Il Corretto Valore Del Test Di Reversibilità Bronchiale

8/18/2019 Il Corretto Valore Del Test Di Reversibilità Bronchiale

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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


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Hanania et al. CHEST 2011; 140:1055


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No clear consensus about what

constitutes reversibility in subjects

with airflow obstruction

Interpretation


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Reversibility is not ” all or nothing”

mechanism!

Interpretation


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Questions

How express a BD response?

variables

calculation

a) % basal

b) % predicted

c) absolute change


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Positive BD response


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Change in normal and patients

Change greater than

random variation


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AJRCCM 1999;159:1163 – 1171


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AJRCCM 1999;159:1163 – 1171


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AJRCCM 1999;159:1163 – 1171


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Changes in normal and patients

108 Lorber et al. Am Rev Respir Dis 1978; 118: 855–

861.109 Dales et al. Am Rev Respir Dis 1988; 138: 317–320.

110 Watanabe et al. Am Rev Respir Dis 1974; 109: 530–537.


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101. Pellegrino et al. Chest 1998; 114: 1607–1612.

111. Anthonisen et al. Am Rev Respir Dis 1986; 133: 814–819.

112 Sourk et al. Am Rev Respir Dis 1983; 128: 153–157.

113 Tweddale et al. Thorax 1987; 42: 487–

490.


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101. Pellegrino et al. Chest 1998; 114: 1607–1612.




490.


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The MEF25–

75% is a highlyvariable spirometric test, in part

because it depends on FVC,whichincreases with expiratory time in

obstructed subjects.101. Pellegrino et al. Chest 1998; 114: 1607–1612.




490.


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Kurashima et al. Respirology 2005;10:316


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CHHABRA,Journal of Asthma, 2005;42:367


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Within-individual difference

• A single test cannot predict both:

–underlying airway responsiveness

–and therapeutic response


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


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Tashkin et al. ERJ 2008;31:742


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Calverley et al. Thorax 2003;58:659

Within-individual difference


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Positive BD response


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FEV1 +4%

FVC +18%

(500ml)

PREPOST

Negative BD response


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• in lung hyperinflation


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Post salbutamol FEV1 change is influenced by baseline lung


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Post-salbutamol FEV1 change is influenced by baseline lung

function

Albert et al. Thorax 2012;67:701


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function


F= ΔPR

R= 8ηlπr4


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function


F= ΔPR

R= 8ηlπr4


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Hadcroft et al. Thorax 2001;56:713


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BD therapy should be withheld prior to spirometry:• Short-acting β-agonists 4 hours

• Short-acting anticholinergic 4 hours

• Long-acting β-agonists 12 hours

• Long-acting anticholinergic 24 hours

• Methylxanthines (theophyllines) 12 hours

• Slow release methylxanthines 24 hours

• Cromolyn sodium 8-12 hours

• Leukotriene modifiers 24 hours

• Inhaled steroids Maintain dosage

BD-test

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


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Response to a BD

Can be tested either:

• after a single dose of the BD or

• after a trial conducted over 2 –8 weeks


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Variazione dei volumi polmonari dopo 6 settimane di BD

-600

500

m L

Picco Trough

-500

-400

-300

-200

-100

0

100

200

300

400

FEV1 FVC RV FRC IC

240 mL

- 560 mL

***

#

*

******

#

#

***

#

#

O’Donnell et al., ERJ 2004;23:832


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• 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


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• Same dose and same route as clinical use

• Delay for SPIR = the reported time of

onset for that drug.

BD-test for therapeutic use

Alt i f tt i?


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Altri fattori?

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


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CHEST 1998; 114:1607

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

E’ dibil ?


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E’ prevedibile?


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• The correlation between BC and BD

response is imperfect , and it is not

possible to infer with certainty thepresence of one from the other.

Response to a BC

C C C


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CLINICAL RELEVANCE BD response

Acute response ≠

Chronic responseNEG response

symptom and patient performanceimprovement


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• 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


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73% of patients show reversibility*

27%

11%

(n = 280)

27%

35%

*Reversibility defined as ≥12% and

> 200 mL increase in FEV1

N = 815

Both

Neither

Albuterol only

Ipratropium only

(n = 217)

(n = 222)

(n = 91)

Imply Nonresponsiveness to Another Class

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

i i?


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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


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BPCO

Broncorev ersibilità


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Grazie

dell’attenzione


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Il Corretto Valore Del Test Di Reversibilità Bronchiale