DZHK SOP K 07 Spiroergometry - V1.1

DZHK-SOP-K-07
Cardiopulmonary exercise test

(spiroergometry)
Version: V1.1 Effective date: 01/07/2015
Replaces version: 1.0 Dated: 01/09/2014
Change note: Corrected note regarding exercise protocols on p. 21
Technical author Technical Approval of Approval DZHK

reviewer Department Head
Name M. Dörr, F. Edelmann Matthias Nauck Thomas
S. Kaczmarek (Göttingen) Eschenhagen
(Greifswald)
Date 13/05/2014 26/08/2014 26/08/2014 26/08/2014
Signature
(appended)
Cardiopulmonary exercise test (spiroergometry)
TABLE OF CONTENTS
1 Introduction.......................................................................................................................................... 4
1.1 List of Abbreviations ................................................................................................................ 4
1.2 Objective ................................................................................................................................. 7
1.3 Target group ............................................................................................................................ 7
1.3.1 Inclusion criteria .............................................................................................................. 7
1.3.2 Exclusion criteria ............................................................................................................. 7
1.4 Application and tasks .............................................................................................................. 8
1.5 Terms and definitions .............................................................................................................. 8
1.6 Relationships to other examinations ...................................................................................... 8
1.7 Quality level ............................................................................................................................. 9
2 Prerequisites of the examination .................................................................................................. 10
2.1 Requirements regarding rooms/equipment ......................................................................... 10
2.2 Devices/hardware ................................................................................................................. 10
2.2.1 Device name and description ........................................................................................ 10
2.2.2 Calibration ..................................................................................................................... 11
2.2.3 Sources of error ............................................................................................................. 11
2.2.4 Spare parts for wear and tear ....................................................................................... 12
2.2.5 Storage .......................................................................................................................... 12
2.2.6 Service / device maintenance ....................................................................................... 12
2.3 Special clinical consumables.................................................................................................. 13
2.4 Essential documents.............................................................................................................. 13
2.5 Essential information ............................................................................................................ 13
2.6 Personnel ............................................................................................................................... 13
3 Implementation/workflow/work steps ......................................................................................... 14
3.1 Flowchart of the procedure................................................................................................... 14
3.2 Preparing for the examination .............................................................................................. 15
3.2.1 Checking the informed consent form............................................................................ 15
3.2.2 Identifying the subject................................................................................................... 15
3.2.3 Reviewing the inclusion criteria .................................................................................... 15
3.2.4 Preparing the workplace ............................................................................................... 15
DZHK-SOP-K-07 Effective date: 01/09/2014

Version: V1.0 Author: M. Dörr et al. Page 2 of 32
All text elements marked in grey in this SOP are binding. All unmarked text elements are to be complied with wherever
possible.
3.2.5 Preparing the devices .................................................................................................... 15

3.2.6 Principles of preparing the subject for the examination............................................... 15
3.3 Performing the examination ................................................................................................. 16
3.3.1 Exercise protocol ........................................................................................................... 16
3.3.2 Preparing the subject, measuring position ................................................................... 16
3.3.3 Performing the exercise test ......................................................................................... 17
3.3.4 Exercise phase: .............................................................................................................. 17
3.3.5 Recovery phase: ............................................................................................................ 18
3.3.6 Documentation:............................................................................................................. 18
3.4 Follow-up and data collection ............................................................................................... 18
3.4.1 Biomaterial .................................................................................................................... 18
3.4.2 Pre-analysis on site ........................................................................................................ 18
3.4.3 After the measurement ................................................................................................. 19
3.4.4 Follow-up discussion, feedback on findings .................................................................. 19
Whether and what information is shared with the subject has to be stipulated in the respective
study protocol. .............................................................................................................................. 19
3.4.5 Assessment / evaluation of the examination ................................................................ 19
3.5 Procedure in case of deviations ............................................................................................ 20
4 Data management ......................................................................................................................... 21
5 Literature and references .............................................................................................................. 22
6 Change ........................................................................................................................................... 23
7 Persons involved............................................................................................................................ 23
8 Annexes ......................................................................................................................................... 24
8.1 eCRF module ......................................................................................................................... 24
8.2 Cycle and treadmill protocols................................................................................................ 27
8.3 BORG scale ............................................................................................................................ 29

possible.
1 INTRODUCTION
1.1 LIST OF ABBREVIATIONS

The following values are measured during the test and explained in the table below.
Abbreviation Unit Explanation Standard

parameter
AT Anaerobic threshold, equivalent to VT1
BE Base excess
BF l/min Breathing frequency *
BGA Blood gas analysis
ECG/EKG Electrocardiogram
EQ CO₂ Ventilatory equivalent for CO₂, corresponds to
VE/VCO₂
EQO₂ Ventilatory equivalent for O₂, corresponds to VE/VO₂
HCO3 Bicarbonate
HR (exercise) Beats per Heart rate at maximum exercise *
minute (bpm) [highest value during exercise]
HR (resting) Beats per Heart rate at rest *
minute (bpm) [last value of the resting phase]
HRR bpm or % Heart rate reserve, as the difference between the
calculated maximum heart rate (200 – age in years)
and the maximum heart rate achieved – absolute or
as a percentage
MVV l Maximum voluntary ventilation as a calculated value
(FEV1 x 41)
O2/HR ml/heartbeat Oxygen pulse, expressed as a ratio between oxygen
uptake and heart rate
PET CO2 mmHg Maximum value of the end-tidal CO2 partial pressure *
(exercise)
PET CO2 mmHg End-tidal CO2 partial pressure (at the end of *
(resting) exhaling) at rest [averaged across 3 minutes of
resting]
PET CO2-AT mmHg End-tidal CO2 partial pressure at the
aerobic/anaerobic threshold
PET O2-AT mmHg O2 partial pressure at the aerobic/anaerobic
threshold
PET O2-max. mmHg Maximum value of O₂ partial pressure

possible.

parameter
PET O2 mmHg End-tidal O₂ partial pressure at rest
(resting)
RCP Respiratory compensation point, corresponds to VT
2 (see 1.5)
RER Respiratory exchange ratio, corresponds to RQ
RQ (exercise) Respiratory quotient at the end of exercise, *
corresponds to RER during exercise
RQ (resting) Respiratory quotient at rest, corresponds to RER at *
rest
RQ maxpost Maximum respiratory quotient post-exercise,
corresponds to the max. RER post-exercise
RR Manual blood pressure measurement
RRdia mmHg Diastolic blood pressure at the end of exercise
(exercise)
RRdia (resting) mmHg Diastolic blood pressure at rest *
RRsys mmHg Systolic blood pressure at the end of exercise *
(exercise)
RRsys (resting) mmHg Systolic blood pressure at rest *
SO₂ (exercise) % Peripheral oxygen saturation at the end of exercise *
SO₂ (resting) % Peripheral oxygen saturation at rest *
VE max l/min Maximum respiratory minute volume, measured *
during exhalation
VE max./MVV % Maximum achieved ventilation in relation to MVV
VE/VCO2 Respiratory equivalent for CO2 (volume of inhaled air *
(resting) to emit one litre of CO2) at rest, corresponds to Eq
CO₂ [averaged across 3 minutes of resting]
VE/VCO2-AT Respiratory equivalent for CO2 at the
VE/VCO2 slope Increase (slope) of the ventilation-CO2 ratio *
[determination via the slope (1 min. after starting
exercise until RCP]
VE/VO₂ Respiratory equivalent for O2 (volume of inhaled air *
(resting) to absorb one litre of O2), corresponds to Eq O₂
[averaged across 3 minutes of resting]
VE/VO₂-AT Respiratory equivalent for O2 at the
VO2 (AT) ml/min O2 uptake at the aerobic/anaerobic threshold *
VO2 (normal) ml/min See section 8.2 for reference values *

possible.

parameter
VO2 (resting) ml/min O2 uptake at rest *
[averaged across a resting phase]
VO2 peak ml/min Peak O2 uptake at the end of exercise1 *
[highest quantifiable value during exercise]
VO2 peak/kg ml/min/kg Peak O2 uptake per kilogram of bodyweight1
VO2-AT/kg ml/min/kg O2 uptake at the aerobic/anaerobic threshold per
kilogram of bodyweight
VO₂/Watt ml/Watt Aerobic capacity
VT L Tidal volume
1
Averaging of the respiratory gas analyses across 30 seconds

possible.
1.2 OBJECTIVE
The cardiopulmonary exercise test is used to assess a patient's general physical fitness and
stamina. This involves a differentiated assessment of the function of the cardiovascular,
pulmonary and peripheral muscle system at rest and at various points during physical
exercise. Important parameters within the scope of this assessment includes values of gas
exchange (oxygen uptake at the anaerobic threshold and at maximum exertion, ratio of
oxygen uptake and carbon dioxide output), of cardiovascular function (heart rate and
blood pressure curves, ECG changes), of ventilation (determination of the respiratory
minute volume, of the breathing pattern, of the relationship between gas exchange and
ventilation, known as respiratory equivalents).
1.3 TARGET GROUP

The SOP shall be applied in all interventional studies and registers in the DZHK.
1.3.1 Inclusion criteria

All subjects who are capable of cycling on an ergometer or of doing exercise on a treadmill
and to whom no exclusion criteria apply can take part. Special inclusion criteria are
stipulated in the study protocol of the respective study/register.
1.3.2 Exclusion criteria

Absolute contraindications:
• Acute relevant disease, e.g. recent myocardial infarction, systemic infections,

thromboses or embolisms, acute exacerbation of a respiratory disease.
• Severe cardiac arrhythmia or blocks (second- or third-degree AV block).
• Insufficiently controlled arterial hypertension (RRsyst >170 mmHg, and/or RRdiast
>110 mmHg).
• Known symptomatic or severe aortic stenosis.
Relative contraindications:
• Tachycardia at rest (>120 bpm).
• Poorly managed epilepsy with the risk of provoking a seizure through exercise.
• Symptomatic electrolyte imbalance or metabolic imbalance.
• Symptomatic impaired cerebral circulation.
If necessary, specific criteria of the respective studies or registers have to be observed.

possible.
1.4 APPLICATION AND TASKS

The cardiopulmonary exercise test is a diagnostic procedure that is used to analyse the reactions and
the interplay of the heart, circulation, breathing and metabolism during gradually increasing exercise,
both in terms of qualitative and quantitative measures. Three signals are recorded by means of a
breathing mask: the oxygen fraction of exhaled air, the carbon dioxide fraction of exhaled air and the
volume of exhaled air. Together with the recorded heart rate and the blood pressure, further
meaningful parameters can be calculated from these variables. Modern devices are programmed to
measure these variables with every breath (breath-by-breath analysis) using rapid analysers and to
numerically record and graphically process the results online using corresponding software.
1.5 TERMS AND DEFINITIONS

Anaerobic threshold determined by ventilation (AT or VT1): Defines the first increase in lactate and
marks the start of the aerobic/anaerobic threshold. This value can be measured by detecting the first
change in the gradient in field 5 of the Wassermann graphs (VCO₂/VE) or the first increase in the
oxygen equivalent in field 6 of the Wassermann graphs (EQO₂).
VE/VCO₂ slope: Defined as the slope of the straight line in field 5 (VE to VCO₂) value one minute after
starting the exercise until VT2 (RCP).
Respiratory compensation point (RCP or VT2): Defined as the point at which there is a
disproportionate increase from VE to VCO₂, which is read as an increase in EQCO2 in field 6.
1.6 RELATIONSHIPS TO OTHER EXAMINATIONS

The relationships between the individual SOP to other procedures are outlined below.
Mandatory screening (SOP …): Lung function test

Recommended screening (SOP …): Examination at rest
Screening to be excluded (SOP …): Other exercise test
Impact on other examination parts: Other (exercise) tests
Mandatory follow-up (SOP …): Not applicable

The cardiopulmonary exercise test should
Recommended follow-up (SOP …): be the last test performed on the
examination day
Follow-up to be excluded (SOP ...): Echocardiography

possible.
1.7 QUALITY LEVEL

DZHK quality level
Performance
Level 1 Performance of the examination taking into account the guidelines of the
specialist associations.
Level 2 Performance of the examination according to the provisions of the DZHK-SOP.
This SOP defines minimum requirements for the quality of the performance and
qualification of the examiner.
Level 3 Performance of the examination according to the provisions of the DZHK-SOP
and certification of the examiners: Definition of intra- and interobserver
variability (standard of epidemiological studies).
This SOP describes Level 2.

possible.
2 PREREQUISITES OF THE EXAMINATION
2.1 REQUIREMENTS REGARDING ROOMS/EQUIPMENT

Requirements regarding rooms
Recommended for all spiroergometry machines:
 Recommended temperature: 22°C (range 20-26°C) stable during the day, with as little need
for ventilation as possible
 Room temperature: is measured and adjusted automatically (+18 - +34°C)
 Humidity: is measured and adjusted automatically
 Brightness: no requirements
 Air pressure: is measured and adjusted automatically
 No connecting room, if possible the room should have a sink/shower for subjects to wash
themselves
Room equipment
 Laptop to enter data

 Colour printer for printing the findings sheet
 Desk with a desk chair
 Desk lamp
 Telephone
 Chair for subjects to sit on
 Body plethysmograph or spirometer (optional, it is sufficient for these to be in close
proximity)
 Blood gas analyser
 Ergometer
 Spiroergometry workplace (complete)
 Examination bed
 Emergency kit
 Defibrillator
 Blood pressure monitor for manual control
 BORG scale (6-20 or 0-10)
 Gloves, consumables (including disinfectant wipes, gauze compresses, plasters)
2.2 DEVICES/HARDWARE
2.2.1 Device name and description
Site-specific.

possible.
2.2.2 Calibration
It is important to perform calibrations using standard gases (once per workday) as per the
manufacturer's instructions.
In addition, volume calibration has to be performed on the device (after every examination).
The device calibration is done every day before commencing the examination and includes the
following components (the device-specific instructions have to be followed):
 Device calibration
 Volume calibration
Volume calibration is carried out in the morning after the calibration and after every examination. As
a result of the calibration, the computer calculates the correction factors.
The results of the calibration and volume calibration are stored in the device.
 Gas analyser calibration
Biological calibration
Every 12 months, one and the same person should perform an examination on the same
spiroergometer to verify the plausibility of the entire system (especially if O2 electrodes with a time
limitation are used).
If the room temperature changes by more than 5°C during the course of the day, the device has to
be re-calibrated.
2.2.3 Sources of error

 Automatic blood pressure measurement:
As the level of exercise increases, so do the upper body movements of the subjects, which can cause
sensors to make movement-related incorrect measurements. If implausible values occur, a second
measurement should be done manually.
 ECG:
Movement and transpiration can cause the electrodes to become detached. In this case, the
electrode should be reattached or replaced.
 Breathing mask:
Insufficient contact of the breathing mask with the skin (e.g. small face, beard, talking, grimacing) can
lead to leakages that result in faulty breathing gas determination. To prevent this, make sure that the
mask is fitted correctly prior to the examination and try a different mask if necessary. Instruct the
subject to speak only in case of emergency and to signal to the examiner to terminate the
examination by hand once the breathing mask has been fitted. The sample tubes connected to the
turbine should always point at least 45° upwards.

possible.
 Adjusting the height of the saddle on the cycle:
The saddle has to be adjusted specifically for the subject prior to each examination to ensure an
optimal transmission of force. The examiner should absolutely ensure that sturdy footwear is
sufficiently attached to the pedals.
2.2.4 Spare parts for wear and tear

Masks:
 2-3 masks in varying sizes (children's mask, small, medium, large) should always be kept handy.
The masks can be used as long as they are working correctly. The Velcro straps for fitting the
masks have to be replaced as soon as they no longer close sufficiently tight to ensure that the
mask is positioned correctly.
Sensors:
 A defective sensor may be the cause of a calibration error.
Condensate tube:
 The condensate tube should be replaced whenever the computer system displays a
corresponding alert.
ECG suction electrodes:
 Replace only in case of a defect (decision by the medical technician).
2.2.5 Storage
No special requirements.
2.2.6 Service / device maintenance

Clean and disinfect the device (ear clip, blood pressure cuff, ECG suction electrodes and cycle) with
Cleanisept wipes after each use.
Maintenance is performed in accordance with EN 62353 [www.ec--normen.de].

possible.
2.3 SPECIAL CLINICAL CONSUMABLES

Prepare the following items for the examination:
 1 skin disinfectant spray,

 1 pair of gloves,
 3 lancets (optional),
 glass capillaries, if possible with lid systems (optional),
 magnets (mixing wires) (optional),
 compresses,
 1 small plaster,
 contact spray for ECG electrodes,
 Elacur ointment (optional).
2.4 ESSENTIAL DOCUMENTS

Information, informed consent, other clinical documents (see below).
2.5 ESSENTIAL INFORMATION

The correct choice of the test program, the subject's complete personal details, patient ID.
2.6 PERSONNEL
The employees must have had special training and certification as an examiner at the examination
centre (see section 6).
1 performing examiner (certified nursing staff or MTA).
1 assisting examiner (certified nursing staff or MTA) (if BGA is planned).
1 medical examiner to monitor and evaluate the examination within calling distance.
The staff must be trained on general emergencies and resuscitation.
Examiner training
Examiners that are to be newly trained should watch an experienced examiner carry out 5
cardiopulmonary exercise tests as specified in the DZHK SOP, and then independently carry out at
least 20 cardiopulmonary exercise tests under supervision, and also complete the regular
certification sessions of level 2/3.

possible.
3 IMPLEMENTATION/WORKFLOW/WORK STEPS
3.1 FLOWCHART OF THE PROCEDURE

Daily prior to
commencing the
examination Termination
• Device calibration
Reasons for terminating the examination

Preparing the workplace
• Enter the subject ID  ST depression (> 0.2 mV) or elevation
 Progressive atrial or ventricular arrhythmia
or block images
 Newly occurring atrial fibrillation
 Drop in heart rate during exercise
Performing the examination
• Briefly explain the examination  Lack of increase or drop in RR across 2
• Attach the 12-lead ECG exercise levels
• Attach the automatic blood pressure cuff  Drop in O2 uptake (or oxygen pulse) in
• Attach the pulse oximeter spite of increasing the load
• Apply the breathing mask  Maximal fatigue (e.g. of the legs)
• Check the breathing mask for leaks  Thoracic pain (e.g. symptoms of angina),
• Prepare the blood gas analysis (optional) severe dizziness
 Excessive dyspnoea
- Subject signals to examiner to end the
examination.
Measuring and data collection
Depending on the exercise protocol used, here the
modified Jones protocol by way of example:
• BGA from the hyperaemic earlobe from lung function
test (optional)
• Rest (subject sits on the ergometer quietly for 3 Follow-up
minutes): • Fill out the BORG scale (20)
→ automatic RR measurement, if necessary manual control • Record any clinical symptoms
→ → if necessary perform the intrabreath manoeuvre • Note down the reason for
(after 1 min.) termination
• Exercise (start at 20 Watts, increase by 16 W/min.): • (Give subject towel and/or drink)
- The subject starts pedalling and should achieve > 50 Follow-up discussion
rotations • Information about the technical
- automatic RR measurement every minute, if
quality of the examination by
necessary manual control
- optional in the area of AT  BGA
the examiner
→ intrabreath manoeuvre • Rough estimation of the physical
- optional at end of exercise → BGA fitness by the examiner
→ intrabreath manoeuvre
• Recovery/cool down at 20 Watts:
→ automatic RR measurement, if necessary manual
control
→ monitor until resting RR is reached
→ remove breathing mask after 2 minutes

possible.
3.2 PREPARING FOR THE EXAMINATION

3.2.1 Checking the informed consent form
When implementing studies, the in- and exclusion criteria are already explained to the subject in the
study information; this means that all study subjects who give their consent can carry out the
examination. Within the scope of the clinical application, make sure by means of a medical history or
medical reports and by interviewing the subject whether there are any contraindications to the
cardiopulmonary exercise test.
3.2.2 Identifying the subject

Verify the subject's identity by asking for their name and date of birth. Within the scope of studies, a
patient ID is entered into the software.
3.2.3 Reviewing the inclusion criteria

Check whether the subject has given his consent to taking part in the study.
3.2.4 Preparing the workplace

Disinfect the materials and device parts listed above. Ensure a pleasant room temperature and air
the room if necessary.
3.2.5 Preparing the devices

Prepare the devices according to the device-specific instructions. Averaging of the respiratory gas
analysis should be done over a period of 10 seconds during the test to ensure that the patient is
being monitored and that the BGA measurements (optional) can be taken as close as possible to the
anaerobic threshold.
3.2.6 Principles of preparing the subject for the examination

Explanations, instructions for the subject
Cardiopulmonary exercise test (spiroergometry):
 Next, the ECG, blood pressure cuff, saturation clip and the breathing mask are attached.
 The breathing mask will be connected to a sensor that measures the respiratory gases. Do
not speak after the sensor has been connected.
 You will now have to sit quietly for 3 minutes so that we can measure your respiration, blood
pressure and ECG at rest.
 You will start the examination with a load of 20 Watts, which will then be increased by
another 16 Watts every minute. Please try to keep up a pace of > 45 rotations. [Note:
example modified Jones protocol]
 During the resting phase, during the exercise and shortly before the exercise is completed I
will ask you to take a deep breath and then to continue breathing normally; this is to record
the intrabreath manoeuvre (optional, defined in the respective study protocol).
 You will decide when to end the examination, unless irregularities occur beforehand that call
for the examination to be terminated. Please give us a signal with your hand when you want

possible.
to end the examination. Please continue pedalling after your hand signal; I will then decrease
the load again to allow you to recover slowly at 20 Watts.
 Immediately after ending the examination please use your fingers to rate your level of
exertion using the BORG scale (6-20 or 0-10 depending on the requirements of the respective
study protocol) which I am showing to you here. You must not speak yet.
 Do you have any questions?
Blood gas analysis (optional):
 During the examination, a colleague will assist me and will collect two samples of blood from
your earlobe.
3.3 PERFORMING THE EXAMINATION

3.3.1 Exercise protocol
In principle, the cardiopulmonary exercise test can be performed according to different exercise
protocols that should be chosen depending on the target population [2].
The respective study/register protocol must define what protocol is to be followed. A choice of cycle
and treadmill protocols is provided in the annex (see 8.2)
3.3.2 Preparing the subject, measuring position

• Correct application of the 12-lead ECG.
• Correct application of the breathing mask and check for tightness.
• Correct application of the blood pressure cuff.
• Correct application of the saturation sensor.
• For cycle ergometers additionally:
• Adjust the height of the saddle and handlebar on the ergometer.
• Attach the Velcro straps of the pedals to the subject's feet.
• For treadmills additionally:
• Attach the safety belt/auto-stop.

possible.
3.3.3 Performing the exercise test

Values measured at rest:
 First carry out a spirometry with the resting patient to rule out significant lung disease
(Tiffeneau's test); alternatively: lung function test prior to the cardiopulmonary exercise test
(spirometry, body plethysmography)
 Then measure the gas exchange for 3 minutes at rest.
 Start the exercise test when the RER is < 1. If the RER is > 1 after 3 minutes at rest and still
after another 3 minutes (total 6 min.), you should commence the test anyway.
 Measure the RR before starting the exercise phase. Prior to starting the exercise, the RR
should not be above 170/110 mmHg.
3.3.4 Exercise phase:

 Throughout the test, maintain a constant speed of > 45 rotations/minute – ideally it should
be 55-65 rotations/minute (cycle ergometer). While the speed (pedalling frequency) remains
constant, increase the resistance step by step according to the exercise protocol. At the end
of every step, measure and record the heart rate and blood pressure.
 The subjects should be strongly encouraged to continue the exercise for as long as possible
(always taking into account the termination criteria, see below).
 Optional: When the RER is 0.9, you should start preparing for the BGA at the AT so that the
blood sample can be collected prior to reaching RER 1.
 Optional: The BGA at the end of the exercise is done when the subject signals to end the
examination shortly, or if the examiner is under the impression that the subject will end the
examination soon (severe exhaustion, decrease in pedalling frequency, etc.) or if reasons for
termination are present
 You should continue the test until the subject meets subjective or objective termination
criteria that justify terminating the test.
Objective termination criteria include:
- ST depression (> 0.2 mV) or elevation
- Progressive atrial or ventricular arrhythmia or block images
- Newly occurring atrial fibrillation
- Drop in heart rate during exercise
- Lack of increase or drop in RR across 2 exercise levels
- Drop in O2 uptake (or oxygen pulse) in spite of increasing the load
Subjective termination criteria include:
- Maximal fatigue (e.g. of the legs)
- Thoracic pain (e.g. symptoms of angina), severe dizziness
- Excessive dyspnoea

possible.
- Subjects signals to examiner to end the examination.
3.3.5 Recovery phase:

 The subject has to keep wearing the mask.
 Immediately after ending the test, ask the patient to rate the BORG scale using his hands.
 The subject should continue pedalling without resistance for 2 minutes. After 2 minutes, the
patient should stop pedalling altogether.
 Remove the mask at the earliest 2 minutes after starting the recovery phase.
Continue the ECG, HR and RR measurements for at least 6 minutes in 2-minute intervals.
Continue the RR measurements until the blood pressure returns to baseline.
 It is a known fact that patients can experience a severe drop in RR during the recovery phase.
For this reason you should ask the patient regularly if he is feeling dizzy or unwell. Terminate
the examination in case of dizziness/extreme pallor or if the patient responds inadequately.
3.3.6 Documentation:
 Document all relevant data in the eCRF after ending the examination.
3.4 FOLLOW-UP AND DATA COLLECTION

Following up the examination
Clean the cardiopulmonary exercise machine with Cleanisept Wipes®. Disinfect the mask and the
sensor as outlined in section 1.3.2.
3.4.1 Biomaterial
As an optional analysis, one capillary of blood is collected from the hyperaemic earlobe treated with
ELACUR hot 2.0 % (Riemser®) at rest, close to the anaerobic threshold and during maximum exertion.
3.4.2 Pre-analysis on site

The blood gas analysis is evaluated on site using a blood gas analyser (e.g. ABL 90).
The analysis is either performed immediately or the capillary is sealed with a cap and analysed after
ending the cardiopulmonary exercise test.
The following parameters are measured at rest, close to the anaerobic threshold and during
maximum exertion:
 pH value
 peripheral oxygen saturation (SO₂)
 partial pressure of oxygen (pO₂)
 partial pressure of carbon dioxide (pCO₂)
 base excess (BE)

possible.
 bicarbonate (HCO3-)
 lactate
3.4.3 After the measurement

a) Print out the stress ECG
b) Activate the blood gas mode and enter data (optional)
c) Print out the findings sheet
3.4.4 Follow-up discussion, feedback on findings
Whether and what information is shared with the subject has to be stipulated in the respective study
protocol.
3.4.5 Assessment / evaluation of the examination

The data from the cardiopulmonary exercise test are evaluated according to the recommendation of
the EACPR and AHA [1]. The assessment should be carried out offline using appropriate software
(e.g. JLAB, CareFusion Corporation, San Diego, USA) following the steps below:
1. Reviewing the settings

 Standard: Averaging of the respiratory gas analyses across 30 seconds
2. Plausibility check
 Review the following plausibility criteria using the 9-field chart:
 RER implausible if e.g. below 0.7 at rest
 VE implausible if the respiratory minute volume is too low (rule of nine: increase of
about 9 l/25 Watts)
 Aerobic capacity implausible if the VO₂ increase/Watt is too low (rule of thumb in
healthy subjects: performance (Watts) x 10 ml)
3. Determining the VO₂ peak:

Highest VO₂ value achieved during exercise. A reliable statement about VO₂ peak can only be
made if an RER of >1.05 was achieved during exercise.
4. Determining the anaerobic threshold (AT or VT1):

5. The AT/VT1 is measured from one minute after starting the exercise until an RER = 1 is
reached, either by measuring the change in the slope of the VE/VCO₂ curve (field 5) or the
increase of the oxygen equivalent (EQO₂) in field 6. Determining the respiratory
compensation point (RCP or VT2):
The RCP is the point at which there is a disproportionate increase from VE to VCO₂, which is
read as an increase in EQCO₂ in field 6.

possible.
3.5 PROCEDURE IN CASE OF DEVIATIONS

Documentation/handling of irregularities
During the exercise test, the subjects may experience clinical symptoms, abnormalities regarding the
ECG and blood pressure may occur or the oxygen uptake may be impaired, all of which were
mentioned in particular in the termination criteria. If any such changes occur, the physician
responsible for monitoring the cardiopulmonary exercise test should be called to make a decision
about whether to continue or terminate the examination. These abnormalities are documented in
the software in the field for termination criteria.
Within the scope of providing first aid, emergency equipment including a defibrillator and emergency
kit has to be readily available. If it is anticipated that the incident will require extended medical care,
inform the rescue coordination centre by calling the emergency number 112 or a resuscitation team.
Termination criteria
Objective termination criteria include:

Subjective termination criteria include:
- Subject signals to examiner to end the examination.

possible.
4 DATA MANAGEMENT
Paper version/findings sheets
Print out and chronologically archive one complete set of findings (including the ECG recording) in
hard copy.
Data flow
The data are stored locally on the PC. The data should also be additionally secured by means of
regular/daily backups.
Currently, all relevant information is entered manually into the eCRF. The following information
should be obtained in all DZHK studies/registers:
1. Details regarding the course of the examination:
 Date of the examination (dd/mm/yyyy)

 Pacemaker (yes/no/unknown/not assessed)
 Heart rhythm (sinus rhythm/atrial fibrillation/pacemaker rhythm)
 Intake of beta-blockers (yes/no/unknown/not assessed)
 Duration of exercise (mm:ss)
 Type of exercise
 Treadmill with details of the specific protocol (options: Bruce protocol /
modified Bruce protocol / modified Naughton protocol)
 Cycle with details of the specific protocol (options: modified Jones protocol /
WHO protocol)
 Specify the reason for termination
- Maximum exertion achieved

- Subject signals to examiner to end the examination.

possible.
2. Findings
 Standard measurements (see "Standard parameters", Abbreviations and definitions,

section 1)
5 LITERATURE AND REFERENCES

1. Guazzi, M., V. Adams, V. Conraads, M. Halle, A. Mezzani, L. Vanhees, R. Arena, G.F. Fletcher, D.E. Forman, D.W.
Kitzman, C.J. Lavie, J. Myers, Eacpr, and Aha, EACPR/AHA Joint Scientific Statement. Clinical recommendations for
cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J, 2012. 33(23): p.
2917-27.
2. Jones, N.L., L. Makrides, C. Hitchcock, T. Chypchar, and N. McCartney, Normal standards for an incremental
progressive cycle ergometer test. Am Rev Respir Dis, 1985. 131(5): p. 700-8.
3. Gläser, S., T. Ittermann, C. Schaper, A. Obst, M. Dörr, T. Spielhagen, S.B. Felix, H. Volzke, T. Bollmann, C.F. Opitz, C.
Warnke, B. Koch, and R. Ewert, [The Study of Health in Pomerania (SHIP) reference values for cardiopulmonary
exercise testing]. Pneumologie, 2013. 67(1): p. 58-63.
4. Koch, B., C. Schaper, T. Ittermann, T. Spielhagen, M. Dörr, H. Völzke, C.F. Opitz, R. Ewert, and S. Gläser, Reference
values for cardiopulmonary exercise testing in healthy volunteers: the SHIP study. Eur Respir J, 2009. 33(2): p. 389-
97.
5. Wasserman, K., J.E. Hansen, D.Y. Sue, W.W. Stringer, K. Sietsema, X. Sun, and B.J. Whipp, Principles of Exercise
Testing and Interpretation: Including Pathophysiology and Clinical Applications. 5th edition ed. 2011: Lippincott
Williams&Wilki.
6. Fletcher, G.F., P.A. Ades, P. Kligfield, R. Arena, G.J. Balady, V.A. Bittner, L.A. Coke, J.L. Fleg, D.E. Forman, T.C.
Gerber, M. Gulati, K. Madan, J. Rhodes, P.D. Thompson, M.A. Williams, C.R. American Heart Association Exercise,
C.o.N.P.A. Prevention Committee of the Council on Clinical Cardiology, C.o.C. Metabolism, N. Stroke, E. Council
on, and Prevention, Exercise standards for testing and training: a scientific statement from the American Heart
Association. Circulation, 2013. 128(8): p. 873-934.
7. Trappe, H.J. and H. Löllgen, Leitlinien zur Ergometrie. Z Kardiol, 2000. 89: p. 821-837.
8. in ACSM´s Guidelines for Exercise Testing and Prescription. 2014. p. 124-125.
9. in Exercise Testing for Primary Care and Sports Medicine Physicians. Exercise Testing Special Protocols, H.E. Corey
and D.W. Russell, Editors., Springer p. 47.
10. Borg, G., Anstrengungsempfinden und körperliche Aktivität. Dtsch Arztebl International, 2004. 101(15): p. 1016-.
11. Löllgen, H., Das Anstrengungsempfinden (RPE, Borg-Skala). Deutsche Zeitschrift für Sportmedizin, 2004. 55(11): p.
299-300.
12. Borg, G.A., Psychophysical bases of perceived exertion. Medicine and science in sports and exercise, 1982. 14(5):
p. 377-81.

possible.
6 CHANGE
Change compared to the previous version
Section Description of the change to the previous version

4.0 In the details regarding the course of the examination, the correct exercise
protocols for treadmills and cycles have been specified.
….
7 PERSONS INVOLVED
Name Role Involvement
Prof. Dr. Marcus Dörr Initial author Creation of SOP
S. Kaczmarek Author Creation of SOP
PD Dr. Frank Edelmann Reviewer Technical review
PD Dr. Andreas Dösch AG phenotyping & QM Technical review

possible.
8 ANNEXES
8.1 ECRF MODULE

possible.

possible.

possible.
8.2 CYCLE AND TREADMILL PROTOCOLS
The following exercise protocols are some of those used within the scope of DZHK studies and
registers; this list can be continuously upgraded as needed:
1. Cycle ergometry
a) Modified Jones protocol [2]:
 3-minute resting phase

 Start exercise with 20 Watts, then increase by 16 Watts every minute; symptom-limited
termination of the exercise
 Advantage: availability of German reference values from a large sample of a population-
based study [3-5].
b) WHO protocol [6, 7]:

 Start exercise with 25 Watts, then increase by 25 Watts every 2 minutes; symptom-limited
termination of the exercise.
2. Treadmill cardiopulmonary exercise test
a) Bruce protocol [8]:

 Symptom-limited exercise in 6 stages (3 minutes per stage) with varying speeds and slopes:
Stage Speed (km/h) Slope (%)

1 2.7 10
2 2.7 12
3 2.7 14
4 4.0 16
5 5.4 18
6 6.7 20
b) modified Bruce protocol [9]

 Symptom-limited exercise in 9 stages (3 minutes per stage) with varying speeds and slopes:

possible.

1 2.7 0
2 2.7 5
3 2.7 10
4 4.0 12
5 5.4 14
6 6.7 16
7 8.0 18
8 8.8 20
c) modified Naughton protocol [8]

 Symptom-limited exercise in 13 stages (2 minutes per stage) with varying speeds and slopes

1 1.6 0
2 2.4 0
3 3.2 3.5
4 3.2 7
5 3.2 10.5
6 4.8 7.5
7 4.8 10
8 4.8 12.5
9 4.8 15
10 4.8 17.5
11 4.8 20
12 4.8 22.5
13 4.8 25

possible.
8.3 BORG SCALE

The original scale that was used to assess the level of perceived exercise (RPE, ratings of perceived
exercise) went from 1-20. A non-linear correlation between the perceived exercise and performance
was found, so that the scale was consequently changed to a scale from 6-20, which has been tried
and tested over many decades [8, 9]. In addition to this, the scale enables an approximate estimation
of the respective heart rate during dynamic exercise (in healthy persons) by multiplying it by a factor
of 10 (scale rating x 10 = heart rate) [8, 9].
A different, new scale ranging from 1-10 was later published. The scale is suitable for other questions
such as evaluating the level of pain and isometric stress.
It is recommended to preferably use the 6/20 scale for DZHK studies. The variant of the BORG scale
to be used has to be stipulated in the study protocol of the respective studies.
BORG Ratings of Perceived Exercise BORG Dyspnoea Scale
Subjectively perceived exertion with exercise Subjectively perceived dyspnoea according to

according to Borg [10, 11]: Borg [12]:
(Borg-RPE scale, RPE = ratings of perceived exercise)
6 No exertion at all 0 Nothing at all

7 0.5 Very, very slight (just
Extremely light
8 noticeable)
9 Very light 1 Very slight
10 2 Slight
11 Light 3 Moderate
12 4 Somewhat severe
13 Somewhat hard 5 Severe
14 6 Severe to very severe
15 Hard (heavy) 7 Very severe
16 8 Very severe to very, very
17 Very hard severe
18 9 Very, very severe (almost
19 Extremely hard maximal)
20 Maximal exertion
10 Maximal dyspnoea

possible.

possible.

possible.

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DZHK-SOP-K-07

Cardiopulmonary exercise test

Version: V1.1 Effective date: 01/07/2015

Replaces version: 1.0 Dated: 01/09/2014

Change note: Corrected note regarding exercise protocols on p. 21

Technical author Technical Approval of Approval DZHK

DZHK-SOP-K-07 Effective date: 01/09/2014

3.2.5 Preparing the devices .................................................................................................... 15

DZHK-SOP-K-07 Effective date: 01/09/2014

1.1 LIST OF ABBREVIATIONS

Abbreviation Unit Explanation Standard

DZHK-SOP-K-07 Effective date: 01/09/2014

Abbreviation Unit Explanation Standard

DZHK-SOP-K-07 Effective date: 01/09/2014

Abbreviation Unit Explanation Standard

DZHK-SOP-K-07 Effective date: 01/09/2014

1.3 TARGET GROUP

1.3.1 Inclusion criteria

1.3.2 Exclusion criteria

• Acute relevant disease, e.g. recent myocardial infarction, systemic infections,

• Tachycardia at rest (>120 bpm).

• Symptomatic electrolyte imbalance or metabolic imbalance.

• Symptomatic impaired cerebral circulation.

If necessary, specific criteria of the respective studies or registers have to be observed.

DZHK-SOP-K-07 Effective date: 01/09/2014

1.4 APPLICATION AND TASKS

1.5 TERMS AND DEFINITIONS

1.6 RELATIONSHIPS TO OTHER EXAMINATIONS

Mandatory screening (SOP …): Lung function test

Mandatory follow-up (SOP …): Not applicable

DZHK-SOP-K-07 Effective date: 01/09/2014

1.7 QUALITY LEVEL

This SOP describes Level 2.

DZHK-SOP-K-07 Effective date: 01/09/2014

2 PREREQUISITES OF THE EXAMINATION

2.1 REQUIREMENTS REGARDING ROOMS/EQUIPMENT

Recommended for all spiroergometry machines:

 Laptop to enter data

DZHK-SOP-K-07 Effective date: 01/09/2014

 Gas analyser calibration

2.2.3 Sources of error

DZHK-SOP-K-07 Effective date: 01/09/2014

 Adjusting the height of the saddle on the cycle:

2.2.4 Spare parts for wear and tear

 A defective sensor may be the cause of a calibration error.

ECG suction electrodes:

 Replace only in case of a defect (decision by the medical technician).

2.2.6 Service / device maintenance

Maintenance is performed in accordance with EN 62353 [www.ec--normen.de].

DZHK-SOP-K-07 Effective date: 01/09/2014

2.3 SPECIAL CLINICAL CONSUMABLES

 1 skin disinfectant spray,

2.4 ESSENTIAL DOCUMENTS

2.5 ESSENTIAL INFORMATION

1 performing examiner (certified nursing staff or MTA).

1 assisting examiner (certified nursing staff or MTA) (if BGA is planned).

The staff must be trained on general emergencies and resuscitation.

DZHK-SOP-K-07 Effective date: 01/09/2014

3.1 FLOWCHART OF THE PROCEDURE