Cardiopulmonary Exercise Testing in Children and Adolescents

Preface
Notice and Disclaimer

Part I: Introduction

Chapter 1: Clinical Applicability of the Pediatric Exercise Test

Thomas W. Rowland

Development of Pediatric Exercise Testing

Unique Features of Exercise Testing in Children

Normative Values

Adjusting Values for Body Size

Tyranny of “Maximal” Testing

Safety of Clinical Exercise Testing

Conclusion

Chapter 2: Conducting the Pediatric Exercise Test

Amy Lynne Taylor

Pediatric Exercise Laboratory Environment and Equipment

Optimizing Safety 

Preparing the Child for an Exercise Test

Test Communication

Conclusion

Part II: Exercise Testing Methodology

Chapter 3: Exercise Testing Protocols 

Richard J. Sabath III, David A. White, and Kelli M. Teson

Exercise Testing Modality 

Protocol Design

Treadmill Protocols

Cycle Ergometer Protocols

Multistage Versus Ramp Protocols

Six-Minute Walk Test

Maximal Test Criteria

Scope of Pediatric Exercise Testing

Conclusion

Chapter 4: Normal Cardiovascular Responses to Progressive Exercise

Thomas W. Rowland

Reductionist’s Disclaimer

Historical Context

Empirical Evidence

Synthesis

Physiological Basis of Cardiovascular Fitness

Conclusion

Chapter 5: Exercise Electrocardiography

Thomas W. Rowland

Effects of Exercise on the Cardiac Conduction System

ECG Setup and Monitoring

Measuring Heart Rate

Identifying Heart Block

Detecting Arrhythmias

Detecting Ischemia

Evaluation of Prolonged QT Interval

Risk Stratification With Ventricular Pre-Excitation

Conclusion

Chapter 6: Blood Pressure Response to Dynamic Exercise

Bruce Alpert and Ranjit Philip

Basic Physiology of Exercise Blood Pressure 

Technical Aspects of Blood Pressure Measurement 

Normal Blood Pressure Response to Dynamic Exercise in Healthy Children

When to Terminate Exercise Testing Based on Blood Pressure Response

Prognostic Value of Exercise BP Testing

Special Conditions

Interpretation of Results

Conclusion

Chapter 7: Maximal Oxygen Uptake

Ali M. McManus and Neil Armstrong 

Physiological Responses to Aerobic Exercise

Measuring Maximal Oxygen Uptake in Children

Developmental Patterns in Maximal Oxygen Uptake

Normal Values

Conclusion

Chapter 8: Other Measures of Aerobic Fitness

Robert P. Garofano

Peak Workload 

Ventilatory Anaerobic Threshold

Submaximal Testing Protocols

Oxygen Uptake Efficiency Slope

Conclusion

Chapter 9: Cardiac Output Measurement Techniques

Darren E.R. Warburton and Shannon S.D. Bredin

Invasive Versus Noninvasive Techniques

Direct Fick Method 

Dye-Dilution Method

Thermodilution Method

Lithium Dilution Method

Foreign Gas Rebreathing Techniques

Doppler Echocardiography

Impedance Cardiography

Arterial Pulse Contour Method

Conclusion

Chapter 10: Assessing Myocardial Function

Thomas W. Rowland

Systolic Time Intervals

Radionuclide Exercise Testing

Pattern of Stroke Volume Response

Oxygen Pulse

Doppler Echocardiographic Techniques During Exercise

Stress Echocardiography

Conclusion

Chapter 11: Pulmonary Function

Patricia A. Nixon

Protocols

Pulmonary Function at Rest and During Exercise

Asthma

Cystic Fibrosis

Conclusion

Part III: Exertion-Based Applications

Chapter 12: Congenital and Acquired Heart Disease

Michael G. McBride and Stephen M. Paridon 

Factors Affecting Exercise Performance

Exercise Testing

Simple Two-Ventricle Defects

Obstructive Lesions

Complex Two-Ventricle Defects

Single-Ventricle Physiology

Primary Arrhythmias and Channelopathies

Acquired Heart Disease and Cardiomyopathies

Conclusion

Chapter 13: Exercise-Induced Dyspnea

Steven R. Boas 

Differential Diagnosis

Evaluation

Exercise Testing

Conclusion 

Chapter 14: Chest Pain With Exercise

Julie Brothers 

Differential Diagnosis

Evaluation 

Exercise Testing

Conclusion

Chapter 15: Presyncope and Syncope With Exercise

Julie Brothers

Differential Diagnosis

Evaluation 

Exercise Testing

Conclusion

Chapter 16: Exercise Fatigue

Thomas W. Rowland

Differential Diagnosis

Evaluation 

Exercise Testing

Conclusion

Part IV: Testing Special Populations

Chapter 17: Pectus Excavatum

Thomas W. Rowland

Physiological Implications

Surgical Results

Cardiopulmonary Testing

Conclusion

Chapter 18: Obesity

Laura Banks and Brian W. McCrindle

Quantifying Childhood Obesity

Physiological Adaptations 

Effects of Obesity on Physiologic Measures 

Cardiopulmonary Exercise Testing Modifications 

Conclusion

Chapter 19: Intellectual Disability

Bo Fernhall and Tracy Baynard

Physiological Implications 

Exercise Testing

Conclusion

Chapter 20: Neuromuscular Disease

Olaf Verschuren, Janke de Groot, and Tim Takken

Cerebral Palsy

Duchenne and Becker Muscular Dystrophy

Conclusion

References
Index
About the Editors
About the Contributors

Exercise testing plays an increasingly important role in the diagnosis and assessment of heart disease and lung disease in children and adolescents. In Cardiopulmonary Exercise Testing in Children and Adolescents, leading expert Thomas W. Rowland, backed by the American College of Sports Medicine (ACSM) and the North American Society for Pediatric Exercise Medicine (NASPEM), compiles the latest evidence-based research to provide guidance for clinical exercise physiologists, cardiologists, pulmonologists, and students of exercise physiology who conduct exercise stress testing for young patients.

The core objective of the book is to clarify the differences between clinical exercise testing for children and testing for adults. Because of obvious differences between the two populations, test protocols must be modified based on the patient’s age, size, level of physical fitness, body composition, intellectual and emotional maturity, and state of cardiac and pulmonary health.

Part I provides an introduction to pediatric exercise testing. Part II examines exercise testing methodologies and discusses blood pressure, cardiac output, electrocardiography, oxygen uptake, and pulmonary function. Part III focuses on specific clinical issues addressed by exercise testing, guiding readers through protocols for diagnosis, evaluation, and exercise testing. Part IV explores testing in special populations and focuses on topics such as childhood obesity, neuromuscular disease, and intellectual disabilities.

Where applicable, sample forms and checklists provide practitioners with practical materials to use during exercise testing. Sidebars offer readers insight into considerations such as the presence of parents during testing and adjustments of cardiac measures for youth body dimensions.

This book serves as a means of focusing and unifying approaches to performing pediatric exercise testing in order to lay the foundation for new and innovative approaches to exercise testing in the health care of children and adolescents.

Thomas W. Rowland, MD, is a pediatric cardiologist at Baystate Medical Center in Springfield, Massachusetts, and a professor of pediatrics at Tufts University School of Medicine. A graduate of the University of Michigan Medical School, Rowland is board certified in pediatrics and pediatric cardiology by the American Board of Pediatrics.

Rowland, who has had more than 150 journal articles published, is the author of four books: Biologic Regulation of Physical Activity; Children’s Exercise Physiology, Second Edition; Tennisology: Inside the Science of Serves, Nerves, and On-Court Dominance; and The Athlete’s Clock. He has served as editor of the journal Pediatric Exercise Science and as president of the North American Society for Pediatric Exercise Medicine (NASPEM) and was on the board of trustees of the American College of Sports Medicine (ACSM). He is past president of the New England chapter of the ACSM and received the Honor Award from that organization in 1993.

Rowland is a competitive tennis player and distance runner. He and his wife, Margot, reside in Longmeadow, Massachusetts.

The American College of Sports Medicine (ACSM), founded in 1954, is the largest sports medicine and exercise science organization in the world. With more than 50,000 members and certified professionals worldwide, ACSM is dedicated to improving health through science, education, and medicine. ACSM members work in a wide range of medical specialties, allied health professions, and scientific disciplines. Members are committed to the diagnosis, treatment, and prevention of sport-related injuries and the advancement of the science of exercise.

The ACSM promotes and integrates scientific research, education, and practical applications of sports medicine and exercise science to maintain and enhance physical performance, fitness, health, and quality of life.

The North American Society for Pediatric Exercise Medicine (NASPEM), founded in 1985, is a professional organization whose membership is composed of medical doctors, researchers, educators, and students interested in pediatric exercise. NASPEM is dedicated to the mission of promoting exercise science, physical activity, and fitness in the health and medical care of children and adolescents. That mission is accomplished in part through scientific meetings, a scholarly journal (Pediatric Exercise Science), collaborative research, student aid in the form of grants and awards, and a training program database.