Cardiopulmonary Exercise Testing (CPET) In Adults

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Original Editor - Anas Mohamed Top Contributors - Anas Mohamed, Lucinda hampton and Kim Jackson


Cardiopulmonary exercise testing (CPET) provides a global assessment of the integrative exercise responses involving the pulmonary, cardiovascular, hematopoietic, neuropsychological, and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. This relatively noninvasive, dynamic physiologic overview permits the evaluation of both submaximal and peak exercise responses, providing the physician with relevant information for clinical decision making. Once the exclusive province of research physiologists and specialized centers, CPET is increasingly being used in a wide spectrum of clinical applications for the evaluation of undiagnosed exercise intolerance and exercise-related symptoms, and for the objective determination of functional capacity and impairment. The use of CPET in patient management is increasing with the understanding that resting pulmonary and cardiac function testing cannot reliably predict exercise performance and functional capacity and that, furthermore, overall health status correlates better with exercise tolerance rather than with resting measurements.[1]

Cardiopulmonary exercise testing (CPET) is an examination that allows the investigator to simultaneously study the responses of the cardiovascular and ventilatory systems to a known exercise stress.This is possible because gas exchange at the airway is a consequence of cardiac output and pulmonary blood flow, as well as peripheral O2 extraction coupled to ventilation. Thus, the heart, with the circulation, couples gas exchanges (O2 and CO2) of muscle respiration with that at the lungs. The adequacy of the cardiovascular transport of O2 for known exercise work rates is described by the lung gas exchange.[2]

CPET involves mainly the analysis of respiratory gases including.

  • Respiratory oxygen uptake (Vo2),
  • Carbon dioxide production (Vco2),
  • Ventilatory measures during a symptom‐limited exercise test.


  • Diagnostic and prognostic evaluation of the cardiovascular and pulmonary diseases.
  • Evaluation of the disease severity and functional effects.
  • Assessment for suitability of treatment, i.e. surgery, transplantation, supplemental oxygen therapy
  • Evaluation of efficacy of therapeutic intervention
  • Outcome variable for clinical trials
  • Measurable goals to improve fitness
  • To measure of exercise rehabilitative training intensity
  • Development of knowledge and understanding of the disease.


Cardiopulmonary exercise testing (CPET) can be assessed by Laboratory method

  • Treadmill
  • Bicycle ergometer


Common measurements like

There are several clinical measurements used in the CPET depends on type of exercise and diagnose


Bruce protocol
There are many different protocols used in the CPET,
treadmill protocol
Treadmill protocol

Common protocols are

  • Bruce treadmill test is one of the most commonly used in cardiac stress testing centers
  • Bruce or Ellestad are better suited for screening younger and/or physically active individuals (larger incremental workload)
  • Naughton or Balke-Ware are preferable for older or deconditioned individuals and patients with chronic diseases.(smaller incremental workload)


  1. Evaluation of Exercise Intolerance
  2. Unexplained Dyspnea
  3. Evaluation of Patients with Cardiovascular Disease
  4. Evaluation of Patients with Respiratory Disease 216
  5. Preoperative Evaluation 216
  6. Exercise Prescription for Pulmonary Rehabilitation
  7. Evaluation of Impairment/Disability[1]


Absolute Relative
Acute myocardial infarction (3–5 days) Left main coronary stenosis or its equivalent
Unstable angina Moderate stenotic valvular heart disease
Uncontrolled arrhythmias causing symptoms Severe untreated arterial hypertension at rest
or hemodynamic compromise (> 200 mm Hg systolic, > 120 mm Hg diastolic)
Syncope Tachyarrhythmias or bradyarrhythmias
Active endocarditis High-degree atrioventricular block
Acute myocarditis or pericarditis Hypertrophic cardiomyopathy
Symptomatic severe aortic stenosis Significant pulmonary hypertension
Uncontrolled heart failure Advanced or complicated pregnancy
Acute pulmonary embolus or pulmonary infarction Electrolyte abnormalities
Thrombosis of lower extremities Orthopedic impairment that compromises exercise performance
Suspected dissecting aneurysm
Uncontrolled asthma
Pulmonary edema
Room air desaturation at rest ⩽ 85%[null *]
Respiratory failure
Acute noncardiopulmonary disorder that may affect
exercise performance or be aggravated by exercise

(i.e. infection, renal failure, thyrotoxicosis)

Mental impairment leading to inability to cooperate



ATS/ACCP Statement on Cardiopulmonary Exercise Testing

ACSM's Guidelines for Exercise Testing and Prescription


  1. 1.0 1.1 1.2 American Thoracic Society; American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003 Jan 15;167(2):211-77. doi: 10.1164/rccm.167.2.211. Erratum in: Am J Respir Crit Care Med. 2003 May 15;1451-2. PMID: 12524257.
  2. Karlman Wasserman. Principles of Exercise Testing and Interpretation Including Pathophysiology and Clinical Application. 5th edition. Wolters Kluwer Bussiness. 2012
  3. Cardiopulmonary Exercise testing CPET. Natural Medicine & Detox. Available from:
  4. A Basic Introduction of Cardio-Pulmonary Exercise Testing -- BAVLS.American Thoracic Society. Available from: