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UO PNEUMOLOGIA

DIPARTIMENTO MEDICO SPECIALISTICO2. UO PNEUMOLOGIA. Bari 29 ottobre 2004 I Congresso AIPO di Telemedicina ed Applicazioni Medico-Informatiche La Telespirometria: Indicazioni, criteri di inclusione, esclusione e valore diagnostico. Pier Aldo CANESSA.

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UO PNEUMOLOGIA

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  1. DIPARTIMENTO MEDICO SPECIALISTICO2 UO PNEUMOLOGIA Bari 29 ottobre 2004I Congresso AIPO di Telemedicina ed ApplicazioniMedico-InformaticheLa Telespirometria: Indicazioni, criteri di inclusione, esclusione e valore diagnostico • Pier Aldo CANESSA www.spezia1.pneumonet.it

  2. RICERCA SU MEDLINE telespirometry: 2 voci telemedicine [MeSH] AND spirometry [MeSH] : 9 voci Non ci sono evidenze: un campo da studiare

  3. Cosa si intende x telespirometria? • Manovra espiratoria forzata • PEF, VEMS, FVC

  4. CURVA FLUSSO VOLUME Curva flusso-volume espiratoria normale V Inviata alla Centrale dove lo specialista valuta la qualità e interpreta l’ esame inviando il referto 6 4 2 0 V

  5. SPIROMETRIA: DIAGNOSI? • Se un paziente ha uno o piu’ sintomi respiratori la spirometria non può fare diagnosi: solo l’ integrazione clinica, radiologica, endoscopica, funzionale, laboratoristica, etc.. permette una diagnosi CENTRO PNEUMOLOGICO

  6. SPIROMETRIA: DIAGNOSI? ESAME NORMALE

  7. Interpretazione della curva flusso-volume • Deficit ventilatorio Restrittivo • Aumentate pressioni di ritorno elastico con volumi piccoli, normale il calibro delle vie aeree. • Deficit ventilatorio Ostruttivo • Pressione di ritorno statico ridotta per distruzione della componente elastica. • Ostruzione delle vie aeree da broncospasmo, infiammazione e rimodellamento bronchiale, secrezioni, ispessimento, collasso per perdita della forza di trazione del parenchima circostante. V V 6 4 2 0

  8. Screening A “man on the street” May not have symptoms May be a cigarette smoker No cost and no reimbursement Case-Finding Patient being seen by a physician Has respiratory symptoms Has COPD risk factors Medicare will pay $20 for the test Screening vsCase-Finding RESPIRATORY CARE • DECEMBER 2003 VOL 48 NO 12

  9. SPIROMETRIA: DIAGNOSI? • persone di 35-70 anni che visitano il MMG, • 23% sintomi (18% ostruiti ), 77% no sint (4% ostruiti ) • 7,4% ostruiti ( 42% no sintomi) Buffels J et Al, CHEST 2004;125:1394–1399

  10. A proposito del 4%... The American Thoracic Society (ATS) recommends using the fifth percentile of the distribution of lung function as the lower limit of the normal range (LLN). This means that from a group of 100 people with healthy lungs, 5 will get a false positive spirometry result.

  11. A recent COPD workshop summary stated that “there are no data to indicate that screening spirometry is effective in directing management decisions or in improving COPD outcomes.” Fabbri LM, Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management and prevention of COPD: 2003 update (editorial). Eur Respir J 2003;22(1):1–2.

  12. Case Finding x diagnosi precoce di BPCO La spirometria dovrebbe essere eseguita dal MMG nei pazienti fumatori con 45 o + anni Office Spirometry for Lung Health Assessment in Adults* A Consensus Statement From the National Lung Health Education Program Gary T. Ferguson, MD, FCCP; Paul L. Enright, MD; A. Sonia Buist, MD; and Millicent W. Higgins, MD, Honorary FCCP CHEST 2000; 117:1146–1161

  13. Diagnosi precoce x smettere di fumare Segnan N, Ponti A, Battista RN, et al. A randomized trial of smoking cessation interventions in general practice in Italy. Cancer Causes Control 1991; 2:239–246 923 fumatori: dopo un anno hanno smesso di fumare il 6,5% del gruppo counseling + spirometria, il 5,5% del gruppo counseling e il 4,5% del controllo (paternale del MMG)

  14. BY PASS PNEUMOLOGICO 2000maggio - dicembre 7 CENTRI PNEUMOLOGICI • SPEZIA • SESTRI LEVANTE • GE S.MARTINO • SAMPIERDARENA • SESTRI P. / ARENZANO • PIETRA LIGURE • IM-COSTARAINERA AIPO Liguria M Bonavia et al: Telespirometry: a close and effective line of communication between GP and pneumologist. ERJ 2001.

  15. M.M.G. (precocemente): 1a misura in telespirometria Inquadramento clinico-anamnestico Posticipo dell’impostazione terapeutica Agenda on-line Specialista PN. (tempestivamente): 2a misura (flussimetria e reattivita’ bronchiale) inquadram. Allergologico Diagnosi conclusiva MMG - Centrale di ascolto - Specialista:BY PASS PNEUMOLOGICO 2000

  16. BY PASS PNEUMOLOGICO 2000Telespirometria 53 M.M.G 6 ore di corso • SPIROTEL + Fax • 3 curve F/V per pz., senza antropometrici

  17. BY PASS PNEUMOLOGICO 2000 3 CRITERI DI INCLUSIONE: • Età 14 - 50 • Almeno 1 sintomo asma-correlabile • Pz. non già monitorizzato per patologia ostruttiva bronchiale

  18. BY PASS PNEUMOLOGICO 2000:RISULTATI TRA I 213 PZ. CHE SONO STATI ARRUOLATI DAL M.M.G., 169 ( 79%) SI SONO RECATI DALLO SPECIALISTA E 149 (70%) COMPLETANO L’ITER DIAGNOSTICO

  19. BY PASS PNEUMOLOGICO 2000:RISULTATI TRA I 149 PZ.CHE HANNO COMPLETATO L’ITER DALLO SPECIALISTA, LE DIAGNOSI DI ASMA SONO RISULTATE 79 (53%)

  20. monitoraggio del paziente: ASMA

  21. monitoraggio del paziente Gibson, 1992

  22. DISPERSIONE DEL DECREMENTODIPEF (%) AL PRIMO SINTOMO CANESSA PA et AL: Perception of methacholine-induced airway obstructionin asthmatics. Monaldi Archives of Chest Diseases, 2000.

  23. A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma. OBJECTIVE: Peak flow meters (PFM) continue to be recommended as an important part of asthma self-management plans. It remains unclear if there is an advantage in using PFM in people with moderate-to severe asthma who are not poor perceivers of bronchoconstriction. METHODOLOGY: 134 adults with moderate-to-severe asthma who did not have evidence of poor perception of bronchoconstriction on histamine challenge testing, who were recruited from inpatients and outpatients of a university teaching hospital. Comparison was made over 12 months of the effectiveness of written action plans using either peak flow monitoring or symptoms to guide management. Subjects were contacted at monthly intervals by telephone for reinforcement and evaluation of use of the action plans, and to provide ongoing education. Spirometry and PD20 histamine were measured at 3-monthly intervals. Measures of health care utilization and morbidity (asthma exacerbations; hospitalizations; emergency department (ED) visits; days absent from work or school due to asthma; medication use and a self-rating of asthma severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs, state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from the study. RESULTS: There were significant improvements for both groups for hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no between-group differences. Appropriate use of action plans was 85% in the symptoms group and 86% in the PFM group. For all subjects, those who subsequently had an ED visit had significantly higher levels of denial (P=0.04) and lower scores for self-confidence (P=0.04), compared to those who did not have an ED visit. CONCLUSIONS: Use of written action plans, combined with regular contact to reinforce self-management, improved airway reactivity and reduced health care utilization. However, use of PFM was not superior to symptom-based plans. Adams RJ, et ALRespirology. 2001 Dec;6(4):297-304

  24. Education, self-management and home peak flow monitoring in childhood asthma. Education, therefore, is the most important component of asthma self-management, and home peak flow monitoring is not needed in the majority of asthmatic children. Kamps AW, Brand PL. Paediatr Respir Rev. 2001 Jun;2(2):165-9.

  25. AUTOGESTIONE COL PEF • ASMA MODERATO E SEVERO (NON CONTROLLATO) • CATTIVI PERCETTORI • ABUSATORI DI BETA 2 Pazienti istruiti e ben motivati Canessa PA, 1999

  26. ADERENZA AL PEF: 44% L’ aderenza a misurare il PEF sale al 89% (alla 64-72 settimana) con uno spirometro che registra elettronicamente i valori e il paziente lo sa. Analysis of adherence to peak flow monitoring when recording of data is electronic. H K Reddel, et al. BMJ 2002;324:146–7

  27. COMPLIANCE • 33 paz dimessi x asma riacutizzato • 80% nel misurare il PEF • 52% nel trasmettere i risultati col modem Steel S et al, J Telemed Telecare. 2002

  28. Telespirometry: novel system for home monitoring of asthmatic patients. Bruderman I, Abboud S. ( Israele) • 39 paz con asma moderato e severo • 19 (49%) spiro: precoci segni di riacutizzazione • In 22 (56%) la spiro correla con l’ invio della Unità Mobile di rianimazione • In patients with severe asthma, the decision was made during oral communication between the patient and the operator and was based on clinical impression rather than functional results. • Telemed J. 1997

  29. HOSPITALIZATION REDUCTION BY AN ASTHMA TELE-MEDICINE SYSTEM • MONITORAGGIO DELLA FUNZIONE DELLE VIE AEREE CON SISTEMA DI TELEMEDICINA • INFERMIERA TELEFONA X AIUTO • DOPO 6 MESI RIDUZIONE RICOVERI 83% RISPETTO AL GRUPPO DI CONTROLLO Kokubu et al, Arerugi, 2000 (in Japanese)

  30. TELESPIROMETRIA • MMG: precoce diagnosi di deficit ostruttivo (?) e di BPCO (D) • MMG + Centro Pneumologico: veloce diagnosi di asma (?) • Paz con ASMA da monitorare + Centro Pneumologico (?)

  31. centrale ?

  32. GRAZIE 1000 x LA PAZIENZA

  33. Grazie AIPO PUGLIA Grazie BARI x l’ ospitalità

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