Wasserman & Whipp's Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications

 

Description:

Thoroughly revised and updated for today’s clinicians, Wasserman & Whipp’s Principles of Exercise Testing and Interpretation, Sixth Edition, provides a comprehensive, practical overview of cardiopulmonary exercise testing (CPET) ideally suited for pulmonologists, cardiologists, anesthesiologists, and others with an interest in clinical exercise testing. Written by authors who are uniquely positioned to convey relevant aspects of research and apply them to clinical contexts, this volume offers in-depth coverage of essential information for conducting CPET, or for utilizing data from this discipline in clinical practice or research.

 

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Table of Contents:

 

1    Exercise Testing and Interpretation

WHAT IS CARDIOPULMONARY EXERCISE TESTING?

CELL RESPIRATION AND BIOENERGETICS

NORMAL COUPLING OF EXTERNAL TO CELLULAR RESPIRATION

WHY MEASURE GAS EXCHANGE TO EVALUATE CARDIORESPIRATORY FUNCTION AND CELLULAR RESPIRATION?

CARDIAC STRESS TESTS AND PULMONARY STRESS TESTS

PATTERNS OF CHANGE IN EXTERNAL RESPIRATION (VO2 AND VCO2) AS RELATED TO FUNCTION, FITNESS, AND DISEASE

FACTORS LIMITING EXERCISE

Fatigue

Dyspnea

Pain

EVIDENCE OF SYSTEMIC DYSFUNCTION UNIQUELY REVEALED BY INTEGRATIVE CARDIOPULMONARY EXERCISE TESTING

Diagnosis of Exercise Intolerance, Especially Exertional Dyspnea and Myocardial Ischemia

Cardiopulmonary Exercise Testing and Prognosis in Patients With Known Disorders

Cardiopulmonary Exercise Testing and Preoperative Assessment

SUMMARY

2    Physiology of Exercise

SKELETAL MUSCLE: MECHANICAL PROPERTIES AND FIBER TYPES

BIOENERGETICS

Sources of High-Energy Phosphate and Cellular Respiration

Phosphocreatine Breakdown

Substrate Utilization

Carbohydrates

Lipids

Amino Acids

OXYGEN COST OF WORK

VO2 Steady State and Work Efficiency

VO2 Nonsteady State

ARTERIAL LACTATE INCREASE

Arterial Lactate Increase as a Function of Work Rate

Arterial Lactate Increase as a Function of Time

Mechanisms of Arterial Lactate Increase

Increasing Glycolytic Flux and Exercise Intensity

Sequential Recruitment of Type II Muscle Fibers

Pyruvate Dehydrogenase Activity

Change in Cytosolic Redox State Limiting Mitochondrial Proton Shuttles

Lactate Production and Clearance

Oxygen Supply and Critical Capillary PO2

pH Change and Oxyhemoglobin Dissociation Above the Anaerobic Threshold

BUFFERING THE EXERCISE-INDUCED LACTIC ACIDOSIS

CARDIOVASCULAR RESPONSES TO EXERCISE

Cardiac Output

Oxygen Pulse

Distribution of Peripheral Blood Flow

Arterial PO2

Oxyhemoglobin Dissociation

Hemoglobin Concentration

Arterial Oxygen Content

GAS EXCHANGE KINETICS

Oxygen Uptake Kinetics

Moderate Exercise

Supra-AT Exercise

Mean Response Time

Oxygen Deficit

Oxygen Debt

Carbon Dioxide Output Kinetics

Moderate Exercise

Supra-AT Exercise

Power-Duration Curve and Critical Power

VENTILATORY RESPONSES TO EXERCISE

Arterial and Venous PCO2 and Carbon Dioxide Content

Ventilatory Determinants

Carbon Dioxide and H+ Elimination

Alveolar Ventilation

Dead Space Ventilation

Total (or Expired) Ventilation

Breathing Pattern

Ventilatory Control

Moderate Exercise

Supra-AT Exercise

SUMMARY

3    Measurements During Integrative Cardiopulmonary Exercise Testing

measurements

Electrocardiographic Changes With Exercise

Maximal and Peak Oxygen Uptake

Oxygen Uptake and Work Rate

Normal Subjects

Upward Displacement of VO2 as a Function of Work Rate in Obesity

Slope of VO2 as a Function of Work Rate (ΔVO2/ΔWR)

Linearity of VO2 as a Function of Work Rate

Can VO2 or METs Be Predicted From the Work Rate?

Cardiac Output and Stroke Volume

Cardiac Output Measurement

Indirect Fick Method Using VCO2 and Estimated CVCO2

Direct Fick Method

Noninvasive Cardiac Output and Stroke Volume by the Fick Principle

Oxygen Pulse and Stroke Volume

Anaerobic (Lactate, Lactic Acidosis) Threshold

Methods of Measurement

V-Slope Method

Ventilatory Equivalent Method

Improving Estimation of the Anaerobic Threshold

False Positives

Heart Rate–Oxygen Uptake Relationship and Heart Rate Reserve

Arterial Blood Pressure

Breathing Reserve

Expiratory Flow Pattern

Inspiratory Capacity

Tests of Uneven VA/Q

Wasted Ventilation and Dead Space–Tidal Volume Ratio

Arterial PO2 and Alveolar–Arterial PO2 Difference

Arterial–End-Tidal PCO2 Difference

Ventilatory Equivalents as Indices of Uneven VA/Q

Differentiating Uneven Ventilation From Uneven Perfusion as the Cause of Uneven VA/Q

Other Measures of Uneven VA/Q

Arterial Bicarbonate and Acid-Base Response

Tidal Volume/Inspiratory Capacity Ratio

Measurements Unique to Constant Work Rate Exercise Testing

VO2 Response in Phase I

VO2 Response in Phase II

VO2 Response Above the Anaerobic Threshold

The Power-Duration Relationship and Endurance Time

Noninvasive Estimation of Metabolic Acidosis Buffering

Carotid Body Contribution to Ventilation

Detecting Exercise-Induced Bronchospasm

SUMMARY

4    Pathophysiology of Disorders Limiting Exercise

OBESITY

PATTERNS OF EXERCISE GAS EXCHANGE COMMON TO CARDIOVASCULAR DISEASES

VO2 Response to Increasing Work Rate (ΔVO2/ΔWR) in Patients With Cardiovascular Abnormalities

Why Do Cardiovascular Disorders Impair Gas Transport?

HEART DISEASES

Coronary Artery Disease

Myopathic Heart Disease (Heart Failure)

Valvular Heart Disease

Congenital Heart Disease

PULMONARY VASCULAR DISEASES

Causes of Increased Ventilation

Exercise Arterial Hypoxemia

Effect on Systemic Hemodynamics

PERIPHERAL ARTERIAL DISEASES

VENTILATORY DISORDERS

Obstructive Lung Diseases

Ventilatory Capacity–Ventilatory Requirement Imbalance

Oxygen Transport–Oxygen Requirement Imbalance

Physiological Markers of Inadequate Oxygen Transport

Restrictive Lung Diseases

Chest Wall (Respiratory Pump) Disorders

DEFECTS IN HEMOGLOBIN CONTENT AND QUALITY

Anemia

Left-Shifted Oxyhemoglobin Dissociation Curve

Carboxyhemoglobinemia and Cigarette Smoking

CHRONIC METABOLIC ACIDOSIS

METABOLIC MUSCLE DISORDERS

Disorders of Carbohydrate Metabolism

Disorders of Lipid Metabolism

Disorders of Mitochondrial Electron Transport Chain

Toxin- or Drug-Induced Muscle Impairment

Endocrine Disorders

NONMETABOLIC CAUSES OF EXERCISE LIMITATION AND DYSPNEA

Anxiety Reactions

Poor Effort and Manipulated Exercise Performance

COMBINATIONS OF DEFECTS

SUMMARY

5    Performance of Clinical Cardiopulmonary Exercise Testing

EXERCISE LABORATORY AND EQUIPMENT

General Laboratory Environment

Gas Exchange Measurement

Mixing Chambers

Breath-by-Breath Systems

Measurement of Volume, Flow Rate, and Ventilation

Breathing Valves, Mouthpieces, and Masks

Gas Analyzers

Elevated Inspired Fractional Oxygen Concentration

Ergometers: Treadmills and Cycles

Treadmill

Cycle Ergometer

Cycle Versus Treadmill

Work and Work Rate (Power)

Electrocardiogram and Systemic Blood Pressure

Exercise Electrocardiogram

Systemic Blood Pressure

Oximetry, Blood Sampling, and Arterial Catheters

Pulse Oximetry

Single Samples of Arterial Blood by Puncture

Multiple Samples of Arterial Blood by Catheterization

Free-Flowing Ear Capillary Blood

Invasive Cardiopulmonary Exercise Testing With Pulmonary Artery Catheter

Data Sampling and Computation

Quality Control, Validation, and Maintenance

PREPARING FOR THE EXERCISE TEST

Requesting the Test and Notifying the Patient

The Patient in the Exercise Laboratory

Preliminary Tests

Physician Evaluation

Equipment Familiarization

Ending the Exercise

Arterial Blood Sampling and Use of Catheter

PERFORMING THE EXERCISE TEST

Incremental Exercise Test to Symptom-Limited Maximum

Selecting the Rate of Work Rate Increase

Resting Measures

Unloaded Exercise and Cycling Rate

Incremental Exercise

Recovery

Postexercise Questioning and Review

Incremental Tests

Constant Work Rate Exercise Tests

Treadmill Test for Detecting Myocardial Ischemia

Comment

Treadmill Tests With Even Increments in Work Rate

Arm Ergometry

Critique

Other Tests Suitable for Fitness or Serial Evaluations

Harvard Step Test and Modifications

600-Yard Run-Walk

12-Minute Field Test

12-Minute Walk Test

6-Minute Walk Test

Incremental Shuttle Walk Test and Endurance Shuttle Walk Tests

SUMMARY

6    Approaches to Data Summary and Interpretation

CONSIDERATIONS IN FORMATTING AND SUMMARIZING DATA

Averaging Breath-by-Breath Data

Formatting Data for Viewing During and After Testing

Quantifying Peak Values

Characterizing Submaximal Exercise Patterns

ORGANIZING DATA: APPROACH TO REVIEW OF A NINE-PANEL GRAPHICAL DISPLAY

Data Reflecting Cardiovascular and Metabolic Responses

Cardiovascular and Metabolic Variables: Summary

Data Reflecting Ventilation Responses to Exercise

Ventilatory Variables: Summary

Data Reflecting Efficiency of Pulmonary Gas Exchange

Pulmonary Gas Exchange Efficiency: Summary

Graphing Strategies to Facilitate Data Analysis

Summarizing Key Variables

EXAMPLES OF FINDINGS IN THE NINE-PANEL DISPLAY IN SELECTED CARDIORESPIRATORY DISORDERS

Panel 1: VO2, VCO2, and Work Rate as Related to Time

Panel 3: Heart Rate and Carbon Dioxide Output as a Function of Oxygen Uptake

Panel 2: Heart Rate and Oxygen Pulse as a Function of Time

Panel 9: Tidal Volume as a Function of Exercise Minute Ventilation

Panel 6: Exercise Minute Ventilation as a Function of Carbon Dioxide Output

Panel 4: Ventilatory Equivalents for Oxygen and Carbon Dioxide Versus Time

Panel 7: End-Tidal Oxygen and Carbon Dioxide Tensions Versus Time

Panel 5: Minute Ventilation as a Function of Time

Panel 8: Respiratory Exchange Ratio at Rest, Increasing Work Rate Exercise, and Recovery

Summary of Sample Response Patterns

WRITING AN EXERCISE TEST REPORT

Elements of the Report

Interpretation

Interpretation of Tests Conducted for Determination of Selected Variables

Interpretation of CPETs Conducted for Diagnostic Purposes

Confounding Factors

7    Normal Values

POTENTIAL LIMITATIONS OF PUBLISHED REFERENCE VALUES FOR CARDIOPULMONARY EXERCISE TESTING

PREDICTED VALUES FOR ADULTS

Peak Oxygen Uptake

Age and Gender

Activity Level

Matching Predicting or Reference Equations to Body Size

Exercise Mode

Recommendations

Peak Heart Rate and Heart Rate Reserve

Recommendations

Relationship of Oxygen Uptake and Heart Rate: Peak Oxygen Pulse

Recommendations

Relationship of Heart Rate and VO2: ΔHR/ΔVO2

Systemic Blood Pressure

Recommendations

Anaerobic Threshold

Recommendations

Oxygen Uptake–Work Rate Relationship

Recommendations

Ventilatory Limitation During Exercise

Exercise Ventilation and Breathing Reserve

Tidal Volume and Breathing Frequency

Recommendations

Gas Exchange Relationships and Ventilatory Efficiency: VE and VCO2

Slope of VE (BTPS) versus VCO2 (STPD)

VE/VCO2 Near the AT

Recommendations

Oxygen Uptake Efficiency Slope: VE and VO2

Physiological Dead Space–Tidal Volume Ratio

Recommendations

Arterial, End-Tidal, and Mixed-Expired Carbon Dioxide Pressures

Recommendations

Arterial, Alveolar, and End-Tidal Oxygen Tensions and Arterial Oxyhemoglobin Saturation

Recommendations

Femoral and Mixed Venous Values and Estimation of Cardiac Output

Recommendations

Acid-Base Balance

Recommendations

PREDICTED VALUES FOR CHILDREN

Peak VO2 in Children

Recommendations

Peak Heart Rate and Heart Rate Reserve

Recommendations

Relationship of Oxygen Uptake and Heart Rate: The Peak Oxygen Pulse

Recommendations

Anaerobic Threshold

Recommendations

Oxygen Uptake–Work Rate Relationship

Recommendations

Ventilatory Efficiency

Recommendations

SUMMARY

8    Clinical Applications of Cardiopulmonary Exercise Testing

CARDIOPULMONARY EXERCISE TESTING IN THE DIAGNOSTIC EVALUATION OF EXERCISE INTOLERANCE

Disorders With Unique or Distinctive Findings During Cardiopulmonary Exercise Testing

Myocardial Dyskinesis Secondary to Myocardial Ischemia During Exercise

Chronic Heart Failure With Preserved Left Ventricular Ejection Fraction

Pulmonary Vascular Occlusive Disease and Clinical Pulmonary Arterial Hypertension (Pulmonary Vasculopathy)

Development of a Right-to-Left Shunt During Exercise

Pulmonary Vascular Disease Limiting Exercise in Chronic Obstructive Pulmonary Disease

Impaired Muscle Bioenergetics

Exercise-Induced Airflow Obstruction

Psychogenic Dyspnea and Behavioral Causes of Exercise Intolerance

GRADING SEVERITY OF HEART FAILURE

CPET FOR EVALUATING PROGNOSIS IN HEART AND LUNG DISEASES

Prognosis in Heart Failure

Peak VO2, Anaerobic Threshold, and Prognosis in Chronic Heart Failure

Decreased “Ventilatory Efficiency” and Prognosis in Chronic Heart Failure

Prognosis in Heart Failure Based on Oscillatory Breathing During Exercise

Cardiopulmonary Exercise Testing and Evolving Management of Chronic Heart Failure

Prognosis in Structural Heart Diseases

Recommendations for Prognostic Evaluation for Potential Cardiac Transplantation

Prognosis in Pulmonary Arterial Hypertension and Prioritizing Patients for Lung Transplantation

Prognosis in Lung Diseases

Chronic Obstructive Pulmonary Disease and Prioritizing Patients for Lung Volume Reduction Surgery

Use of CPET for Prognosis in Other Lung Diseases Including Idiopathic Pulmonary Fibrosis

PREOPERATIVE EVALUATION OF SURGICAL RISK

Thoracic Surgery

Abdominal Surgery

Current Recommendations for the Use of Preoperative Exercise Training (“PreHab”) Prior to Thoracic or Abdominal Surgery

Who Should Undergo Cardiopulmonary Exercise Testing Preoperatively?

DETERMINING IMPAIRMENT FOR DISABILITY EVALUATION

Impairment and Disability

Assessing Impairment in Lung or Heart Disease Only Using Resting Measurements

Exercise Testing and Impairment Evaluation

Oxygen Cost of Work

EXERCISE TRAINING OR REHABILITATION

Physiological Basis of Exercise Rehabilitation

Skeletal Muscle

Cardiac Output and Heart Rate

Arterial Blood [Lactate]

Oxygen Uptake

Ventilation

Other Physiological Responses

Exercise Rehabilitation in Heart Disease

Exercise Rehabilitation in Chronic Obstructive Pulmonary Disease

ASSESSING THE EFFECTIVENESS OF TREATMENT

SCREENING FOR DEVELOPMENT OF DISEASE IN AT-RISK PATIENTS

GRADED EXERCISE TESTING AND THE ATHLETE

SUMMARY

9    Diagnostic Specificity of Exercise Intolerance: A Flowchart Approach

INTRODUCTION TO FLOWCHARTS

PEAK VO2 AND ANAEROBIC THRESHOLD (FLOWCHART 1)

EXERCISE INTOLERANCE WITH NORMAL PEAK OXYGEN UPTAKE (FLOWCHART 2)

LOW PEAK OXYGEN UPTAKE WITH NORMAL ANAEROBIC THRESHOLD (FLOWCHART 3)

LOW PEAK OXYGEN UPTAKE WITH LOW ANAEROBIC THRESHOLD (FLOWCHART 4)

LOW PEAK OXYGEN UPTAKE WITH ANAEROBIC THRESHOLD NOT DETERMINED (FLOWCHART 5)

SUMMARY

10  Case Presentations

PURPOSE AND MATERIAL

FORMAT FOR CASE PRESENTATIONS

Graphing Conventions

CHARACTERISTICS OF CASES

Scope

Conditions

SYMBOLS, ABBREVIATIONS, AND CALCULATIONS

Case 1: Normal Man

Case 2: Normal Athletic Man

Case 3: Normal Woman: Air and Oxygen Breathing Studies

Case 4: Normal Man

Case 5: Fit Cyclist

Case 6: Normal Individual: Cycle and Treadmill Studies

Case 7: Normal Individual: With and Without β-Adrenergic Blockade

Case 8: Normal Man With and Without Acute Cigarette Smoking

Case 9: Active Man With Dyspnea at High Altitude

Case 10: Active Woman With Patent Foramen Ovale

Case 11: Normal Aging Athletic Man: Serial Tests Between Age 66 and 76

Case 12: Mild Airflow Obstruction and Hyperventilation

Case 13: A Submaximal Test

Case 14: A Long Test

Case 15: Chronic Heart Failure With Reduced Ejection Fraction

Case 16: Chronic Heart Failure With Reduced Ejection Fraction

Case 17: Chronic Heart Failure With Reduced Ejection Fraction and Pacemaker Dependence

Case 18: Chronic Heart Failure: Oscillatory Ventilation and Gas Exchange

Case 19: Chronic Heart Failure With Preserved Ejection Fraction (Exercise-Induced Pulmonary Venous Hypertension)

Case 20: Gas Exchange Evidence of Myocardial Ischemia

Case 21: Claudication: Gas Exchange Findings in Peripheral Arterial Disease

Case 22: Exertional Chest Pain With Gas Exchange Evidence of Myocardial Ischemia

Case 23: Exercise-Induced Myocardial Ischemia

Case 24: Myocardial Ischemia With Diffuse Distal Coronary Artery Disease

Case 25: Myocardial Ischemia: Development of Inducible Myocardial Ischemia Over 3 Years

Case 26: Atrial Septal Defect and Hemochromatosis

Case 27: Symptomatic Chronic Mitral Insufficiency

Case 28: Congenital Heart Disease: Coarctation and Ventricular Septal Defect Surgically Repaired

Case 29: Congenital Heart Disease: Transposition of the Great Arteries With Surgical Repair

Case 30: Patent Ductus Arteriosus With Left-to-Right Shunt, Presurgical Closure

Case 31: Patent Ductus Arteriosus With Right-to-Left Shunt (Eisenmenger Ductus Syndrome)

Case 32: Bicuspid Aortic Valve With Aortic Regurgitation

Case 33: Surgically Repaired Coarctation of the Aorta With Bicuspid Aortic Valve

Case 34: Fontan Circulation

Case 35: Ventricular Septal Defect With Eisenmenger Syndrome

Case 36: Tetralogy of Fallot, Surgically Repaired

Case 37: Tetralogy of Fallot, Unrepaired

Case 38: Amyloid Cardiomyopathy

Case 39: Athletic Man With Tachyarrhythmia

Case 40: Heart Rate Impairment Due to β-Adrenergic Blockade for Treatment of Hypertension

Case 41: Atrial Fibrillation With Rapid Ventricular Response During Exercise

Case 42: Chronotropic Insufficiency With Escape Rhythm

Case 43: Active Older Man With Second-Degree Heart Block

Case 44: Active Man With Cardiac Conduction Defects

Case 45: Early Onset of Exercise Lactic Acidosis: Differentiating Circulatory From Muscular Impairment

Case 46: Early Onset of Exercise Lactic Acidosis Suggesting Circulatory Impairment

Case 47: Mixed Connective Tissue Disease With Pulmonary Involvement

Case 48: Pulmonary and Systemic Vasculitis: Air and Oxygen Breathing Studies

Case 49: Idiopathic Pulmonary Arterial Hypertension

Case 50: Severe Pulmonary Vascular Disease Secondary to Sarcoidosis: Air and Oxygen Breathing Studies

Case 51: Pulmonary Arterial Hypertension on Multidrug Therapy

Case 52: Pulmonary Hypertension, Patent Foramen Ovale, and Exercise-Induced Right-to-Left Shunt

Case 53: Idiopathic Pulmonary Arterial Hypertension Before and After Treatment

Case 54: Long-Standing Idiopathic Pulmonary Arterial Hypertension: Serial Tests Over 17 Years of Treatment

Case 55: Intrapulmonary Right-to-Left Shunt Due to Pulmonary Arteriovenous Fistulae

Case 56: Severe Interstitial Lung Disease

Case 57: Sarcoidosis

Case 58: Interstitial Pneumonitis: Before and After Empiric Corticosteroid Therapy

Case 59: Severe Interstitial Lung Disease: Air and Oxygen Breathing Studies

Case 60: Mild Pulmonary Asbestosis

Case 61: Severe Pulmonary Asbestosis

Case 62: Pleural and Pulmonary Asbestosis

Case 63: Mild Chronic Bronchitis With Normal Exercise Performance

Case 64: Emphysema With Mild Airway Obstruction

Case 65: Severe Combined Obstructive and Restrictive Lung Disease

Case 66: Severe Chronic Obstructive Lung Disease

Case 67: Emphysema, Untreated

Case 68: Severe Emphysema and Bronchitis: Air and Oxygen Breathing Studies

Case 69: Bullous Emphysema: Before and After Bullectomy

Case 70: A Runner With Obstructive Lung Disease

Case 71: Mild Obstructive Airway Disease With Disproportionate Exertional Dyspnea

Case 72: Obesity Contributing to Ventilatory Limitation

Case 73: Extrapulmonary Restriction: Ankylosing Spondylitis

Case 74: Extrapulmonary Restriction: Scoliosis

Case 75: Interstitial Lung Disease and Hemidiaphragm Paralysis

Case 76: Active Man With Paralyzed Hemidiaphragm

Case 77: McArdle Disease

Case 78: Myopathy With Exertional Rhabdomyolysis

Case 79: Congenital Mitochondrial Myopathy

Case 80: Mitochondrial Myopathy

Case 81: Woman With Multiple Sclerosis and Dyspnea

Case 82: Congenital Myotonia

Case 83: Mixed Disorder: Chronic Bronchitis and Obesity

Case 84: Mixed Disorder: Peripheral Arterial Disease, Anemia, Carboxyhemoglobinemia, and Cardiac Dysfunction

Case 85: Mixed Disorder: Mild Interstitial Lung Disease, Obstructive Airway Disease, and Myocardial Ischemia

Case 86: Chronic Heart Failure With Preserved Ejection Fraction and Obesity Hypoventilation Syndrome

Case 87: Mixed Disease: Aortic Stenosis, Mitral Stenosis, and Obstructive Airway Disease

Case 88: Mixed Disorder: Obstructive Airway Disease, Talc Pneumoconiosis, and Pulmonary Vascular Disease

Case 89: Mixed Disorder: Peripheral Arterial Disease and Obstructive Lung Disease: Cycle and Treadmill Exercise

Case 90: Morbid Obesity and Aortic Valve Disease

Case 91: Morbid Obesity

Case 92: Exercise Testing for Staging and Prognosis in Chronic Heart Failure

Case 93: Exercise Testing for Preoperative Evaluation for Lung Cancer Resection

Case 94: Exercise Testing for Evaluation of Work Fitness: Morbid Obesity

Case 95: Exercise Testing for Assessment Before and After Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease

Case 96: Evaluation of Unexplained Dyspnea: A Morbidly Obese Asthmatic

Case 97: Evaluation of Unexplained Dyspnea: Chronic Thromboembolic Pulmonary Vascular Disease

Case 98: Evaluation of Unexplained Dyspnea: An Obese Woman at Risk for Pulmonary Hypertension

Case 99: Serial Tests: Active Man With CREST Syndrome

Case 100: Serial Tests: Delayed Cardiotoxicity From Chemotherapy

Appendices

Index

 

An aparitie	25 Sept. 2020
Autor	Kathy E. Sietsema MD, Darryl Y. Sue MD, William W. Stringer MD, Susan Ward PhD
Dimensiuni	21.08 x 2.03 x 27.43 cm
Editura	LWW
Format	Paperback
ISBN	9781975136437
Limba	Engleza
Nr pag	600
Versiune digitala	DA