FEV - aimarpuglia

L’ostruzione bronchiale:
rivisitazione degli
indicatori funzionali
UNIVERSITA’ DEGLI STUDI DI BARI
FACOLTA’ DI MEDICINA E CHIRURGIA
SEZIONE DI MALATTIE DELL’APPARATO RESPIRATORIO
Onofrio Resta
Vieste, 29 Maggio 2014
Logica simbolica e BPCO
Diagramma di Venn
Chronic obstructive pulmonary disease: a definition and implications of structural
determinants of airflow obstruction for epidemiology.
Snider GL. Am
Rev Respir Dis 1989
BPCO
Definizioni
Chronic obstructive pulmonary disease (COPD) may be defined as a process
characterized by the presence of chronic bronchitis or emphysema that may
lead to the development of airways obstruction.
Snider GL ARRD 1989
Chronic obstructive pulmonary disease (COPD) is defined as a disease that
is characterized by the presence of airflow obstruction due to chronic
bronchitis or emphysema.
American Thoracic Society 1995
Chronic obstructive pulmonary disease (COPD) is a disorder characterized
by reduced maximum expiratory flow and slow forced emptying of the
lungs;…………….The airflow limitation is due to varying combinations of
airway disease and emphysema; the relative contribution of the two
processes is difficult to define in vivo.
European Respiratory Society 1995
The chronic airflow limitation characteristic of COPD is caused by a mixture
of small airway disease (obstructive bronchiolitis) and parenchymal
destruction (emphysema), the relative contribution of which vary from
person to person.
GOLD guidelines 2009
Chronic bronchitis/Bronchiolitis
Small airway disease
Emphysema
Parenchymal destruction
Airflow
limitation
Asthma
Snider GL. Am Rev Respir Dis 1989
Z.Q. Morris et Al. Response to editor Chest 2014
Eur Respir J 2009 ; 34, 527-528
Debating the definition of airflow
obstruction: time to move on?
M. R. Miller , O. F. Pedersen , R. Pellegrino and V. Brusasco
Revue des Maladies Respiratoires (2010) 27, 1003-1007
Lettre ouverte aux membres du comité GOLD
Open letter to the members of the GOLD committee
Celli. et Al. ERS 2003
Perez-Padilla R. et Al. Plos One August 2013
Lamprecht. et Al. Pumonary Medicine 2011
Lamprecht. et Al. Pumonary Medicine 2011
Al diminuire della funzione polmonare
i sintomi aumentano
FEV1 correla scarsamente
con l’indice basale di dispnea
10
R = 0.36
BDI
8
6
4
2
0
10
Mahler et al. JCOPD. 2004
20
30
40 50 60
FEV1 (baseline)
70
80
90
FEV1 correla scarsamente
con la performance d’esercizio
120
3000
R=0.38
Distanza (piedi)
Watts
R=0.66
80
40
0
0.0
0.5
1.0 1.5
FEV1 (L)
National Emphysema Treatment Trial
2.0
2000
1000
0
0.0
0.5
1.0
1.5
FEV1 (L)
2.0
FEV1 correla scarsamente
con la qualità di vita
r2=0.053
Jones, Thorax 2001
Rappresentazione schematica della
storia naturale della BPCO
Macklem , ERJ 2010
BPCO
Ostruzione bronchiale
Limitazione del flusso espiratorio
Intrappolamento d’aria
Iperinflazione
Outcomes centrati sul
paziente
Dispnea
Decondizionamento
Intolleranza all’esercizio
Ridotta attività
Scarsa qualità della vita
Probabilità di sopravvivenza nella BPCO
Casanova et al. AJRCCM 2004
Normal
PL
COPD
X
.
V
.
PL
V
Reduced recoil
Reduced tethering
  compliance ×
resistance
Increased airways resistance
Expiratory flow limitation
Courtesy of DE O'Donnell
La terapia broncodilatatrice determina
desuflazione polmonare
BPCO
 Flusso aereo
DESUFLAZIONE
BRONCODILATATORE
 Aumento del flusso – FEV1
 Aumento dei volumi – FVC e CI
 Aumento della tolleranza all’esercizio
Mahler et al, ERS 2009
Patterns of responce to broncodilatator therapy.
Bronchodilator response in COPD
In some patients, the FVC increases without an increase in FEV1
FVC responder
FEV1 & FVC
responder
4
4
3
Flow (L/s)
Flow (L/s)
3
2
2
1
1
0
0
1
-1
2
3
4
Volume (L)
1
-1
2
3
4
Volume (L)
Cerveri et al., JAP 2000
Gagnon P. et Al.International Journal of COPD 2014:9
Lung volumes during exercise:
dynamic hyperinflation in COPD
IRV = inspiratory reserve volume
BPCO
Meccanismi patogenetici
2009
The words ‘‘expiratory airflow limitation’’ express
our present inaccuracy in differentiating
increased airway resistance from increased lung
compliance. HRCT studies have shown that at
least two radiological patterns exist in which
either airway obstruction or emphysematous
destruction predominate.
COPD
Clinical phenotypes
Very severe COPD
Very severe COPD
Chronic bronchitis
Emphysema
FEV1 30%
FEV1 28%
Pistolesi 2008
Airflow limitation
Airflow limitation
COPD
Small airway disease
Hasegawa et al AJRCCM 2006
COPD
Small airway disease
Hasegawa et al AJRCCM 2006
COPD
Small airway disease
Hasegawa et al AJRCCM 2006
Luminal area (Ai) and wall area (WA%) were not correlated
with FRC and DLCO
Conclusions: Maximum mid‐expiratory flow and flow
towards the end of the forced expiratory manoeuvre do
not contribute usefully to clinical decision making over
and above information from FEV1, FVC and FEV1/FVC.
Quanjer P.H., et al., ERJExpress, sept.2013
Airflow limitation
COPD
Clinical phenotypes
Prospective classification of 93 patients by the
multivariate model derived from 322 patients
Absent or occasional cough
Occasional sputum
Reduced breath sounds
Increased lung volume
Reduced lung density
Lower BMI
Lower FEV1, higher FRC
Parenchymal
Lower
DLCO
Chronic cough
Purulent sputum
Adventitious breath sounds
Increased vascular markings
Bronchial wall tickening
Small airways
disease
Destruction
(chronic bronchitis/
(emphysema)
bronchiolitis)
0.56
COPD
HRCT phenotypes
Extent of emphysema and airways thickening in COPD
Nakano et al. Chest 2002
Parenchymal
destruction
+ 2 SD
Intermediate
Small
airways
disease
+ 2 SD
Pistolesi. et Al. Eur Resp. J. 2013
CHEST 2013; 143(6):1607-1617
Eur Resp J 2012;40:801-803
Therapeutic implications of the
pathophysiology of COPD
PT Macklem
Eur Respir J 2010; 35: 676-680