Gülbin Bingöl Karakoç,MD,Prof. of Pediatrics,Cukurova University,Medicine Faculty, Division of Alergy-Immunology, Adana

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SPIROMETRY,BRONCHODILATATION,

BRONCHIAL PROVOCATION

CONFLICT OF INTERESTNONE

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AgendaSpirometry

Definition and indicationsFlow-volume relationshipGeneral considerations Indices measuredInterpretation of lung function tests

Definiton of obstructive and restrictive abnormalitiesDefinition of central and upper airway obstruction

BronchodilatationBronchial provocation

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DefinitionSpirometry is a physiological test that

measures how an individual inhales or exhales volumes of air as a function of time.

The primary signal measured in spirometry may be volume or flow.

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BIG BANG ???

John Hutchinson 1811-1861 A.D.

Born Newcastle upon Tyne, 1811 Devoted to mechanical tinkering as a

child Medical education in London M.R.C.S in 1836; M.D. in 1848 Assistant Physician to the Hospital for

Consumption, Brompton in 1850 Invented the spirometer and the science

of spirometry Related vital capacity to height and

presented his work to the Statistical Society and the Royal Medical and Surgical Society

1846, “On the capacity of the lungs” reported on 2130 subjects in Medico-Chiurgical Transactions 29:137, London

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Indications Diagnostic

To evaluate symptoms, signs or abnormal laboratory tests To measure the effect of disease on pulmonary function To screen individuals at risk of having pulmonary disease To assess pre-operative risk To assess prognosis To assess health status before beginning strenuous physical activity programmes

Monitoring To assess therapeutic intervention To describe the course of diseases that affect lung function To monitor people exposed to injurious agents To monitor for adverse reactions to drugs with known pulmonary toxicity

Public health Epidemiological surveys Derivation of reference equations Clinical research

Disability/impairment evaluations

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LUNG VOLUMESFLOW-VOLUME CURVES

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IRV

TV

ERV

RV

IC

FRC

VC

RV

TLC

TV : Tidal volume:The volume of gas inhaled or exhaled during the respiratorycycle

ERV : Ekspiratory reserve volume; The volume of gas that can be maximally exhaled from the end-expiratory level during tidal breathing.

IRV : Inspiratory reserve volume; The maximum volume of gas that can be inhaled from the end-inspiratory level during tidal breathing.

RV : Residual volume: The volume of gas remaining in the lung after maximal exhalation

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IRV

TV

ERV

RV

IC

FRC

VC

RV

TLC

FRC : Functional residual capacity.

IC : Inspiratory vital capacity; where the measurement is performed in a relaxed manner, without undue haste or deliberately holding back, from a position of full expiration to full inspiration;

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IRV

TV

ERV

RV

IC

FRC

VC

RV

TLC

VC :Vital capacity; The volume change at the mouth between the positions of full inspiration and complete expiration.

TLC : Total lung capacity; the volume of gas in the lungs after maximal inspiration, or the sum of all volume compartments.

FVC :Forced vital capacity; the volume of gas that is exhaled during a forced expiration, starting from a position of full inspiration and ending at complete expiration

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GENERAL CONSIDERATIONS

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Dynamic>5-6 years Spirometry is a method of assessing lung

function by measuring the volume of air the patient is able to expel out from the lungs after maximal inspiration

Age, Height, Sex, Weight, and Ethnicity affect the results

What is Spirometry?

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General considerationsMany different types of equipmentRequires cooperation between the subject and

the examiner, Results depend on technical and personal

factors

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Standardisation of spirometry

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Before starting GET READY

Clean and quite roomCheck the spirometer calibrationExplain the testPrepare the subject (The parents should be with children)Ask about smoking, recent illness, medication use etc.Measure weight and height without shoesWash hands Instruct and demonstrate the test to the subject, to include

Correct posture with head slightly elevatedPosition of the mouthpiece (closed circuit) Inhale rapidly and completelyExhale with maximal forcecorrect posture with head

slightly elevated,inhale rapidly and completely

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Perform manoeuvre Have subject assume the correct posture

Attach nose clip, place mouthpiece in mouth and close lips around the mouthpiece

Inhale completely and rapidly with a pause of,1 s at TLC

Exhale maximally until no more air can be expelled while maintaining an upright posture

Repeat instructions as necessary, coaching vigorously

Repeat for a minimum of three manoeuvres; no more than eight are usually required

Check test repeatability and perform more manoeuvres as necessary

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video

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INDICES MEASURED

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FVC :Forced vital capacity FEV1 :Forced expiratory volume in one second FEV1/ FVC :Forced expiratory ratio; FER (%)

PEFR :Peak expiratory flow rateı FEF25-75 :Forced Expiratory Flow 25%- 75%

(maximum mid-expiratory flow)

Volme time curve Flow-volume curve

Indices Measured

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PFT Reportso When performing PFT’s three values are

reported:

o Actual – what the patient performed

o Predicted – what the patient should have performed based on Age, Height, Sex, Weight, and Ethnicity

o % Predicted – a comparison of the actual value to the predicted value

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Vital capacity

Inspiration

Expiration

Normal spirometry (flow-volume curve)

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Forced expiratory flow-volume curve

100TLC

2575 50 0RV

PEF

FEF75%

FEF50%

FEF25%

0

9

6

3

12

Flow

Expired Vital Capacity (%) 20.04.2326

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Flow-volume and Volume-time curves

FEV1

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Flow

Volume

Effort that is not maximal throughout

cough

Early termination

Leak

Artefacts during spirometry

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cough

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Forced vital capacity(FVC) The volume of gas that is exhaled during a forced

expiration, starting from a position of full inspiration and ending at complete expiration

Healthy patients can exhale their FVC within 6 seconds

Patients with severe obstruction (e.g., emphysema) may require 20 seconds, however, exhalation times >15 seconds will rarely change clinical decisions

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FVC: Criteria for Acceptability

1. Maximal effort; no cough or glottic closure during the first second; no leaks or obstruction of the outhpiece.

2. Good start-of-test; back extrapolated volume <5% of FVC or 150 ml, whichever is greater

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FVC: Criteria for Acceptability

3. Tracing shows 6 seconds of exhalation or an obvious plateau (<0.025L for ≥1s); no early termination or cutoff; or subject cannot or should not continue to exhale

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FVC: Criteria for Acceptability

4. Three acceptable spirograms obtained; two largest FVC values within 150 ml; two largest FEV1 values within 150 ml

5. The largest FVC and largest FEV1 (BTPS) should be reported, even if they do not come from the same curve

If reproducible values cannot be obtained after

eight attempts, testing may be discontinued

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FVC

FVC equals VC in healthy individuals FVC is often lower in patients with

obstructive disease

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FVC

FVC can be reduced by: Mucus plugging Bronchiolar narrowing Chronic or acute asthma Bronchiectasis Cystic fibrosis Trachea or mainstem bronchi obstruction Neuromuscular disorders Chest deformities

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FEV1:Forced Expiratory Volume

The volume expired over the first second of an FVC maneuver

May be reduced in obstructive or restrictive patterns, or poor patient effort

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FEV1 may be reduced inObstructive disease

Airway narrowing during forced expirationemphysema

Mucus secretionsBronchospasmAsthmaLarge airway obstruction

tumors/foreign bodies

Restrictive disease

FibrosisEdemaSpace-occupying

lesionsNeuromuscular

diseasesObesityChest wall deformity

FEV1/FVC is one of the most important parameters for determining airway obstruction.

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PEFThe maximum flow obtained during a

FVC maneuverIn laboratory, must perform a minimum of 3

PEF maneuvers Primarily measures large airway functionMany portable devices available Effort dependentGenerally used for monitoring asthma.

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FEF25-75 ;Forced Expiratory Flow 25%- 75%(maximum mid-expiratory flow)

FEF 25%-75% is measured from a segment of the FVC Includes flow from medium and small airways Decreases in early stage of obstructive diseases In the presence of a borderline value for FEV1/FVC, a low FEF

25%-75% may help confirm airway obstruction Effort independent Sensitive but not specific for small airway obstruction

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INTERPRETATION OF LUNG FUNCTION TESTS

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1. Obstructive type:• FEV1 / FVC • Lung volumes

2 basic models

2. Restrictive type:• TLC • VC • FEV1 /FVC normal or • Lung volumes

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FRC resp.muscle weakness;N

TLC RV exp. muscle weakness;

obstructive

restrictive

normal

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PFT

Obstructive disease

Restrictive disease

Miksed type

VCFEV1FEV1/FVCFRCRVTLC

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A. Evaluation of PFT according to the flow-volume curve

B. Check FEV1 value !!!!

> 80% (%pred) = normalFEV1/FVC < 80% and/or

FEF 25-75 < 50%Early obstruction

< 80%(%pred) = anormalFEV1/FVC ?

>80% Restriction??

Check lung volumes

< 80%Coexistance of restriction

can not be ruled out

<80% or < 2SDObstruction

FVC ?

>80% =Only obstructionSeverity classification

according to FEV1

C. Check the curve for upper airway obstruction

FEV1

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Obstructive Diseases

•Asthma

•COPD

•Bronchiectasis

•Cystic fibrosis

•Bronchiolitis

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Diagnosis of ObstructionBronkodilatation

Coming Soon,Stick around!!!

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Mild obstruction Severe obstruction

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FEV1 FEF25-75,

FEF50

FEV1/FVC Degree of severity

80

61-79

40-60

< 40 veya

1 L

> 60

56-60

45-55

30-44

>70

50-70

36-50

35

Normal

Mild

Moderate

Severe

Severity classification in obstructive diseases

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Restrictive Diseases

Paranchimal•Pneumonia,atelactasis

•Fibrosis

•Sarcoidosis

•Idiopathic pulmonary fibrosis

• Pneumocaniosis

•Intertitial lung diseases.

Extraparanchimal

Neuromuscular diseases •Diaphragmatic eventration

• Miyastenia gravis*

• Guillain- Barre synd.*

• Muscular dystrophy*

Chest wall deformity

•Kyphoscoliosis

• Obesity

• Ankylosing spondylitis *

* Both insp.and eksp. 20.04.2353

restrictive

Volume

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Restrictive disease 20.04.2355

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VC

(or VC)

FEV1/FVC Degree of severity

> 80

70-80

60-70

< 60

Normal

Normal

Normal

Normal

Normal

Mild

Moderate

Severe

Severity classification in restrictive diseases

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Sarcoidosis

Idiopathic pulmonary fibrosis

Asthma with air trap and hyperinflation

COPD with pneumonia and pleural effusion

Mixed abnormalities

(Obstructive and restrictive):

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• 3 types of upper airway obstruction :

• Extrathoracic variable obstruction

• Intrathoracic variable obstruction

• Fixed obstruction

Upper airway obstruction

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A CB

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Extrathoracic variable obstruction(vocal cord dysfunction)20.04.2365

Intrathoracic variable obstruction

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Fixed airway obstruction20.04.2367

BRONCHODILATATION

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DefinitionA determination of airflow-limitation

reversibility with bronchodilator drug

Bronchodiator drugsShort-acting β-agonists Long-acting β-agonistsShort-acting anticholinergics

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Prior to spirometryRoutine bronchodilator therapy should

be withheld prior to spirometry

Short-acting β-agonists 4 hoursShort-acting anticholinergic 4 hoursLong-acting β-agonists 12 hoursLong-acting anticholinergic 24 hoursMethylxanthines (theophyllines) 12 hoursSlow release methylxanthines 24 hoursCromolyn sodium 8-12 hoursLeukotriene modifiers 24 hours Inhaled steroids Maintain

dosage

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TEST PROCEDURE

There is no clear consensusPerforme spirometry before bronchodilator drugAdministration of bronchodilator drugs

Salbutamol :4 separate doses of 100(inhalation)Salbutamol :2.5mg(nebül)Ipratopium bromid :4 separate doses of 40 cg

Repeat spirometry 15 minutes after Short-acting β-agonists 30 minutes after Short-acting anticholinergic

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2 4

0

4

4

l/s

l

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EVALUATION

Percentage of change is calculated

%Change = Postdrug – Predrug X 100Predrug

FEV1 and/or FVC are the most commonly used tests for quantifying bronchodilator response

Considered significant if:FEV1 or FVC increase ≥12% and ≥200 ml

The MEF25–75% is a highly variable spirometric test, in part because it depends on FVC.

If FVC changes, post-bronchodilator FEF25–75% is not comparable with that measured before the bronchodilator.

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Reversibilite= FEV1’de bronkodilatör sonrası en az % 12 artış

Ekspiratuar akım

Hacim

bronkodilatasyon

sonraönce

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Ekspiratuar akım

Hacim

bronkodilatasyon

sonraönce

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Reversibility

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BRONCHIAL PROVOCATION

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Definition and aimTo determine airway

hyperreactivity

Normal PFTClinical findings of

bronchospasmSuspicious results in

reversibility

For diagnosis and severity of the disease

Performe provocation tests

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Selective Non selective Direct Histamine    Methacholine    Prostaglandins    Leukotrienes Indirect Exercise    EVH  Cold air    Non-isotonic aerosols    AMP   Propranolol    Bradykinin   Mannitol

Immunologic     Allergen High MW protein-containing IgE mediated    Occupational Low MW sensitizer Mechanism uncertain Non-immunologic     ASA    NSAIDs    BFood additives (?)

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ProcedureFEV1RawSgaw

evaluatedStart with SF

> %10 change in PFT ; test ???

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MetacholineIncreases prasympathic tonus in bronchial

smooth muscleInhalation of metacholine with increasing

concentrationDosimeter is more effectiveMeasure FEV1 after every single inhalation Results are expressed as the provocation

concentration (or dose) producing a 20% FEV1 fall (PC20 or PD20).

Start with 0.0025mg/ml

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Normal – PC20 >16 mg/mL

Borderline – PC20; between 4 and 16 mg/mL

Mild AHR – PC20 between 1 and 4 mg/mL

Moderate AHR – PC20 between 0.25 and 1 mg/mL

Marked AHR – PC20 < 0.25 mg/mL.

HistamineSimilar procedure with metacholine

Effective within 30second-2minutes

>20% FEV1 fall (PC20 or PD20).;POSITIVE TEST

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EVH; Eucapnic voluntary hyperpneaPerformed by having individuals inhale dry air

with 5% CO2 for 6 minutes

FEV1 is measured before and at intervals after the EVH for up to 10 or 15 minutes.

A 10% reduction in FEV1 is considered positive

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Allergen challengeUsually for research

Inhalation of allergen with increasing concentration

Start with SF

Measure FEV1 after every inhalation

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THANK YOU“TEŞEKKÜRLER”

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