8-肺功能解读 ACCP-Chest PFT Simulation Area - 2013 - Sun [兼容模式]

Pulmonary Function Testing: Simulation Center Chest/ACCP 2013.MD, FCCP *James E. Hansen,and William W. Stringer, MD,Harbor-UCLA has received pulmonary function and exercisetesting equipment at reduced costs from several manufacturers of such equipment for several years.Topics1. History of Respiratory Physiology2. Lung structure and Function3. Preparation for testingi bilitgogogogo5. More spirometry: variability, equations, ethnicity, FEF25-75% or 1-FEV3/FVC for small airways, GOLD vs LLN vs Lung6. Bronchodilators in the laboratory8. DLCO (TLCO), VA’, DLCO/VA’, IVC9. Quality control and instrument/ individual variabilityTestinggogogogogo10. Exercise Testing11. Referencesgogogoreturnreturn return y g yCast of airways of human lung. Airwaysbranch by irregular dichotomy, NOTregular dichotomy0%20%40%normal obese thin60%80%100%AIRSPACESPerfusion and ventilation may not matchNORMAL High V/Q or Low Q/V(Pulm emboli or vasculopathy)Low V/Q (Atelectasis, obesity)Both Normal and low Q/V;(Emphysema)returnreturnInspiratory Vital Capacity return returnExpiratory Vital CapacityNormal 11 year old boy Time vs volume and volume vs flowNormal 37 year old manTime vs volume and volume vs timeNormal 83 year old man Time vs volume and volume vs time80 year old woman: moderatelysevere obstructionTime vs volume and volume vs time73 year old man: Very Severe obstructionFlow Volume LoopNormal Moderate Severe Time vs volume and volume vs timeFixed upper airway obstructionTime vs volume and volume vs timeVariable extra-thoracic obstructionVariable Intra-Thoracic Variable Extra-Thoracic Fixed Upper Airway ATS/ERS Task Force; Standardization of Lung Function Testing. “Standardization of Spirometry” ERJ 26:153-161, 2005Maximum Voluntary VentilationDirect and indirect MVV at several breathingfrequencies150return reference equations returnVariability of “normals”FEV1 values of Black men by age50006000FVC of Latin women sorted by height5500100020003000400020304050607080Age, yearsF E V 1, L100015002000250030003500400045005000130140150160170180Height, cmF V C , m LEven when “accounting for ethnicity,age, height, and gender, there still is marked variability of FVC and FEV1Hansen case 1Flow-volume loop. FVC = 4.0 L, IRV = 2.0 L, VT = 1.0 L, ERV = 1.0 L, FEV1 = 3.0 L, FEV3 = 3.8 L FEV1/FVC = 75%. Pick the correct answer:A. FEV1 extends from arrow 0 to arrow 2 and FEF25-75% extends from arrow 2 to arrow 3.B. FEV1 extends from arrow 0 to arrow 3 and FEF25-75% extends from arrow 1 to arrow 3.C FEV1extends from arrow 0to arrow 2and FEF25-75%extends from arrow 2to arrow 4C. FEV1 extends from arrow 0 to arrow 2 and FEF25-75% extends from arrow 2 to arrow 4.D. FEV1 extends from arrow 0 to arrow 3 and FEF25-75% extends from arrow 2 to arrow 4.Does FEF25‐75% measure small airways?Not Usually. But the FEV3/FVC or 1-FEV3/FVC does.5. C. 1. Why 80% of predicted is poor.J Hansen, et al. Chest 129: 369-377, 2006NEVER-SMOKERSModified from Hansen et al, CHEST 131:349, 2007CURRENTSMOKERS Modified from Hansen et al CHEST 2007;131:349-355.Note that fornever-smokers,mean agesare too low with Morrisequation too equation, toohigh for Newburyequation andnormal forHansen equation.Prim Care RespJ, JEHansen The black lines are the lines ofidentity.-Compare the NHANES-3 whitemale never-smokers with the whitemale current-smokers .-It is clear that the %FEV1/FVCdeclines more rapidly in smokers declines more rapidly in smokersthan never-smokers.-Consequently calculated lungages from the Hansen et al 2010equation increase considerablywith cigarette smoking.-What percentage of smokersshow decreasing %FEV1/FVC?-Does it take at least 20 years toshow this?Letter to editor Prim Care Resp J,JEHansenreturnreturnDoes absolute variability increase as baselinevolume increases? YES !not betterbetter not betterRespir Med 2008, Hansen et alreturn return0%20%40%normal obese thin60%80%100%Tracings to measure trapped gas volume (Vtg) which ideally equals FRCThe steeper the slope, the smaller the Vtg and FRC.Tracings to measure FRC by N2 washout Instrument calculates volume of lung “washed out” with each breath and cumulates total volume on X-axis.DLCO and VA’ method:Spirometric tracing shows rapid fullinhalation from residual volume,holding breath for 10 seconds, andexhaling to near residual volume.Lower tracings show response ofcontinuous gas analyzers to(C)insoluble methane (CH4) andcarbon monoxide (CO) attracted tohemoglobin. Vertical dashed linesshow time (about 10.5 to 11 seconds)when gas concentrations areselected for calculations. (Takinggas concentrations and time later intracings works well also.)VA’ = IVC x CH4 inspired / alveolar exhaled CH4.C = Crapo et al, G = Gutierrez et al, Q = Quanjeret al, and M = mean of these 3 series Equations for RV, TLC, and RV/TLC are in Appendices. Remember that in any populationany population, values for absolute volumes (VC, FRC, RV, and TLC) inherently vary much more than values forFEV1/FVCFEV1/FVC orRV/TLC.return returnDLCO and VA’ method:Spirometric tracing showsrapid full inhalation fromresidual volume, holdingbreath for 10 seconds, andexhaling to near residualvolume.Lower tracings showresponse of continuous gasanalyzers to insolublemethane and CO attracted tohemoglobin. Vertical dashedlines show time (about 10.5 to11 seconds) when gasconcentrations are selectedfor calculations(Taking gasfor calculations. (Taking gasconcentrations and time laterin tracings works well also.Three different methods of calculating time •Equation for calculation of DLCO.qFigure shows calculatedline of equation whichaverages the valuesfrom 13 series at thefollowing heights in cmand ages in years, fromleft to right:165/70175/70165/50165/70,175/70,165/50,185/70,175/50,165/30,185/50,175/30,and 185/30.The equation is:DLCO in mL/min/mm Hg=-10.06 + 0.3043 x cm –022x years“Whit”M0.22 x years. “White” Men Figure shows calculated line of equation which averages the values from 9 series at the following heights in cm and ages in years, from left to right: 150/70,160/70,150/50,170/70160/50150/30170/70,160/50,150/30,170/50,160/30,and 170/30.The equation is:DLCO in mL/min/mm Hg = -4.34 + 0.2094 x cm –0.139 x years.returnreturnDoes FEF25‐75% measure small airways?Hansen case 1Flow-volume loop. FVC = 4.0 L, IRV = 2.0 L, VT = 1.0 L, ERV = 1.0 L, FEV1 = 3.0 L, FEV3 = 3.8 LFEV1/FVC = 75%. Pick the correct answer:A. FEV1 extends from arrow 0 to arrow 2 and FEF25-75% extends from arrow 2 to arrow 3.B. FEV1 extends from arrow 0 to arrow 3 and FEF25-75% extends from arrow 1 to arrow 3.C FEV1extends from arrow0to arrow2and FEF25-75%extends from arrow2to arrow4C. FEV1 extends from arrow 0 to arrow 2 and FEF25-75% extends from arrow 2 to arrow 4.D. FEV1 extends from arrow 0 to arrow 3 and FEF25-75% extends from arrow 2 to arrow 4.Not Usually. But the FEV3/FVC or 1-FEV3/FVC does.Does FEF25‐75% measure small airways?Not Usually. But the FEV3/FVC or 1-FEV3/FVC does.Spirometry Quality ControlreturnSpirometry Quality Control Indications for SpirometryRange and Accuracy for SpirometryAcceptability Criteria for SpirometryreturnreturnCourtesy JEHansen, Harbor-UCLA55 year old executivemale complains ofdecreasing exercisetolerance. No chest pain,syncope, palpitations, orcough. Smokes 3-4cigarettes per day. 182cm. 80 kg. BP 144/81.Physical, chest X-ray,ECG normal.PFT’s (pred., act.):FVC –4.75, 6.06;FEV1 –3.76, 4.52,DLCO –28.8, 28.3.With exercise, BP rose to225/87 at peak exercise.Stopped with thigh fatigueStopped with thigh fatigue.ECG’s remained normal.Resting pH -7.42, HCO3--25. Recovery pH -7.22,HCO3--12.43 year old female electronics assembler with rheumatic feverat age 10. Increasing dyspneaand orthopnea for 6 months with past pleural effusion and intermittent atrial fibrillation. Echocardiogram shows mitral regurgitation, LAE, and LVH. Angiography normal. Rx –27digoxin, furosemide, and KCl.160 cm. 56 kg. No edema or rales. PFT’s (pred., act.): FVC –2.88,2.03; FEV1 –1.92, 1.49;%FEV1/FVC –82, 86; TLC –4.33, 3.32; DLCO –21.7, 23.5. Sinus rhythm. Stopped exercise because of general fatigue No arrhythmias or ST-T fatigue. No arrhythmias or ST-T changes.61 year old retired shipyard worker with breathing difficulties and a peculiar feeling in his chest. Never-smoker. Essentially normal physical exam. 176 cm. 70 kg. BP 144/75. 17X-ray -Pleural plaques.ECG –probable LVH. PFT –normalStopped exercise because of shortness of breath and tired thighs. No chest discomfort.BP rose to 246/108ECG developed 2 mm STp segment depression at 120 W in 2, 3, AVF, V5, V6, and up to 5 mm depression at 180 W. Returned to normal after 14 minutes.62 year old retiredaccountant; stopped heavy cigarette smoking 4 years prior. With chronic cough and shortness of breath. He began training andbicycle riding several miles daily. No angina or history of heart failure. Rx: oral 42 Atheophylline. 173 cm. 78 kg.ECG not remarkable. PFT’s (pred., act.): FVC –4.30, 1.67; TLC –6.87, 8.30; FEV1 –3.40, 0.54;%FEV1/FVC –79, 32; MVV –131, 32; DLCO –309185DLCO –30.9, 18.5. BP 169/106 rising to250/125 at peak exercise. Stopped test because of shortness of breath.This test on 100% O2. 62 year old retired accountant;Stopped both tests because of dyspnea.PaO2 at rest and peak exercise (off-scale) are 587 and 583 mm Hg.42 B37 year old active housewifewho developed progressive shortness of breath overseveral months. Referred for pulmonary and exercisetesting before and 6 mo after beginning and continuing 30 mgm/day prednisone therapy for interstitial pneumonitis 54 A for interstitial pneumonitis.168 cm. 57 kg. BP –119/68. PFT’s (pred., actual): FVC –3.76, 1.71; FEV1 –3.08, 1.52;%FEV1/FVC –82, 89; MVV –120, 60;DLCO –28.5, 16.2. Stopped exercise test because of shortness of breath.This is test after prednisone. 37 year old active housewife who developed progressive shortness of breath over several months. This 2nd test after RX 30 mg/day prednisone therapy for 6 54 B mo for interstitial disease.. No symptoms at time of 2nd test. 168 cm. 57 kg. BP –125/75. PFT’s pred, Tests 1 & 2: FVC –3.76, 1.71, 3.85; FEV1 –3.08, 1.52, 3.10; %FEV1/FVC –82, 89, 81; MVV –120, 60, 130;DLCO –28.5, 16.2, unk. .50 yr old male shipyard worker with dyspnea for 1 year, hospitalized 6 mo previously for severe substernal chest. Light smoker. 185 cm. 92 kg. Physical –normal. BP –125/80. X-ray –minimal pleural thickening. ECG –59negative T waves V1-V3. PFT’s (pred., act.) FVC –5.10, 4.68; FEV1 –4.06, 3.62; TLC –7.45, 5.49; DLCO –32.3, 21.2.Stopped because of fatigue and exhaustion. Exercise ECG –0.5 mm ST depression in II V5and V6Later in II, V5, and V6. Laterreview of prior hospitalization revealed no good evidence for MI; all findings suggest PE..64 year old retired man with 11 years of episodic dyspneacalled “asthma” and known hypertension. Many hospitalizations for HF. No MIor valvular HD. Prior smoker.Rx: furosemide, KCl, digoxin, hydralazine, albuterol, prednisone, ranitidine, and25 Adiazepam. 170 cm. 82 kg.BP 112/95. No rales, wheezes,or leg edema. X-ray –cardiomegaly and Kerley-Blines. ECG –LVHand LAE. PFT’s (pred. B&A albuterol): FVC-3.65, 2.70, 2.80; FEV1 –2.92, 2.01, 2.30; FEV1/FVC –8974;MVV–1178089, 74; MVV –117, 80,92; TLC –5.95, 4.33; DLCO –23.4, 22.0. BP rose to139/88. Stopped exercisebecause of fatigue.RUB 64 M 64 year old retired manwith 11 years of LHF..Other Rx: ARB added todigoxin, furosemide,hydralazine, KCl,prednisone, ranitidine,albuterol, and diazepam;Resting BP139/88rising25 BResting BP 139/88 risingto 204/104 at peakexercise. Stoppedexercise because ofgeneralized fatigue. Nochest pain, arrhythmias orabnormal ST changes.9-panel plots of exercise studies of two women both about 50 years of age and of the same size.Blue = normal Black = PAH 51 yr old woman withprogressive exercisedyspnea of 2-3 yearsduration. Seven months ofphenteramine andfenfluramine 5 yearspreviously. Recent rightheart catheterizationdemonstrated pulmonaryXPA 51 F80 Ahypertension. Also systemichypertension. Rx –verapamil, benazepril,atrovastatin, and aspirin.164 cm. 99 kg. BP –131/89.PFT (pred., act.) –3.20,3.01; FEV1 –2.63, 2.53; DLCO –22.7,25.7. This test baseline;later test after endothelin-1later test after endothelin -1receptor antagonist therapy.During both exercisestudies, BP rose normallyand patient stoppedexercise because ofdyspnea. No exercise-induced ECG abnormalities.6 mo later test 51 yr oldwoman with progressiveexercise dyspnea of 2-3years duration. Seven monthsof phenteramine andfenfluramine for 5 years.Recent right heartcatheterization demonstratedXPB 51 F80 Bcatheterization demonstratedpulmonary hypertension. Alsosystemic hypertension.Rx –verapamil, benazepril,atrovastatin, and aspirin.164 cm. 99 kg.BP –131/89.PFT (pred., act.)FVC –3.20, 3.01;FEV1 –2.63, 2.53;DLCO –22.7, 25.7.This test after endothelin -1receptor antagonist therapyadded for 6 months.During both exercise studies,BP rose normally and patientstopped exercise because ofdyspnea. No exercise-induced ECG abnormalities.return return 2005 ATS/ERS PFT Task ForceLung Function Testing Series–ERJ/2005 2005 ATS/ERS Pulmonary Function Interpretation –ERJ November 2005return returnNAME, Last, first # yrs cm KgPatient Five 5 59 163 54 Measure, units mean LLN/ACTUALL 2.89 2.19 1.28 SVC,L 2.89 2.19 1.40 FVC,IC, L 2.17 0.88ERV, L 0.72 0.52FRC, L 2.41 2.33RV L168229181RV, L 1.68 2.29 1.81L(LLN) 4.57 3.66 3.21 TLC,RV/TLC 0.37 0.46 0.56L 2.27 1.70 1.19 FEV1,%FEV1/FVC 78.6 69.1 85(L/min) 91 66 27 MVVSBO2 ^%N2/L ULN 5.7 3.2IVC, L 1.20VA, L 4.57 2.50VA'L4572500.78 VA'/TLC 0.95>0.85 DLCO, ml/min/torr20.5 15.4 5.5DLCO/VA' 4.49 3.36 2.20return return Why 80% of predicted is poor.J Hansen, et al. Chest 129: 369-377, 2006Harbor formula for lung age:For every percent For every percent that actual%FEV1/FVC is lower than mean predicted, the lung age is increased3years increased 3 years over the patient’s chronological lung age.。