortic gradient) have a lower increase in BP response during exercise than less severe AS patients

A

True

117
Q

True or False: The lower the transaortic gradient, the more likely ST segment changes will occur

A

False

118
Q

True or False: Patients with more severe AS achieve a lower VO2 max

A

True

119
Q

What happens to the maximum aerobic power and ventilation relative to VO2 for unrepaired single ventricle patients?

A
  • Reduced maximal power

- Excessive ventilation relative to VO2

120
Q

True or False: Unrepaired single ventricle patients have decreased total work, maximal power achieved, exercise time and maximal oxygen uptake when compared to 1st stage repaired or complete repair patients as well as normal patients

A

True

121
Q

What happens to SpO2 in unrepaired and stage 1 single ventricle patients during exercise?

A

Significantly decrease

122
Q

What happens to SpO2 in complete repair for single ventricle patients during exercise?

A

May have small decrease

*Similar to normal, healthy patients who have little to no decrease with exercise

123
Q

When should ECGs be obtained during exercise testing?

A

At rest sitting, supine and standing then at each workload and peak exercise as well as each minute of recovery (1-5)

124
Q

What kind of rhythm strip should be running during exercise testing?

A
  • At least 3 standard surface ECG leads during the study and for 5-10 minutes after the study completed
  • Should have the option of switching between various combinations of leads
125
Q

What is important to do to limit artifact during exercise testing?

A

Appropriate ECG electrode and lead placement… cleansing/abrading, electrode paste, ECG lead cable securing with elastic band/knit shirt

126
Q

True or False: BP can be difficulty to measure accurately during exercise testing?

A

True- especially diastolic BP

127
Q

What happens to BP if you use an a-line during exercise testing?

A

Overestimate central aortic pressure due to peripheral amplification

128
Q

Compared to an aycanotic patient, a cyanotic patient at peak exercise will exhibit higher…?

A

Ventilatory equivalent

129
Q

Why do cyanotic patients have a higher ventilatory equivalent at peak exercise?

A

R-L shunt results in increased dead space… they over-ventilate to remove additional CO2

*Ventilation is disproportionately high relative to VO2

130
Q

What are the 2 rebreathing techniques used most frequently to measure CO non-invasively?

A
  1. CO2 rebreathing technique

2. Acetylene-Helium rebreathing technique

131
Q

What is the CO2 rebreathing technique based on?

A

Fick principle CO2

132
Q

What are 2 ways to get the arterial CO2 content needed in the CO2 rebreathing technique?

A
  1. Directly measured from systemic arterial blood pCO2

2. Noninvasively using the Bohr equation

133
Q

What is this equation?

VD/VT = (PaCO2-PeCO2)/PaCO2

A

Bohr equation

134
Q

Why isn’t the CO2 rebreathing technique tolerated (especially by children)?

A

Can cause dyspnea, unpleasant taste and transient headache

135
Q

What are 2 areas for error of with CO2 rebreathing technique?

A
  1. Adjust CO2 concentration for patient’s size/exercise intensity
  2. Take into account dead space

Peds Cardiology (20 decks)

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