KINS-153
Part#1 Graded & Cardiopulmonary Exercise Testing
Clinical cardiovascular testing is a useful tool to screen individuals with potential CAD (diagnosis) and to
assess cardiovascular function and fitness (prognosis). Cardiorespiratory capacity testing (VO2max or peak) is a
skill that requires both experience and knowledge (ACSM Box 5-3). The validity of a cardiovascular test
requires an experienced technician to administer the test correctly under proper ACSM guidelines (ACSM
Table 5-2). Knowledge of the cardiovascular response to exercise allows for the correct interpretation of the
test and subsequent exercise prescription.
One important factor in GXT and CPX is proper selection of a proper exercise protocol. An exercise test
should begin only after a proper warm-up (exercise for 5-15 min at 25% of VO2 max) and last 8-12 minutes.
If the test is too long or too short in duration peripheral muscle fatigue may limit the subject from achieving
a true VO2 max test. Therefore, the workload increments and duration of each increment must be chosen
carefully to allow the test to last approximately 10 minutes. It is important to start a workload that is
approximately 50% of the lactate threshold (LT). If the workload is too high at the start the subject may
fatigue prematurely before attainment of a VO2 max due to the large O2 deficit occurred and the increased
acidity caused by glycolysis and lactate production. How do you go about selecting proper workload
increments and duration of each stage? Workload increments of 1-2 minutes are usually chosen since they
allow for small workload increments and keep the test within 10 minutes. A good way to calculate
workloads is to predict the VO2 max based on normative tables and physical activity. Once VO2 max is
predicted, back calculate to determine the max workload (Table 4.7, Figure 5.4-5.5, Table 6.3 & Figure 6.1).
Once this is determined you calculate the 5 workload increments. An example of a good protocol is the
Naughton protocol which utilizes 2 min stages and even workload increments. However, in most clinical
settings the Bruce protocol is often employed which utilizes 3 min stage and large/uneven workload
increments!!!
Another important factor to choose small and even workload increments during a CPX is the determination
of the ventilation threshold (VThreshold ) and LT. The determination of these thresholds is dependent on small
even workloads. This allows precise determination on thresholds as a percentage of VO2max. However,
workloads must be adjusted accordingly when using GXT data as a basis for exercise prescription since GXT
workloads are not representative of steady state exercise conditions.
Therefore, the purpose of this laboratory is to become familiar with clinical graded exercise testing and
cardiovascular responses to a VO2 max test.
Procedures (Refer to Chapter 5 especially Table 5-2 & Box 5-2, 5.4)
The laboratory will consist of designing proper VO2 max exercise protocols based on your client’s Medical History (see ACSM
pgs 121). Each student will be tested on the treadmill. HR, BP, RPE, signs and symptoms (SS) must be recorded manually
for each test!
For the exercise test we must have a recorder (BP, HR, RPE, SS), an EKG technician, an ergometer/treadmill technician, a
metabolic technician, and BP/RPE technician. When administering the test you must follow ACSM testing procedures and
guidelines. The procedures are outlined in chronological order and must be adhered when performing a clinical exercise test (See
an ACSM GXT outline of procedures on next page).
General Open Circuit GXT Procedures
1) Open Circuit Gas Analysis Procedures for a VO2max test
2) Turn on Metabolic Gas Analyzers, Pneumotach Heater/Pump switch, & Computer (30 min lead warmup)
3) Calibrate the CO2, O2 analyzers and pneumotach before test with calibration gases and volume syringe
4) Use a protocol listed in ACSM (pgs 121) or develop your own exercise protocol based on subject’s physical activity and
predicted VO2max. Write this protocol down on GXT data sheet.
5) Enter subject and room environment data into PARVO by clicking on VO2/Metabolic Testing. Once complete hit OK and
select NO COMPUTER CONTROL.
6) Prepare the two way valve, head support piece, mouth piece, & noseclips
7) Prepare ECG supplies
8) Prep subject for ECG (see ECG lab)
9) Take 2 resting BP and 12 lead ECG (see ACSM procedures next page)
10) Place subject on treadmill or bike. Give instructions and adjust headgear, valve, tubing, and noseclip.
11) Make sure it is positioned properly and tighten sufficiently.
12) Attach the gas hose to the expired side of valve.
13) Place nose clip on subject with piece of gauze/tape secured underneath noseclip
14) Have the subject rest and check CO2% on PARVO.
15) If CO2, >3.00%, start treadmill or bike & increase workload until your reach the first stage (speed & grade or RPM & Force)
16) Once you reach 1st stage workload, start GXT, TIMER & Parvo by clicking on OK.
17) During the GXT record the RPE, ECG, Speed/Grade or Force/RPM based on ACSM procedures (see next page)
18) When the subject stops exercise:
a) Stop treadmill and reduce grade or reduce bike resistance
b) Hit test end on metabolic cart
c) Record the maximum values for the data: BP, ECG, RPE, S/S & Workload
d) Remove the subject’s headpiece and valve. Be careful not to spill saliva!!
19) Afterward have subject perform an “active” recovery or warm-down
20) Record ECG, HR, and SS during recovery based on ACSM Procedures (see next page)
21) Increase the speed and grade of treadmill or resistance until RPE reaches an “8”
22) Stop recovery when HR and BP approach resting conditions (minimum of 6 min of active recovery).
23) Turn off the pumps to analyzers and remove the ECG/BP. Clean up exercise station.
24) Clean two way valve mouthpiece, & nosepiece by disassembling and rinsing with soap/water then placing in the Germicide
Solution for 20 min. Rinse afterward 3x times in a bowl of water then place in drying rack (small room sink).
25) Clean the gas hose by draining it then spraying each end with bleach then rinse with water hang to dry on rack with paper
towels in each end (main lab sink).
26) Clean the headgear, sweat pad, and grey rubber stopper with Lysol cleaning solution. Rinse well and place in drying rack
(main lab sink)
27) Clean BP, ECG belt, and Exercise equipment with Lysol or alcohol spray. Rinse well and leave on back counter with paper
towels underneath to dry (main lab sink).
28) Use a USB drive to download the VO2max data from Parvo Metabolic computer
29) Collect ECG printouts and Data Collection sheet.
Informed Consent and Subject Medical History
___ Pre-participation Screening (ACSM)
___ Informed Consent
___ Subject Information & Medical History (Ht, Wt & Lipid Profile)
___ Vital Signs (HR + BP)
___ Pre-exercise Evaluation (ACSM)
___ Time 15 minutes
Incremental Exercise Test
Exercise Supplies & Equipment (can be done prior to arrival of patient)
___ BP Cuff, Stethoscope, Tape, ECG prep pads, Electrodes
___ Exercise data sheet with protocol
___ Data entered into ECG & Metabolic System
___ Valve built properly with tubing, noseclip, & headgear
___ Time 5 minutes
ECG Preparation for Exercise Test
___ Explanation of EKG
___ EKG preparation & correct anatomical location
___ ECG lead wire connections
___ Lead artifact check
___ Time 20 minutes
Rest measurements
___ BP cuff size and placement
___ BP manometer inflation & deflation
___ BP reading
___ Supine and exercise positions (EKG, HR & BP)
___ ECG belt placement & taping of leads
___ Quality of 12 lead EKG tracing
___ Time 5 minutes
Pre-Exercise Instructions/checks
___ General explanation of a VO2 max test
___ Treadmill instructions (stepping on/off TM)
___ Explanation of RPE
___ Explanation of test termination criteria (ie volitional fatigue, SS, Requests to Stop)
___ Explanation of test termination signals (ie cut throat, placing hands on both handrails)
___ Check CO2 measurement for accuracy (>3.00%)
___ Time 5 minutes
Exercise Measurements
___ Workload Adjustments
___ EKG monitoring continuously
___ HR recorded last 5 secs of every min
___ EKG (12 lead & if necessary 3 lead rhythm) last 15 secs of every stage or every 2 min if ramp
___ BP monitoring last 45 secs for every stage or every 2 min if ramp
___ BP (correct technique and measurement w/it 45 sec)
___ RPE last 5 secs of every stage
___ Signs & Symptoms continuously & recorded as observed
___ Test ended in a safe manner (hit treadmill stop button no jumping off treadmill)
___ Test termination measurements (BP, EKG, RPE) within 10 secs of end of test
___ Time 20 minutes
Recovery Measurements
___ Active/non-active recovery & proper workloads (restarting of treadmill or supine recovery)
___ EKG @ 60 secs & every 2 min
___ HR last 5-10 secs of every min
___ BP @ 60s & every 2 min min
___ Signs & Symptoms continuously
___ End recovery (HR & BP approach resting levels or alleviation of SS)
___ Time 10 minutes
Post-Exercise
___ Post-Exercise Congratulations!
___ Removal of ECG wires/monitor, electrodes, & valve/noseclip headgear
___ Clean & Disinfect: nose clip, 2-way valve, tubing, headgear, BP cuff plus TM
___ Return equipment to proper location
___ Time 10 minutes
Data Analysis:
VO2peak or VO2max
1) Graph the VO2 values (y-axis) for each stage.
2) Determine whether the subject reach a VO2peak or a VO2max
Y or N: a plateau in VO2 with increasing workload (strong validity)
(< 2 ml O2/kg/min increase with workload)
Y or N: Volitional Exhaustion (complete exhaustion) (strong validity)
Y or N: RER > 1.10 – 1.15 (weak validity) RER > 1.05 is sufficient (strong validity)
Y or N: RPE > 17 (weak validity)
Y or N: HR: Plateau in HR with increasing workload (weak validity)
3) Symptom limited Test: Y or N: Describe S/S:____________________________________________
_________________________________________________________________________________
4) Interpret VO2max/peak values: ______% and description __________________________________
5) VO2max/peak Interpretation:____________________________________________________________
_________________________________________________________________________________
6) VO2max & peak power : _________________ HRmax/peak direct: _______ BPmax/peak: _______
Estimated VO2max vs VO2peak or VO2max
7) HRmax estimated Error = HRmax Direct _________ - HRmax Estimated _________ = _________bpm
HRmax estimated % Error = HRmax estimated _________%
8) VO2max Estimated Error
VO2max Estimated (See Table 6.3) based on last completed GXT stage
VO2max Estimated =__________________________________________________________________
VO2max Estimated Error = VO2max/peak_________ - VO2max estimated (WL) _________ = ____mL/min/kg
VO2max Estimated % Error = VO2max Estimated _________%
Recovery
9) HR recovery at 1 min=___HR max - ___HR@1min Recovery= ___ BPM
Abnormal findings
10)
Rest (Circle): ECG Rate - ECG Rhythm - ECG Intervals - ECG ST Depression - ECG Other – BP - S/S
Describe:___________________________________________________________________
Exercise (Circle): ECG Rate - ECG Rhythm - ECG Intervals - ECG ST Depression - ECG Other – BP - S/S
Describe:___________________________________________________________________
Recovery (Circle): ECG Rate - ECG Rhythm - ECG Intervals - ECG ST Depression - ECG Other – BP - S/S
Describe:___________________________________________________________________
Discussion - Questions (Refer to Chapter 5)
1) Did the client have a normal EKG at rest, during exercise and post exercise?
2) What was the clients max HR and how did the HR recover? Did it demonstrate chronotropic
incompetence or an abnormal HR recovery? What is the significance of these two conditions?
3) Did the client have a normal BP response to exercise and recovery? Why are Sbp and Dbp interpreted
differently?
4) Did the client have normal or abnormal test? Interpret your clients VO2 max or peak based on Table 4.7
& Figure 5-4 or 5.5? How does it compare to average values? What would be an ideal VO2 max?
5) What was the error in estimating Vo2max off workload (WL) compared to directly measured VO2max?
HUMAN PERFORMANCE RESEACH LABORATORY
EXERCISE DATA COLLECTION SHEET
Name____________________ Age___________ Gender___________ Date_________
Ht__________ cm Wt___________ kg Predicted MaxHR____________ Treadmill_____ Cycle Ergometer______
Min Stage Speed/RPM Grade/Kg/W Heart Rate ECG BP RPE Other______
REST 0 0 0 _____ ________ _____ _____ _____
REST 0 0 0 _____ ________ _____ _____ _____
1 __ _____ _____ _____ ________ _____ _____ _____
2 __ _____ _____ _____ ________ _____ _____ _____
3 __ _____ _____ _____ ________ _____ _____ _____
4 __ _____ _____ _____ ________ _____ _____ _____
5 __ _____ _____ _____ ________ _____ _____ _____
6 __ _____ _____ _____ ________ _____ _____ _____
7 __ _____ _____ _____ ________ _____ _____ _____
8 __ _____ _____ _____ ________ _____ _____ _____
9 __ _____ _____ _____ ________ _____ _____ _____
10 __ _____ _____ _____ ________ _____ _____ _____
11 __ _____ _____ _____ ________ _____ _____ _____
12 __ _____ _____ _____ ________ _____ _____ _____
13 __ _____ _____ _____ ________ _____ _____ _____
14 __ _____ _____ _____ ________ _____ _____ _____
15 __ _____ _____ _____ ________ _____ _____ _____
16 __ _____ _____ _____ ________ _____ _____ _____
17 __ _____ _____ _____ ________ _____ _____ _____
18 __ _____ _____ _____ ________ _____ _____ _____
19 __ _____ _____ _____ ________ _____ _____ _____
20 __ _____ _____ _____ ________ _____ _____ _____
21 __ _____ _____ _____ ________ _____ _____ _____
REASON FOR TEST TERMINATION:
GXT SIGNS/SYMPTOMS/EVENTS/COMMENTS:
GXT ECG FINDINGS:
OTHER FINDINGS:
Part#2
ACSM Exercise RX based on CPX/GXT Testing
A) Based on your CPX/GXT test, plot figures of:
VO2 vs %VO2max/peak
HR vs VO2%
RPE vs VO2%.
S/S vs VO2%
You will use these figures for the basis for C and D.
B) Direct HRmaxpeak:_______
VO2max Power/peak:___________MPH-Grade VO2max/peak:_______mL/min/kg
% Ranking:___________ Fitness level:___________ S/S Limitation:___________
Healthy or Unhealthy:___________
Unhealthy: ECG - BP - S/S – VO2max/peak (circle type occurred & explaination):
_____________________________________________________________________
_____________________________________________________________________
Recommended VO2max/peak:_________________________________________
B) Describe the components of individual exercise session in general terms (enter actual VO2, HR, RPE values):
Warm-up
Conditioning
Cool-down
Stretching
D) Determine ACSM Recommended Cardiorespiratory FITT-VP based on your current
fitness level
Initial 4-6 wks
a. First select activity (mode) and set an energy expenditure (kcal) initial goal
Energy Expend (kcal) goal per week:_______________ Frequency:_______________
EE per day:___________________________kcal per day
b. List the appropriate recommended ACSM intensity of exercise using
%VO2 range:__________________________
%HRmax range:________________________
RPE range:____________________________
c. Mode: Treadmill (Select Walking or Running)
Speed of treadmill at 2% Grade:___________to _____________MPH
Mode: Bike
Workload:___________to _____________Kgm/min or W
RPM_______ Force: _______to_______Kg
d. Energy Expenditure (EE) :___________________kcal per min
e. Daily Duration:________________________min per frequency
f. Weekly Duration:______________________min per week
g. Weekly Increase per week:_______________min per week
h. Daily Steps per day:_____________________
Post 4-6 wks to > 4-8 months
i. First select activity (mode) and set an energy expenditure (kcal) initial goal
Energy Expend (kcal) goal per week:_______________ Frequency:_______________
EE per day:___________________________kcal per day
j. List the appropriate recommended ACSM intensity of exercise using
%VO2 range:__________________________
%HRmax range:________________________
RPE range:____________________________
k. Mode: Treadmill (Select Walking or Running)
Speed of treadmill at 2% Grade:___________to _____________MPH
Mode: Bike
Workload:___________to _____________Kgm/min or W
RPM_______ Force: _______to_______Kg
l. Energy Expenditure (EE) :___________________kcal per min
m. Daily Duration:________________________min per frequency
n. Weekly Duration:______________________min per week
o. Weekly Increase per week:_______________min per week
p. Daily Steps per day:_____________________
