O prezentare mai veche, dedicata unui prieten drag.

1. Poate fi inlocuita spirometria?
Traian Mihaescu
traian@mihaescu.eu
www.pneumo-iasi.ro

2. Spirometria
 Cel mai utilizat test de masurare a
functiei respiratorii!

3. Asigurarea calitatii!
Variabilitatea (“zgomotul”) este mai
mare in spirometrie decit in majoritatea
altor teste de laborator clinic, datorita
inconsistentei eforturilor pacientilor.
Becklake MR. Am J Med 1986; 80: 1158-1164

4. Asigurarea calitatii!
In 1990, in SUA, numai 57% din
spirometre intruneau standardele ATS!
Nelson SB et al. Chest 1990; 97: 288-297

5. + alti factori perturbatori
 Procedurile de testare?
 Program permanent de asigurare a
calitatii?
 Valori de referinta corespunzatoare?
 Algoritmi corecti de interpretare a
rezultatelor?

6. …
 National Asthma Education Program:
spirometria este esentiala pentru
diagnosticul si ingrijirea astmului
deoarece atit medicii, cit si pacientii au
o perceptie gresita asupra severitatii
astmului ceea ce duce la erori de
tratament.
NIH publication no.91-3042

7. …
Medicii nu pot identifica patternul
obstructiv sau restrictiv din istoric si
examenul fizic. Cind incearca sa o
faca gresesc in 61% din cazuri!
Russell NJ et al. Thorax 1986; 41: 360-363

8. …
Subestimarea obstructiei cailor
aeriene se asociaza cu o crestere a
mortalitatii in astm!
Sly MR. J Allergy Clin Immunol 1989; 84: 421-434

9. Dar…

10. Spirometria la batrini, de ex.
 59% din pacientii cu astm pot avea
spirometrie normala!
Enright PL et al. Chest 1999; 116: 603-613

11. Obstructive airways disease in
old age
Dr Stephen Allen
The Royal Bournemouth
Hospital

12. Spirometry in old age - myths
‘Most old people can’t do a meaningful PEFR, FEV1 and
FVC’
FALSE
‘Almost all old people can do spirometry if encouraged’
FALSE

13. Spirometry in old age - facts
* >80% of 65-94 year olds can meet the ATS’94 criteria
* performance is related to cognitive scores, functional
scores and educational attainment
* not independently related to age, BMI, or GDS
* the proportion of incompetent patients rose with age, to
about 40% at age 85 or over
Pezzoli et al Age Ageing(2003);32:43-46
Bellia et al Am J Respir Crit Care Med(2000);161:1094-
99

14. Spirometry in old age - how?
* screen for cognitive impairment (? thresholds)
* High level of operator skill, patience, enthusiasm
* use the ATS’94 criteria for quality control
* if ATS’94 criteria not met, consider using PEFR, Slow VC
* if in doubt, try to do spirometry

15. ATS’94 criteria
* 3 curves acceptable, 2 of which reproducible
* acceptable curve has - no artefact, an acceptable start (back
extrap. Vol <5%), FVC time of 6s or more, final plateau 1s
* reproducible curves have - difference of 200ml or less in
FEV1 and FVC

16. Alternatives to spirometry
* respiratory impedance by forced oscillation
* whole body plethysmography
* helium dilution volumetry
* inspiratory ‘impedance’ (ratio of dP/dtmax to Vt/Ti)
* cross-sectional radiography
All these limited by complexity, cost, unavailability or lack of data
for elderly patients

17. Punctaj total 15
+3
+2
+3
+3
+4

18. Valoarea limita pentruValoarea limita pentru ACTACT – controlat sau nu ?– controlat sau nu ?
Pacientii cu scor ACTPacientii cu scor ACT ≤≤ 1919 sunt necontrolatisunt necontrolati

19. ACT asigura o valoare predictiva mai buna in evaluarea
controlului astmului comparativ cu VEMS ; cea mai buna
strategie este cea care le combina pe ambele
Contributia ACT si spirometriei inContributia ACT si spirometriei in
evaluarea controlului astmuluievaluarea controlului astmului

20. Monitorizare BPOC
 Sintem obsedati de VEMS!
... Dar
 Imbunatatirea simptomelor poate
apare fara modificarea VEMS si
schimbarea VEMS poate avea loc fara
repercursiuni clinice!

21. Monitorizare BPOC
 Consecintele bolii includ simptomele,
pierderea in greutate, intoleranta la
effort, exacerbarile, calitatea vietii,
utilizarea resurselor sanitare si
decesul.
 VEMS nu poate fi utilizat ca un marker
global si sint necesari alti markeri!
Jones PW. Eur Respir J 2006; 27: 822-832

22. Monitorizare BPOC
 Spirometria nu este adecvata pentru a
descrie impactul BPOC sau a evalua
eficacitatea interventiilor terapeutice!
Jones PW. Eur Respir J 2006; 27: 822-832

23. Markeri biologici
 Celule inflamatorii in expectoratie
 Markeri solubili in expectoratie
 Gaze expirate
 Condensat aerian expirat
 Markeri periferici sanguini
 Nivelurile din sputa proteaze/antiproteaze
 etc.

24. Markeri fiziologici
 Testul de mers la 6 min
 Functia muschilor sheletici
 Rata si tipul exacerbarilor
 Imagistica: CT, PET
 etc.

25. Markeri simptomatici
 Simptome: chestionarul MRC
 Dispnee: scala de dispnee MRC, Borg,
UCSD
 Calitatea vietii legata de boala: SGRQ,
CRDQ, BPQ, PFSDQ, PFSS, CCQ
 Calitatea vietii generica: SF-36, NHP,
EQ-5D
 Functia cognitiva

26. Markeri compoziti
 BODE index

27. Concluzie:
 Ce vine mai intii este intotdeauna
istoricul!

28.  “Spirometry helps confirm the
diagnosis and establishes the initial
severity of the disease, but you are
usually 95% of the way there with the
history”
Pownall M. Airways J 2003; 2: 191-2

29.  “How are you?”
 “What would you like to be able to
do”?
 “How far can you walk?”
Pownall M. Airways J 2003; 2: 191-2