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Il corretto valore del test di

reversibilità bronchiale

Mario Polverino Polo Pneumologico Provinciale Centro Regionale Ad Alta Specializzazione Azienda Sanitaria Salerno

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

Interpretation

Interpretation No clear consensus about what constitutes reversibility in subjects with airflow obstruction

No clear consensus about what

constitutes reversibility in subjects

with airflow obstruction

Interpretation

Reversibility is not all or nothing

mechanism!

Questions

How express a BD response?

variables

calculation

a) % basal

b) % predicted

c) absolute change

Questions How express a BD response?  variables  calculation a) % basal b) % predicted

Positive BD response

Positive BD response

Change in normal and patients

Change in normal and patients Change greater than random variation

Change greater than

random variation

AJRCCM 1999;159:1163 – 1171

AJRCCM 1999;159:11631171

AJRCCM 1999;159:1163 – 1171

AJRCCM 1999;159:11631171

AJRCCM 1999;159:1163 – 1171
AJRCCM 1999;159:1163 – 1171
AJRCCM 1999;159:1163 – 1171

AJRCCM 1999;159:11631171

Changes in normal and patients

Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855
Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855

108 Lorber et al. Am Rev Respir Dis 1978; 118: 855861.

109 Dales et al. Am Rev Respir Dis 1988; 138: 317320.

110 Watanabe et al. Am Rev Respir Dis 1974; 109: 530537.

Changes in normal and patients

Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855
Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855

108 Lorber et al. Am Rev Respir Dis 1978; 118: 855861.

109 Dales et al. Am Rev Respir Dis 1988; 138: 317320.

110 Watanabe et al. Am Rev Respir Dis 1974; 109: 530537.

Changes in normal and patients

Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855
Changes in normal and patients 108 Lorber et al. Am Rev Respir Dis 1978; 118: 855

108 Lorber et al. Am Rev Respir Dis 1978; 118: 855861.

109 Dales et al. Am Rev Respir Dis 1988; 138: 317320.

110 Watanabe et al. Am Rev Respir Dis 1974; 109: 530537.

Changes in normal and patients

Changes in normal and patients 101. Pellegrino et al. Chest 1998; 114: 1607 – 1612. 111.

101. Pellegrino et al. Chest 1998; 114: 16071612. 111. Anthonisen et al. Am Rev Respir Dis 1986; 133: 814819. 112 Sourk et al. Am Rev Respir Dis 1983; 128: 153157. 113 Tweddale et al. Thorax 1987; 42: 487490.

Changes in normal and patients

Changes in normal and patients 101. Pellegrino et al. Chest 1998; 114: 1607 – 1612. 111.

101. Pellegrino et al. Chest 1998; 114: 16071612. 111. Anthonisen et al. Am Rev Respir Dis 1986; 133: 814819. 112 Sourk et al. Am Rev Respir Dis 1983; 128: 153157. 113 Tweddale et al. Thorax 1987; 42: 487490.

Changes in normal and patients

The MEF25–75% is a highly variable spirometric test, in part because it depends on FVC,which
The MEF25–75% is a highly
variable spirometric test, in part
because it depends on FVC,which
increases with expiratory time in
obstructed subjects.

101. Pellegrino et al. Chest 1998; 114: 16071612. 111. Anthonisen et al. Am Rev Respir Dis 1986; 133: 814819. 112 Sourk et al. Am Rev Respir Dis 1983; 128: 153157. 113 Tweddale et al. Thorax 1987; 42: 487490.

Kurashima et al. Respirology 2005;10:316

Kurashima et al. Respirology 2005;10:316

CHHABRA,Journal of Asthma, 2005;42:367

CHHABRA,Journal of Asthma, 2005;42:367

CHHABRA,Journal of Asthma, 2005;42:367

CHHABRA,Journal of Asthma, 2005;42:367

CHHABRA,Journal of Asthma, 2005;42:367

CHHABRA,Journal of Asthma, 2005;42:367

Within-individual difference

Within-individual difference • A single test cannot predict both: – underlying airway responsiveness – and

A single test cannot predict both:

underlying airway responsiveness

and therapeutic response

Mariotta et al. Journal of Asthma, 2005;42:487

Mariotta et al. Journal of Asthma, 2005;42:487

Tashkin et al. ERJ 2008;31:742

Tashkin et al. ERJ 2008; 31:742

Tashkin et al. ERJ 2008;31:742

Tashkin et al. ERJ 2008; 31:742

Tashkin et al. ERJ 2008;31:742

Tashkin et al. ERJ 2008; 31:742

Within-individual difference

Within-individual difference Calverley et al. Thorax 2003;58:659

Calverley et al. Thorax 2003;58:659

Positive BD response

Positive BD response
FVC PRE POST
FVC
PRE
POST

FEV1 +4%

+18%

(500ml)

FVC PRE POST FEV1 +4% +18% (500ml)

Negative BD response

Negative BD response •  in lung hyperinflation

in lung hyperinflation

Negative BD response •  in lung hyperinflation

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

Post-salbutamol FEV1 change is influenced by baseline lung function

Post-salbutamol FEV1 change is influenced by baseline lung function Albert et al. Thorax 2012;67:701

Albert et al. Thorax 2012;67:701

Post-salbutamol FEV1 change is influenced by baseline lung

function

FEV1 change is influenced by baseline lung function F= Δ P R R= 8 η l

F= ΔP

R

R= 8ηl πr 4

Calverley et al. Thorax 2003;58:659

Post-salbutamol FEV1 change is influenced by baseline lung

function

FEV1 change is influenced by baseline lung function F= Δ P R R= 8 η l

F= ΔP

R

R= 8ηl πr 4

Calverley et al. Thorax 2003;58:659

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055
Hadcroft et al. Thorax 2001;56:713

Hadcroft et al. Thorax 2001;56:713

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

BD-test

BD therapy should be withheld prior to spirometry:

Short-acting β-agonists

Short-acting anticholinergic

Long-acting β-agonists

Long-acting anticholinergic

Methylxanthines (theophyllines)

Slow release methylxanthines

Cromolyn sodium

Leukotriene modifiers

Inhaled steroids

4 hours

4 hours 12 hours 24 hours 12 hours 24 hours 8-12 hours 24 hours

Maintain dosage

Ruppel 9th edition, pg. 66: Table 2-2

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

Response to a BD

Can be tested either:

Response to a BD Can be tested either: • after a single dose of the BD

after a single dose of the BD or

after a trial conducted over 28 weeks

mL

Variazione dei volumi polmonari dopo 6 settimane di BD

Picco Trough 500 # 400 300 # *** # 200 *** 240 mL * 100
Picco
Trough
500
#
400
300
#
***
#
200
***
240 mL
*
100
0
-100
-200
- 560 mL
-300
***
-400
***
#
-500
-600
#
FEV 1
FVC
RV
FRC
IC

O’Donnell et al., ERJ 2004;23:832

Hanania et al. CHEST 2011; 140:1055

Hanania et al. CHEST 2011; 140:1055

BD-test

BD-test • There is no consensus about the drug, dose or mode of administering a BD

There is no consensus about the

drug, dose or mode of administering

a BD in the laboratory.

4 doses of SABA by MDI

Tests should be repeated after a 15’

BD-test for therapeutic use

BD-test for therapeutic use • Same dose and same route as clinical use • Delay for

Same dose and same route as clinical use

Delay for SPIR = the reported time of

onset for that drug.

Altri fattori?

Lehmann et al. Pulm. Pharm. Ther.2006; 19:272

Lehmann et al. Pulm. Pharm. Ther.2006; 19:272

Deep inhalations tend to reduce airway calibre, especially after a BD

Deep inhalations tend to reduce airway calibre, especially after a BD CHEST 1998; 114:1607

CHEST 1998; 114:1607

E’ prevedibile?

Response to a BC

Response to a BC • The correlation between BC and BD response is imperfect , and

The correlation between BC and BD

response is imperfect, and it is not

possible to infer with certainty the

presence of one from the other.

CLINICAL RELEVANCE BD response

Acute response

Chronic response

NEG response

symptom and patient performance

improvement

Negative BD response

Negative BD response • The lack of a response in lab does not preclude:  a

The lack of a response in lab does not

preclude:

a clinical response (in terms of symptom)

a successive functional response

a clinical-functional response to another

class of drug

Lack of Short-Term Response to One Class of Drug Does Not

Lack of Short-Term Response to One Class of Drug Does Not Imply Nonresponsiveness to Another Class

Imply Nonresponsiveness to Another Class

*Reversibility defined as ≥12% and > 200 mL increase in FEV 1 N = 815

73% of patients show reversibility*

11% (n = 91) 35% (n = 280) 27% (n = 222) 27% (n =
11%
(n = 91)
35%
(n = 280)
27%
(n = 222)
27%
(n = 217)

Albuterol only Ipratropium only

BothNeither

Both

NeitherBoth

Neither

Donohue JF, et al. Chest 2004; 125;125S 137S

Potranno aiutarci?

1. Trend del FEV1.0 basale (perdita in ml/anno)

2. Reversibilità al BD (e trend) in acuto

3. Reversibilità al BD (e trend) in cronico

BPCO

Broncorev ersibilità
Broncorev ersibilità
Grazie dell’attenzione
Grazie
dell’attenzione