The interrater reliability of ventilatory thresholds and maximum values of three different cycling ergometry protocols - appendices

APPENDIX 1: PROTOCOL FOR CYCLING ERGOMETRY TEST

Protocol

1. Open Cosmed on the computer and log in¹.
2. Make sure the device has been turned on for 10 minutes. Perform ‘metabolic gas calibration’. Check if red and blue lines coincide with the dashed lines. If not, restart the calibration¹.
3. Add a new subject to the system. As a name fill in ‘FTP Test [number of test]’. Note date of birth, sex, weight, height, and race.
4. Click on add a new test, ‘spirometry’. Perform a spirometry twice. Accept if the lines coincide. If they do not coincide perform another spirometry and select the two best attempts¹.
5. Fit the subject with a gas analysis mask. Test to make sure it is fully sealed by placing your hand on the mouth opening while the patient is breathing out. If there is any air escaping adjust the mask¹.
6. Position the subject on the bike. Adjust the measurements so that the patient is comfortable. Connect the mask to the gas analysis device¹.
7. Place the electrocardiogram electrodes on the back and chest of the subject following the clinical guidelines of the Society for cardiological science and technology. By placing the extremity electrodes on the shoulder blades and lower back you minimize movement interference².
8. Click on add a new test, ‘Cardio Pulmonary Exercise Testing, breath by breath’. Select the correct protocol.
   1. Ramp protocol:
      1. Men: 6 x weight / 10 (for example: ramp_45)
      2. Women: 5 x weight / 10 (for example: ramp_30)
   2. 1-minute step protocol:
      1. Men: 6 x weight / 10 (for example: 1-min_45)
      2. Women: 5 x weight / 10 (for example: 1-min_30)
   3. 3-minute step protocol:
      1. Men: rikschaatsen_heren
      2. Women: rikschaatsen_dames
9. Press record and start 1 minute warm up¹.
10. Do a quality control check¹.
    1. Are the percentages of O₂ and CO₂ correct?
    2. To detect leakage of the mask: are the inhaled and exhaled volumes the same?
    3. Do the measurements seem plausible: heart rate, tidal volume.
11. Start the test protocol. Instruct the subject to not speak during the test and to keep a steady cadence between 70-100. Give verbal encouragement during the test¹.
12. Go to cool down phase when subject cannot keep up the cadence¹.
13. 3-minute cool down phase, instruct the subject to keep pressure on the paddles to avoid dizziness¹.
14. Take of the mask and electrodes. Subject can step off the bike.
15. Clean the mask, flowsensor, seat, handles and EKG device. Clean the entire bike at the end of the day¹.
16. Change the date of birth to 1-1-1990, the weight to 100kg and the height to 200cm, for anonymization.

References

1. CPET Protocol, department of sports medicine, OLVG Hospital.
2. Clinical Guidelines by Consensus Recording a Standard 12-Lead Electrocardiogram, Society for Cardiological Science & Technology (2017)

APPENDIX 2: PROTOCOL FOR ASSESSMENT OF THE CYCLING ERGOMETRY TEST RESULTS/THRESHOLDS

Protocol

1. Go to ‘adjust data’ and choose ‘time average’ at data filtering. Adjust the time slider button on the right side all the way to the left, until it is on 10s average.
2. Determine if it is a maximum test^1,2,3.
   1. Has >85% of the predicted maximum heart rate been reached?
   2. Has a respiratory exchange ratio (RER) (VCO₂/VO₂) of >1.1 been reached?
3. Determine the VO₂-peak by adjusting the two lines to the 20s peack VO2 in the VO2 graph (20s average peak VO2 uptake)^1,4,5.
4. Determine the aerobic threshold (AT) using the following methods³:
   1. The point at which a systematic increase in the ventilatory equivalent for oxygen (V̇e/V̇o₂) occurs without an increase in the ventilatory equivalent for carbon dioxide (V̇e/V̇co₂).
   2. The point at which a systematic rise in end-tidal oxygen pressure (P_ETO₂) occurs without a decrease in the end-tidal carbon dioxide pressure (P_ETCO₂).
   3. V-slope method: the departure of V̇o₂ from a line of identity drawn through a plot of V̇co₂ versus V̇o₂.
   4. If AT is not the same using the different methods: choose AT at which two methods correspond, if AT is different for al methods weigh method ‘a’ the heaviest, then method ‘b’, then method ‘c’.
5. Determine the heart rate at AT.
6. Determine VO₂ at AT, 10 seconds before AT and 10 seconds after AT.
7. Determine the power at AT.
   1. Ramp protocol: power output at AT.
   2. 1-min step protocol: power output in the step before AT + ½ x the power output increment if AT falls after 30 seconds into a step.
   3. 3-min step protocol: power output in the step before AT + 1/6 x the power output increment for each 30 seconds that AT falls into the step.
8. Determine the respiratory compensation point (RC) using the following method⁵:
   1. The point where end-tidal PCO₂ begins to fall.
   2. This point can be confirmed by examining the rise of V_E/VCO_2p plotted against time.
9. Determine the heart rate at RC.
10. Determine VO₂ at RC, 10 seconds before RC and 10 seconds after RC.
11. Determine the power at RC.
    1. Ramp protocol: power output at RC.
    2. 1-min step protocol: power output in the step before RC + ½ x the power output increment if RC falls after 30 seconds into a step.
    3. 3-min step protocol: power output in the step before RC + 1/6 x the power output increment for each 30 seconds that RC falls into the step.
12. Interpretation:
    1. Determine the maximum heartrate.
    2. Determine the maximum RQ during exercise.
    3. Determine the maximum VE (in L/min).
    4. Determine the maximum power.
       1. Ramp protocol: maximum power output reached.
       2. 1-min step protocol: power output in last completed step + ½ x power output increment for each 30 seconds into the non-completed step⁶.
       3. 3-min step protocol: power output in last completed step + 1/6 x power output increment for each 30 seconds into the non-completed step⁶.
13. Change all the outcomes back to autodetect in the computer.

References

1. Sietsema K, Stringer W, Ward S, Sue D. Wasserman & Whipp’s Principles of Exercise Testing and Interpretation. 6th edition. Philadelphia: Lippincott Williams & Wilkins
2. Chambers DJ, Wisely NA. Cardiopulmonary exercise testing—a beginner’s guide to the nine-panel plot. BJA Education. May 1^st 2019;19(5):158-64.
3. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, e.a. Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults. Circulation. 13 july 2010;122(2):191-225.
4. Amann M, Subudhi A, Foster C. Influence of testing protocol on ventilatory thresholds and cycling performance. Med Sci Sports Exerc. April 2004;36(4):613-22.
5. Keir DA, Fontana FY, Robertson TC, Murias JM, Paterson DH, Kowalchuk JM, e.a. Exercise Intensity Thresholds: Identifying the Boundaries of Sustainable Performance. Medicine & Science in Sports & Exercise. September 2015;47(9):1932.
6. Roffey DM, Byrne NM, Hills AP. Effect of stage duration on physiological variables commonly used to determine maximum aerobic performance during cycle ergometry. J Sports Sci. October 2007;25(12):1325-35