Spirometric testing: How much is enough?

The author comments on the report by Dr. Benjamin Chan and associates on spirometry utilization rates in Ontario (see pages 169 to 176 of this issue). Their findings indicate that the overall utilization of spirometry in the province is not unreasonably high and may in fact be too low in certain regions and patient groups. The author argues, however, that to a large extent the wrong type of spirometry is being done. Although the wider use of flow studies should be promoted, the utility of flow-volume loops rather than simple spirograms as an office procedure is highly questionable.     

Spirometric standards for healthy male lifetime nonsmokers

The FVC, FEV1.0, FEF25-75%, and FEV1.0/FVC (%) were measured in 162 males aged 18.9-78.6 yr using a Stead-Wells spirometer. Multiple regression equations were generated to predict these lung parameters from the best weighted combination (p less than or equal to 0.05) of age, standing height, sitting height, biacromial breadth, and chest expansion (FVC: R = 0.843, SEE = 513 ml BTPS; FEV1.0: R = 0.850, SEE = 436 ml BTPS; FEF25-75%: R = 0.665, SEE = 997 ml/s BTPS; FEV1.0/FVC: R = 0.537, SEE = 4.95%). The lower limit of normality was defined as the predicted value minus the 95% confidence interval (one-tailed test). Cross-validation of other FVC, FEV1.0, and FEF25-75% equations in the literature indicate that all the FVC and FEV1.0 ones are unsuitable for the sample and instrumentation used in this investigation.     

Spirometric parameters of the working population of young non-smoking males of the Murcia area

A prospective study on dynamic spirometric parameters on 195 healthy non-smoking men-workers, representing the non-smoking labor population from 16 to 40 years of age, in the Murcia Region (Spain), has been carried out. Men were selected upon two criteria: age and height. Lower normality limits, have been estimated with 95% reliability by developing regression equations for the following spirometric parameters: forced vital capacity, forced expiratory volume (timed and relative), peak flow and forced mid-expiratory flow.     

Spirometric changes during exacerbations of COPD: a post hoc analysis of the WISDOM trial

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function and poor outcomes for patients. However, there are limited data on the time course of changes in forced expiratory volume in 1?s (FEV₁) preceding the first reported symptom and after the start of an exacerbation.

Methods

WISDOM was a multinational, randomized, double-blind, active-controlled, 52-week study in patients with severe-to-very severe COPD. Patients received triple therapy (long-acting muscarinic antagonist and long-acting β₂-agonist/inhaled corticosteroid [ICS]) for 6?weeks, and were randomized to continue triple therapy or stepwise withdrawal of the ICS (dual bronchodilator group). After suitable training, patients performed daily spirometry at home using a portable, battery-operated spirometer. In the present post hoc analysis, patients who continued to perform daily home spirometry and completed at least one measurement per week for a 56-day period before and after the start of a moderate or severe exacerbation were included. Missing values were imputed by linear interpolation (intermittent), backfilling (beginning) or carry forward (end). Exacerbation onset was the first day of a reported symptom of exacerbation.

Results

Eight hundred and eighty-eight patients in the WISDOM study had a moderate/severe exacerbation after the complete ICS withdrawal visit; 360 of them contributed at least one FEV₁ measure per week for the 8?weeks before and after the event and are included in this analysis.Mean daily FEV₁ began to decline from approximately 2?weeks before the onset of symptoms of an exacerbation, dropping from 0.907?L (mean Days ??56 to ??36 before the exacerbation) to 0.860?L on the first day of the exacerbation. After the exacerbation, mean FEV₁ improved but did not return to pre-exacerbation levels (mean Days 36–56 after the exacerbation, 0.875?L).The pattern of FEV₁ changes around exacerbations was similar in the triple therapy and dual bronchodilator groups, and a similar pattern was seen in moderate and severe exacerbations when analysed separately.

Conclusions

Mean lung function starts to decline prior to the first reported symptoms of an exacerbation, and does not recover to pre-exacerbation levels 8?weeks after the event.

Trial registration

WISDOM (ClinicalTrials.gov number, NCT00975195).

     

Changes in Spirometric Parameters upon Local Heating of Forearm or Hand Skin

Local heating of the forearm or hand moderately decreases the respiratory volume parameters without changing bronchoconstriction. At the same time, a significant increase in the maximal expiratory flow (MEF₅₀ and MEF₇₅) indicates a limited enhancement of expiration upon local heating. In contrast, local cooling limits the maximum inspiration without affecting expiration.     

A Novel Scoring System to Measure Radiographic Abnormalities and Related Spirometric Values in Cured Pulmonary Tuberculosis

Background

Despite chemotherapy, patients with cured pulmonary tuberculosis may result in lung functional impairment.

Objective

To evaluate a novel scoring system based on the degree of radiographic abnormalities and related spirometric values in patients with cured pulmonary tuberculosis.

Methods

One hundred and twenty seven patients with cured pulmonary tuberculosis were prospectively enrolled in a referral hospital specializing in respiratory diseases. Spirometry was performed and the extent of radiographic abnormalities was evaluated twice by each of two readers to generate a novel quantitative score. Scoring reproducibility was analyzed by the intra-class correlation coefficient (ICC) and the Bland-Altman method. Multiple linear regression models were performed to assess the association of the extent of radiographic abnormalities with spirometric values.

Results

The intra-observer agreement for scoring of radiographic abnormalities (SRA) showed an ICC of 0.81 (CI:95%, 0.67–0.95) and 0.78 (CI:95%, 0.65–0.92), for reader 1 and 2, respectively. Inter-observer reproducibility for the first measurement was 0.83 (CI:95%, 0.71–0.95), and for the second measurement was 0.74 (CI:95%, 0.58–0.90). The Bland-Altman analysis of the intra-observer agreement showed a mean bias of 0.87% and -0.55% and an inter-observer agreement of -0.35% and -1.78%, indicating a minor average systematic variability.After adjustment for age, gender, height, smoking status, pack-years of smoking, and degree of dyspnea, the scoring degree of radiographic abnormalities was significantly and negatively associated with absolute and percent predicted values of FVC: -0.07 (CI:95%, -0.01 to -0.04); -2.48 (CI:95%, -3.45 to -1.50); and FEV₁ -0.07 (CI:95%, -0.10 to -0.05); -2.92 (CI:95%, -3.87 to -1.97) respectively, in the patients studied.

Conclusion

The extent of radiographic abnormalities, as evaluated through our novel scoring system, was inversely associated with spirometric values, and exhibited good reliability and reproducibility. As intra-observer and inter-observer agreement of the SRA varied from good to excellent, the use of SRA in this setting appears acceptable.     

Estimation of the Spirometric Residual Volume (RV) by a Regression Built from Gower Distances

We estimate the Residual Volume, a spirometric parameter, by use of four continuous and four categorical variables. The estimation is done using distance-based regression, which allows to construct the predicting regression equation from mixed-type explanatory variables. The additionally introduced categorical variables improve essentially the goodness of fit of the regression equation.