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Stanojevic S, Kaminsky DA, Miller MR, Thompson B, Aliverti A, Barjaktarevic I, Cooper BG, Culver B, Derom E, Hall GL, Hallstrand TS, Leuppi JD, MacIntyre N, McCormack M, Rosenfeld M, Swenson ER. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J 2022; 60:2101499. [PMID: 34949706 DOI: 10.1183/13993003.01499-2021] [Citation(s) in RCA: 415] [Impact Index Per Article: 207.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Appropriate interpretation of pulmonary function tests (PFTs) involves the classification of observed values as within/outside the normal range based on a reference population of healthy individuals, integrating knowledge of physiological determinants of test results into functional classifications and integrating patterns with other clinical data to estimate prognosis. In 2005, the American Thoracic Society (ATS) and European Respiratory Society (ERS) jointly adopted technical standards for the interpretation of PFTs. We aimed to update the 2005 recommendations and incorporate evidence from recent literature to establish new standards for PFT interpretation. METHODS This technical standards document was developed by an international joint Task Force, appointed by the ERS/ATS with multidisciplinary expertise in conducting and interpreting PFTs and developing international standards. A comprehensive literature review was conducted and published evidence was reviewed. RESULTS Recommendations for the choice of reference equations and limits of normal of the healthy population to identify individuals with unusually low or high results are discussed. Interpretation strategies for bronchodilator responsiveness testing, limits of natural changes over time and severity are also updated. Interpretation of measurements made by spirometry, lung volumes and gas transfer are described as they relate to underlying pathophysiology with updated classification protocols of common impairments. CONCLUSIONS Interpretation of PFTs must be complemented with clinical expertise and consideration of the inherent biological variability of the test and the uncertainty of the test result to ensure appropriate interpretation of an individual's lung function measurements.
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Affiliation(s)
- Sanja Stanojevic
- Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - David A Kaminsky
- Pulmonary Disease and Critical Care Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Martin R Miller
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Bruce Thompson
- Physiology Service, Dept of Respiratory Medicine, The Alfred Hospital and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Andrea Aliverti
- Dept of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Milan, Italy
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, CA, USA
| | - Brendan G Cooper
- Lung Function and Sleep, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bruce Culver
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Eric Derom
- Dept of Respiratory Medicine, Ghent University, Ghent, Belgium
| | - Graham L Hall
- Children's Lung Health, Wal-yan Respiratory Research Centre, Telethon Kids Institute and School of Allied Health, Faculty of Health Science, Curtin University, Bentley, Australia
| | - Teal S Hallstrand
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joerg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Basel, Liestal, Switzerland
- University Clinic of Medicine, University of Basel, Basel, Switzerland
| | - Neil MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Dept of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Meredith McCormack
- Pulmonary Function Laboratory, Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Erik R Swenson
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
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Wuorimaa T, Haukka J, Tikkinen J, Parkkola K, Piirilä P. Large lungs may predict increased air trapping in navy divers. Physiol Rep 2022; 10:e15153. [PMID: 35212176 PMCID: PMC8874342 DOI: 10.14814/phy2.15153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/20/2021] [Accepted: 11/20/2021] [Indexed: 06/14/2023] Open
Abstract
Navy divers tend to have large lungs and low expiratory flow rates in the terminal portion of a spirogram. We examined Finnish Navy divers for the presence of air trapping, airway obstruction, and functional airway compression, and their association with lung volumes. Divers (n = 57) and non-diving men (n = 10) underwent a variety of pulmonary function tests. The amount of trapped air was calculated as the subtraction of the total lung capacity (TLC) measured in a single-breath helium dilution test from the TLC in body plethysmography (TLCb). Mean vital capacity (VC) was 6.4 L in the divers versus 5.8 L in the controls (p = 0.006) and TLCb 8.9 L in the divers versus 8.1 L in the controls (p = 0.002). No difference existed between them in the amount of trapped air. However, we found break points in a linear regression model (Davies test) between trapped air and several pulmonary parameters. Those individuals above the break points had lower ratio of forced expiratory volume in first second to forced vital capacity, lower resistance of airways, and higher reactance than those below the break points. In conclusion, navy divers had larger lungs than controls. Large lung volumes (VC >7.31 L or >122% of predicted value) were associated with air trapping. Furthermore, large volumes of air trapping (>1.1 L) were associated with increased residual volume (RV) and RV/TLCb. Despite no concurrent obstruction, functional airway compression, or reduced diffusing capacity, this slowly ventilated trapped air might remain disadvantageous for divers.
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Affiliation(s)
- Tomi Wuorimaa
- Diving Medical CentreCentre for Military MedicineUpinniemiFinland
- Department of Clinical Physiology and Nuclear Medicine of HUS Medical Diagnostic CenterLaboratory of Clinical PhysiologyHelsinki University HospitalsHelsinkiFinland
| | - Jari Haukka
- Clinicum/Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Janne Tikkinen
- Diving Medical CentreCentre for Military MedicineUpinniemiFinland
| | - Kai Parkkola
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- National Defence UniversityHelsinkiFinland
| | - Päivi Piirilä
- Department of Clinical Physiology and Nuclear Medicine of HUS Medical Diagnostic CenterLaboratory of Clinical PhysiologyHelsinki University HospitalsHelsinkiFinland
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Urbankowski T, Przybyłowski T. Blood eosinophils, FeNO and small airways dysfunction in predicting airway hyperresponsiveness in patients with asthma-like symptoms. J Asthma 2021; 59:1376-1386. [PMID: 33926353 DOI: 10.1080/02770903.2021.1923741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE In patients with suspected asthma and no airflow limitation in spirometry, methacholine challenge testing (MCT) for airway hyperresponsiveness (AHR) is an option of documenting variable airflow limitation. The goal of the study was to assess the ability of blood eosinophils, fractional concentration of exhaled nitric oxide (FeNO) and distal airways function to discriminate patients with AHR from those with normal airway responsiveness (AR). METHODS We analyzed baseline data from 42 participants who underwent MCT because of asthma-like symptoms and no airflow limitation in spirometry. RESULTS Eosinophil count was higher among participants with borderline AHR comparing to those with normal AR (340 cells/µL, IQR 285-995 vs. 125 cells/µL, IQR 75-180, post-hoc p = 0.041). FeNO and percent predicted of functional residual volume (FRC%pred) were higher in participants with moderate-marked AHR compared to those with normal AR (40 ppb, IQR 30.5-100.5 vs. 18 ppb, IQR 13-50, post-hoc p = 0.008; 140.1%±17.0% vs. 107.3%±20.7%, post-hoc p < 0.001, respectively). Percentage predicted of the maximal expiratory flow at 25% of the forced vital capacity (MEF25%pred) was lower in participants with mild AHR and borderline AHR compared to those with normal AR (72.9%±16.9% vs. 113.0%±36.8%, post-hoc p = 0.017; 73.3%±15.9% vs. 113.0%±36.8%, post-hoc p = 0.045; respectively). Level of AHR correlated with eosinophil count, FeNO, MEF25%pred, forced expiratory flow between 25% and 75% of vital capacity (FEF25-75%pred), FRC%pred and specific airway resistance (sRaw). CONCLUSIONS Blood eosinophils, FeNO and small airways dysfunction markers are related to the level of AR to methacholine in patients with asthma-like symptoms and no airflow limitation in spirometry.
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Affiliation(s)
- Tomasz Urbankowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Tadeusz Przybyłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
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Methacholine-induced cough as an indicator of bronchodilator-responsive cough. Pulm Pharmacol Ther 2020; 64:101962. [PMID: 33039668 DOI: 10.1016/j.pupt.2020.101962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/27/2020] [Accepted: 09/30/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cough variant asthma (CVA) is the most common cause of chronic cough and responds well to bronchodilator therapy. Previous studies on methacholine -induced cough have shown that heightened cough response due to bronchoconstriction is a feature of CVA. The aim of this study was to assess Mch-induced cough as an indicator of bronchodilator-responsive cough (BRC). METHODS This was a single-center retrospective study of prolonged/chronic cough cases who underwent evaluation via spirometry, FeNO and bronchial challenge testing using Mch and capsaicin (C5). Resultant bronchoconstriction after Mch challenge was assessed by flow-volume curves measuring the expiratory flow of the partial flow-volume curve 40% above residual volume (PEF40) and FEV1. BRC was defined as a decrease in cough with bronchodilator therapy by 30% or more on a visual analog scoring scale. RESULTS Of the 100 patients evaluated, 63 were diagnosed with BRC. Mch-induced cough at a decrease in PEF40 of 35% (PC35-PEF40) was predictive of BRC on AUROC analysis with an AUC of 0.82 (95% CI 0.73-0.90) and cut-off of 24. The AUC for C5, FeNO and PC20-FEV1 were 0.65, 0.47, and 0.58, respectively. CONCLUSION Compared to C5, FeNO and PC20-FEV1, Mch-induced cough better supports a diagnosis of BRC.
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Sood N, Wasilewski NV, Day AG, Wall T, Fisher T, Fisher JT, Lougheed MD. Methacholine-Induced Cough in the Absence of Asthma: Insights From Impulse Oscillometry. Front Physiol 2020; 11:554679. [PMID: 33123021 PMCID: PMC7573225 DOI: 10.3389/fphys.2020.554679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/11/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction The pathophysiologic differences between methacholine-induced cough but normal airway sensitivity (COUGH) and healthy individuals (CONTROL) are incompletely understood and may be due to differences in the bronchodilating effect of deep inspirations (DIs). The purpose of this study is to compare the bronchodilating effect of DIs in individuals with classic asthma (CA), cough variant asthma (CVA), and COUGH with CONTROL and to assess impulse oscillometry (IOS) measures as predictors of the bronchodilating effect of DIs. Methods A total of 43 adults [18 female; 44.8 ± 12.3 years (mean ± SD); n = 11 CA, n = 10 CVA, n = 7 COUGH, n = 15 CONTROL] underwent modified high-dose methacholine challenge, with IOS and partial/maximal expiratory flow volume (PEFV/MEFV) maneuvers (used to calculate DI Index) to a maximum change (Δ) in FEV1 of 50% from baseline (MAX). Cough count and dyspnea were measured at each dose. The relation between IOS parameters and DI Index was assessed at baseline and MAX using multivariable linear regression analysis. Results Cough frequency, dyspnea intensity, and baseline peripheral resistance (R5-R20) were significantly greater in COUGH compared with CONTROL (p = 0.006, p = 0.029, and p = 0.035, respectively). At MAX, the DI Index was significantly lower in COUGH (0.01 ± 0.36) compared with CA (0.67 ± 0.97, p = 0.008), CVA (0.51 ± 0.73, p = 0.012), and CONTROL (0.68 ± 0.45, p = 0.005). Fres and R5-R20 were independent IOS predictors of the DI Index. Conclusion The bronchodilating effect is impaired in COUGH and preserved in mild CA, CVA, and CONTROL. Increased peripheral airway resistance and decreased resonant frequency are associated with a decreased DI Index. COUGH is a clinical phenotype distinct from healthy normals and asthma.
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Affiliation(s)
- Nilita Sood
- Department of Medicine, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Nastasia V Wasilewski
- Department of Medicine, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Taylar Wall
- Department of Medicine, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Thomas Fisher
- Department of Medicine, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - John T Fisher
- Department of Biomedical and Molecular Sciences, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - M Diane Lougheed
- Department of Medicine, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada.,Kingston General Health Research Institute, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
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