1
|
Crowhurst TD, Butler JA, Bussell LA, Johnston SD, Yeung D, Hodge G, Snell GI, Yeo A, Holmes M, Holmes-Liew CL. Impulse Oscillometry Versus Spirometry to Detect Bronchiolitis Obliterans Syndrome in Bilateral Lung Transplant Recipients: A Prospective Diagnostic Study. Transplantation 2024; 108:1004-1014. [PMID: 38044496 DOI: 10.1097/tp.0000000000004868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD), and especially bronchiolitis obliterans syndrome (BOS), remain dominant causes of morbidity and mortality after lung transplantation. Interest is growing in the forced oscillation technique, of which impulse oscillometry (IOS) is a form, as a tool to improve our understanding of these disorders. However, data remain limited and no longitudinal studies have been published, meaning there is no information regarding any capacity IOS may have for the early detection of CLAD. METHODS We conducted a prospective longitudinal study enrolling a consecutive sample of adult bilateral lung transplant recipients with healthy lung allografts or CLAD and performed ongoing paired IOS and spirometry tests on a clinically determined basis. We assessed for correlations between IOS and spirometry and examined any predictive value either modality may hold for the early detection of BOS. RESULTS We enrolled 91 patients and conducted testing for 43 mo, collecting 558 analyzable paired IOS and spirometry tests, with a median of 9 tests per subject (interquartile range, 5-12) and a median testing interval of 92 d (interquartile range, 62-161). Statistically significant moderate-to-strong correlations were demonstrated between all IOS parameters and spirometry, except resistance at 20 Hz, which is a proximal airway measure. No predictive value for the early detection of BOS was found for IOS or spirometry. CONCLUSIONS This study presents the first longitudinal data from IOS after lung transplantation and adds considerably to the growing literature, showing unequivocal correlations with spirometry but failing to demonstrate a predictive value for BOS.
Collapse
Affiliation(s)
- Thomas D Crowhurst
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jessica A Butler
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Lauren A Bussell
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sonya D Johnston
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Yeung
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Lung Transplant Service, The Alfred, Melbourne, VIC, Australia
| | - Greg Hodge
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Greg I Snell
- School of Medicine, Monash University, Melbourne, VIC, Australia
- SA Lung Transplant Unit, Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Aeneas Yeo
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Holmes
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Chien-Li Holmes-Liew
- Department of Haematology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| |
Collapse
|
2
|
Toumpanakis D, Usmani OS. Small airways in asthma: Pathophysiology, identification and management. CHINESE MEDICAL JOURNAL PULMONARY AND CRITICAL CARE MEDICINE 2023; 1:171-180. [PMID: 39171124 PMCID: PMC11332871 DOI: 10.1016/j.pccm.2023.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Indexed: 08/23/2024]
Abstract
Background The aim of this review is to summarize the current evidence regarding small airway disease in asthma, focusing on recent advances in small airway pathophysiology, assessment and therapeutic implications. Methods A search in Medline was performed, using the keywords "small airways", "asthma", "oscillometry", "nitrogen washout" and "imaging". Our review was based on studies from adult asthmatic patients, although evidence from pediatric populations is also discussed. Results In asthma, inflammation in small airways, increased mucus production and airway wall remodelling are the main pathogenetic mechanisms of small airway disease. Small airway dysfunction is a key component of asthma pathophysiology, leading to increased small airway resistance and airway closure, with subsequent ventilation inhomogeneities, hyperresponsiveness and airflow limitation. Classic tests of lung function, such as spirometry and body plethysmography are insensitive to detect small airway disease, providing only indirect measurements. As discussed in our review, both functional and imaging techniques that are more specific for small airways, such as oscillometry and the multiple breath nitrogen washout have delineated the role of small airways in asthma. Small airways disease is prevalent across all asthma disease stages and especially in severe disease, correlating with important clinical outcomes, such as asthma control and exacerbation frequency. Moreover, markers of small airways dysfunction have been used to guide asthma treatment and monitor response to therapy. Conclusions Assessment of small airway disease provides unique information for asthma diagnosis and monitoring, with potential therapeutic implications.
Collapse
Affiliation(s)
- Dimitrios Toumpanakis
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, United Kingdom
- General State Hospital for Thoracic Diseases of Athens “Sotiria”, Athens, 11527, Greece
| | - Omar S. Usmani
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, United Kingdom
| |
Collapse
|
3
|
Wang R, Usmani OS, Chung KF, Sont J, Simpson A, Bonini M, Honkoop PJ, Fowler SJ. Domiciliary Fractional Exhaled Nitric Oxide and Spirometry in Monitoring Asthma Control and Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1787-1795.e5. [PMID: 36801491 DOI: 10.1016/j.jaip.2023.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Domiciliary measurements of airflow obstruction and inflammation may assist healthcare teams and patients in determining asthma control and facilitate self-management. OBJECTIVE To evaluate parameters derived from domiciliary spirometry and fractional exhaled nitric oxide (Feno) in monitoring asthma exacerbations and control. METHODS Patients with asthma were provided with hand-held spirometry and Feno devices in addition to their usual asthma care. Patients were instructed to perform twice-daily measurements for 1 month. Daily symptoms and medication change were reported through a mobile health system. The Asthma Control Questionnaire was completed at the end of the monitoring period. RESULTS One hundred patients had spirometry, of which 60 were given additional Feno devices. Compliance rates for twice-daily measurements were poor (median [interquartile range], 43% [25%-62%] for spirometry; 30% [3%-48%] for Feno); at least 15% of patients took little or no spirometry measurements and 40% rarely measured Feno. The coefficient of variation (CV) values in FEV1 and Feno were higher, and the mean % personal best FEV1 lower in those who had major exacerbations compared with those without (P < .05). Feno CV and FEV1 CV were associated with asthma exacerbation during the monitoring period (area under the receiver-operating characteristic curve, 0.79 and 0.74, respectively). Higher Feno CV also predicted poorer asthma control (area under the receiver-operating characteristic curve, 0.71) at the end of the monitoring period. CONCLUSIONS Compliance with domiciliary spirometry and Feno varied widely among patients even in the setting of a research study. However, despite significant missing data, Feno and FEV1 were associated with asthma exacerbations and control, making these measurements potentially clinically valuable if used.
Collapse
Affiliation(s)
- Ran Wang
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom; Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - Jacob Sont
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew Simpson
- Department of Sport, Health and Exercise Science, The University of Hull, Hull, United Kingdom
| | - Matteo Bonini
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - Persijn J Honkoop
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom; Manchester University NHS Foundation Trust, Manchester, United Kingdom.
| |
Collapse
|
4
|
Deprato A, Ferrara G, Bhutani M, Melenka L, Murgia N, Usmani OS, Lacy P, Moitra S. Reference equations for oscillometry and their differences among populations: a systematic scoping review. Eur Respir Rev 2022; 31:220021. [PMID: 35831009 PMCID: PMC9724817 DOI: 10.1183/16000617.0021-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/05/2022] Open
Abstract
Respiratory oscillometry is gaining global attention over traditional pulmonary function tests for its sensitivity in detecting small airway obstructions. However, its use in clinical settings as a diagnostic tool is limited because oscillometry lacks globally accepted reference values. In this scoping review, we systematically assessed the differences between selected oscillometric reference equations with the hypothesis that significant heterogeneity existed between them. We searched bibliographic databases, registries and references for studies that developed equations for healthy adult populations according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A widely used Caucasian model was used as the standard reference and compared against other models using Bland-Altman and Lin's concordance correlational analyses. We screened 1202 titles and abstracts, and after a full-text review of 67 studies, we included 10 in our analyses. Of these, three models had a low-to-moderate agreement with the reference model, particularly those developed from non-Caucasian populations. Although the other six models had a moderate-to-high agreement with the standard model, there were still significant sex-specific variations. This is the first systematic analysis of the heterogeneity between oscillometric reference models and warrants the validation of appropriate equations in clinical applications of oscillometry to avoid diagnostic errors.
Collapse
Affiliation(s)
- Andy Deprato
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Giovanni Ferrara
- Alberta Respiratory Centre and Division of Pulmonary Medicine, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mohit Bhutani
- Alberta Respiratory Centre and Division of Pulmonary Medicine, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lyle Melenka
- Synergy Respiratory and Cardiac Care, Sherwood Park, AB, Canada
| | - Nicola Murgia
- Dept of Medicine, University of Perugia, Perugia, Italy
| | - Omar S Usmani
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
| | - Paige Lacy
- Alberta Respiratory Centre and Division of Pulmonary Medicine, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Subhabrata Moitra
- Alberta Respiratory Centre and Division of Pulmonary Medicine, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
5
|
Stanford GE, Jones M, Charman SC, Bilton D, Usmani OS, Davies JC, Simmonds NJ. Clinimetric analysis of outcome measures for airway clearance in people with cystic fibrosis: a systematic review. Ther Adv Respir Dis 2022; 16:17534666221122572. [PMID: 36066081 PMCID: PMC9459493 DOI: 10.1177/17534666221122572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Airway clearance techniques (ACTs) are integral to cystic fibrosis (CF) management. However, there is no consensus as to which outcome measures (OMs) are best for assessing ACT efficacy. OBJECTIVES To summarise OMs that have been assessed for their clinimetric properties (including validity, feasibility, reliability, and reproducibility) within the context of ACT research in CF. DESIGN AND METHODS A systematic review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) standards. Any parallel or cross-over randomised controlled trial (RCT) investigating outcome measures for ACT in the CF population were eligible for inclusion. The search was performed in five medical databases, clinicaltrials.gov, and abstracts from international CF conferences. The authors planned to independently assess study quality and risk of bias using the COnsensus-based Standards for the selection of health status Measurement InstrumeNts (COSMIN) risk of bias checklist with external validity assessment based upon study details (participants and study intervention). Two review authors (GS and MJ) independently screened search results against inclusion criteria, and further data extraction were planned but not required. RESULTS No completed RCTs from the 187 studies identified met inclusion criteria for the primary or post hoc secondary objective. Two ongoing trials were identified. DISCUSSION AND CONCLUSION This empty systematic review highlights that high-quality RCTs are urgently needed to investigate and validate the clinimetric properties of OMs used to assess ACT efficacy. With the changing demographics of CF combined with the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies, an accurate assessment of the current benefit of ACT or the effect of ACT withdrawal is a high priority for clinical practice and future research; OMs which have been validated for this purpose are essential. REGISTRATION This systematic review was registered on the PROSPERO database (CRD42020206033).
Collapse
Affiliation(s)
- Gemma E. Stanford
- Research Fellow and Highly Specialist
Physiotherapist, Department of Adult Cystic Fibrosis, Royal Brompton
Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial
College, London, UK
| | - Mandy Jones
- Department of Health Sciences, College of
Health, Medicine and Life Sciences, Brunel University London, Uxbridge,
UK
| | | | - Diana Bilton
- National Heart and Lung Institute, Imperial
College, London, UK
- Department of Respiratory Medicine, Royal
Brompton Hospital, London, UK
| | - Omar S. Usmani
- National Heart and Lung Institute, Imperial
College, London, UK
- Department of Respiratory Medicine, Royal
Brompton Hospital, London, UK
| | - Jane C. Davies
- National Heart and Lung Institute, Imperial
College, London, UK
- Department of Paediatric Respiratory Medicine,
Royal Brompton Hospital, London, UK
| | - Nicholas J. Simmonds
- Department of Adult Cystic Fibrosis, Royal
Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial
College, London, UK
- Omar S. Usmani is now affiliated to Imperial
College Respiratory Research Unit, St. Mary’s Hospital, London, UK
| |
Collapse
|
6
|
Kouri A, Dandurand RJ, Usmani OS, Chow CW. Exploring the 175-year history of spirometry and the vital lessons it can teach us today. Eur Respir Rev 2021; 30:30/162/210081. [PMID: 34615699 DOI: 10.1183/16000617.0081-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/02/2021] [Indexed: 12/25/2022] Open
Abstract
175 years have elapsed since John Hutchinson introduced the world to his version of an apparatus that had been in development for nearly two centuries, the spirometer. Though he was not the first to build a device that sought to measure breathing and quantify the impact of disease and occupation on lung function, Hutchison coined the terms spirometer and vital capacity that are still in use today, securing his place in medical history. As Hutchinson envisioned, spirometry would become crucial to our growing knowledge of respiratory pathophysiology, from Tiffeneau and Pinelli's work on forced expiratory volumes, to Fry and Hyatt's description of the flow-volume curve. In the 20th century, standardization of spirometry further broadened its reach and prognostic potential. Today, spirometry is recognized as essential to respiratory disease diagnosis, management and research. However, controversy exists in some of its applications, uptake in primary care remains sub-optimal and there are concerns related to the way in which race is factored into interpretation. Moving forward, these failings must be addressed, and innovations like Internet-enabled portable spirometers may present novel opportunities. We must also consider the physiologic and practical limitations inherent to spirometry and further investigate complementary technologies such as respiratory oscillometry and other emerging technologies that assess lung function. Through an exploration of the storied history of spirometry, we can better contextualize its current landscape and appreciate the trends that have repeatedly arisen over time. This may help to improve our current use of spirometry and may allow us to anticipate the obstacles confronting emerging pulmonary function technologies.
Collapse
Affiliation(s)
- Andrew Kouri
- Division of Respirology, Dept of Medicine, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
| | - Ronald J Dandurand
- Lakeshore General Hospital, Quebec, Canada.,Dept of Medicine, Respiratory Division, McGill University, Montreal, Quebec, Canada.,Montreal Chest Institute, Meakins-Christie Labs and Oscillometry Unit of the Centre for Innovative Medicine, McGill University Health Centre and Research Institute, Montreal, Canada
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Chung-Wai Chow
- Dept of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology and Multi-Organ Transplant Programme, Dept of Medicine, Toronto General Hospital, University Health Network, Toronto, Canada
| |
Collapse
|
7
|
Kouri A, Gupta S, Yadollahi A, Ryan CM, Gershon AS, To T, Tarlo SM, Goldstein RS, Chapman KR, Chow CW. Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic. Chest 2020; 158:2502-2510. [PMID: 32652095 PMCID: PMC7345485 DOI: 10.1016/j.chest.2020.06.065] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.
Collapse
Affiliation(s)
- Andrew Kouri
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON.
| | - Samir Gupta
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON,Department of Medicine, University of Toronto, Toronto, ON
| | - Azadeh Yadollahi
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON,KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON
| | - Clodagh M. Ryan
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
| | - Andrea S. Gershon
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Sunnybrook Health Sciences Center, Toronto, ON
| | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON,Dalla Lana Graduate School of Public Health, University of Toronto, Toronto, ON
| | - Susan M. Tarlo
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Roger S. Goldstein
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respiratory Medicine, West Part Healthcare Centre, Toronto, ON, Canada
| | - Kenneth R. Chapman
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Chung-Wai Chow
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
| |
Collapse
|
8
|
Lundblad LKA, Chow CW. Lung function monitoring in the era of respiratory pandemics. Clin Physiol Funct Imaging 2020; 40:377-379. [PMID: 32510779 PMCID: PMC7300824 DOI: 10.1111/cpf.12650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/08/2020] [Accepted: 06/01/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Lennart K A Lundblad
- Meakins-Christie Laboratories, McGill University & THORASYS Thoracic Medical Systems Inc., Montréal, QC, Canada
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Programme, Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| |
Collapse
|