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Principles of Exercise Testing and Interpretation, Fourth Edition FREE TO VIEW

Albert Miller, MD, FCCP
Chest. 2006;130(1):307. doi:10.1378/chest.130.1.307
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By Karlman Wasserman, MD, PhD, James E. Hansen, MD, Darryl Sue, MD, William Stringer, MD, and Brian J. Whipp, PhD, DSc. Philadelphia, PA: Lippincott Williams & Wilkins, 2005; 585 pp; $99.00

Doctors Wasserman, Hansen, Sue, Stringer, and Whipp are founding fathers of cardiorespiratory exercise testing and have continued to make substantial contributions over the considerable period of time since the first edition of this widely used text was published. Consequently, the publication of a new edition of this volume is always worthy of note. %The organization of the book is similar to that of previous editions. The first chapters provide background on the physiology of exercise from skeletal muscles, to metabolic-cardiovascular-ventilatory coupling, and onward to the control of breathing. The following chapters describe the various measurements, their use in clinical testing, and the pathophysiology of disorders that limit exercise. Interpretation is covered in the chapters on “Normal Values,” “Principles,” “Clinical Applications,” and “Case Presentations.” Relationships between oxygen uptake (V̇o2) and work rate, and V̇o2 and carbon dioxide output (V̇co2) [graphic approaches to identification of the anaerobic threshold] are well-discussed and are approached from a variety of perspectives in these chapters. The appendices (“Glossary,” “Calculations and Formulas,” “Conversion Tables,” and “Nomograms”) are valuable and concise references in themselves. %Succinct statements in the text provide useful insights (or confirmations of knowledge already appreciated), such as the following: {nl}1. Certain diagnoses (eg, silent myocardial ischemia, pulmonary vascular disease, or chronic heart failure due to diastolic dysfunction) that may, in particular cases, be difficult to uncover can be inferred from gas exchange responses to exercise. %2. There is no easier way than exercise testing to confirm normal cardiorespiratory status. %3. An increase in minute ventilation (V̇e)/V̇o2 ratio without an increase in V̇e/V̇co2 ratio demonstrates that the anaerobic threshold has been reached and cannot have been caused by hyperventilation secondary to pain, hypoxemia, or psychogenic factors.

The authors are well-known for their flow charts, which serve to guide the reader to the proper pathophysiologic diagnosis; these are in fact the subject of a full chapter. Readers whose thought processes do not easily move with the flow tend to deviate from the prescribed path somewhere en route. Also, the flowcharts are based on serial branch points beginning with peak V̇o2 and anaerobic threshold, goals that many patients do not reach or clearly demonstrate. Later branch points (eg, physiologic dead space ventilation and alveolar-arterial pressure differences) require arterial blood gas measurements, which may not conform to the protocol used in some laboratories, may not be permitted by referral sources, or may not be acquiesced to by individual patients. Flow chart 5 and the accompanying discussion in the text, which are meant for use when the anaerobic threshold is not available, provide a potentially useful but perhaps contradictory approach involving the determination of the V̇e/V̇co2 ratio and end-title CO2 pressure (Petco2) at anaerobic threshold. Fortunately, clear and complete diagnostic strategies are presented from alternate perspectives in other chapters and serve to provide the flow chart-illiterate reader with the ability to differentiate the basic pathophysiologic impairments, exclude those that are not applicable, and arrive at the correct diagnosis. Finally, although the graphic displays of the many different combinations of variables collected during exercise testing are familiar to readers of the authors’ previous publications (and to all who use modern exercise testing equipment), it would increase the reader-friendliness of the nine graphic displays if they adjoined the descriptive text. %Well more than half of the text in this book (305 of 547 pages) is devoted to case presentations. These are useful demonstrations of the physiologic principles and unique features of the different clinical scenarios and also serve to test the reader’s evaluative process against that of the authors. Fewer than the 85 cases presented would probably suffice, but there is little downside to the larger number save some increment in the weight of the book (and presumably in the price). Judging from the background information provided, most of these cases date back many decades to the authors’ evaluations of asbestos-exposed workers. Since these studies came before “the major advances that have occurred in this area [of cardiorespiratory exercise testing],” their presence does somewhat contradict the authors’ rationale for publishing a new edition. %Certain of these major advances indeed would benefit from greater attention and updating. Foremost among these are the following: {nl}1. The considerable information that can be obtained from the tidal flow-volume loop and the change in functional residual capacity during exercise, which have been the subject of many investigational and review articles and of textbook discussions. %2. That the same instrumentation that is in wide use and the same exercise protocols can provide vastly expanded physiologic data, including virtually instantaneous information on diffusing capacity, pulmonary blood flow, and cardiac output. %3. That although these topics are touched on in several chapters, clear advice on how to further evaluate muscle enzyme disorders and to distinguish psychogenic nonmalingering hyperventilation (especially in the absence of arterial gas measurements) would have been useful.

Much of value in this fourth edition is present in the third edition, which was published in 1999. However, for the many physicians and physiologists who may not possess the penultimate version, the purchase of this most recent edition is strongly advised. Such a resource should be in every laboratory where cardiorespiratory exercise testing is performed and in every medical facility where the clinical entities explicated by exercise testing are encountered.




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