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Cardiopulmonary Exercise Testing in Children and Adolescents


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    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.


    Applied professional reference book for clinical exercise physiologists, cardiologists, pulmonologists, and medical professionals working in exercise testing laboratories; supplemental text for courses related to clinical exercise testing.

    Table of Contents

    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
    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

    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
    Chapter 4: Normal Cardiovascular Responses to Progressive Exercise
    Thomas W. Rowland
    Reductionist’s Disclaimer
    Historical Context
    Empirical Evidence
    Physiological Basis of Cardiovascular Fitness
    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
    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
    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
    Chapter 8: Other Measures of Aerobic Fitness
    Robert P. Garofano
    Peak Workload
    Ventilatory Anaerobic Threshold
    Submaximal Testing Protocols
    Oxygen Uptake Efficiency Slope
    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
    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
    Chapter 11: Pulmonary Function
    Patricia A. Nixon
    Pulmonary Function at Rest and During Exercise
    Cystic Fibrosis

    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
    Chapter 13: Exercise-Induced Dyspnea
    Steven R. Boas
    Differential Diagnosis
    Exercise Testing
    Chapter 14: Chest Pain With Exercise
    Julie Brothers
    Differential Diagnosis
    Exercise Testing
    Chapter 15: Presyncope and Syncope With Exercise
    Julie Brothers
    Differential Diagnosis
    Exercise Testing
    Chapter 16: Exercise Fatigue
    Thomas W. Rowland
    Differential Diagnosis
    Exercise Testing

    Part IV: Testing Special Populations
    Chapter 17: Pectus Excavatum
    Thomas W. Rowland
    Physiological Implications
    Surgical Results
    Cardiopulmonary Testing
    Chapter 18: Obesity
    Laura Banks and Brian W. McCrindle
    Quantifying Childhood Obesity
    Physiological Adaptations
    Effects of Obesity on Physiologic Measures
    Cardiopulmonary Exercise Testing Modifications
    Chapter 19: Intellectual Disability
    Bo Fernhall and Tracy Baynard
    Physiological Implications
    Exercise Testing
    Chapter 20: Neuromuscular Disease
    Olaf Verschuren, Janke de Groot, and Tim Takken
    Cerebral Palsy
    Duchenne and Becker Muscular Dystrophy
    About the Editors
    About the Contributors

    About the Editor

    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.