1. Carl D. Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs and Rehabilitation Associate Professor of Medicine - Mayo Clinic College of Medicine Carl D. Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs and Rehabilitation Associate Professor of Medicine - Mayo Clinic College of Medicine Quality Control of Exercise and Gas Exchange Equipment

2. Exercise Testing Guidelines ACC/AHA Guidelines for Exercise Testing ACC/AHA Guidelines for Exercise Testing J Am Coll Cardiol 1997;30:260-315 Updated in 2002 (www.americanheart.org) ATS/ACCP Statement on Cardiopulmonary Exercise Testing ATS/ACCP Statement on Cardiopulmonary Exercise Testing Am J Respir Crit Care Med Vol 167. pp 211– 277, 2003 Am J Respir Crit Care Med Vol 167. pp 211– 277, 2003 ACC/AHA Guidelines for Exercise Testing ACC/AHA Guidelines for Exercise Testing J Am Coll Cardiol 1997;30:260-315 Updated in 2002 (www.americanheart.org) ATS/ACCP Statement on Cardiopulmonary Exercise Testing ATS/ACCP Statement on Cardiopulmonary Exercise Testing Am J Respir Crit Care Med Vol 167. pp 211– 277, 2003 Am J Respir Crit Care Med Vol 167. pp 211– 277, 2003

3. Exercise Testing Guidelines Guidelines for Exercise Testing in the Pediatric Age Group - Council on Cardiovascular Disease in the Young, American Heart Association Guidelines for Exercise Testing in the Pediatric Age Group - Council on Cardiovascular Disease in the Young, American Heart Association Reginald Washington MD et al ( Circulation 90:2166-2179, 1994) Reginald Washington MD et al ( Circulation 90:2166-2179, 1994) Guidelines for Methacholine and Exercise Challenge Testing ( Am J Respir Crit Care Med Vol 161. pp 309-329, 2000) Guidelines for Methacholine and Exercise Challenge Testing ( Am J Respir Crit Care Med Vol 161. pp 309-329, 2000) ATS Pulmonary Function Laboratory Management and Procedure Manual (updated 2005) ATS Pulmonary Function Laboratory Management and Procedure Manual (updated 2005) www. thoracic.org www. thoracic.org Guidelines for Exercise Testing in the Pediatric Age Group - Council on Cardiovascular Disease in the Young, American Heart Association Guidelines for Exercise Testing in the Pediatric Age Group - Council on Cardiovascular Disease in the Young, American Heart Association Reginald Washington MD et al ( Circulation 90:2166-2179, 1994) Reginald Washington MD et al ( Circulation 90:2166-2179, 1994) Guidelines for Methacholine and Exercise Challenge Testing ( Am J Respir Crit Care Med Vol 161. pp 309-329, 2000) Guidelines for Methacholine and Exercise Challenge Testing ( Am J Respir Crit Care Med Vol 161. pp 309-329, 2000) ATS Pulmonary Function Laboratory Management and Procedure Manual (updated 2005) ATS Pulmonary Function Laboratory Management and Procedure Manual (updated 2005) www. thoracic.org www. thoracic.org

4. Quality Models Clinical and Laboratory Standards Institute (formerly NCCLS) Clinical and Laboratory Standards Institute (formerly NCCLS) “Quality System Model for Healthcare” HS-1 (ISO 9000) “Quality System Model for Healthcare” HS-1 (ISO 9000) Application of a Quality System Model for Respiratory Services” HS-4 Application of a Quality System Model for Respiratory Services” HS-4 Clinical and Laboratory Standards Institute (formerly NCCLS) Clinical and Laboratory Standards Institute (formerly NCCLS) “Quality System Model for Healthcare” HS-1 (ISO 9000) “Quality System Model for Healthcare” HS-1 (ISO 9000) Application of a Quality System Model for Respiratory Services” HS-4 Application of a Quality System Model for Respiratory Services” HS-4

5. Application of a Quality System Model for Respiratory Services Path of workflow

6. Cardiopulmonary Exercise Testing Path of Workflow Pre-testing Pre-testing Demographic information Demographic information History History Exercise limitations - orthopedic considerations Exercise limitations - orthopedic considerations Laboratory results – Na, K, etc. Laboratory results – Na, K, etc. Medications Medications Digitalis, β – blockers, calcium channel blockers Digitalis, β – blockers, calcium channel blockers Pre-testing Pre-testing Demographic information Demographic information History History Exercise limitations - orthopedic considerations Exercise limitations - orthopedic considerations Laboratory results – Na, K, etc. Laboratory results – Na, K, etc. Medications Medications Digitalis, β – blockers, calcium channel blockers Digitalis, β – blockers, calcium channel blockers

7. Cardiopulmonary Exercise Testing Path of Workflow Pre-Test (cont) Pre-Test (cont) Pre-test instructions Pre-test instructions Appropriate shoes and clothing Appropriate shoes and clothing Refrain from smoking (8 hours) Refrain from smoking (8 hours) Light meal 2-4 hours prior to testing Light meal 2-4 hours prior to testing Medication instructions Medication instructions Appropriate order Appropriate order Type of exercise test, adjuncts (FV loops, ABG’s, etc. Type of exercise test, adjuncts (FV loops, ABG’s, etc. Pre-Test (cont) Pre-Test (cont) Pre-test instructions Pre-test instructions Appropriate shoes and clothing Appropriate shoes and clothing Refrain from smoking (8 hours) Refrain from smoking (8 hours) Light meal 2-4 hours prior to testing Light meal 2-4 hours prior to testing Medication instructions Medication instructions Appropriate order Appropriate order Type of exercise test, adjuncts (FV loops, ABG’s, etc. Type of exercise test, adjuncts (FV loops, ABG’s, etc.

8. Cardiopulmonary Exercise Testing Path of Workflow Testing Testing Patient instructions Patient instructions l Understanding, effort & cooperation Technologist’s performance & training Technologist’s performance & training Equipment Equipment Testing Testing Patient instructions Patient instructions l Understanding, effort & cooperation Technologist’s performance & training Technologist’s performance & training Equipment Equipment

9. Cardiopulmonary Exercise Testing Path of Workflow Technologist’s competency Technologist’s competency Job qualifications Job qualifications Job descriptions Job descriptions Orientation Orientation Training Training Competency assessment Competency assessment Continuing education Continuing education Performance appraisal Performance appraisal Technologist’s competency Technologist’s competency Job qualifications Job qualifications Job descriptions Job descriptions Orientation Orientation Training Training Competency assessment Competency assessment Continuing education Continuing education Performance appraisal Performance appraisal

11. Cardiopulmonary Exercise Testing Equipment - Ergometers Calibration every 3-6 months Calibration every 3-6 months Cycle ergometers Cycle ergometers static-bar and weights static-bar and weights dynamic-calibrators dynamic-calibrators Treadmill Treadmill Speed: beat length, stopwatch (subject on TM) Speed: beat length, stopwatch (subject on TM) % Grade = Length of the treadmill vertical height of elevation % Grade = Length of the treadmill vertical height of elevation Calibration every 3-6 months Calibration every 3-6 months Cycle ergometers Cycle ergometers static-bar and weights static-bar and weights dynamic-calibrators dynamic-calibrators Treadmill Treadmill Speed: beat length, stopwatch (subject on TM) Speed: beat length, stopwatch (subject on TM) % Grade = Length of the treadmill vertical height of elevation % Grade = Length of the treadmill vertical height of elevation

12. Cardiopulmonary Exercise Testing Equipment – Flowmeter and analyzers ATS/ERS standard for flow-volume devices ATS/ERS standard for flow-volume devices 3 liter syringe 3 liter syringe ± 3.5% or ± 50 ml ± 3.5% or ± 50 ml Gas analyzers Gas analyzers Paramagnetic, infrared, mass spectrometer Paramagnetic, infrared, mass spectrometer Linearity: 2-pt. calibration over range testing Linearity: 2-pt. calibration over range testing ATS/ERS standard for flow-volume devices ATS/ERS standard for flow-volume devices 3 liter syringe 3 liter syringe ± 3.5% or ± 50 ml ± 3.5% or ± 50 ml Gas analyzers Gas analyzers Paramagnetic, infrared, mass spectrometer Paramagnetic, infrared, mass spectrometer Linearity: 2-pt. calibration over range testing Linearity: 2-pt. calibration over range testing

13. Cardiopulmonary Exercise Testing Equipment –Analyzers Phase/time delay Phase/time delay Establish lab mean and STD Establish lab mean and STD Proctor DN. Beck KC. Journal of Applied Physiology. 81(6):2495-9, 1996 Dec. Proctor DN. Beck KC. Journal of Applied Physiology. 81(6):2495-9, 1996 Dec. Phase/time delay Phase/time delay Establish lab mean and STD Establish lab mean and STD Proctor DN. Beck KC. Journal of Applied Physiology. 81(6):2495-9, 1996 Dec. Proctor DN. Beck KC. Journal of Applied Physiology. 81(6):2495-9, 1996 Dec.

14. Cardiopulmonary Exercise Testing Equipment – Biological QC Laboratory personnel Laboratory personnel 1-2 individuals: 100 watts cycle or 4.0 mph treadmill or below their anaerobic threshold 1-2 individuals: 100 watts cycle or 4.0 mph treadmill or below their anaerobic threshold Establish mean and confidence limits (95% CI) for VO 2, VCO 2, V E Establish mean and confidence limits (95% CI) for VO 2, VCO 2, V E Perform at regular intervals depending on machine use or whenever data integrity are questioned Perform at regular intervals depending on machine use or whenever data integrity are questioned Laboratory personnel Laboratory personnel 1-2 individuals: 100 watts cycle or 4.0 mph treadmill or below their anaerobic threshold 1-2 individuals: 100 watts cycle or 4.0 mph treadmill or below their anaerobic threshold Establish mean and confidence limits (95% CI) for VO 2, VCO 2, V E Establish mean and confidence limits (95% CI) for VO 2, VCO 2, V E Perform at regular intervals depending on machine use or whenever data integrity are questioned Perform at regular intervals depending on machine use or whenever data integrity are questioned

15. Cardiopulmonary Exercise Testing Equipment – Biological QC

16. Cardiopulmonary Exercise Testing Path of Workflow - Testing Protocols Protocols Cycle or treadmill Cycle or treadmill Steady state, incremental, ramp Steady state, incremental, ramp Defined (e.g. Bruce) or ad hoc Defined (e.g. Bruce) or ad hoc Reference Reference Adult: Jones, Wasserman, Blackie, Zavala, Bruce Adult: Jones, Wasserman, Blackie, Zavala, Bruce Pediatric: James, Cooper, Cumming Pediatric: James, Cooper, Cumming Protocols Protocols Cycle or treadmill Cycle or treadmill Steady state, incremental, ramp Steady state, incremental, ramp Defined (e.g. Bruce) or ad hoc Defined (e.g. Bruce) or ad hoc Reference Reference Adult: Jones, Wasserman, Blackie, Zavala, Bruce Adult: Jones, Wasserman, Blackie, Zavala, Bruce Pediatric: James, Cooper, Cumming Pediatric: James, Cooper, Cumming

17. Cardiopulmonary Exercise Testing Path of Workflow Post- testing Post- testing Data analysis and selection Data analysis and selection Report review Report review Demographic Demographic Data Data Interpretation Interpretation Post- testing Post- testing Data analysis and selection Data analysis and selection Report review Report review Demographic Demographic Data Data Interpretation Interpretation

18. Cardiopulmonary Exercise Testing Path of Workflow Information management Information management Timely posting of the data to the medical record or Information system (HIS/LIS) Timely posting of the data to the medical record or Information system (HIS/LIS) Turn-around time: ATS PFL Registry Abstract AARC 2005 Turn-around time: ATS PFL Registry Abstract AARC 2005 Average TRT: 7 d (3%) Average TRT: 7 d (3%) Information management Information management Timely posting of the data to the medical record or Information system (HIS/LIS) Timely posting of the data to the medical record or Information system (HIS/LIS) Turn-around time: ATS PFL Registry Abstract AARC 2005 Turn-around time: ATS PFL Registry Abstract AARC 2005 Average TRT: 7 d (3%) Average TRT: 7 d (3%)

19. What is Quality? “Doing the Right thing” “Doing the Right thing Right!!!” Kathleen Sazama MD, JD M.D. Anderson Cancer Center “Doing the Right thing” “Doing the Right thing Right!!!” Kathleen Sazama MD, JD M.D. Anderson Cancer Center