Pulmonary Function Testing 10:00 AM – 11:20 AM

Tuesday, November 1, 1994 Title: Author(s):

(DVT) AND DEEP VENOUS THROMBOSIS PULMONARY EMBOLISM (PE) IN HIP SURGERY: EARLY AND LATE INCIDENCE.

A. Palla*, M. Pazzagli, D. Manganelli, R. Troiani, M. Ciampitti, M. Manca, G. Punzi, C. Vignali, C. Giuntini. CNR Institute of Clinical Physiology, Respiratory Pathophysiology, 3rd Department of Anesthesiology, 1st and 2nd Orthopedic Clinics, Department of Radiology, University of Pisa, Italy. 52 patients (17 males, mean age 66.2+10.0 years) scheduled for elective hip surgery, were followed by serial CIP until discharge. When CIP became positive, venography was performed and when clinical suspicion of PE was raised lung perfusion scan and/or pulmonary angiography were performed. After 7 weeks from surgery, patients performed CIP and venography. 28 patients received subcutaneous heparin (5000 U. x 3 daily) from the day before arthroplasty to discharge; the remainder 24 had heparin for 10 further days. The overall incidence of DVT and PE were 15.4% (8/52) and 3.8% (2/52) respectively. Isolated proximal and calf DVT occurred in 2 (3.8%) and 3 (5.8%) patients respectively; proximal plus calf DVT occurred in 3 (5.8%) patients. During hospitalization, a proximal DVT occurred only in one patient (1.9%) and there were no cases of PE. At follow-up, venography detected DVT in 5 patients (18%) who interrupted heparin prophylaxis after discharge and in 2 patients (8.3%) who received long term prophilaxis. Two cases of P'E occurred in the former group (7%)and no one in the latter. In hip surgery the risk for £V/Tand/or PE after discharge is still high when heparin Proph0lalis is discoritinued.

TITLE:

ANT EVALUATION'I OF RISK FACTORS FOR PULMONARY THROMBOEMBOLISM FCCP.

AUTHOR(S): D. Hill, MD, B. Lahiri, M1D, The University of Connecticut School of Medicine, Farmington, CT., and St. Francis lIospital & Med. Center, Ilartford, CT. Pulmonary thrromboembolism (PTE) remains a significant cause of morbidity and mortality in hospitalized patients. To evaluate risk factors for PTE, we reviewed the medical records of all patients at our institution with documented PIE between 1989 and 1992. A total of 110 patients met our diagnostic criteria for PUE. Sixty-five percent were diagnosed using lung scans, 13% by pulmonary angiogram, 19% using venous studies, and 90 at autopsy. All patients diagnosed pre-mortem hLad a compatible cliinical presentation. cixty-eight percent of PTE patients had what we consider one or more predisposing factors. These included: cancer (16%), post-op state (18%), trauma (7%), hypercoagulable state (2%), history of deep venous thrcmbosis or PTE (19%), congestive heart failure (5%), estrogen use (4%), and prolonged immobility (4%). Interestingly, corticosteroid use was present in 19% of patients presenting with PTE. Although predisposing conditions are often found at the time of PTE diagnosis, a significant number of patients present without an identifiable risk factor.

Pulmonary Function Testing 10:00AM 11:20 AM -

HIGH RISK FAC'TORS FOR BLEEDING COMPLICATIONS IN PATIENTS (P) WITH THROMBOLYTIC THERAPY (TT) AND MASSIVE PULMONARY LMfULISM (PC). ELIZALDE J. FCCP*, JERJES-SANCHEZ C. FCCP, RAMIREZ-RIVE RA A. FCCP, FRANCO J., MARTINEZ-SANCHEZ J. ABC HOSPITAL AND HOSPITAL DE CARDIOLOGIA CMN. MEXICO CITY. One of the absolute contraindications for TT irn PE P are recent major surgery and puerperium, being unfortunately the frecuency of these conditions high although poorly studied and rarely reported. We report a series of 4 feinale G-0 P, with X age: 40.5+/- 5 ys. (34-60) that developed massive PE in their first postpartum,

Ilth postcaesarean section, 2nd and 6th posthisterectomy days respectively. All of them with a high probability V/Q scan, echo sugesting RV dysfunction, cardiogenic shock and in one TI was instituteJ during cardlac arrest unresponsive to CPR (electromechanical dissociation).

In two cases the TT used consisted of STK 1'500,000 IU in one hour and in the others rTPA was selected, one with a 0.7 mg /Kg BW bolus that was repeated 4 Hs later during a reembolism, and other with a 100 mg over 1 Hr infusion dose. TT was succesfull in the cardiopulmonaryterms, and bleeding presented only in one case (mild UGIT and surgical bleeding that decreased the Hb level 3 gm after a hugh positive fluid balance). Mortality presented only in this patient, being the causes a combination of unresponsive cardiogenic shock, bleeding. severe metabolic acidosis and multiple organ failure. Two Greenfield filters were inserted after the TT without complications. Control echo's and V/Q lung scans were PAP, improved In all P, except one which remain with high but survived. Follow-up in two P at 12 and 2 months showed NYHA class I, without high PAP or recurrences. TT for massive PE in the postop period is feasible in selected P, were benefits can overcome potential bleeding risks.

Title: PORTABLE SPIROMETRY ACCURACY DEPENDS ON OPERATOR EXPERIENCE Author(s): Joel N. Kline* MD, Mary D. Nettleman MD, Twila J. Whipple RRT,

Iowa City, John F. Fieselmann MD FCCP. University of Iowa College of Medicine, IA. the majority Cost and convenience have conspired over the past decade to shift of spirometry examinations from the dedicated pulmonary function testing (PFT) laboratory to the physician's office or clinic using compact, portable spirometers. little experience or training These spirometers may be used easily by operators with these units, it calibrated, may be very in pulmonary function testing. precise, their accuracy is diminished if the tests are performed improperly. (using a portable Because of the perception that spirometry performed in the clinic we hypothesized spirometer) underestimated true measures of pulmonary function, for the that operator experience, and not equipment specifications, is responsible and the lab. difference in spirometry values between studies performed in the clinic on 52 In order to test this hypothesis, spirometry was performed sequentially the aduit patients using both a portable spirometer (Spiromatic FlowmateTM) and Iowa of pulmonary function laboratory (Med GraphicsTM 1070) at the University a single registered technician; were by studies performed PFT lab The Hospital. a the portable spirometer was used in separate studies by the PFT technician, techrespiratory therapist, a nurse, and Internal Medicine residents. Standard of the patients niques were used for all studies; their order was varied so that half We were tested first on the Flowmate and half on the Med Graphics spirometer. found that the values for forced vital capacity (FVC) obtained using the portable when the spirometer were significantly lower than those obtained at the PFT lab or therapy nurse respiratory the residents, was operated by portable spirometer (each p<0.05) but not when it was operated by the PFT technician. Significant the one-second differences between the portable and PFT lab exams were found in the forced expiratory volume (FEV1) in studies performed by all operators except residents. Based on this study, we concluded that, even though spirometry may be reproducible and accurate, operator differequipment in a clinic to significantly underestimating patients' pulmonary function. ences can lead

Aithough

selting

CHEST /106 / 2 / AUGUST, 1994 / Supplement

123S

Tuesday, November 1, 1994 Pulmonary Function Testing, continued Title: CLINICAL SIGNIFICANCE OF BRONCHODILATOR (8D) RESPONSE PATTERNS IN AIRWAYS OBSTRUCTION

Author(s): *Zaidi, Syed A.J., MD; Kreimid, M., MD; Shah, R.M. MD FCCP - VAMC WiLkes-Barre, PA Patterns of BD response were determined in 56 consecutive patients with airways obstruction who had a significant 8D response and correlated with clinical dx, preBD PFT. The stability of response pattern was assessed in subgroup of 22 patients who had multiple BD studies. The B8 response pattern was classified as a flow response (FR) in 14 patients (25%) with aAFEV1(ml)/AzFVC(ml) >1 and as a votlume response (VR) in 42 patients (75%) with aAFEV1ImI)/AFVC(ml) s1 (Ref.1). The clinicat dx, given by referring pulmonologist and verified by chart review, was Asthma in 25 and COPD in 31 patients. 17/42 patients (40%) in the VR group were Asthmatics; 8/14 patients (57%) in the FR group were Asthmatics (P=NS). The degree of airways obstruction preBD, assessed by FEV1% pred.,FEF25-75% pred.,FVC% pred., and degree of hyperinflation/air-trapping preBD, assessed by RV% pred. and RV/TLC ratio, were both greater in the VR group (Table I). Table I Pre-Bronchodilator PFT Mean (SD) RV/. Pred. RV/TLC% FEV1% Pred. FEF25-75% Pred. FVC% Pred. 67 (15) 147 (35) 53 (9) 50 (18) 26 (15) VR n=42 41 (14) 64 (14) 81 (19) 114 (32) 36 (14) FR n=14 0.002 0.006 0.009 0.015 0.042 P The forced expiratory time (FET) pre/post BD was similar in both groups but the change in FET following BD was greater in the VR group (Table II). Table II: PreBD FET(sec) Mean (SD) 7.7 (2) VR 7.9 (1.9) FR

Post BD FET(sec) Mean (SD)

8.4 (2) 7.7 (1.8)

Delta Post-PreBD FET(sec) Mean (SD) + 0.71 (1.3) - 0.27 (0.9)

NS 0.015 NS P Of 22 patients with multiple BD studies, 6 had no response to BD, while response patterns changed in 5/16 patients (31%); a higher RV% pred. seen at time of VR (126% pred. VR vs. 88% pred. FR, P=0.03) was the only significantly different index of pulmonary function. We conclude that a volume response to BD, as defined here, is common in our patients with airways obstruction; is associated with more severe airway obstruction and hyperinflation and is seen equally as often in Asthma and COPD. Patient's 8D response pattern changes often (31% of the patients) and may be determined by the degree of hyperinflation. Ref.1 PD Pare. LH Lawson and LA Brooks. Patterns of response to inhaled bronchodilators in asthmatics. Am Rev Respir Dis 1983; 127:680-685.

Title: FEVl FLUCTUATION LEVELS RELATED WITH AIRWAY REVE1&IBILITY Author(s): Gu yli GC.

EgeUniversity,Faculty of NlIeoicine,Dept Chest Diseases,Izmir,TURKEY

of

We evaluated the effects of spontaneous FEVI fluctuation on the existence and the degree of airway reversibility on the same day.For this purpose in 50 patients with airway obs truction we measured FEVl for two times lea ving a 20 minute-interval between the two tests.Later we assessed reversibility of air way obstruction using 4 puffs of salbutamol. We compared first and second measurements before beta agonist to determine the fluctu ation level and we also investigated the rel ation between the FEVI fluctuation level and reversibility with salbutamol.Mean FEVI was 1.517:O.60 liter on the first measurement and 1.529±0.63 liter on the second measurem ent.39 patient (78%) showed FEVI fluctuation equal to or less than lOOml and it was less than 200 ml in 48 patients(96%).Less than 250 ml dof airway reversibility was associa ted less than 100 ml of FEVI fluctuation(95% confidence limit).More than 100 ml FEVI fluc tuation was found to be associated with more than 250ml of airway reversibilty (10/11 pa tients,91%).FEVl fluctuation has found to be linearly related to the amount of airway re versibility and usually minimal.

124S

COMPARISON OF RESPIRATORY EFFORT SENSATION AND ACUTE OR SUBACUTE FEVI DECREASE. GC Montiel. AUTHOR(S): SA Quadrelli. AJ Roncoroni (FCCP). GB Semeniuk*(FCCP) Instituto de Investigaciones Medicas - University of Buenos Aires Buenos Aires - ARGENTINE Fifwt patients (21 male, 15-65 vears) with a positive histamine bronchoprovocation test (PC20 <8 mg/ml) have been studied. Histamine challenge test was carried out (Cockcroft's technique) until a decrease ot FEVI>20% was reached. The sensation of respiratory effort (SRE) was determined by means of modified Borg scale. asking patients 30 seconds after each histamine dilution nebulization was finished. Borg 0 observations (n=182) showed a decrease of FEVI of 4.73+9.12% vs 17.94+14.20% in Borg >0 observations(n=163) with great overlap among Borg values for each FEVI decrease interval. In 16% of the observations with Borg 0 the FEVI fall was >20% and in 39% of the observations wvith Borg >0, the FEVI fall was <20%. The response to the acute decrease of FEV1 >20% was evaluated in two groups: Group I patients whose basal FEVI (at the beginning of the challenge test) was >80% of predicted (n 18) and Group II with a basal FEV1 <80% (n=32). In Group I: 9% of the observations and 13.3% of the patients showed Borg 0. In Group II: 23% of the observations and 40% of the patients showed Borg 0 (p=<0.05 y p=<0.01 respectivelv). A subgroup of patients (n=10) was evaluated with serial histamine challenge tests (6-12 tests). Respiratory effort sensation measured by Borg was compared with acute (within each challenge test) and subacute (among different tests along 4 weeks to 4 montlhs) decrease of FEVI >15% in each patient. In all patients the percentage of episodes with Borg 0 was higher in subacute decrease (86.8+24% of episodes, rank 33-100% for each patient) than in acute decrease (41.33±21%. rank 23-75%) (p=<0.05%). We conclude: 1. Borg sensitivity and specificity to detect FEVI acute decrease is low., showing great interpersonal variation as well. 2. Borg sensitivity and specificity is greater in patients with normal FEV1, pointing out that patients who present chronic obstruction have a lower SRE response to equal FEVI decrease, 3. Borg sensitivity to detect subacute vs acute falls of FEVI is much lower in each patient.

TITLE

Title

METABOLIC CART MEASUREMENT OF CALORIC REQUIREMENTS IN CHRONIC VENTILATOR DEPENDENT PATIENTS

Author(s):*J. Votto FCCP, W. Carroll, T. Dotson, C.

Wollschlager FCCP. Hospital for Special Care, New Britain, CT, Univ. of CT School of Medicine, Farmington, CT, USA. We observed that using established formulae, Harris Benedict (HB) or 25 Kcal/kg/day (cal) frequently over or underestimates caloric needs leading to actual weight gain or loss in chronic ventilator dependent (CVD) patients. To assess more accurately the caloriE needs in CVD patients we compared metabolic cart (MC) measurement of caloric needs with two frequently used formulae. 27 CVD patients who were medically stable were studied during a 2 week period. There were 12 males, 15 females, age range 18 to 88 years (mean 57 years) and had various diagnoses including COPD, cardiac disease and neuromuscular disease. A SensorMedics DeltaTrac metabolic cart was used in all studies done by the same technician using standard technique, Usual precautions were used to optimize each study (i.e. steady state measurement). We found no correlation between MC and calculated values. In only 5 of the patients (18.5%) did the HB calculation or cal come within 10% of the MC determination of caloric needs. In 17 patients (63%) the HB calculation was off by greater than 20% of the MC value and in 16 patients (59%) the cal calculation was off by greater than 20% of the MC determination. Usual prediction equations cannot be used in the CVD population to accurately predict actual measured caloric requirements. Abstracts, 60th Annual

Intemational Scientific Assembly

Tuesday, November 1, 1994 Title: ACCURACY AND REPRODUCIBILITY OF PORTABLE PEAK FLOW METERS

Author(s): B.Interiano,MD, K.Guntupalli,MD Baylor College of Medicine Houston,Tx Current NIH guidelines recommend home peak flow monitoring by

patients to assess control of asthma and assist in self management. Since it is important the peak flow meters are accurate and reproducible, we evaluated measurements obtained by the Professional Wrights (PW), a standard laboratory instrument as compared to commonly available peak flow meters. Methods: Forty normal subjects, 1 2 COPD and 20 asthma patients performed peak flow maneuvers on different days. Best of 3 maneuvers was recorded. Accuracy was determined by comparing to PW while reproducibility was evaluated by analysis of variance for multiple measures. Results: Pocket

Patient

PW

Assess

Mini Wrights

Vitalo-

Spiro

Personal Best

Wrights

Asthmat

0.92

0.85R

0.81

0.92

0.78'

0.88

0.92

xPFt

411.0

490.2

429.2

422

506.5

403.2

410.5

COPDt

0.89

0.92*

0.92

0.91'

0.87*

0.90

0.76

graph

gPFt

220.4

268.3

250.0

283.3

338.7

232.5

232.0

Normalst

0.97

0.91

0.95

0.95

0.84'

0.92

0.96

RPFF

518.7

581.6

519.8

510.6

553.5

from

PW

500.7 'I...

'p<0.05 differs

teliebility coefficient

518.7

pe.ak flow L/M

Conclusion: 1) Reproducibility was best for normals and least in COPD patients 2) There is a significant difference in accuracy and reproducibility of the peak flow meters which should be taken into consideration in interpreting the values and recommending interventions. Peak flow meters tend to be less stable at low flows.

ASSESSMENT OF A NEW TRANSTELEPHONIC PORTABLE SPIROMETER

Shimon Abboud Ph.D. Biomedical Engineering Dept., Tel Aviv University and Israel Bruderman* M.D., FCCP, Sapir Medical Center, and Sackler School of Medicine, Tel Aviv University, Israel. A new portable spirometer, the Spirophone, with a receiving center was recently developed by Card Guard Ltd. The Spirophone transmits the expiratory lung function parameters to a receiving center by telephone. The spirometric data are presented at the receiving center on a computer screen as the volume-time and flow-volume curves with the following expiratory

parameters: SVC, FVC, FEV1, FEV3, PEFR, FEF25%, FEF50%, and FEF75%. The accuracy, reliability, and reproducibility of the Spirophone was assessed by several methods: 1. Computer generated FVC waveforms were applied to the analog to digital converter of the Spirophone to test the analog circuits and the program that calculates the lung function parameters from the flowvolume and flow-time curves. The results for each expiratory lung function parameters were accurate and the differences between the measured and the theoretical values were less than 1%. 2. FVC maneuvers simulated with 1 liter and 3 liter calibrated syringes were delivered at various flow rates to the Spirophone. The Spirophone recorded volumes were accurate within ±5% of the actual value. 3. Repeated FVC tests with the Spirophone and with a commercial spirometer in a healthy subject and in a COPD patient showed no significant differences in the expiratory parameters obtained. 4. Comparing FVC and FEVy parameters in 10 healthy subjects obtained with the Spirophone connected in series with a commercial spirometer showed ±5% difference in 9 out of 10 subjects. 5. Comparison of the Spirophone results with a commercial spirometer in COPD patients showed high correlation with the identity line for the VC, FVC, FEVy, FEV3, PEF, FEF25%, FEF50% and FEF75%. 6. The Spirophone performed reliably with no significant drift in calibration or battery change over a period of 3 month. In conclusion: The Spirophone system has been shown to produce results with acceptable accuracy, reliability and reproducibility, and it displays the volumetime and the flow-volume curves similarly to spirometers in a pulmonary function laboratory,

Title:

Author(s):

USE OF AIRWAY RESISTANCE(Raw) A-ND SPECIFIC RESISTANCE(SRaw)' TO DEFINE REVERSIBLE AIRWAYS OBSTRUCTION(RAO) *MG Snow, AM Gharghourv and RJ Fallat Califomia Pacific Mledical Center San Francisco, Califomia

BACKGROUND: During forced expiration, elastic recoil and patient effort combine with airway resistance to limit expiratory flows. Measurements of Raw and SRaw minimize non-resistive components. Previous studies of

brondcodilator effests on Raw and SRaw evaluated patients with prior spirometric evidence of reversibility and used RAO limits of >40%. METHODS: 554 consecutive (371 rmale, 183 female) patients, age 6-91 (mean=57)., were assessed by plethlysmography and spirometry before and after 3 puffs albuterol MDI. RAO is defined by ATS as >200ml and > 2%). Raw and SRaw variability was previously reported by us as 25% for 2 SO's. RESULTS: 144 patients were identified as RAO based on ATS criteria. Analvsis of data confinned RAO limits for Raw and SRaw at 25% ratherthan 40%,. The number with RAO by the different criteria are shown below. LIMITS

RAW >25%

RAW >40%

SRaw >25%

SRaw >40%

TLC >10%

FEVI NO

172

68

197

79

59

FEVI

96

58

103 -

71

33

TOTAL RESPONSE

268

126

300

150

RESPONSE RESPONSE

_I

92 I

CONCLUSIONS: Significance limits for Raw and SRaw can be substantially less than previously reported(25% rather than 40%). Using 25% limits for RAO identifies 48-55% (300/554) with RAO compared to 26% (144/554) bv FEVI alone. Further studies are needed to correlate these objective indices of RAO to

subjedive, clinical improvement.

Title:

Author(s):

EFFECT OF ELIMINATING THE SALINE CHALLENGE STEP ON THE RESULTS OF BRONCHOPROVOCATION

CHALLENGE TESTING Abel WR*, Alberts WM FCCP - Division of Pulmonary, Critical Care and Occupational Medicine, University of South Florida College of Medicine, Tampa, Florida Non-specific bronchoprovocation challenge testing, using methacholine or histamine, has proven to be a valuable clinical tool. Established protocols have been standardized but are time consuming. A recent report has suggested that the saline solution challenge step could eliminated be without affecting the safety of the test (Chest 1993;104:133841). We conducted this study to investigate the effect of eliminating this step on the results of the test. Traditionally, the postsaline FEV1 has been used as the baseline for calculating the PC20FEV1. We sought to investigate the effect of using the pre-saline FEV1 instead of the postsaline measurement.

We reviewed the results of 249 methacholine

bronchoprovocation challenge studies (110 positive and 139 negative) performed in our laboratories (ages 12-78, avg age 43, 106 men, 143 women). For each study, we calculated the PC20FEV1 by using both the pre-saline and the postsaline FEVI as the baseline. Among those positive studies, there was no significant difference in the mean PC20FEV1 (Pre-saline baseline = 0.99 +/- 1.52 mg/ml and post-saline baseline = 1.04 +/- 1.50 mg/ml) when analyzed by Student's paired t-test (t= -0.808, p= 0.21). When a "negative" challenge was defined as a PC20FEV1 > 8.0 mg/ml, fouT studies (1.6%) were miscategorized by using the pre-saline FEV1 as baseline (2 positive by post-saline baseline but negative by pre-saline and 2 negative by post-saline baseline but positive by presaline). The results of each of these studies fell into the "grey area" between 4 mg/rnl and 16 mg/ml and would therefore be normally questioned. When categorized into normal (> 8 mg/ml), mild (>2 but <8), moderate (>.25 but <2), and severe (< .25) hyperresponsiveness, in only 12 (4.8%) studies was a disci epancy noted.

We conclude that the results of

a

non-specific

bronchoprovocation challenge are not significantly affected by using the pre-saline FEV1 as the baseline. Based on the earlier study confirming safety and our study confirming the equivalency of results, we suggest that the saline challenge step may be omitted.

CHEST / 106/2 1 AUGUST, 1994 / Supplement

125S

Tuesday, November 1, 1994 Pulmonary Function Testing, continued Title: GAS TRAPPING AS A PREDICTOR OF POSITIVE METHACHOLINE CHALLENGE IN PATIENTS WITH NORMAL SPIROMETRY

Author(s): Matthew B. Stanbrook* BSc, Kenneth6R. Chapman MD FCCP, Steven Kesten MD FCCP (Asthma Centre, Toronto Hospital - Western Division, Toronto, Ontario, Canada) Methacholine challenge studies are often conducted to diagnose asthma when screening spirometry is normal. We hypothesized that patients with increased non-specific bronchial hyperreactivity (NSBHR) but normal spirometry may have pre-existing changes in lung volumes such as gas trapping that are secondary to asthma. It was further hypothesized that a finding of such changes might negate the need to proceed with a test of NSBHR such as a methacholine challenge. In order to determine whether measures of gas trapping can be used to predict a positive methacholine challenge study and whether the degree of gas trapping correlates with the degree of increase in NSBHR, a retrospective chart review of 500 patient records from pulmonary function laboratory files was conducted. Measurements of airflow, lung volumes, and methacholine PC20 values FRC was determined by body were compiled and analyzed. plethysmography (FRCB) and by helium dilution (FRCH). FRCB-FRCH, RV (% of predicted), RV/TLC, and RV/TLC (% of predicted) were used as measures of gas trapping. RV % and RV/TLC % were the best predictors of a PC20 _ 8 mg/mL (p <0.05). Linear regression revealed no correlation between any measure of gas trapping and a measurable PC20 value. These results suggest that patients with a normal FEVl/FVC who demonstrate gas trapping have an increased likelihood of a positive methacholine challenge study. Furthermore, in these patients, RV/TLC (% of predicted) is the best predictor of a positive methacholine challenge and this parameter may be useful in raising the clinical suspicion of asthma in the large population of patients presenting with respiratory symptoms and normal flow rates.

TITLEPOSTURAL

EFFECT ON MEMBRANE DIFFUSING CAPACITY

(Din) AND PULMONARY CAPILLARY BLOOD VOLUME (Vc)

AUTHOR(S): IN PATIENTS WITH COPD Shi-Chuan Chang, MD, PhD, FCCPX; Guang-Ming Shiao, MD, FCCP; Reury-Perng Perng, MD, PhD, FCCP. Chest Department, Veterans General Hospital-Taipei, Taipei, Taiwan, Republic of China The effect of body position on DLco,and its components, Dm and Vc, was evaluated in 17 men with chronic bronchitis (CB) and 19 men with pulmonary emphysema (PE). The results showed that PE Gr had than CB Kco significantly lower values of DLco and Gr despite comparable data of spirometry and lung volumes between the two Gr. Kco and Vc were significantly higher in the supine than in the erect position in the CB Gr, but Dm and Dm/Vc were significantly lower in the supine position. Postural change didn't affect DLco and its components in the PE Gr. DLco, Kco and Vc obtained in both positions were significantly higher in the CB than in the PE Gr. Vc-SE (supine minus erect position) was also significantly higher in the CB Gr. There was a significant correlation between DLco-SE and Dm-SE as well as Vc-SE in CB Gr. DLco-SE and Kco-SE were highly correlated with Vc-SE in the PE Gr. In sumnary, an increase in Vc in the supine position may account for the postural change of Kco in the CB Gr. Ihe causes of decreased DLco and absence of postural effect on DLco and its components in the PE Gr may be due to a widespread abnormality of the pulmonary capillary bed.

126S

Tide:

INLN UENCE OF SEVERITY OF ALR FLOW OBSTRUCTION ON PATIENT IMETERED-DOSE INHALER TECHNIQLUE

Auihor(s): K H. Komadina*, MD., FCCP. G. Sathe, RRT, and Y. ChriArise, RRT Park Niollet Medical Ceruer, Minneapos -Minnesota Patients frequendy use mndered-dose inhale= (MDI) improperly. We previously reported no sigisifitn difference m pasen perfomace when usmg.MDrs aloae or MDrs with spacer devices The reasoa for poor patent tediique is unclear. In this sudy, we explored the relationship between FEV, and FEV,/FVC toMDI tedinique. We hypothesizeddw patients wilh more severe air flow obsiucdiuio would den nestrate poorer MD[ technique. 119 paiens with obAnstive lung disease referredto our puhnonasy lab were proqxenively enrofled. MDI tedmique (with a spacer if presribed) was evaluated by either oftwo repirstory care practrsners. MDI technique wss evaluated in 4 ategories preparation, expiraion and positiona g, aipastoy technique, and breath-oldin& Priorto deonatratigtheir MDI tedcmique, all patients had a standard spirmetryperfemed.i FEVI and FEVI/ FVC were subcategorzed as shown, andthe pereusage of patients denwn Pratingpieper MDItedaise

FEV, in liters (n) % oant tedcnique

<1 (27)

> 2 (48)

1-2 (44)

18%s

I 1%ef

35%

'p

-

0.03

FEV,JFVC (n) %

c orrecttechnique

< 0.5 (24)

> 0.6 (73)

0.5 -0.6 (22) 14%

17%

29%

p =NS An FEV, < .0 L was asatd wilh sigpificanty wosee MDI tedmique. PatiatAs i an FEVI < 1.0 L made sigeificmaty nore errs in mprparAton, inspiratory tedique, and the athergoups (p <0.01). No differee in pert on tedique was found arnsFEX4/FVC We spenslaethat patiens with an FEV, < I .0 L may renpxd bettel to nebulizedtherapy than to MDrs.

breatbodi
poups

OF ATS CRITERIA FOR BRONCHODILATOR RESPONSE (BR) tuINADEQUACY IN SEVERE OBSTtRUCTIVE AIRWAY DISEASE Tle

JN PATIENTS WITH ALPHA-1-ANTITRYPSIN DEFICIENCY(ATD) AM Gharghoury, MG Snow, L Moriyama, N Charles and RJ Fallat California Pacific Medical Center, San Francisco, California BACKGROUND: ATS criteria for BR is defined by an increase in FEVI of 12% AND 200ml. Many patients with ATD have severe OAD with FEVi < 1.0 liter; a 200ml improvement, therefore, demands a >25% increase in FEVI. We postulate that other measurements, such as FVP, Airway Resistance (Raw) and Specific Raw (SRaw) maybe more sensitive indicators of BR. METHODS: 56 consecutive patients (26 males, 30 females) with ATD (all homozygote ZZ phenotype) ages 19 to 80 years (mean=49) were assessed by spirometry and plethysmography before and after albuterol inhaler. A sub-group of 23 patients with severe ATD (FEV1 < 1.0 liter) was analyzed separately. In normal subjects and patient populations, Raw and SRaw were previously determined to have a variance of +25% for 2 SD, which was then used as the BR criteria. RESULTS: In the total population (Tablet), only 12 patients (21 %) showed a BR be FEVI, whereas 19 (34%) and 30 (54%) showed a BR by FVC and SRaw, respectively. If the 200ml criteria for FEVW were omited,, then 27 (48%) would show a BR. In the sub-group with severe OAD (Table 2), only 4 patients (17%) meet ATS criteria for FEV1, whereas 14 (61%) would meet the "'12% only' criteria. FVC, Raw, and SRaw were again more sensitive than the ATS criteria, in similar fashion to the 12% only' criteria. SRaw Raw FEVI FVC FEVI Table I (n=56) (ATS) (12%) (ATS)

AutIor(5s)

RESPONDERS

12

27

19

24

30

NO RESPONSE

44

29

37

32

26

FEVI

FEVI

FVC

Raw

SRaw

4

14

13

9

7

Table 2 (N=23)

RESPONDERS

(ATS)

(12%)

(ATS)

16 14 9 10 19 NO RESPONSE CONCLUSION: ATS criteria for BR is insensitive, particularly in patients with severe ATD.

Abstracts, 60th Annual Intemational Scientific Assembly