Exercise testing in pediatrics

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Changes in the cardiovascular and pulmonary systems in the normal patient during dynamic exercise

In the healthy individual, cardiac output may increase fivefold during exercise as a result of an increase in stroke volume and heart rate. This increased output is not evenly distributed. The muscles, heart, and skin (to effectuate proper cooling) are the primary recipients of this increased blood flow. Other vital organs such as the gut, kidneys, and central nervous system see no significant changes in blood flow during exercise. Therefore, exercise can be thought of as the state of increased

Indications for exercise stress testing

Most pediatric patients undergo exercise testing for evaluation of nonischemic heart disease. The most common reason is the evaluation of exercise performance in preoperative or postoperative congenital heart defects. Other common indications include cardiomyopathies, exercise-induced symptoms including palpitations or syncope, possible arrhythmias during exercise, and suspected pulmonary disorders such as exercise-induced bronchospasm (Box 1) [3].

Risk to the patient and contraindications to exercise testing

The actual risk of exercise testing in the pediatric population is believed to be quite low. Indeed, in adults, exercise entails a small risk: data confirm up to 1 myocardial infarction or death per 2500 tests [5]. Given that ischemic heart disease is rare in the pediatric population, the authors estimate the risk is far less than in adults.

Exercise physiologists generally agree that there are absolute and relative contraindications to graded exercise testing (Box 2). Before the test, all

Laboratory equipment, staff, and procedures

All laboratories should have basic equipment, which includes an automated blood pressure monitoring system with manual override, a cycle ergometer, a treadmill, high-quality ECG recording systems and writers, spirometers, and pulse oximeters. In most pediatric laboratories, metabolic carts with gas analyzers, which can assess ventilation and cardiac output, are typically in place. Qualified technicians, physicians, and emergency equipment and supplies in the event of respiratory or cardiac

Types of protocols and choice of test

The choice of treadmill testing or cycle ergometry depends on the type of information desired. The cycle ergometer has practical advantages over treadmill testing: it is less expensive to purchase and maintain, is safer, and is less intimidating to exercising subjects. One of the most important advantages of cycle ergometry is decreased artifact when measuring ECG and blood pressure data. Physical working capacity can be easily assessed with modern electronically braked cycle ergometers but is

Assessment of aerobic fitness

Assessing aerobic fitness has been the topic of many publications. Space does not allow an in-depth analysis of how fitness is assessed. Numerous studies have examined heart rate, ratings of perceived exertion by the subject or examiner, oxygen consumption, working capacity, and endurance times, alone or in combination, as a way of assessing whether the test was maximally strenuous. The advantages and disadvantages of these indices are discussed briefly here, and then the authors discuss their

Congenital heart disease

More formal exercise studies have been performed more in children with congenital heart disease than in any other pediatric group. Exercise testing in patients with congenital lesions can aid the decision-making process as to whether an intervention such as surgery is needed or can help in assessing the success of an intervention.

Summary

State-of-the-art stress testing laboratories can provide a myriad of useful physiologic data on patients with congenital malformations or suspected of having acquired disorders. Unlike most medical tests, which are performed on resting subjects, exercise stress testing can assess the functional capacity of the individual and can provide a more complete understanding of the patient's physical abilities and limitations.

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