Presentazione di PowerPoint - A.I.T.F.R · 2009-11-05 · DEGREE OF SEVERITY FEV 1, % predicted...
Transcript of Presentazione di PowerPoint - A.I.T.F.R · 2009-11-05 · DEGREE OF SEVERITY FEV 1, % predicted...
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Dott. Roberto TorchioResponsabile
Laboratorio Fisiopatologia Respiratoriae Centro del Sonno
AOU S.Luigi Orbassano Torino
Refertazione e interpretazione
dei risultatiw
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Report dellaspirometria
Ruolo del tecnico!
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-Data
-Dati ambientali
-Dati provenienza
- Dati tecnicoww
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-Dati paziente
- Motivo esame
- Dati su qualità esame
-Dati esame funzionalecon valori di riferimento
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-Dati ambientali
non dimenticare cosa è il BTPS
Non dimenticare le unità di misuraw
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UNITA’ MISURA SI pressione
pascal = Paequivale a 1 N · m−2 = kg · m−1 · s−2
cmH2O (3,98 °C) = 98,06 Pa= 0.98 kPa
mmHg ≈ 1 torr = 133,3 Pa= 1.33 kPa
1 kPa = 7.5 mmHgww
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LO STATO GASSOSO
Equazione di stato:
PV = n RT
P = pressione;
V = volume;
n = numero moli;
T = temperatura assoluta;
R = costante dei gas
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STPD and BTPS
• STPD = Standard Temperature, Pressure, desiccated (273 degrees Kelvin, 760 mmHg, and PH2O = 0)
• BTPS = Body Temperature, ambient pressure, saturated (273 + 37 = 310 degrees Kelvin, ambient pressure and PH2O = 47 mmHg)
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-Dati paziente
-Dati ambientali
-Dati su qualità esame
-Dati esame funzionalecon valori di riferimento
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PesoAltezzaSesso……..!
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Anamnesi breve
FumoEsposizione professionale
Dispnea Farmaci
broncodilatatori da quando sospesi?
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-Dati su qualità esame
- Volume estrapolato
- PEFT (time to obtain PEF)
- FET100 (time of forc. expir.)ww
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-Dati su qualità esame
FET100 (time of forc. expir.)
Dice se il paziente ha espiratoper almeno 6 secondi
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-Volume estrapolato
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PEFT (time to obtain PEF)
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Valori predetti?!?
Quando un esameè normale?
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10 20 30 40 50 60 70 80
1
2
3
4
5
6FE
V 1 in
Litre
s
Age in Years
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Numerical Data
20 30 40 50 60 700
1
2
3
4
5
6
FEV
1 in
Litr
es
Age
Residual2.1L - 3.8L
= -1.7 L
Standardised Residual = SR
SR=(observed-predicted)/RSD
SR = -1.7/0.51 = -3.3
RSD = residual standard deviation w
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Residual Standard Deviation
A statistical term used to describe the standard deviationof points formed around a linear function, and is an estimateof the accuracy of the dependent variable being measured.
Residual standard deviation is also referred to as thestandard deviation of points around a fitted line.
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Reference Range
Ref. Range = predicted ±1.645*RSD includes 90% of normal observations(90% confidence limits)5% normal population below lower limit of normal LLN5% normal population above upper limit of normal ULN
ULN = Mean +1.645*RSD LLN = Mean -1.645*RSD
LLN will give 5% ‘false positives’ in a normal population
CI : indice di confidenza
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“Normalità” = 3.14 + 0.92 4.063.14 - 0.92 2.22 Range 90%
dei “normali”
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Numerical Data
-5 -4 -3 -2 -1 0 1 2 3 4 50.0
0.2
0.4
0.6
0.8
1.0
5% ofpopulation
5% ofpopulation
Freq
uenc
y
Value of X
Mean = 0.0SD = 1.0
Normal Distribution Curve
90%
VC
1.5 2.0 2.5w
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Quadrelli et al. Respir Med 1999
n = 1000 patients consecutively tested during daily clinical practice
*
In 97.8% of tests, the lower limit of normal for FEV1 (calculated by 90% CI) was under 80% of the predicted value
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The practice of using 80% predicted as a fixedvalue for the lower limit of normal may beacceptable in children, but can lead to importanterrors when interpreting lung function in adults [5].
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Giudizio di severitàdella alterazione .
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DEGREE OF SEVERITY FEV1, % predictedMILD >70%MODERATE 60-69MODERATELY SEVERE 50-59SEVERE 35-49VERY SEVERE <35
Assessment of severity
Note: The ratio FEV1/FVC should not be used for severity classification.
Although there is good evidence that FEV1 correlates with the severity of symptoms and prognosis in many circumstances, the correlations do not allow one to accurately predict symptoms or prognosis for individual patients.
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DEFINIZIONE DI OSTRUZIONE AL FLUSSO
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RESTRIZIONE
OSTRUZIONE
MALATTIA POLMONARE
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DEFINIZIONE DI RESTRIZIONE:RIDUZIONE DELLA
CAPACITA’ POLMONARE TOTALE
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Simplified algorithm for pulmonary function testing in
clinical practice
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volume residuo volume residuoww
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volume residuovolume residuow
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DEFINIZIONE DI OSTRUZIONE AL
FLUSSO:RIDUZIONE DEL FLUSSO
ESPIRATORIO FORZATO PER UN VOLUME POLMONARE
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FLU
SSO
VOLUMEFVC
FEV1 /FVC
FEV1ww
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FLU
SSO
VOLUME
FEV1
FVC
FEV1 /FVC
FEV1 ww
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Simplified algorithm for pulmonary function testing in
clinical practice
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OSTRUZIONE SE
FEV1/VC < lower normal limit
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….in pratica ……………
obstruction assessed asFEV1/VC <88% predicted in men
or <89% predicted in women
(i.e. >1.64 residual standard deviation <predicted)
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The practice of using 0.70 as a lower limit of the FEV1/FVC ratio results in a significant number of False positive results in males aged >40 yrs and females >50 yrs, as well as in a risk of overdiagnosis of chronicobstructive pulmonary diseases (COPD) in asymptomatic elderly neversmokers.
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FEV1/VC + 1.64 RSD
Age
70%
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Definizione BPCO (su 1727 soggetti):
1) ERS FEV1/VC , <88% pred M , <89% pred F,
2) FEV1/FVC <70%ww
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<46 anni >46 anni
ERS 10.8% 12.2%
FEV1/FVC 9.9% 28.8%<70%
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OSTRUZIONE: FEV1/VC ridotto
VO
LUM
E
TEMPO FLUSSOw
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OSTRUZIONE: FEV1/VC normale
VO
LUM
E
TEMPO FLUSSOw
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Simplified algorithm for pulmonary function testing in
clinical practice
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Obstruction, typical pattern
Obstruction, atypical pattern
Restrictionw
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ARRD 1972; 106: 366
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Criteri di reversibilità
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Criteri di reversibilità
Incremento dopo broncodilatatore di FEV1 e/o di
FVC del 12% e di 200 mL ww
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Il test non consente una distinzione
sicura tra asma e BPCO (eccetto che
nel caso di reversibilità totale) ma
aumenta la probabilità diagnostica.
Test di reversibilità
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TLC pre
TLC post
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Attenti a valutare i
“Cosiddetti”Flussi terminali
(FEF75, FEF25-75)w
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Una chiara prova del riscaldamentoglobale della Terra.w
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MEF25 COME INDICE DIMALATTIA DELLE PICCOLE VIE AEREE?
MEF25:1. PRESSIONE ELASTICA POLMONARE
2. COMPRESSIONE GAS INTRATORACICO3. GRANDEZZA CAPACITA’ VITALE RISPETTO
AL PREDETTO4. OSTRUZIONE CENTRALE
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Nello stesso soggetto misuro differenti FEF75
Se ho diverso PEF, o volumi
Se ad esempioda linee guida i flussi vengono da una curva con la migliore somma FVC-FEV1
il FEF75 può anche venire da una curvacon FVC diversa dalla massimale
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Compressionfree
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75% uno
75% due
uno
dueww
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ALTERAZIONI ISOLATE :
- Flussi inspiratori/espiratori
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0 1 2 3 4 5 6
-8
-6
-4
-2
0
2
4
6
8
10
12Fl
ow in
L/s
Liters0 1 2 3 4 5 6
-8
-6
-4
-2
0
2
4
6
8
10
12
Flow
in L
/s
Liters
0 1 2 3 4 5 6
-8
-6
-4
-2
0
2
4
6
8
10
12
Flow
in L
/s
Liters0 1 2 3 4 5 6
-8
-6
-4
-2
0
2
4
6
8
10
12
Flow
in L
/s
Liters
Extra-thoracic
Asthma COPD
Intra-thoracic
Flow-volume curve, but not
PEF, differentiates
types of airway
obstruction
Pellegrino et al. ERJ 2005
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Miller e Hyatt( Mayo Clin Proc 1969;44:145-61
Am Rev Respir Dis 1973;198:475-481).w
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Nella ostruzione FISSA l’incremento della resistenza al flusso aereo rimane costante in entrambe le fasi della respirazione.
La curva flusso-volume evidenzia un plateau sia inspiratorio che espiratorio.
Il rapporto flussi inspir-espiratoriFIF50/FEF50 è normale ( ≥ 1).
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CAUSE DI OSTRUZIONE FISSA
Ostruzione intratoracica•Stenosi tracheale post-intubazione•Gozzo •Tumori endotracheali•Stenosi dei bronchi principali
Ostruzione extratoracica•Respirazione in un tubo endotratrachealeo cannula tracheost. troppo piccoli
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La ostruzione VARIABILE si
riferisce alla dinamica del flusso
e della pressione durante il ciclo
respiratorio con differenza fra
inspirazione ed espirazioneww
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La ostruzione può essere realmente “variabile” come nella paralisi delle corde vocali, e nella tracheomalacia
o può essere immodificabile come nei tumori intraluminali localizzati e non circonferenziali, che creano una riduzione del lume, ma lasciano normale la compliance della restante parete.
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OSTRUZIONE VARIABILE EXTRATORACICA
Durante la ESPIRAZIONE la pressione positiva tiene aperto il lume e la forma della curva flusso-volume rimane invariata.
Durante INSPIRAZIONE la pressione intraluminale negativa determina un’ulteriore riduzione del calibro delle vie aeree extratoraciche, creando un plateau nella curva flusso-volume
FIF50/FEF50 è ridotto e FEV1 > FIV1w
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CAUSE DI OSTRUZIONE EXTRATORACICA VARIABILE
•Paralisi di una o entrambe le corde vocali •Adesione delle CV•Costrizione delle CV•Apnea ostruttiva (aspetto a denti di sega della curva flusso-volume)•Ustioni
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OSTRUZIONE VARIABILE INTRATORACICA
Durante ESPIRAZIONE, la pressione pleurica èpositiva e supera la pressione intraluminale, con ulteriore riduzione del calibro delle vie aeree intratoraciche, (curva espiratoria).
Durante INSPIRAZIONE, la pressione intraluminale negativa espande le vie aeree e la curva inspiratoria rimane invariata
FIF50/FEF50 è aumentato
e FEV1 < FIV1w
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La diagnostica del sonnoLa diagnostica del sonnoal prossimo corso!al prossimo corso!
Grazie per l’attenzione!
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