Transcript Pulmonary Function from 1954 to 2010 Michael Hughes

Pulmonary Function from 1954 to 2010
Michael Hughes
National Heart and Lung Institute
Hammersmith Hospital
Imperial College
London
Why 1954?
The modern era of PFT testing began with Julius
Comroe’s Beaumont Lecture to the Wayne
University Medical School, Detroit, and the book
“The Lung” which followed, co-authored with his
colleagues from the Graduate School of Medicine,
University of Pennsylvania, Philadelphia
Julius H Comroe
A born leader and teacher; “The Lung” put Pulmonary Function Testing on the map
OUTLINE
• “The Lung” (1955)
Comroe, Forster, Dubois, Briscoe, Carlsen
• Pulmonary physiology 1940–1954: a “golden age”
• Pulmonary function case history: 1954 versus 2010
• Development of pulmonary function testing:
from 1940 to 2010
• Physiology and Practice of Pulmonary Function
published by the ARTP, 2009
In the preface to The Lung
• “a monograph constructed largely around
illustrations”
• “understanding of physiological principles and broad
concepts more than technical completeness”
• “this is not a primer (which would be too simple) nor
an encyclopedia”
Rochester, New York State
Arthur Otis,
Hermann Rahn,
Wallace Fenn
pressure–volume plots of respiratory system; O2–CO2 diagram
Leon Farhi
John West
¢A/§ and MIGET analysis
Ventilation–perfusion (¢A/§)
effects of gravity and microgravity
stress mechanics “Teacher”
Harvard School of Public Health
Jere Mead
surfactant; EPP; Konno–Mead diagram
Jim Whittenberger
Mead and Whittenberger measurement of
lung resistance; artificial respiration
Peter Macklem
resistance partitioning (retrograde catheter);
chest wall mechanics; respiratory muscles
Milic–Emili
regional expansion and ventilation
(onion skin diagram); closing volume;
expiratory tidal flow limitation
Columbia, New York; John’s Hopkins, Baltimore
Dick Riley
DLO2; three compartment gas exchange lung; alveolar air equation,
physiological dead space, venous admixture; bubble technique for PO2
Moran Campbell
respiratory muscles; rebreathing P®CO2;
controlled O2 in resp failure (venturi mask)
Neil Pride
max expiratory flow analysis (choke point)
lung compliance and resistance; diaphragm
1940 – 1950
birthplace of clinical pulmonary function
College of Physicians and Surgeons, Columbia University, New York
Cournand, Richards, Riley,
[Baldwin, Austrian, Weibel]
R. heart catheterization
N2 washout for lung volumes and uneven ventilation;
obstructive versus restrictive disease
alveolar–capillary block; three compartment gas exchange lung
André Cournand
Dickinson Richards
The Lung: clinical physiology and pulmonary
function tests.
Year Book Publishers, 1955
• Julius Comroe: founder of the Cardiovascular Research
Institute (CVRI), San Francisco.
• Robert Forster: rediscovered the TLCO–sb of Marie Krogh
(1914) and made it a practical clinical test. The Roughton–
Forster equation.
• Arthur Dubois: first to measure airways resistance and lung
volume with the body plethysmograph; first to measure
pulmonary resistance with forced oscillation
• Bill Briscoe: contributed to gas exchange (¢A/§ and diffusion
limitation)
• [Ward Fowler]: originator of the SB–N2 test (alveolar plateau
or Phase III); suggested helium be added to TLCO–sb.
Forster
Roughton
[operating the continuous flow rapid reaction apparatus]
The Roughton Forster equation (1957) partitioned DLCO into membrane (DM) and
reactive (Vc) components
Arthur Dubois
Body plethysmographic methods for airways resistance and absolute lung volumes;
forced oscillation technique for respiratory resistance
From The Lung, part 2: Clinical applications of pulmonary function tests, Case 2
Male: a. 17 yrs; nocturnal dyspnea and wheezing
1954
Spirometry
% pred
Vital capacity
post b.d
max vol vent (MVV)
post–bd
2.8 L
58
3.6
75
62 L·min-1
44
111
79
max exp flow rate:
0.8 L·s-1
spirogram:
air trapping
[> 3.3]
“Although MVV gives information
regarding mechanics of breathing
….. a low value is not diagnostic of
any single disease …
Furthermore, it is a needlessly
exhausting test, and will probably
be replaced within the next few
years by simpler tests utilizing a
single breath ….”
Comroe et al THE LUNG (1955)
Air trapping
1987
Lim TK, Pride NB, Ingram RL. Effects of volume history during spontaneous and
acutely induced airflow obstruction in asthma. Am Rev Respir Dis 1987: 135: 591-6.
normal
methacholine-induced
constriction
spontaneous asthma
~ air trapping
Adapted from Gibson GJ, Clinical Tests of Respiratory Function, 2009
M/P ratio = max expiratory flow after 60% FVC expired on MEFV curve versus flow at
same lung volume on a partial (PEFV) from end tidal inspiration
Male: a. 17 yrs; nocturnal dyspnea and wheezing
2010
Spirometry
FEV1
post b.d
L
% pred
1.5
2.2
2.8
36
– 5.2
58
– 3.4
FVC
FEV1/FVC (actual)
SRs
0.54
MEFV curve : scooping, low ++ ¢ exp
Tiffeneau R, Pinelli A. Air circulant et air captif dans l’exploration de la
fonction ventilatrice pulmonaire. Paris Méd 1947; 133: 624-8.
Yernault J-C. The birth and development of the forced expiratory
manoeuvre: a tribute to Robert Tiffeneau. Eur Respir J 1997; 10: 2704-10.
Fig 1.2 Forced expiratory volumes in normal subjects and COPD
1958
Hyatt RE, Schilder DP, Fry DL. Relationship between maximum expiratory
flow and degree of lung inflation. J Appl Physiol 1958; 13: 331-6.
Fig 1.3 MEFV curves in young and elderly normals and in COPD
1960
Fry DL, Hyatt RE. Pulmonary mechanics: a unified analysis of the
relationship between pressure, volume and gas flow in the lungs of
normal and diseased patients. Am J Med 1960; 29: 672-89.
Fig 1.4 The IVPF curve: the key to understanding effort independence
Bronchodilators increase expiratory flows and reduce hyperinflation
Fig 2.1 Response in asthma to a bronchodilator challenge
1959
the peak flow meter
• Wright BM, McKerrow CB.
Maximum expiratory flow rate as a measure of
ventilatory capacity.
Brit Med J 1959; ii: 1041-7.
Figure 12.1 Asthmatic subjects attending clinic with peak flow charts, symptom records, bronchodil.
and steroid use; methacholine challenge on each visit. From Sont et al AJRCCM 1999; 159: 1043-51.
Table 12.9 Airway hyperreactivity and inflammation in asthma
methods
diagnostic outcome
Airway hyperreactivity
Bronchoconstrictor
response
methacholine challenge
(Chapter 2.4 lists
other agents)
Bronchodilator response
salbutamol given by MDI
overlaps with COPD, but
or nebuliser
FEV1 >12% + ≥ 200 mL (or
PC20
8 to 4 mg mL-1 borderline
< 4 mg mL-1
positive
< 1 mg mL-1 severe asthma
FVC) is +ve
Table 12.9 Airway hyperreactivity and inflammation in asthma
methods
diagnostic outcome
Airway hyperreactivity
Airway inflammation
Airway eosinophils
Bronchial NO production
Sputum induction with
2–agonist given beforehand
hypertonic saline19
> 3% eosinophil cell count +ve
Exhaled NO concentration20
> 47 ppb is positive, but NO
or multi-flow analysis
production suppressed by
(Fig 6.8, p. 118)
steroids, even at low dose
Lehtimäki L, Kankaanranta H, Saarelainen S, Turjanmaa V, Moilanen E. Inhaled fluticasone
decreases bronchial but not alveolar NO in asthma. Eur Respir J 2001; 18: 635-9.
Fig 6.8 Model and analysis of bronchial and exhaled NO
Male: a. 17 yrs; nocturnal dyspnea and wheezing
1954–2010
Lung volumes
L
% predicted
SRs
TLC
7.0
106
+ 0.5
FRC
4.4
190
+ 3.1
RV
3.5
300
+ 5.4
RV/TLC
50%
1949
Meneely GR, Kaltreider NL. The volume of the lung
determined by helium dilution. J Clin Invest 1949; 28: 129-39.
Fig 3.3. Closed circuit for helium equilibration calculation of lung volumes
1956
Dubois AB, Botelho SY, Bedell GN, Marshall R, Comroe JH. A
rapid plethysmographic method for measuring thoracic gas
volume. J Clin Invest 1956; 35: 322-6.
Fig 3.1 Body box estimation of lung volume (VL)
1956
Dubois AB, Brody AW, Lewis DH, Burgess BF. Oscillation
mechanics of lungs and chest in man. J Appl Physiol 1956; 8: 327-35.
Fig 4.5 Forced oscillation for measuring respiratory resistance
Male: a. 17 yrs; nocturnal dyspnea and wheezing
1954
• Diffusion and distribution
pred
DLCO (trad.)
ND
SB-N2 slope 6.0 %·L-1 (< 1.5%)
• Gas exchange
%
SaO2
mmHg
90
PaO2
PaCO2
38
1951 and 1967
Comroe JH, Fowler WS. Detection of uneven ventilation during a single
breath of oxygen. Am J Med 1951; 10: 408-13.
Milic-Emili J, Torchio R, D’Angelo E. Closing volume; a reappraisal. Eur J
Appl Physiol 2007; 99: 567-83.
Fig 3.5 Single breath nitrogen for uneven ventilation and closing volume
Multi–breath nitrogen washout
1940: for estimates of RV
Darling RC, Cournand A, Richards DW.
An open circuit for measuring residual air. J
Clin Invest 1940; 19: 609-18.
1952: for analysis of uneven ventilation
Fowler WS, Cornish ER, Kety SS.
Analysis of alveolar ventilation by
pulmonary N2 clearance curves. J Clin
Invest 1952; 31: 40-50.
1990–2000
Verbanck S, Schuermans D, Meysman M, Paiva M, Vincken W.
Noninvasive assessment of airway alterations in smokers. The small
airways revisited. Am J Respir Crit Care Med 2004; 170: 414-9.
Fig 6.2 Conducting airway and acinar dispersion of ventilation from N2 washout
Male: a. 17 yrs; nocturnal dyspnea and wheezing
2010
•
Transfer
SI units % pred
TLCO
KCO
•
12.7
98
2.0
105
SRs
– 0.14
+ 0.28
Gas exchange
%
SaO2
kPa
90
PaO2
8.1
PaCO2
5.1
Marie Krogh. The diffusion of gases through the lungs of man.
J Physiol 1915; 49: 271-96.
Qu i c k T i m e ™ a n d a
Pl a n a r RGB d e c o m p re s s o r
a re n e e d e d t o s e e t h i s p i c tu re .
1957
Ogilvie CM, Forster RE, Blakemore WS, Morton JW. A standardized breath holding
technique for the clinical measurement of diffusing capacity of the lung for carbon
monoxide. J Clin Invest 1957; 36: 1-17.
Fig 6.4 Single breath TLCO
set–up and protocol
Colin Ogilvie (Liverpool)
Fig 6.5 CO and helium analysis in the single breath TLCO
Ward Fowler
Marie Krogh
Hughes JMB, Pride NB. In defence of the carbon monoxide transfer
coefficient KCO (TL/VA). Eur Respir J 2001; 17: 168-74.
Fig 6.7 Physiological influences on TLCO and KCO
Measurement of oxygen and CO2 in blood
Van Slyke analysis of O2 and CO2 contents: PaO2 obtained from
dissociation curves and PaCO2 from content and pH
PaO2
1945: Riley bubble technique: small air bubble introduced into blood
syringe and equilibrated; measured by Haldane gas analysis.
1954: Clark polarographic electrode (in general use in 1960s)
PaCO2
1958: glass electrode for PaCO2 (Severinghaus and Bradley)
1960: PaCO2 versus pH determined base excess (Astrup et al)
Oxygen saturation in blood
1942: Millikan’s “ear oximeter” using two wavelengths
1964: Multi–wavelength fibreoptic oximeter (Hewlett Packard)
1972: Pulse oximeter (Takuo Aoyagi)
Die Methode ist Alles
devices
date
inventor
Application
capacitance
pressure transducer
1947
Lilly
body plethysmograph measures
of volumes and Raw
1950
Fleisch, Lilly,
Silverman
spirometry
MEFV, MIFV curves
1920s
–1941
van Slyke
et al
TLC, FRC, RV volumes
TLCO (DLCO), KCO
N2 rapid response 1946
meter
Lilly–Hervey
SB-N2 and multi-breath N2
tests. TLC, FRC volumes
infra-red CO
meter
19401950
Germany
WW II
TLCO (DLCO), KCO
respiratory mass
spectrometer
1956
Kemp Fowler
breath by breath gas exchange
analysis (exercise): lung volumes
pneumotachographs 1924-
helium
katharometer
cigarette smoking detection
Buytendijk HJ. Oesophagusdruck en longelasticiteit.
Groningen: Dissertatie. 1949.
Mead J, Whittenberger JL. Physical properties of human lungs
measured during spontaneous respiration. J Appl Physiol 1953; 5:
779-96. resistance
Butler J, White HC, Arnott WM. Pulmonary compliance in normal
subjects. Clin Sci 1957; 16: 709-29. elasticity
Fry DL, Hyatt RE. Iso-volume pressure flow curve for maximal
expiratory flow. Am J Med 1960; 29: 672-89. muscle pressure
Agostoni E, Rahn H. Abdominal and thoracic pressures at different
lung volumes. J Appl Physiol 1960; 15: 1087-92.
(first measurement of transdiaphragmatic pressure)
Kim MJ, Druz WS, Danon J, Machnach W, Sharp JT. Effects of lung
volume and electrode position on esophageal diaphragmatic EMG.
J Appl Physiol 1978; 45: 392-8. muscle activation
Fig 5.4 Measurement of maximum static mouth pressures
1954: “The test has been used but little clinically, largely because a high
pressure develops within the middle ear that causes discomfort”
Black LF, Hyatt RE. Maximum static respiratory pressures in generalized
neuromuscular disease. Am Rev Respir Dis 1971; 103: 641-50.
1985
Miller JM, Moxham J, Green M. The maximal sniff in the
assessment of diaphragm function in man. Clin Sci 1985; 69: 91-6.
Fig 5.5 Sniff oesophageal, gastric and transdiaphragmatic pressures
Non–volitional tests: a new method of nerve stimulation
1989
Similowski T, Fleury B, Launois S, Cathala HP, Bouche P,
Derenne J-P. Cervical magnetic stimulation: a new painless
method for bilateral phrenic nerve stimulation in conscious
humans. J Appl Physiol 1989; 67: 1311-18.
Hawkins P, Davison AG, Dasgupta B, Moxham J. Diaphragm
strength in SLE in a patient with paradoxical abdominal motion
and reduced lung volumes. Thorax 2001; 56: 329-30.
Fig 13.1 Volitional and non–volitional diaphragm contractions in SLE
1976
McGavin CR, Gupta SP, McHardy GJR. Twelve-minute walking test for
assessing disability in chronic bronchitis. Brit Med J 1967; I: 822-3.
Fig 8.7 Six minute and incremental shuttle walk tests
Chapter 11
Chapter 10
Non–invasive ventilatory support
Sleep disordered breathing
Chapter 15
Chapter 9
Breathlessness and breathing control
Interpretation and reporting Lung Function