SPIROMETRY, BRONCHODILATATION, BRONCHIAL PROVOCATION

1. SPIROMETRY,BRONCHODILATATION,BRONCHIAL PROVOCATION Gülbin Bingöl Karakoç,MD,Prof. of Pediatrics, Cukurova University,Medicine Faculty, Division of Alergy-Immunology, Adana

2. CONFLICT OF INTEREST • NONE

3. Spirometry Definition and indications Flow-volume relationship General considerations Indices measured Interpretation of lung function tests Definiton of obstructive and restrictive abnormalities Definition of central and upper airway obstruction Bronchodilatation Bronchial provocation Agenda

4. Definition • Spirometry 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.

5. 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

6. 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

7. LUNG VOLUMES FLOW-VOLUME CURVES

8. TV : Tidal volume:The volume of gas inhaled or exhaled during the respiratory cycle IRV : Inspiratory reserve volume; The maximum volume of gas that can be inhaled from the end-inspiratory level during tidal breathing. ERV : Ekspiratory reserve volume; The volume of gas that can be maximally exhaled from the end-expiratory level during tidal breathing. RV : Residual volume: The volume of gas remaining in the lung after maximal exhalation TLC VC IC IRV TV FRC ERV RV RV

9. 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; FRC : Functional residual capacity. TLC VC IC IRV TV FRC ERV RV RV

10. VC :Vital capacity; The volume change at the mouth between the positions of full inspiration and complete expiration. 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 TLC : Total lung capacity; the volume of gas in the lungs after maximal inspiration, or the sum of all volume compartments. TLC VC IC IRV TV FRC ERV RV RV

11. GENERAL CONSIDERATIONS

13. What is Spirometry? • 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

14. General considerations • Many different types of equipment • Requires cooperation between the subject and the examiner, • Results depend on technical and personal factors

15. Standardisation of spirometry

16. Before starting • GET READY • Clean and quite room • Check the spirometer calibration • Explain the test • Prepare the subject (The parents should be with children) • Ask about smoking, recent illness, medication use etc. • Measure weight and height without shoes • Wash hands • Instruct and demonstrate the test to the subject, to include • Correct posture with head slightly elevated • Position of the mouthpiece (closed circuit) • Inhale rapidly and completely • Exhale with maximal forcecorrect posture with head slightly elevated,inhale rapidly and completely

17. 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

18. video

21. INDICES MEASURED

22. Indices Measured • 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

23. PFT Reports • When performing PFT’s three values are reported: • Actual – what the patient performed • Predicted – what the patient should have performed based on Age, Height, Sex, Weight, and Ethnicity • % Predicted – a comparison of the actual value to the predicted value

25. Normal spirometry (flow-volume curve) Inspiration Expiration Vital capacity

26. Forced expiratory flow-volume curve 12 PEF 9 FEF75% 6 Flow FEF50% 3 FEF25% 0 100TLC 75 50 25 0RV Expired Vital Capacity (%)

28. Flow-volume and Volume-time curves FEV1

29. Flow Effort that is not maximal throughout cough Early termination Volume Leak Artefacts during spirometry

30. cough

31. 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

32. FVC: Criteria for Acceptability Maximal effort; no cough or glottic closure during the first second; no leaks or obstruction of the outhpiece. Good start-of-test; back extrapolated volume <5% of FVC or 150 ml, whichever is greater

33. FVC: Criteria for Acceptability 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

34. FVC: Criteria for Acceptability Three acceptable spirograms obtained; two largest FVC values within 150 ml; two largest FEV1 values within 150 ml 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

35. FVC FVC equals VC in healthy individuals FVC is often lower in patients with obstructive disease

36. 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

37. 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

38. Obstructive disease Airway narrowing during forced expiration emphysema Mucus secretions Bronchospasm Asthma Large airway obstruction tumors/foreign bodies Restrictive disease Fibrosis Edema Space-occupying lesions Neuromuscular diseases Obesity Chest wall deformity FEV1 may be reduced in FEV1/FVC is one of the most important parameters for determining airway obstruction.

39. PEF • The maximum flow obtained during a FVC maneuver • In laboratory, must perform a minimum of 3 PEF maneuvers • Primarily measures large airway function • Many portable devices available • Effort dependent • Generally used for monitoring asthma.

40. 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

41. INTERPRETATION OF LUNG FUNCTION TESTS

43. 2 basic models 1. Obstructive type: • FEV1 / FVC • Lung volumes  • 2. Restrictive type: • TLC • VC  • FEV1 /FVC normal or  • Lung volumes 

44. obstructive normal restrictive FRC resp.muscle weakness;N TLC   RV  exp. muscle weakness;

46. Evaluation of PFT according to the flow-volume curve • Check FEV1 value !!!! FEV1 > 80% (%pred) = normal FEV1/FVC < 80% and/or FEF 25-75 < 50% Early obstruction < 80%(%pred) = anormal FEV1/FVC ? >80% Restriction?? Check lung volumes <80% or < 2SD Obstruction FVC ? >80% = Only obstruction Severity classification according to FEV1 < 80% Coexistance of restriction can not be ruled out C. Check the curve for upper airway obstruction

47. Obstructive Diseases • Asthma • COPD • Bronchiectasis • Cystic fibrosis • Bronchiolitis

48. Diagnosis of Obstruction • Bronkodilatation • Coming Soon,Stick around!!!

49. Mild obstruction Severe obstruction