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Why 1954?

Pulmonary Function from 1954 to 2010 Michael Hughes National Heart and Lung Institute Hammersmith Hospital Imperial College London. Why 1954?.

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Why 1954?

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  1. Pulmonary Function from 1954 to 2010Michael HughesNational Heart and Lung InstituteHammersmith HospitalImperial CollegeLondon

  2. Why 1954? The modern era of PFT testing began with Julius Comroe’s Beaumont Lecture to the Wayne University Medical School, Detroit, and the book “The Lung” which followed, co-authored with his colleagues from the Graduate School of Medicine, University of Pennsylvania, Philadelphia

  3. Julius H Comroe A born leader and teacher; “The Lung” put Pulmonary Function Testing on the map

  4. OUTLINE • “The Lung” (1955) Comroe, Forster, Dubois, Briscoe, Carlsen • Pulmonary physiology 1940–1954: a “golden age” • Pulmonary function case history: 1954 versus 2010 • Development of pulmonary function testing: from 1940 to 2010 • Physiology and Practice of Pulmonary Function published by the ARTP, 2009

  5. In the preface to The Lung • “a monograph constructed largely around illustrations” • “understanding of physiological principles and broad concepts more than technical completeness” • “this is not a primer (which would be too simple) nor an encyclopedia”

  6. Rochester, New York State Arthur Otis, Hermann Rahn, Wallace Fenn pressure–volume plots of respiratory system; O2–CO2 diagram

  7. John West Leon Farhi ¢A/§ and MIGET analysis effects of gravity and microgravity stress mechanics “Teacher” Ventilation–perfusion (¢A/§)

  8. Harvard School of Public Health Jere Mead Jim Whittenberger Mead and Whittenberger measurement of lung resistance; artificial respiration surfactant; EPP; Konno–Mead diagram

  9. Peter Macklem Milic–Emili regional expansion and ventilation (onion skin diagram); closing volume; expiratory tidal flow limitation resistance partitioning (retrograde catheter); chest wall mechanics; respiratory muscles

  10. Columbia, New York;John’s Hopkins, Baltimore Dick Riley DLO2; three compartment gas exchange lung; alveolar air equation, physiological dead space, venous admixture; bubble technique for PO2

  11. Moran Campbell Neil Pride respiratory muscles; rebreathing P®CO2; controlled O2 in resp failure (venturi mask) max expiratory flow analysis (choke point) lung compliance and resistance; diaphragm

  12. 1940 – 1950birthplace of clinical pulmonary functionCollege of Physicians and Surgeons, Columbia University, New York Cournand, Richards, Riley, [Baldwin, Austrian, Weibel] R. heart catheterization N2 washout for lung volumes and uneven ventilation; obstructive versus restrictive disease alveolar–capillary block; three compartment gas exchange lung André Cournand Dickinson Richards

  13. The Lung: clinical physiology and pulmonary function tests. Year Book Publishers, 1955 • Julius Comroe: founder of the Cardiovascular Research Institute (CVRI), San Francisco. • Robert Forster: rediscovered the TLCO–sb of Marie Krogh (1914) and made it a practical clinical test. The Roughton–Forster equation. • Arthur Dubois: first to measure airways resistance and lung volume with the body plethysmograph; first to measure pulmonary resistance with forced oscillation • Bill Briscoe: contributed to gas exchange (¢A/§ and diffusion limitation) • [Ward Fowler]: originator of the SB–N2 test (alveolar plateau or Phase III); suggested helium be added to TLCO–sb.

  14. Forster Roughton [operating the continuous flow rapid reaction apparatus] The Roughton Forster equation (1957) partitioned DLCO into membrane (DM) and reactive (Vc) components

  15. Arthur Dubois Body plethysmographic methods for airways resistance and absolute lung volumes; forced oscillation technique for respiratory resistance

  16. From The Lung, part 2: Clinical applications of pulmonary function tests, Case 2 Male: a. 17 yrs; nocturnal dyspnea and wheezing 1954 Spirometry % pred Vital capacity 2.8 L 58 post b.d 3.675 max vol vent (MVV)62L·min-144 post–bd 11179 max exp flow rate: 0.8L·s-1[> 3.3] spirogram: air trapping

  17. “Although MVV gives information regarding mechanics of breathing ….. a low value is not diagnostic of any single disease … Furthermore, it is a needlessly exhausting test, and will probably be replaced within the next few years by simpler tests utilizing a single breath ….” Comroe et al THE LUNG (1955)

  18. Air trapping

  19. 1987 Lim TK, Pride NB, Ingram RL. Effects of volume history during spontaneous and acutely induced airflow obstruction in asthma. Am Rev Respir Dis 1987: 135: 591-6. spontaneous asthma ~ air trapping normal methacholine-induced constriction Adapted from Gibson GJ, Clinical Tests of Respiratory Function, 2009 M/P ratio = max expiratory flow after 60% FVC expired on MEFV curve versus flow at same lung volume on a partial (PEFV) from end tidal inspiration

  20. 2010 Spirometry L % pred SRs FEV1 1.5 36 – 5.2post b.d2.2 FVC2.8 58 – 3.4 FEV1/FVC (actual)0.54 MEFV curve: scooping, low ++ ¢ exp Male: a. 17 yrs; nocturnal dyspnea and wheezing

  21. Tiffeneau R, Pinelli A. Air circulant et air captif dans l’exploration de la fonction ventilatrice pulmonaire. Paris Méd 1947; 133: 624-8.Yernault J-C. The birth and development of the forced expiratory manoeuvre: a tribute to Robert Tiffeneau. Eur Respir J 1997; 10: 2704-10. Fig 1.2 Forced expiratory volumes in normal subjects and COPD

  22. 1958 Hyatt RE, Schilder DP, Fry DL. Relationship between maximum expiratory flow and degree of lung inflation. J Appl Physiol 1958; 13: 331-6. Fig 1.3 MEFV curves in young and elderly normals and in COPD

  23. 1960 Fry DL, Hyatt RE. Pulmonary mechanics: a unified analysis of the relationship between pressure, volume and gas flow in the lungs of normal and diseased patients. Am J Med 1960; 29: 672-89. Fig 1.4 The IVPF curve: the key to understanding effort independence

  24. Bronchodilators increase expiratory flows and reduce hyperinflation Fig 2.1 Response in asthma to a bronchodilator challenge

  25. 1959the peak flow meter • Wright BM, McKerrow CB. Maximum expiratory flow rate as a measure of ventilatory capacity. Brit Med J 1959; ii: 1041-7.

  26. Figure 12.1 Asthmatic subjects attending clinic with peak flow charts, symptom records, bronchodil. and steroid use; methacholine challenge on each visit. From Sont et al AJRCCM 1999; 159: 1043-51.

  27. Table 12.9 Airway hyperreactivity and inflammation in asthma

  28. Table 12.9 Airway hyperreactivity and inflammation in asthma

  29. Lehtimäki L, Kankaanranta H, Saarelainen S, Turjanmaa V, Moilanen E. Inhaled fluticasone decreases bronchial but not alveolar NO in asthma. Eur Respir J 2001; 18: 635-9. Fig 6.8 Model and analysis of bronchial and exhaled NO

  30. 1954–2010 Lung volumes Male: a. 17 yrs; nocturnal dyspnea and wheezing

  31. 1949 Meneely GR, Kaltreider NL.The volume of the lung determined by helium dilution. J Clin Invest 1949; 28: 129-39. Fig 3.3. Closed circuit for helium equilibration calculation of lung volumes

  32. 1956 Dubois AB, Botelho SY, Bedell GN, Marshall R, Comroe JH. A rapid plethysmographic method for measuring thoracic gas volume. J Clin Invest 1956; 35: 322-6. Fig 3.1 Body box estimation of lung volume (VL)

  33. 1956 Dubois AB, Brody AW, Lewis DH, Burgess BF. Oscillation mechanics of lungs and chest in man. J Appl Physiol 1956; 8: 327-35. Fig 4.5 Forced oscillation for measuring respiratory resistance

  34. 1954 Diffusion and distribution pred DLCO (trad.) ND SB-N2 slope 6.0 %·L-1 (< 1.5%) Gas exchange %mmHg SaO290 PaO2 PaCO238 Male: a. 17 yrs; nocturnal dyspnea and wheezing

  35. 1951 and 1967 Comroe JH, Fowler WS. Detection of uneven ventilation during a single breath of oxygen. Am J Med 1951; 10: 408-13. Milic-Emili J, Torchio R, D’Angelo E. Closing volume; a reappraisal. Eur J Appl Physiol 2007; 99: 567-83. Fig 3.5 Single breath nitrogen for uneven ventilation and closing volume

  36. Multi–breath nitrogen washout 1940: for estimates of RV Darling RC, Cournand A, Richards DW. An open circuit for measuring residual air. J Clin Invest 1940; 19: 609-18. 1952: for analysis of uneven ventilation Fowler WS, Cornish ER, Kety SS. Analysis of alveolar ventilation by pulmonary N2 clearance curves. J Clin Invest 1952; 31: 40-50.

  37. 1990–2000 Verbanck S, Schuermans D, Meysman M, Paiva M, Vincken W. Noninvasive assessment of airway alterations in smokers. The small airways revisited. Am J Respir Crit Care Med 2004; 170: 414-9. Fig 6.2 Conducting airway and acinar dispersion of ventilation from N2 washout

  38. 2010 Transfer SI units % pred SRs TLCO12.798– 0.14 KCO2.0105+ 0.28 Gas exchange % kPa SaO290 PaO2 8.1 PaCO25.1 Male: a. 17 yrs; nocturnal dyspnea and wheezing

  39. Marie Krogh. The diffusion of gases through the lungs of man. J Physiol 1915; 49: 271-96.

  40. 1957 Ogilvie CM, Forster RE, Blakemore WS, Morton JW. A standardized breath holding technique for the clinical measurement of diffusing capacity of the lung for carbon monoxide. J Clin Invest 1957; 36: 1-17. Fig 6.4 Single breath TLCO set–up and protocol

  41. Colin Ogilvie (Liverpool)

  42. Fig 6.5 CO and helium analysis in the single breath TLCO Ward Fowler Marie Krogh

  43. Hughes JMB, Pride NB. In defence of the carbon monoxide transfer coefficient KCO (TL/VA). Eur Respir J 2001; 17: 168-74. Fig 6.7 Physiological influences on TLCO and KCO

  44. Measurement of oxygen and CO2 in blood Van Slyke analysis of O2 and CO2 contents: PaO2 obtained from dissociation curves and PaCO2 from content and pH PaO2 1945: Riley bubble technique: small air bubble introduced into blood syringe and equilibrated; measured by Haldane gas analysis. 1954: Clark polarographic electrode (in general use in 1960s) PaCO2 1958: glass electrode for PaCO2 (Severinghaus and Bradley) 1960: PaCO2 versus pH determined base excess (Astrup et al)

  45. Oxygen saturation in blood 1942: Millikan’s “ear oximeter” using two wavelengths 1964: Multi–wavelength fibreoptic oximeter (Hewlett Packard) 1972: Pulse oximeter (Takuo Aoyagi)

  46. Die Methode ist Alles

  47. Buytendijk HJ. Oesophagusdruck en longelasticiteit. Groningen: Dissertatie. 1949. Mead J, Whittenberger JL. Physical properties of human lungs measured during spontaneous respiration. J Appl Physiol 1953; 5: 779-96. resistance Butler J, White HC, Arnott WM. Pulmonary compliance in normal subjects. Clin Sci 1957; 16: 709-29. elasticity Fry DL, Hyatt RE. Iso-volume pressure flow curve for maximal expiratory flow. Am J Med 1960; 29: 672-89. muscle pressure Agostoni E, Rahn H. Abdominal and thoracic pressures at different lung volumes. J Appl Physiol 1960; 15: 1087-92. (first measurement of transdiaphragmatic pressure) Kim MJ, Druz WS, Danon J, Machnach W, Sharp JT. Effects of lung volume and electrode position on esophageal diaphragmatic EMG. J Appl Physiol 1978; 45: 392-8. muscle activation

  48. Fig 5.4 Measurement of maximum static mouth pressures 1954: “The test has been used but little clinically, largely because a high pressure develops within the middle ear that causes discomfort” Black LF, Hyatt RE. Maximum static respiratory pressures in generalized neuromuscular disease. Am Rev Respir Dis 1971; 103: 641-50.

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