Acceptable Maneuvers Research Articles

Characteristics of subjects unable to perform even a single acceptable spirometry maneuver (ATS grade F) identified within a cohort of 10,193 subjects.

Characteristics of subjects unable to perform even a single acceptable spirometry maneuver (ATS grade F) identified within a cohort of 10,193 subjects.

New reference values for maximum respiratory pressures in healthy Brazilian children following guidelines recommendations: A regional study.

To determine reference values for maximum static respiratory pressures in healthy children from a Brazilian region, following recommendations of the European Respiratory Society (ERS) and the Brazilian Society of Pneumology and Tisiology (SBPT). A cross-sectional observational study was conducted with healthy children (6 to 11 years) of both sexes. The maximum inspiratory and expiratory pressures (PImax and PEmax, respectively) were measured using a digital manometer. Each child performed a minimum of three and a maximum of five maneuvers; three acceptable and reproducible maneuvers were considered for analysis. Minimum time for each maneuver was 1.5 seconds, with a one-second plateau, and one minute of rest between them. A stepwise multiple linear regression analysis was conducted for PImax and PEmax, considering correlations between independent variables: age, weight, and sex. We included 121 children (62 girls [51%]). Boys reached higher values for maximum respiratory pressures than girls. Respiratory pressures increased with age showing moderate effect sizes (PImax: f = 0.36; PEmax: f = 0.30) between the stratified age groups (6-7, 8-9, and 10-11 years). Age and sex were included in the PImax equation (PImax = 24.630 + 7.044 x age (years) + 13.161 x sex; R2 = 0.189). PEmax equations were built considering age for girls and weight for boys [PEmax (girls) = 55.623 + 4.698 x age (years) and PEmax (boys) = 82.617 + 0.612 x weight (kg); R2 = 0.068]. This study determined new reference equations for maximal respiratory pressures in healthy Brazilian children, following ERS and SBPT recommendations.

Regional lung function measures determined by electrical impedance tomography during repetitive ventilation manoeuvres in patients with COPD

Objective. Current standards for conducting spirometry examinations recommend that the ventilation manoeuvres needed in pulmonary function testing are carried out repeatedly during sessions. Chest electrical impedance tomography (EIT) can determine the presence of ventilation heterogeneity during such manoeuvres, which increases the information content derived from such examinations. The aim of this study was to characterise regional lung function in patients with chronic obstructive pulmonary disease (COPD) during repetitive forced full ventilation manoeuvres. Regional lung function measures derived from these manoeuvres were compared with quiet tidal breathing. Approach. Sixty hospitalised patients were examined during up to three repeated ventilation manoeuvres. Acceptable spirometry manoeuvres were performed and EIT recordings suitable for analysis obtained in 53 patients (12 women, 41 men; age: 68 ± 12 years (mean ± SD)). Pixel values of tidal volume, forced full inspiratory and expiratory volume in 1 s, and forced inspiratory and expiratory vital capacity were calculated from the EIT data. Spatial ventilation heterogeneity was assessed using the coefficient of variation, global inhomogeneity index, and centres and regional fractions of ventilation. Temporal inhomogeneity was determined by examining the pixel expiration times needed to exhale 50% and 75% of regional forced vital capacity. Main results. All EIT-derived measures of regional lung function showed reproducible results during repetitive examinations. Parameters of spatial heterogeneity obtained from quiet tidal breathing were comparable with the measures derived from the forced manoeuvres. Significance. Measures of spatial and temporal ventilation heterogeneity obtained in COPD patients by EIT provide comparable findings during repeated examinations within one testing session. Quiet tidal breathing generates similar information on ventilation heterogeneity as forced manoeuvres that demand a high amount of patient effort.

Methacholine Challenge Testing: Comparison of FEV1 and Airway Resistance Parameters.

A 20% reduction in the FEV1 is routinely used as an end point for methacholine challenge testing (MCT). Measurement of FEV1 is effort dependent, and some patients are not able to perform acceptable and repeatable forced expiration maneuvers. The goal of the present study was to investigate the diagnostic value of airway resistance measurement by forced oscillation technique (FOT), body plethysmography, and interrupter technique compared with the traditionally accepted standard FEV1 measurement in evaluating the responsiveness to methacholine during MCT. We included in the study adult subjects referred for MCT because of asthma-like symptoms and with normal baseline spirometry. We modified routine MCT protocol by adding the assessment of airway resistance to the measurement of FEV1 at each step of MCT. We observed, in the subjects with airway hyper-responsiveness versus those with normal airway responsiveness, a significantly greater percentage change in median (interquartile range) FOT resistance at 10 Hz (25.9% [13.7%-35.4%] vs 16% [15.7%-27.2%]), plethysmographic resistance (70.2% [39.5%-116.3%] vs 37.1% [23.9%-81.9%]), and mean ± SD conductance (-41.3 ± 15.4% vs -29.6 ± 15.9%); and a significantly greater change in mean ± SD FOT reactance at 10 Hz (-0.41 ± 0.48 cm H2O/L/s vs -0.09 ± 0.32 cm H2O/L/s) and at 15 Hz (-0.29 ± 0.2 cm H2O/L/s vs -0.1 ± 0.19 cm H2O/L/s). We also recorded significant differences in airway resistance parameters (FOT resistance at 10 Hz, FOT reactance at 15 Hz, plethysmographic airway resistance, and conductance indices as well as interrupter resistance) in FEV1 non-responders at the onset of respiratory symptoms during MCT compared with baseline. Measurements of airway resistance could possibly be used as an alternative method to spirometry in airway challenge. Significant changes in airway mechanics during MCT are detectable by airway resistance measurement in FEV1 non-responders with methacholine-induced asthma-like symptoms. (ClinicalTrials.gov registration NCT02343419.).

A CROSS-SECTIONAL COMPARISON BETWEEN TWO TYPES OF FORCED EXPIRATORY MANEUVERS DURING PULMONARY FUNCTION SURVEILLANCE OF US COAL WORKERS, 2016-2019

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Recent spirometry standardization guidelines focus on the flow-volume loop maneuver [FVL] to measure both inspiratory and expiratory airflow during spirometry testing. However, many occupational health surveillance programs routinely perform ‘exhalation only’ maneuvers [EO]. Our aim was to determine spirometry quality differences based on the type of forced vital capacity (FVC) maneuver performed. METHODS: Between 2016–2019, the National Institute for Occupational Safety and Health (NIOSH) conducted health surveillance inclusive of spirometry testing for U.S. coal miners. Tests were conducted in a NIOSH mobile examination unit, by the same technicians using the same flow-type spirometer model. From 2016 to 2018, the EO-FVC maneuver was performed by miners. In 2018, NIOSH spirometry protocols were updated, and subsequent miners were tested using the FVL-FVC maneuver. We compared spirometry test quality differences between EO-FVC and FVL-FVC testing techniques. Quality metric variables of interest were number of acceptable maneuvers, repeatability of maneuvers, maximal expiration to zero flow, excessive hesitation, and overall test quality. Fisher’s exact tests identified univariate quality variable differences. Poisson regression models using SAS Proc GENMOD determined associations between the type of FVC maneuver and test-quality metrics with adjustment for sex, race, BMI, age, and test technician. RESULTS: We compared 2,010 EO-FVC and 3,340 FVL-FVC spirometry tests. Univariate analyses revealed that tests from FVL-FVC maneuvers were more likely to contain three acceptable maneuvers, be repeatable, and have quality grades ‘C ‘or better (p<0.0001, p=0.035, and p<0.0001, respectively). Exhalation to zero flow was more often achieved in EO-FVC maneuvers (p<0.0001). Poisson models indicated that FVL-FVC maneuvers produced significantly more tests with three acceptable maneuvers (PRR=1.07, 95% CI: 1.01, 1.15), and repeatable maneuvers (PRR=1.06, 95% CI: 1.01, 1.13). No significant associations were seen for excessive hesitation and maximal expiration to zero flow parameters. CONCLUSIONS: The type of FVC maneuver performed can influence spirometry test quality. FVL-FVC maneuvers were more likely to produce spirometry tests meeting criteria for acceptability and repeatability when compared to EO-FVC type maneuvers. CLINICAL IMPLICATIONS: Our findings will help inform occupational health surveillance programs as to which type of FVC maneuver they may choose to implement during worker spirometry testing. A change from the EO-FVC to FVL-FVC maneuver would also make occupational health surveillance spirometry records more comparable to spirometry testing being performed in acute care pulmonary function laboratories. DISCLOSURES: No relevant relationships by Kathleen Clark, source=Web Response No relevant relationships by scott hendricks, source=Web Response

Spirometry in clinical practice

Spirometry is one of the world most common methods of functional diagnostics of the respiratory system. Obtained by this method data play an important role in determining the type of ventilation disorders, clinical diagnosis, evaluating the effectiveness of treatment and prognosis. Therefore, special attention is paid to the technical standards of the study, which is well standardized. Spirometry guidelines are reviewed periodically. In 2019, spirometry quality standards developed by the American Thoracic Society and the European Respiratory Society were published, which updated the indications and contraindications for spirometry, criteria for the quality and reproducibility of technically acceptable maneuvers. The article presents the main parameters and the algorithm for interpreting spirometry results. An important role is played by the selection of a set of predicted values, which define the range of normal values for the population. In 2012, new universal equations were developed − Global Lung Function Initiative 2012, which allow calculating the reference value of spirometry in a wide age range (from 3 to 95 years). A modern approach to determining the degree of deviations from normal values is described, which must be determined using the lower limit of the norm and the z-score. The role of spirometry in obstructive ventilation disorders is emphasized.

FEV1/FEV6 is effective as a surrogate for FEV1/FVC in the diagnosis of chronic obstructive pulmonary disease

Background and objectiveChronic Obstructive Pulmonary Disease (COPD) causes substantial morbidity and mortality across the globe. Diagnosis of COPD requires post-bronchodilator FEV1/FVC <0.70 as per GOLD Guidelines. FVC maneuver requires a minimum of 6 seconds of forceful expiration with no flow for 1 second for an accepted effort, which lacks any fixed cut-off point. This leads to discomfort, especially in advanced COPD and old aged population. We conducted this study to find the utility of FEV1/FEV6 as a surrogate for FEV1/FVC, the correlation between the two ratios, and the fixed cut-off value of FEV1/FEV6 for COPD diagnosis. MethodsThis was a prospective, cross-sectional study approved by the institutional ethics committee conducted from January 2017 to November 2018. Consented patients above 18 years suspected of COPD underwent Spirometry as per ATS guidelines. FEV1, FEV6, FEV1/FEV6 and FEV1/FVC ratios were recorded from the best acceptable maneuver. ResultsOut of 560 screened patients, 122 diagnosed as COPD. The correlation coefficient between the post-bronchodilator FEV1/FVC ratio and FEV1/FEV6 ratio was 0.972 (p < 0.01). The relationship between the post-bronchodilator FEV1/FVC ratio and FEV1/FEV6 ratio (linear regression analysis) was found out as: FEV1/FVC = −1.845 + 1.009(FEV1/FEV6). Using this formula, the post-bronchodilator FEV1/FEV6 value of 71.845 was obtained corresponding to the post-bronchodilator FEV1/FVC value of 70.00. ConclusionWe found a positive correlation coefficient (r = 0.972, p < 0.001) between the FEV1/FEV6 and FEV1/FVC ratios and the cut off value of 71.845 (p < 0.01) for the post-bronchodilator FEV1/FEV6 ratio for the diagnosis of COPD. Thus FEV1/FEV6 should be used as a surrogate for FEV1/FVC for the diagnosis of COPD.

Improvement of the anti­collision method "Velocity Obstacle" by taking into consideration the dynamics of an operating vessel

This paper has proposed an algorithm that accounts for the dynamics of an operating vessel within the Velocity Obstacle collision prevention method. This algorithm provides the basis for selecting joint maneuvers by course and speed with the assigned start for divergence with multiple targets by determining, applying a sorting method, a representative set of acceptable maneuver options. In order to employ the method of sorting, we have selected the ranges of change in the maneuver parameters (course and speed) and performed their sampling at a small enough step. One finds, for all pairs of discrete values of change in the course and speed, taking into consideration the dynamics of an operating vessel, a trajectory and duration of a maneuver, with determining, at the time it ends, the location of an operating vessel and targets, as well as it is to be established if it is accompanied by the intersection of target danger domains. If none of these domains is crossed, the maneuver option is considered acceptable. The totality of such joint changes in course and speed, derived from sorting, creates a set of permissible maneuver options. When finding this set, the dynamics of an operating vessel is taken into consideration simplistically. It is believed that the turns are performed at a constant angular speed, a change in the linear speed at braking can be represented by a power polynomial of second order, and changes in course and speed in the joint maneuver are independent. The targets involve circular danger domains whose center is shifted, from a target's center of mass to the stern, by 1/3 of the domain's radius. This radius has been amended to include the size of a target and an operating vessel.To test the resulting algorithm, the software has been developed in the Borland Delphi programming language. Employing it for calculations has confirmed the operability of the algorithm. That enables the derivation, in real time, of a set of velocity vectors for divergence taking into consideration the dynamics of own vessel, which makes it possible to improve the accuracy of forecasting and the safety of calculated maneuvers. The use of displaced circular danger domains for targets makes it possible to take into account the unequal degree of risk when crossing their course along the bow and stern

Spirometry and Impulse Oscillometry in Preschool Children: Acceptability and Relationship to Maternal Smoking in Pregnancy

Comparisons of the technical acceptability of spirometry and impulse oscillometry (IOS) and clinical correlations of the measurements have not been well studied in young children. There are no large studies focused on African American and Hispanic children. We sought to (1) compare the acceptability of spirometry and IOS in 3- to 5-year-old children and (2) examine the relationship of maternal smoking during pregnancy to later lung function. Spirometry and IOS were attempted at 4 sites from the Urban Environmental and Childhood Asthma Study birth cohort at ages 3, 4, and 5 years (472, 471, and 479 children, respectively). We measured forced expiratory flow in 0.5 s (forced expiratory volume in 0.5 seconds [FEV0.5]) with spirometry and area of reactance (AX), resistance and reactance at 5 Hz (R5 and X5, respectively) using IOS. Children were more likely to achieve acceptable maneuvers with spirometry than with IOS at age 3 (60% vs 46%, P < .001) and 5 years (89% vs 84%, P= .02). Performance was consistent among the 4 study sites. In children without recurrent wheeze, there were strong trends for higher FEV0.5 and lower R5 and AX over time. Maternal smoking during pregnancy was associated with higher AX at ages 4 and 5years (P < .01 for both years). There was no significant difference in FEV0.5 between children with and without in utero exposure to smoking. There is a higher rate of acceptable maneuvers with spirometry compared with IOS, but IOS may be a better indicator of peripheral airway function in preschool children.

Validation of Global Lung Function Initiative and All Ages Reference Equations for Forced Spirometry in Healthy Spanish Preschoolers

IntroductionRecent publication of multi-ethnic spirometry reference equations for subjects aged from 3 to 95 years aim to avoid age-related discontinuities and provide a worldwide standard for interpreting spirometric test results. ObjectivesTo assess the agreement of the Global Lung Function Initiative (GLI-2012) and All ages (FEV0.5) reference equations with the Spanish preschool lung function data. To verify the appropriateness of these reference values for clinical use in Spanish preschool children. MethodsSpirometric measurements were obtained from children aged 3–6 years attending 10 randomly selected schools in Barcelona (Spain). Stanojevic's quality control criteria were applied. z-Scores were calculated for the spirometry outcomes based on the GLI equations. If the z-score (mean) of each parameter was close to 0, with a maximum difference of ±0.5 from the mean and a standard deviation of 1, the GLI-2012 equations would be applicable in our population. ResultsOf 543 children recruited, 405 (74.6%) were ‘healthy’, and of these, 380 were Caucasians. Of these 380, 81.6% (169 females, 141 males) performed technically acceptable and reproducible maneuvers to assess FEVt, and 69.5% achieved a clear end-expiratory plateau. z-Scores for FVC, FEV1, FEV1/FVC, FEV0.75, FEV0.75/FVC, FEV0.5, FEF75 and FEF25–75 all fell within ±0.5, except for FEV1/FVC (0.53 z-scores). ConclusionsGLI equations are appropriate for Spanish preschool children. These data provide further evidence to support widespread application of the GLI reference equations.

Validación de las ecuaciones propuestas por la Iniciativa Global de Función Pulmonar (GLI) y las de Todas las Edades para espirometría forzada en preescolares sanos españoles

IntroductionRecent publication of multi-ethnic spirometry reference equations for subjects aged from 3-95 years aim to avoid age-related discontinuities and provide a worldwide standard for interpreting spirometric test results. ObjectivesTo assess the agreement of the Global Lung Function Initiative (GLI-2012) and All ages (FEV0.5) reference equations with the Spanish preschool lung function data. To verify the appropriateness of these reference values for clinical use in Spanish preschool children. MethodsSpirometric measurements were obtained from children aged 3 to 6 years attending 10 randomly selected schools in Barcelona (Spain). Stanojevic's quality control criteria were applied. Z-scores were calculated for the spirometry outcomes based on the GLI equations. If the z-score (mean) of each parameter was close to 0, with a maximum variance of ± 0.5 from the mean and a standard deviation of 1, the GLI-2012 equations would be applicable in our population. ResultsOf 543 children recruited, 405 (74.6%) were ‘healthy’, and of these, 380 were Caucasians. Of these 380, 81.6% (169 females, 141 males) performed technically acceptable and reproducible maneuvers to assess FEVt, and 69.5% achieved a clear end-expiratory plateau. Z-scores for FVC, FEV1, FEV1/FVC, FEV0.75, FEV0.75/FVC, FEV0.5, FEF75 and FEF25-75 all fell within ± 0.5, except for FEV1/FVC (0.53 z-scores). ConclusionsGLI equations are appropriate for Spanish preschool children. These data provide further evidence to support widespread application of the GLI reference equations.

Baroreceptor reflex during forced expiratory maneuvers in individuals with chronic spinal cord injury

Pulmonary and cardiovascular dysfunctions are leading causes of morbidity and mortality in patients with chronic Spinal Cord Injury (SCI). Impaired respiratory motor function and decreased Baroreflex Sensitivity (BS) are predictors for the development of cardiopulmonary disease. This observational case-controlled clinical study was undertaken to investigate if respiratory motor control deficits in individuals with SCI affect their ability to perform the Valsalva maneuver, and to determine if a sustained Maximum Expiratory Pressure (MEP) effort can serve as an acceptable maneuver for determination of the BS in the event that the Valsalva maneuver cannot be performed. The BS outcomes (ms/mmHg) were obtained using continuous beat-to-beat arterial blood pressure (BP) and heart rate (HR) recordings during Valsalva or MEP maneuvers in thirty nine individuals with chronic C3–T12 SCI. Twenty one participants (54%) reported signs of intolerance during the Valsalva maneuver and only 15 individuals (39%) were able to complete this task. Cervical level of injury was a significant risk factor (p=0.001) for failing to complete the Valsalva maneuver, and motor-complete injury was a significant risk factor for symptoms of intolerance (p=0.04). Twenty eight participants (72%) were able to perform the MEP maneuver; the other 11 participants failed to exceed the standard airway pressure threshold of 27cm H2O. Neither level nor completeness of injury were significant risk factors for failure of MEP maneuver. When the required airway pressure was sustained, there were no significant differences between BS outcomes obtained during Valsalva and MEP maneuvers. The results of this study indicate that individuals with high-level and motor-complete SCI are at increased risk of not completing the Valsalva maneuver and that baroreflex-mediated responses can be evaluated by using sustained MEP maneuver when the Valsalva maneuver cannot be performed.

Functional Respiratory Study in Preschool Children: A Review

Introduction: Children of preschool age have high chronic respiratory morbidity and a tendency to progressive increase. The pulmonary function tests (PFT) quantify objectively the lung commitment and are proving very useful in the diagnosis, therapeutic monitoring and prognostic evaluation of several pathologies. Purpose: The purpose of this literature review is to understand the relevance and value of PFT to this age group, taking into account the new criteria of the American Thoracic Society/European Respiratory Society (ATS / ERS) (2007). Methods: We conducted a literature review, based on the keywords: respiratory function test, pre-school, spirometry and asthma. We consulted the databases PubMed and B-on, from which 38 articles were selected. 18 of them were analyzed with respect to the keywords above. Results/Discussion: PFT are valuable for the diagnostic evaluation of preschoolers, with high technically acceptable success rates and reproducible maneuvers. Conclusion: The evaluation of lung function is very important in the study of the genetic and environmental determinants of lung disease, as well as being a strong predictor of long-term illness.

Spirometry quality in preschool children

Carrying out quality spirometric maneuvers in preschool children in both the diagnosis and follow-up of respiratory diseases continues to be very scarce. This is due to several reasons, including a lack of consensus on quality criteria and the acceptability of the test. The purpose of this study is therefore to obtain reference norms from a population of healthy preschool children from the Autonomous Community of Navarre (Spain). A total of 114 healthy preschool children aged between 3 and 7 years of age, without prior experience in carrying out lung function tests, were included. A total of 76 were able to realize at least two acceptable spirometric maneuvers, and 60 of them maneuvers that were acceptable and reproducible, according to ATS/ERS criteria. This represents a global success percentage of 59%. The most common failing was premature and brusque termination of the spirometric maneuver, followed by an inadequate peak in breathing. Over half of the preschool children were able to realize quality spirometric maneuvers. Our data make it possible to recommend the proposed quality criteria as being suitable for routine use, and to encourage the use of spirometry in regular clinical practice within the setting of specialized care.

LUNOKID: can numerical American Thoracic Society/European Respiratory Society quality criteria replace visual inspection of spirometry?

The gold standard for assessing quality of forced expiratory manoeuvres is visual inspection by an expert. American Thoracic Society/European Respiratory Society numerical quality criteria (NQC) include back-extrapolated volume (BEV), repeatability and forced expiratory time (FET). Equipment currently available provides feedback tempting the investigator to use NQC as pass-fail criterion. To investigate whether using NQC instead of visual acceptability is a valid option, we analysed data from a multicentre national reference study in Germany of children aged 4-18 years. Spirometry was performed under field conditions. Receiver operating characteristic analysis was used to assess performance of BEV, repeatability, FET and a combination thereof in relation to visual acceptability. We included data from 3133 healthy Caucasians in the analyses; 72% delivered at least two visually acceptable manoeuvres. Of these, 59% would have been rejected based on combined NQC, mainly because the FET criterion was not feasible. Specificity of the NQC was generally low (BEV 10%, repeatability 30% and FET 50%). Receiver operating characteristic analysis showed that a combination of the three measures could reach at best a sensitivity of 90% and specificity of 56%. We conclude that visual control is mandatory and NQC may help obtain the best possible results, but a fixed cut-off for FET should be abandoned.

Quality and reproducibility of spirometry in COPD patients in a randomized trial (UPLIFT®)

This study explores spirometry quality and reproducibility in the Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT(®)) trial. Four-year, randomized, double-blind, placebo-controlled, multicenter trial in 5993 patients with chronic obstructive pulmonary disease. Within-test variability of pre- and post-bronchodilator forced expiratory volume in 1 s (FEV(1)) was compared across study visits. Between-test variability of best pre- or post-FEV(1) values between two visits 6 months apart was compared at the start, middle and end of the trial. Three or more acceptable maneuvers were obtained in 93% of visits. Within-test variability of pre- and post-FEV(1) (mean standard deviation: 0.092 and 0.098 L) decreased during the trial. Between-test variability also decreased: pre-FEV(1) (visit 3-5 = 0.141 ± 0.138 L; visit 9-11 = 0.129 ± 0.121 L; visit 17-19 = 0.121 ± 0.122 L); post-FEV(1) (0.139 ± 0.140, 0.126 ± 0.123, 0.121 ± 0.122 L, respectively), and was dependent on age, sex, smoking status and disease stage, but not on bronchodilator response or study treatment. Spirometry quality in UPLIFT(®) was good and improved during the trial. Between-test variability across patient subgroups suggests that relevant cut-offs for individual disease monitoring are difficult to establish. NCT00144339.

Quality of spirometry in 5-to-8-year-old children

Although spirometry quality standards for children were proposed by American Thoracic Society/European Respiratory Society (ATS/ERS) in 2007, there is limited information on the percentage of children that fulfill these criteria during routine clinical testing, especially among 5-to-8-year-olds. to report the percentage of children that met the current 2007 ATS/ERS quality criteria; explore factors potentially associated with poor quality spirometry; and ascertain the repeatability of forced expiratory volume at 0.5 sec (FEV0.5 ), and at 1 sec (FEV1 ), as well as forced vital capacity (FVC). We evaluated the quality of spirometries without bronchodilator use performed at our laboratory in 2008 by 5-to-8-year-old children. FEV1 , FEV0.5 , FVC, back-extrapolated volume (BEV), forced expiratory time (FET), number of acceptable maneuvers, and repeatability, were computed and the percentage of tests that met the quality criteria standards was calculated. Based on our results, we propose a quality scoring system for spirometry for children that grades on a scale from A-to-F. Three hundred seventy-six spirometries were reviewed. Mean age was 6.7 years; (53% males); 68% fulfilled the 2005 and 2007 ATS/ERS quality standards; >90% reached a repeatability ≤150 and ≤100 ml, or 10%, in FVC or FEV1 ; 87.2% reached FET ≥3 sec; 88% had a BEV ≤80 ml. The 90 percentile repeatability was 120 ml for FVC and FEV1 . Quality improved with age. Our results support the proposal that a FET ≥3 sec, a BEV ≤80 ml, and repeatability in FEV1 and FVC ≤100 ml, or 10%, be taken into account as elements in quality control for spirometry in children.

Clinically Useful Spirometry in Preschool-Aged Children: Evaluation of the 2007 American Thoracic Society Guidelines

Rationale. In 2007 the American Thoracic Society (ATS) recommended guidelines for acceptability and repeatability for assessing spirometry in preschool children. The authors aim to determine the feasibility of spirometry among children in this age group performing spirometry for the first time in a busy clinical practice. Methods. First-time spirometry for children age 4 to 5 years old was selected from the Children's Hospital Boston Pulmonary Function Test (PFT) database. Maneuvers were deemed acceptable if () the flow-volume loop showed rapid rise and smooth descent; () the back extrapolated volume (Vbe), the volume leaked by a subject prior to the forced maneuver, was ≤80 ml and 12.5% of forced vital capacity (FVC); and () cessation of expiratory flow was at a point ≤10% of peak expiratory flow rate (PEFR). Repeatability was determined by another acceptable maneuver with forced expiratory volume in t seconds (FEVt) and FVC within 10% or 0.1 L of the best acceptable maneuver. Post hoc analysis compared spirometry values for those with asthma and cystic fibrosis to normative values. Results. Two hundred and forty-eight preschool children performed spirometry for the first time between August 26, 2006, and August 25, 2008. At least one technically acceptable maneuver was found in 82.3% (n = 204) of the tests performed. Overall, 54% of children were able to perform acceptable and repeatable spirometry based on the ATS criteria. Children with asthma or cystic fibrosis did not have spirometry values that differed significantly from healthy controls. However, up to 29% of the overall cohort displayed at least one abnormal spirometry value. Conclusions. Many preschool-aged children are able to perform technically acceptable and repeatable spirometry under normal conditions in a busy clinical setting. Spirometry may be a useful screen for abnormal lung function in this age group.

Sustained 24-h efficacy of NVA237, a once-daily long-acting muscarinic antagonist, in COPD patients

NVA237 is a once-daily inhaled long-acting muscarinic antagonist in development for the treatment of COPD. This randomized, double-blind, placebo-controlled, four-period, incomplete block crossover study, with open-label active comparator (tiotropium), assessed the efficacy and safety of NVA237. Patients (>or=40 years; smoking history >or=10 pack-years) with stable moderate-to-severe COPD (post-bronchodilator FEV(1) >or= 30% and <80% predicted, FEV(1)/FVC < 0.7) received NVA237 12.5, 25, 50 or 100 microg, placebo, or tiotropium 18 microg once-daily for 7 days. The primary endpoint was mean trough (23-24 h post-dose) FEV(1) on Day 7. Secondary endpoints included mean trough FEV(1) on Day 1, and FEV(1) and FVC at individual time points post-dose on Days 1 and 7. 83 patients (mean age 64.4 years; male 83.1%; mean COPD duration 6.7 years; mean post-bronchodilator FEV(1) 1.5 L/52.7% predicted) were randomized; 78 completed. Mean trough FEV(1) on Day 7 and Day 1 was significantly higher with all active treatments versus placebo (p < 0.05). NVA237 50 microg, 100 microg and tiotropium showed clinically relevant improvements versus placebo on Day 7 (differences of 131, 142 and 127 mL, respectively; p < 0.0001) and 1 (differences of 121, 135 and 112 mL, respectively; p < 0.0001). On Day 1, but not Day 7, FEV(1) was significantly higher (p < 0.05) with NVA237 50 and 100 microg versus tiotropium from 5 min up to 2 and 4 h post-dose, respectively. All doses of NVA237 and tiotropium were well tolerated. NVA237 once-daily was effective and well tolerated versus placebo, and demonstrated rapid and sustained 24-h bronchodilation. (ClinicalTrials.gov Identifier: NCT00501852).

Longitudinal analysis of a four-year follow up of pulmonary function development in children with a past history of asthma

In order to longitudinally study the pulmonary function development of children with a history of asthma, we measured the flow-volume curves of 441 fourth-grade children in seven primary schools randomly selected from the Kashima district in Ibaraki prefecture in 1980, and again in 1982 and 1984. Levels and slopes of pulmonary function indices for individual children were calculated in 325 children who performed acceptable forced expiratory maneuvers at all of the three surveys. In FVC and FEV1, no significant difference of levels and slopes was observed between children with asthmatic history and control children. However, the level and slope of V25 of children with asthmatic history were significantly lower than those of control children (0.5 l/sec for the level, 0.08 l/sec for the slope) even when only those who did not suffer from wheezing attack during the follow-up period were concerned. These results suggested that the functional change of peripheral airways in children with asthmatic history did not recover within a couple of years even when they were in remission. Moreover, the functional differences between those two groups of children might become larger in early adolescence.