دکتر رامین کردی

1. LUNG FUNCTION TESTS In SPORTS MEDICINE مرکز تحقیقات پزشکی ورزشی • دکتر رامین کردی

2. Outline • PFT in Sports Medicine • EIP (Intro & Tests) • Lab challenge test • Field challenge test • Notes not to be forget

3. PFT in sports medicine • انجام اسپیرومتری و تفسیر آن برای تعیین ظرفیت تنفسی در ورزشکاران • انجام 15 اسپیرومتری • آسم و برونکواسپاسم ناشی از ورزش و راهکارهای اداره آنها درحین ورزش

4. ورزش و بیماری‌های داخلی الف) بخش ریه • فیزیولوژی تهویه، کنترل تهویه، خونرسانی ریوی، انتقال و انتشار گازها • ارزیابی بیماران مبتلا به بیماری ریوی • روش‌های پرتونگاری ریه و تفسیر آنها • تست عملکرد ریوی (PFT) و تفسیر آن • آنالیز گاز خون شریانی (ABG) و تفسیر آن • پالس اکسی‌متری و تفسیر آن • پاتوفیزیولوژی، علائم و نشانه‌ها، تشخیص و درمان بیماری آسم • پاتوفیزیولوژی، علائم و نشانه‌ها، تشخیص و درمان بیماری‌های انسدادی مزمن ریه (COPD) • اثرات متقابل ورزش و آسم • اثرات متقابل ورزش و COPD • اثرات ورزش در پیشگیری و توانبخشی بیماران مبتلا به کانسر ریه • برونکواسپاسم ناشی از ورزش و روشهای تشخیص، پیشگیری و درمان آن • پنوموتوراکس و انواع آن • تست ورزش در بیماران ریوی

5. Lung Sports Medicine • Most sports, even endurance sports, it is not the lungs that is the limiting factor to improvements • Rowers?? • due to the enormous absolute amounts of oxygen required by their muscles, Faulman et al Journal of Sports Sciences 1996, Vol. 14, No. 1, p 81

6. International SportMed Journal PPE The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes

7. Cambridge Sports & Exercise Medicine Unit Performance Tests Available VO2 max testing Lung Function

8. Exercise Induce Asthma • The prevalence of asthma in athletes is high and varies • From 3-23% in summer sports • to 12-50% in winter sports • An estimated 90% of individuals with asthma

9. Endurance versus nonendurance Olympic Summer Sports 1996 to 2004 mean percentage b2-agonists notified/approved.

11. DIRECT & INDIRECT CHALLENGES • Indirect tests such as Exercise, EVH, inhaled powdered mannitol, nebulized hypertonic saline, or AMP appear to be • more effective in identifying EIB in the elite athlete population • than direct challenges such as methacholine or histamine

12. ASTHMA Version 1.4 14.06.2009 Laboratory Testing The most objective indicator of asthma severity is the measurement of airflow obstruction by spirometry. Exercise Challenge Tests (field or laboratory) (10% fall of FEV1) Many elite athletes have levels of lung function above normal predicted values and therefore normal lung function may still represent a sign of airway obstruction.

13. ASTHMA Version 1.4 14.06.2009 • The absence of a bronchodilator response does not exclude a diagnosis of asthma. • A 12% increase in FEV1 following beta-2 agonist use is considered to be the standard diagnostic test for the reversibility of bronchospasm. Bronchial provocation may be performed by the use of physiological (exercise or eucapnic voluntary hyperventilation tests) or pharmacological (metacholine, mannitol, hypertonic saline, histamine) challenge tests of hyperventilation. Further reference should be made to the European Respiratory Society (ERS) and American Thoracic Society (ATS) standards.

14. IOC Consensus Statement on Asthma in Elite Athletes Lausanne ,2008 Diagnosis of asthma in elite athletes objective tests are required to confirm the diagnosis. The fall in FEV1 from the baseline value used to define abnormality is the mean plus 2 SDs of the fall documented in healthy subjects without asthma in response to the maximum dose of the test stimulus. For exercise and EVH, a fall in FEV1 of 10% is consistent with EIB.

16. Exercise challenge test • Lab test • Field test

17. Lab test

18. Typical change in FEV1 in response to an 8-minute exercise challenge in EIB-positive individuals.

19. EXERCISE CHALLENGE • Typical postprovocationspirometry times are at 5, 10, 15, and 30 minutes after the completion of the challenge

20. Criterion for EIB in Exercise challenge • Post-exercise ↓ in FEV1 >10% to 25% have been used. • A 15% fall in FEV1 for field exercise challenges • A 10% fall in FEV1 for laboratory challenges The American Thoracic Society and the European Respiratory Society recommend a 10% ↓ in FEV1,

21. the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN A standardized exercise test at a high enough and standardized exercise load, breathing air of stable temperature and humidity (20–25C and 40–50% relative humidity) should be employed, either in a laboratory or as a field test, demonstrating at least 10% reduction in FEV1 from baseline after exercise. The type of exercise may be varied in accordance with the type of sport practiced, although running is most often the best suited for provoking EIB. Responsiveness to inhaled bronchodilators: An increase in FEV1 of 12% (in per cent of baseline or of predicted value) before and after inhalation of a bronchodilator, preferably an inhaled b2-agonist, administered by a pressurized metered dose inhaler, dry powder inhaler or a nebulizer.

22. Exercise-induced asthmaJ Allergy Clin Immunol 2007 • Treadmill test , Exercised for 8 minutes. • During the first 2 minutes, heart rate reaches at least 80% to 90% of predicted maximum. • During the remaining 6 minutes, exercise should continue at this heart rate.

23. Exercise-induced asthmaJ Allergy Clin Immunol 2007 • At this level of exercise, ventilation should reach 40% to 60% of maximum. • ↓ ≥ 10% in FEV1 • Especially if symptoms accompany the drop in FEV1. • It is important to recognize that the drop in FEV1 after exercise is normally distributed in large population studies, meaning that there is no absolute FEV1 cut off that can be used to make the diagnosis of EIA. • FEV1 2.5, 5, 10, 15, and 30 minutes after exercise.

24. An exercise challenge, • free-run challenge sufficiently strenuous to increase the baseline heart rate to 80% max for 4–6 minutes. • the patient may simply undertake the task that previously caused the symptoms. • A 15-percent decrease in PEF or FEV1 (with measurements taken before and after exercise at 5-minute intervals for 20–30 minutes) is compatible with EIB. August 28, 2007

25. Filed test

26. Eighteen of 23 elite winter athletes who tested positive by a field-based sport-specific exercise challenge but tested negative by laboratory treadmill run in ambient conditions of 218C, 60% RH. Med Sci Sports Exerc 2000;32:309-16.10 FEF25-75,

27. Wilber et al used sports-specific tests (Nordic skiing, speed skating, ice hockey, ice skating) to identify EIB in Winter Olympic athletes • Ogston and Butcher used a 15-minute ski exercise • to identify EIB in Nordic skiers. • Free running or a 6-minute run has often been used in screening large groups for EIB. • Lack of control (e.g. stimulus and the varied environmental Conditions) , this type of testing may not be reliable • It is not appropriate to use as a means of monitoring treatment.

28. rink-side (temperature 5 14°C, humidity 5 60%) spirometry before and 1, 5, 10, and 15 min after 5 min of intense skating CHEST 1999; 115:649–6 Measurements prior to exercise and at 5-minute increments following a 15-minute cross-country skiing exercise session on a groomed ski trail. They was instructed to perform the exercise challenge at “race pace,” with a specific heart rate range of >85% age-predicted maximum heart rate. Clin J Sport Med 2002;12:291–295

29. The exercise challenge was 6 minutes of outdoor, free-range running at 85–90% of maximum heart rate, measured by heart rate monitor. Nose clips were worn. After baseline lung function was measured, children underwent a 6 min run on a 100 m track on a flat, grassed oval marked with cones spaced 10 m apart. Each subject wore a nose-clip to ensure mouth-breathing Heart rate was recorded at one minute intervals ( a Polar Accurex ) Children were encouraged to run at an intensity which gave a heart rate of 85–90% of their predicted maximum which is approximately 180–190 beats per minute (bpm) for 8–11 year olds, and to maintain a heart rate of 180±10 bpm for the final 4 min of exercise. EurRespir J, 1994, 7, 43–49

30. Notes

31. EXERCISE CHALLENGE • The lack of using a standardized exercise challenge for EIB may explain the wide range in reported prevalence within specific sports, • whereas the variety of exercise challenges at different intensities with no control over challenge minute ventilation (VE) or water content of inhaled air may result in poor test-retest reliability. (20-258C; relative humidity [RH] <50%)

32. the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN • EIB is heavily influenced by the • humidity • temperature of the inhaled air • The use of inhaled cold air (–20C) during exercise testing markedly increased the sensitivity in diagnosing EIB • Important items: • Strict environmental standardization • with a high enough exercise load • Both ERS and ATS recommendations set a 10% reduction in FEV1 as criterion for EIB Allergy 2008: 63: 387–403

33. Version 1.4 14.06.2009 • Patients should stop all bronchodilator or anti-inflammatory therapy prior to the provocation test. • for short acting Beta-2-agonists this will be for 8 hours • for long acting Beta-2- agonists and inhaled lucocorticosteroids (GCS) for 24 hours prior to testing.

34. Heart rate-based protocols for exercise challenge testing do not ensure sufficient exercise intensity for inducing exercise-induced bronchial obstruction ? Br J Sports Med 2009;43:429–431. doi:10.1136/bjsm.2007.041715

35. No similar simple, efficient diagnostic exercise challenge exists for adults with EIA, because the risk of coronary heart disease requires cardiac monitoring and immediate availability of resuscitation resources.

41. The mouthpiece must be inserted well into the mouth (beyond the teeth) During total expiration (slowly or forced) it is suggested to bend forward at the waist as this movement helps to force air out of the lungs.

42. FVC If required (this is optional) before the test make several breaths at rest. When ready inspire slowly as much air as possible (opening the arms helps) and then expire all of the air as fast as possible. Then, without removing the mouthpiece from the mouth, finish the test by inspiring again as fast as possible. This final inspiration is not necessary if the inspiratory parameters (FIVC, FIV1, FIV1%, PIF) are not required. It is possible to repeat the cycle several times, (without removing the mouthpiece) and in this case Spirolab will automatically select the best test and will show the results. To end the test press or wait 3 sec. after the last volume cycle.

43. Performance of FVC maneuver • Give instructions and demonstrate: • Show nose clip and mouthpiece. • Demonstrate position of head with chin slightly elevated and neck somewhat extended. • Inhale as much as possible, put mouthpiece in mouth (open circuit), exhale as hard and fast as possible. • Give simple instructions. (adapted from ATS, 1994)

44. Performance of FVC maneuver • Patient performs the maneuver • Patient assumes the position • Puts nose clip on • Inhales maximally • Puts mouthpiece on mouth and closes lips around mouthpiece (open circuit) • Exhales as hard and fast and long as possible • Repeat instructions if necessary –be an effective coach • Repeat minimum of three times (check for reproducibility.) (adapted from ATS, 1994)