Airway Obstruction Diagnosis & Management

AIRWAY OBSTRUCTION
SPIROMETRY
INHALATION THERAPY
PARTHIV MEHTA
AHMEDABAD

ACKNOWLEDGEMENTS..
TEAM Pulmocare

SCOPE OF DISCUSSION
Obstructive Pulmonary
Diseases (OPD) –
specifically focusing
Dynamic Obstruction
1
Detection of OPD and
assessment of severity
and progress – with
Spirometry
2
Management of OPD –
specific use of
Inhalation as modality
3

There are some 300 million alveoli in two adult
lungs, to provide a surface area of some 160 m2
(equal to that of a Tennis Court and 80 times the
area of our skin - BSA!).

OBSTRUCTIVE PULMONARY DISEASES
• Understanding Airflow and
Obstruction

• CF (Cystic Fibrosis), RWI (Recurrent Wheezing in Infants), BPD (Broncho Pulmonary Dysplasia), PCD (Primary
Ciliary Dyskinesia), NCFB (Non-Cystic Fibrosis Bronchiectasis), PB (Plastic Bronchitis), BO (Bronchiolitis
Age of onset and prevalence of major
OPD in Children
REACTIVE AIRWAY DISEASE - RAD

DIAGNOSIS OF OPD
FIXED
(ANATOMICAL)
Obstruction
REACTIVE
(DYNAMIC)
RADIO DIAGNOSTICS
PULMONARY
FUNCTION TESTS

ANATOMICAL - DIAGNOSIS
• Sleep Fluoroscopy

• Ultra Fast CT Scan
RECORDING AND IMAGES

• Ultra Fast CT Scan Permits diagnosis of
• Dynamic changes in airway caliber
• Small intraluminal polyps
• Focal tracheal atresia
• Compressive mediastinal masses
• Foreign body obstructions of the major
bronchi.
BETTER OPTION!

REACTIVE - DYNAMIC
• Establishment of presence of
Obstruction
• Establishment of presence of
Reversibility
• Establishment of InflammationObstruction Reversibility Inflammatio

Obstruction and Reversibility
• “Presence” of Airflow limitation - Obstruction
• “Variation” in Airflow
• “Improvement” upon usage of
“RELIEVERS”
Peak Flow Meter
Spirometer
Osillometer

Peak Flow Meter
• Peak expiratory flow (PEF), also called peak
expiratory flow rate (PEFR) is a person's
maximum speed of expiration
• Directly correlates with “available aperture” of
airway
• Measures the airflow through the bronchi and
thus the degree of obstruction in the airways
• Effort Dependent
R e v e r s i b i l i t y

Peak Flow Meter
• Simple
• Handheld
• Easy to perform and interpret
• “DO IT YOURSELF”
Weighing Scale
Thermometer
Sphygmomanometer

• Asthma is suspected when there is >/= 20% diurnal
variation on >/= 3 days a week or for 2 weeks in a
PEF
• Wide range of ‘normal' values and high degree of
variability >> Not “the recommended test” to
identify asthma
Peak Flow Meter
Good tool to MONITOR Asthma
Higher the FLOW
Lesser the SEVERITY

• Spirometry is a vital test to establish “Airway
Obstruction” and its “Reversibility” objectively
and accurately.
Spirometer

Spirometer
• Vital capacity (VC/FVC*) : measurement of the
maximum amount of air that can be inhaled
(breathe in) or exhaled (breathe out). FVC is
Forced Vital Capacity
• Peak Expiratory Flow Rate (PEFR): the maximum
flow rate that can be produced during forced
expiration.
• Forced Expiratory Volume (FEV1): the maximum
amount of air that can be forced out in 1 second.
• FEV1/FVC: is the FEV1/FVC ratio is the percentage
of FVC that can be expired in one second.

Spirometer
• Reversibility : Significant reversibility is
indicated by an increase of > 12 % and/or 200
ml in FEV1 after inhaling a short-acting B2
agonist – bronchodilator.

Spirometer
• Performing Reversibility:
– Spirometry test (with at least 2 reproducible flow
volume loops)
– Intake of a fast acting bronchodilator (often
Salbutamol) through inhalation
– 15 minutes pause
– Second (Post Bronchodilatation) Spirometry test
(with at least 2 reproducible flow volume loops)

• Challenge Test: If there are no signs of airflow
obstruction and asthma is still suspected, a
challenge test by administrating Histamine or
Methacholine, cold air or an exercise
challenge test will help establishing diagnosis.
Spirometer
Episodic Symptoms

• Methacholine / Histamine Challenge:
inhalation of doubling concentrations of
Methacholine/ histamine using a special
nebulizer at tidal volumes for 2-min periods.
The results are expressed as the concentration
of Methacholine/Histamine inducing a 20%
decrease in FEV1 (PC20)
Spirometer
Episodic Symptoms

• Methacholine Challenge Test:
Spirometer
Episodic Symptoms
> 16 mg/ml: Normal BR
1 - 4 mg/ml: Mild BHR
4 - 16 mg/ml:
Borderline BHR
< 1 mg/ml: Moderate -
Severe BHR

• Methacholine Challenge Test: Following are
MUST
1. Baseline Airway Obstruction is ABSENT
2. Spirometry is of GOOD QUALITY
3. Substantial Post Challenge RECOVERY is
there
Spirometer
Episodic Symptoms

• Exercise Test: During start of exercise
pulmonary functions tends to be normal,
but within 5 to 10 minutes symptoms of
asthma such as wheezing, breathlessness,
tightness of chest appear. Patient may also
feel extreme fatigue.
• After a rest period, the symptoms subside.
But sometimes symptoms may become
worse for a longer time.
• Hyperventilation and airway cooling are the
two most important triggers of EIA.
Spirometer
Episodic Symptoms
Eucapnic Voluntary Hyperventilation (EVH)
is an option against classical Exercise testing.

• Exercise Testing: Drop of > 15% in FEV1 after 6
minutes of running or other exercise can be
diagnostic of exercise induced asthma.
• Useful for detection of Exercise Induced
Asthma in athletes, children and workplace
related Asthma.
Spirometer

• Impulse Osillometery:
– Conventional Spirometry: Effort Dependent
Spirometer

• Impulse Osillometery (IOS): Very
useful for diagnosis of Asthma,
especially in children where
dependency of Spirometry and
flow volume loop is questionable.
– IOS uses small amplitude pressure
oscillations to determine the
resistance of the airway.
– It is largely independent of effort
does not require coordination, but
does require cooperation of patient.
Spirometer

• To perform IOS, patient holds a mouth piece in place
over a 30 second period of time while breathing
normally.
• Sound impulses of various frequencies from 5 to 35 Hz
are applied to the airway through the mouth piece.
• Total Respiratory System Resistance (Rrs)and
Reactance (Xrs)determined at various frequencies.
• Change in Rrs and Xrs is noted after inhalation of a
beta-agonist.
• Young children with asthma show significant change in
Rrs following beta-agonist inhalation.
Spirometer
Episodic Symptoms
Use is restricted to RESEARCH in Asthma

Inflammation
• Inflammation in airways is MUST to confirm
Asthma.
• Airways – Upper and Lower
• Eosinophilic >> Neutrophilic
• Modalities:
– Direct: Sputum - Eosinophilia
– Indirect: Markers - Exhaled NO, ECP, EPX

Sputum
• Sputum is induced using inhalations of 3% of
hypertonic saline and processed.
• Sample: should look more opaque and/or
dense and unlike saliva.
• Cell differential counts are performed.

Sputum
• Eosinophilia in sputum:
– Directly linked with the underlying eosinophilic
airway inflammation.
– Used as a tool in most of the studies for monitoring
exacerbation of asthma.
– Monitoring sputum eosinophilia, a marker of the
underlying airway inflammation, allows medication to
be adjusted more efficiently than is possible with
traditional approaches.
– Management employing sputum monitoring has
been found useful in preventing asthma
exacerbations and hospitalizations.

Exhaled Nitric Oxide
• Nitric Oxide (NO) is produced in discrete
concentrations in the healthy human airway
(Respiratory epithelium, Nose, upper and lower
airways) where it is important in physiological
functions such as maintaining airway patency.
• It is responsible for airway inflammation and is also
the product of airway inflammation. So, Evaluation
of NO as “Surrogate marker of Eosinophilic
Inflammation” is gaining acceptance.

• Nitric oxide analyzers are used to
measure exhaled nitric oxide
(FENO).
• FENO is measured as part per
billion (ppb) in asthmatic patient.
• Normal values vary with the
patient, but it is considered that 20
to 30 ppb in the steroid –naive
patient is indicative of
inflammation.
• Online / offline techniques

• NO is over produced in asthmatic individuals.
• Potential of FENO to predict exacerbations of
asthma has been examined in various studies and
levels were found to be elevated before the fall in
lung functions or the development of clinical
symptoms of asthma exacerbations.
• NO is increased in inflammation of lung e.g.
asthma. If bronchospasm without inflammation,
NO is not increased i.e. it is not Asthma.

• Ingestion of foods containing nitrates,
smoking status, ambient nitric oxide level,
nasopharyngeal contamination, airway
infections and drugs such as leukotriene
modifiers may affect the actual collection and
quantification of exhaled nitric oxide.
• Patients are asked to take nothing by mouth
for one hour before sample collection.

Markers of Inflammation
• Important especially for diagnosis of Asthma in
Children
• Currently, the noninvasive clinical assessment of
airway inflammation in young children is limited.
• The detection of raised blood eosinophil levels or
evidence of Eosinophil Activation Proteins in
blood or urine, such as Eosinophil Cationic
Protein (ECP) or Eosinophil Protein X (EPX), can
be used in addition to the examination of
nasopharyngeal secretions.

Markers of Inflammation
• Tidal breathing methods for measuring
exhaled nitric oxide (NO) and other gases are
validated for use in the younger children.
• The analysis of other constituents of breath,
such as exhaled proteins, is currently being
investigated as potential indicators of airway
pathology.
May that day come soon…

MANAGEMENT OF OPD (RAD)
Short Term Management
• Relief from Symptoms
• Reducing risk of worsening
Long Term Management
• Maintenance Treatment
• Prevention of Exacerbation

SHORT TERM
QUICK-RELIEF MEDICATIONS
• Short-acting bronchodilators (also inhaled short-
acting beta-2 agonist, or SABA) are highly
effective for relieving asthma symptoms by
rapidly relaxing the muscles around narrowed
airways.
• There is insufficient evidence about the safety of
treating asthma with SABA alone. This option
should be reserved for patients with infrequent
symptoms (less than twice a month) of short
duration, and with no risk factors for
exacerbations.
• Salbutamol is the most commonly used SABA

LONG-TERM
CONTROLLER MEDICATIONS
• Medications taken daily for asthma are called "long-term controller" medicines
and function to decrease inflammation of the small airways over time.
Types of long-term control medications:
• Inhaled corticosteroid (ICS) are anti-inflammatory medications most
commonly used for long-term control
• Leukotriene modifiers like Montelukast (Singulair) are added as a secondary
medication when inhaled corticosteroids are not enough to control the
asthma alone
• Long-acting bronchodilators (also called long-acting beta agonists, or LABA)
• Combination inhalers combine two medications (an inhaled corticosteroid
and a long-acting beta-agonist LABA) in a single inhaler. Combination
therapy is used as step-up therapy for children not well controlled on inhaled
glucocorticoids or Montelukast alone
• Theophylline is a bronchodilator that opens the airways but is not used as
often now as in the past

DRUG DELIVERY IN LUNGS
Particle Size Delivery
(Mass Median diameter) (In Respiratory Tree)
• <1μm: Reach up to the Alveoli
• 0.5~5μm: Beyond the 10th
generation of
bronchi (respirable
particles),
• >5μm: Oropharynx

AIRWAYS –
JOURNEY OF
PARTICLES

Delivery Devices for Children
• The choice of depends on the type of medication
and the child’s age.
• There is no perfect device for delivering inhaled
medications to paediatric patients because may
not be able to consistently produce the same
inspiratory flow required by these devices.
• Other considerations are ease of use and
portability.

Delivery Devices for Children
Nebulizer: Jet -small volume, large
volume Ultrasonic
Metered dose inhaler, MDI + Spacer
Dry powder inhaler, DPI + Rotahaler
Multidose DPI – Dischaler, Spinhaler
Misthaler

Nebulizers
• Converts solution into aerosol particles, <
5μm.
• Patient cooperation and coordination is not
as critical
• An acceptable time 5-10minutes.
• Commercially available nebulizers deliver
12% to
• 20% of the nebulized dose into the
bronchial tree.

MEDICINES
Inhaled Beta-2 Agonist Bronchodilators
Short-acting (3~6hr)
• Salbutamol
• Terbutaline
• Fenoterol
Long-acting (>12hr)
• Salmeterol
• Formoterol
Frequent dosing leads to
HYPOKALEMIA
? Cardiac Risk in
ADULTS

MEDICINES
Inhaled Anti-Cholinergics
• Ipratropium bromide
• Tiatropium
• Indacetrol
Inhaled Corticosteroids
• Beclomethasone
• Triamcinolone
• Budesonide
Frequent dosing leads to
DRYNESS
BE CAREFUL
For Oropharyngeal
Candidiasis

MEDICINES
Antiallergic agents
• Cromolyn Sodium (Cromoglicic acid)
Anesthetics
• Opioids
Mucolytic agents
• Acetylcysteine
• Ambroxol
• Mistabron (Mesna)

MEDICINES
Antimicrobials
• Tobramycin(anti bacterial)
• Pentamidine(anti fungal)
• Ribavirin(antiviral)
• Amphotericin
Other agents
• Adrenaline
• Lignocaine
• Saline (N/S or 3%)

BEYOND INHALATION
• Injections
• Transdermal Patch
• Quick prolonged effect
• Control of symptoms
• Well tolerated

Corticosteroids are the most potent
and effective anti-inflammatory
medication currently available
for asthma*
*GINA (NHLBI & WHO Workshop Report)
*Guidelines for the diagnosis and management of Asthma NIH,

INHALED CORTICOSTEROIDS
• Budesonide/ Beclomethasone/
Fluticasone – use any
• Start (100-200 mcg/day approx. in 2
divided doses)
• Maintain for 3 months
• Taper slowly
• Safe for long-term use (years)

Are these safe?
• Even in small children for several years
• 30% of Olympic athletes
• Not anabolic (performance-enhancing)
steroid
• Even highest ICS dose is safer than low dose
oral steroid
• Best “Addiction” for asthmatics

Safe even for children?
• 400 mcg/day (Budesonide)
• Over 9 years of continuous use
• No growth retardation
• Uncontrolled asthma causes growth
retardation
Pedersen & Agertoft NEJM 2000

SUMMARY:
DIAGNOSIS OF RAD
For children older than 5 years, asthma diagnosis is based on:
• (1) a history of acute respiratory failure crises that improve
with short-acting bronchodilators (SABA)
• (2) increased serum IgE in the absence of parasitic
diseases, eosinophilia, and positive immediate
hypersensitivity skin tests for airborne allergens
• (3) spirometry and measurement of bronchial
hyperresponsiveness (BHR) to methacholine challenge.
The diagnosis can be made with the isolated presence
and/or combination of the above items 1;1 + 2; 1 + 3; or 1 +
2 + 3.

SUMMARY:
RAD MANAGEMENT
In the management of patients with RAD, the following are essential:
(i) Management supported by evidence-based medicine;
(ii) to perform the diagnosis and, if possible, the phenotype (e.g.,
allergic and
non-allergic);
(iii) to exclude and treat comorbidities;
(iv) to assess and recommend the adequate use of prescribed drugs;
(v) to assess, advise, and encourage treatment adherence;
(vi) to assess and advise about environmental prophylaxis;
(vii) to assess and advise on the triggering factors;
(viii) to educate

FURTHER READING
Eur Respir Mon, 2005, 31, 166–194. ERS Journals 2005.

WHAT IS PULMONARY FUNCTION TEST?
 Test that determine objectively and
accurately all the components of the process
of respiration consisting VENTILATION,
DISTRIBUTION, DIFFUSION, PERFUSION AND
COMPLIANCE.
 HELPS TO
 Prove/Disprove a clinical DIAGNOSIS
 Quantitatively determine the SEVERITY of a
disorder
 Objectively measure PROGRESS OR REMISSION
of disease and EFFECT OF THERAPY

PFT - INDICATIONS
• To Define the type and severity of the pulmonary
physiologic abnormality
• To Monitor the course of pulmonary diseases and lung
function impairment
• To Determine the effectiveness of therapy and guide
treatment changes
• To Follow pulmonary side effects of certain therapies
(chemotherapy or radiation therapy)
• To Assist in the preoperative planning of anaesthesia
and in anticipating the need for postoperative oxygen
and/or assisted ventilation

WHY PFT?
• PFTs measure specific parameters of lung
function, namely inspiratory and expiratory flow
rates and lung volumes.
• In some children, PFTs may detect abnormal
changes in the lungs EARLY before they are
appreciated on physical examination or chest X-
ray.
• PFTs actually consist of several different or
separate tests, each test examining lung function
in a different way.

PFT - INDICATION
IN CHILDREN
In children grown up – 6 years and beyond
1. As a diagnostic aid, to help determine the nature of the lung
function disorder
2. To quantify the magnitude of the lung function disorder
3. To assist in determining prognosis or peri-operative risk
4. To assess the effects of medical interventions or diagnostic
tests (such as the effects of bronchodilator and
bronchoconstrictor stimuli)
5. To evaluate innovative therapies aimed at improving
prognosis, quality of life and lung function
6. To study the natural course of respiratory disease
7. To study the growth and development of the lungs and
airways and evaluate early determinants of airway function.

INDICATION OF PFT
IN CHILDREN
PFT in the children are
rarely performed not to
diagnose but rather to
monitor the nature and
severity of respiratory
disease or to assess the
response to treatment

PFT - CONTRAINDICATIONS
• Young age or inability to follow directions
• Hemoptysis of unknown origin
• Recent pneumothorax
• Unstable cardiovascular status
• Thoracic, abdominal, cerebral aneurysm
• Recent eye surgery
• Nausea, vomiting, pain
• Recent thoracic or abdominal surgery

TESTS INCLUDED IN PFT
1. Peak Flow measurement
2. Spirometry: Pre and post-Bronchodilator
3. Positional (upright versus supine)
4. Lung volume (LV)
5. Diffusion Capacity (DLCO)
6. Fractional Exhaled Nitric Oxide (FeNO)
7. Challenge studies: Methacholine, Exercise, Cold air
8. Exercise Physiology with Gas Exchange
9. Six-Minute walk
10. Resting Metabolic Rate
11. Maximal Respiratory Pressures (PI Max and PE Max)
12. Ventilatory Drive Study

PFT IN CHILDREN
• During childhood, beyond the neonatal
period, lung function disorders are usually of
an obstructive nature, generally being
confined to the intrathoracic, intrapulmonary
airways.
• Hence, measurements of Airway Patency
(Maximal Expiratory Flow Volume (MEFV)
curves, Spirometry, Resistance
measurements) are of most relevance for
these patients.

PFT
• PFTs are patient effort- and technique-dependent.
• Short or incomplete exhalations, variable technique,
suboptimal maximal effort will affect results by
underestimating lung function.
• PFT require maximal patient effort for a good quality
test.
• ATS standards for PFT are set as to what is an
acceptable blow and for repeatability (how closely
repeated efforts should match). Essentially, PFT results
should be acceptable and repeatable.
• Most children can perform a valid spirometry study by
6 years of age

PFT – SPIROMETRY
Spirometry measures the amount of air that can
be blown out and the speed (flow rate) of the air
exhaled and inhaled.
Spirometry defines following values
Forced vital capacity (FVC)
Forced expiratory volume in one second (FEV1)
Flow between 25 and 75 percent of the vital capacity
(FEF25-75%)
Peak expiratory flow rate (PEFR)
Flow volume loops Volume time graph

PFT – SPIROMETRY
Spirometry measures inspiratory and
expiratory flow rates and compares the child’s
absolute values (in liters) with predicted
values.
The predicted values are based on height,
gender, race and age using appropriate
reference equations.
In the end, there is a percentage of what is
predicted for each child compared to other
similar children.

PFT – SPIROMETRY
Spirometry helps to differentiate:
If the lung function abnormality is obstructive,
restrictive or mixed.
Obstructive disease is associated with a decreased
FEV1, normal FVC, and decreased FEV1/FVC ratio.
Restrictive disease is associated with a
symmetrically decreased FEV1 and FVC with a
normal ratio.

PFT – SPIROMETRY
• If a patient is diagnosed with an obstructive
disorder,
• The reversibility of the obstruction should be assessed
by measuring FEV1 after inhalation of a bronchodilator.
• A post-bronchodilator increase in FEV1 of >12 %
predicted (or more than 25% predicted in FEF25-75%)
and 200 mL (in children 12 years and older) would
suggest a reversible obstructive lung defect -
supporting the diagnosis of asthma.
• However, lack of response to a bronchodilator should
not preclude the use of it, if clinically indicated.

PFT – SPIROMETRY
• It is also essential to assess Flow Volume
Loops.
• Can help in the diagnosis of obstructive or restrictive
defects;
• Able to identify variable intrathoracic obstruction,
variable extrathoracic obstruction (vocal cord
dysfunction) or fixed obstruction (tumors compressing
airways).
• Specifically, small airway obstruction as seen in asthma
causes a concave appearance or “scooping” near
residual volume

PFT - LUNG VOLUMES
LV measure the volume of all air-containing spaces in the
thorax using either plethysmography or gas dilution.
Lung volumes are subdivided into fractions related to normal
physiological function.
Each subdivision is called a volume and a combination of two
or more volumes is called a capacity.
Measurements of lung volumes require a Plethysmograph or
“Body Box” and usually are only done in a dedicated PFT lab.
They are particularly helpful confirming restrictive lung defects
(decreased TLC), but they also are helpful assessing patients
with obstructive lung defects (increased RV or FRC).

PFT - LUNG VOLUMES
Tidal volume (TV) -the volume of gas inhaled and exhaled
with each breath
Vital capacity (VC) - the maximum volume that can be
exhaled after a maximal inspiration
Total Lung Capacity (TLC)- the total amount of gas after a
maximal inspiration
Residual volume (RV)-the amount of gas left in the lungs
after maximal exhalation
Functional Residual Capacity (FRC)- the amount of gas left
in the lungs at the end of exhalation

PFT - LUNG VOLUMES
Clinical indications may include:
• Interstitial lung disease
• Pulmonary fibrosis
• Neuromuscular diseases (Duchenne Muscular
Dystrophy)
• Chest wall pathology (Scoliosis)
• Asthma
• Cystic fibrosis

PFT - DIFFUSION CAPACITY (DLCO)
• DLCO provides information about the rate at
which oxygen is transferred from the lungs to the
pulmonary circulation.
• It is a measure of impedance to gas flow across
the alveolar capillary membrane.
• DLCO value varies directly with lung size, but
exercise, haemoglobin and evenness of
ventilation perfusion affect results as well.
• Smoking may decrease DLCO.

PFT - DIFFUSION CAPACITY (DLCO)
• DCLO is increased in left-to-right shunts, hepato-renal
syndrome, pulmonary arteriovenous malformations, intra-
alveolar/pulmonary hemorrhage and polycythemia.
• DLCO is decreased in interstitial lung diseases, pulmonary
fibrosis, collagen vascular diseases, hypersensitivity
pneumonitis, histiocytosis X, drug-induced lung disease
(amiodarone, methotrexate, bleomycin) and anaemia. It also
can be reduced in congestive heart failure, alveolar
proteinosis, bronchial obstruction, bronchiolitis obliterans,
pulmonary vascular obstruction (pulmonary embolism) and
pneumonectomy.
• DLCO is performed only in specialized centers

PFT - FENO
Fractional Exhaled Nitric Oxide (FeNO)
• FeNO is a test that measures the Nitric Oxide (NO) production by
lung epithelium.
• This NO production can be elevated in a patient with Eosinophilic
Airway Inflammation (asthma) and atopy.
• FeNO is mostly used in the diagnosis and management of asthma.
• Patients with elevated FeNO values are likely to respond to inhaled
corticosteroids (ICS).
• It is also helpful to assess adherence to ICS (poor compliance or
ineffective technique may be present in patients with unchanged or
increased FeNO values who have been prescribed ICS)

INFANT PFT
• A very common question is “How young can a child be to
perform PFTs?”
• Most children by the age of 6 years can perform spirometry, other
tests at older ages.
• However, newer technologies enable clinicians to obtain this
information in infants.
• Utilizing the raised volume rapid thoraco-abdominal compression
technique (RVRTC), we are able to perform PFTs in infants who
are least 5 kg and less than 36 inches tall. They also should be at
least 57 weeks post-conceptual age.
• Given that this test requires sedation, expensive equipment and a
high level of training by the respiratory therapists, it is limited to
specialized centers.

• Infant PFTs,
which
measure
spirometry
and lung
volumes in
infants
PFT IN
INFANT

PFT - SPIROMETRY
Contraindication
There is no absolute contraindication for spirometry, the following
conditions are considered relative contraindications:
1. Presence of respiratory tract infection (e.g. influenza)
2. Haemoptysis of unknown origin
3. Pneumothorax
4. Aneurysm
5. Uncontrolled hypertension,
6. Recent thoracic, abdominal or eye Surgery
7. Nausea, Vomiting or Pain
8. Confusion or Dementia

SPIROMETRY - INTERPRETATION
How to interpret spirometry results?
The steps for interpreting spirometry results
include:
(1) Assessing the tests for acceptability and
repeatability
(2) Identifying the spirometry pattern (normal,
obstructive, restrictive, or mixed)
(3) Grading the severity of the pattern identified
(4) Diagnosing and treating the condition or
investigating further

PFT
ACCEPTABLE SPIROMETRY
Errors in Spirometry test
Poor Cough Premature
Effort Start &
Finish

CONCLUSION
• Conclusions:
• • PFTs assist in the diagnosis of lung disease by
describing and quantifying the
• impairment in function.
• • They can also helpful to assess the response to
treatment.
• • PFTs consist of several different or separate tests –
each test examines lung
• function in a different way
• • Providers should be familiar with the benefits and
limitations of each test available.

PULMONARY EXACERBATION IN
OAD
• In all COPDC, PE is often triggered by viral and/or bacterial
infections, pollution, and aeroallergens. The PE manifests as
acute respiratory failure of varying intensity, both in asthma
and RWI, and as increased cough and chronic infection in
CF, BPD, NCFB, and PCD. The signs and symptoms of PE are
more frequent and intense at night time. While the majority
of acute respiratory diseases can be diagnosed easily and
efficiently through history and physical examination, those
with a chronic nature may require sophisticated laboratory
tests. Continuous and scheduled evaluations by
interdisciplinary health teams in specialized centers are
required for effective management, better prognosis, and
improved quality of life in COPDC

DIAGNOSIS OF ASTHMA
• For children older than 5 years, asthma diagnosis is
based on: (1) a history of acute respiratory failure crises
that improve with short-acting bronchodilators
(SABA);(2) increased serum IgE in the absence of
parasitic diseases, eosinophilia, and positive immediate
hypersensitivity skin tests for airborne allergens; (3)
spirometry and measurement of bronchial
hyperresponsiveness (BHR) to methacholine challenge.
The diagnosis can be made with the isolated presence
and/or combination of the above items 1;1 + 2; 1 + 3;
or 1 + 2 + 3.

CONTROL OF ASTHMA
• It is essential to verify at all consultations, whether the
asthma is controlled or not, from the clinical and/or
functional point of view, based on six parameters:
(i)nocturnal signs and symptoms; (ii) daytime signals
and symptoms; (iii) signs and symptoms with physical
exercise or limitation in daily activities; (iv) PE; (v) need
for relief medication (SABA); (vi) changes in lung
function. Hence, asthma is considered controlled when
all parameters are normal; it should be classified as
partially controlled in the presence of one or two
altered parameters; and finally, non-controlled asthma
should be considered when three or more parameters
are altered.

SIGNS OF ASTHMA WITH HIGH
RISK OF EXACERBATION
• The absence of control of signs and
symptoms, frequent exacerbations,
previous admission to an intensive care
unit(ICU), low values of forced expiratory
volume in 1 s (FEV1),exposure to tobacco
smoke, and need to use high-dose
medications are characteristics associated
with increased risk of adverse events in
the future

ASTHMA MANAGEMENT
• In the management of patients with asthma, the
following are essential: (i) management
supported by evidence-based medicine; (ii) to
perform the diagnosis and, if possible, the
phenotype (e.g., allergic and non-allergic);(iii) to
exclude and treat comorbidities; (iv) to assess and
recommend the adequate use of prescribed
drugs; (v) to assess, advise, and encourage
treatment adherence; (vi) to assess and advise
about environmental prophylaxis; (vii) to assess
and advise on the triggering factors; (viii) to
educate

ASTHMA MANAGEMENT
• (viii) to educate patient’s caregivers about asthma and the factors
influencing it; (ix) to give instructions on the adequate use of devices
for administration of metered-dose and dry powder inhalers;(x)
instructions for patients to be able to recognize when asthma control
is deteriorating and what medications to use, when it occurs; (xi) to
identify non-controlled patients and causes of lack of control; (xii) to
advise that inhaled medications should be used with spacers; (xiii) to
advise on the hygiene of spacers, which must be washed and left to
soak in water with detergent; (xiv) LABA must not be used in children
younger than 4 years; (xv) SABA are the agents of choice in PE; (xvi)
IC alone or associated with bronchodilators are the basis of asthma
treatment; (xvii)children younger than 6 years can use inhaled
medication with spacer and those older than 6 years can use dry
pow-der inhalers; (xviii) to assess pulmonary function regularly;(xix) to
advise on the need for long-term medical care;(xx) omalizumab
should be prescribed in reference centers for the management of
patients with difficult-to-control asthma.

COPDC
• Final considerations The paediatrician's actions are vital for the
management of COPDC. The clinician should suspect the disease in
the presence of signs and symptoms in order to attain an early and
accurate diagnosis, know the risk factors and associated
comorbidities, and assess treatment adherence, the correct use of
prescribed drugs, and their side effects based on well-defined
management protocols, preferably based on specific guidelines.
Management benefits should be assessed through the reduction in
acute pulmonary exacerbations, increased quality of life, and
decreased evolution of lung function loss (spirometry, measurement
of oxygen saturation, lung clearance index) and lung damage (HRCT
every 2 years, if necessary). Therefore, the sequential evaluation of
lung function and damage should be standardized and continuous,
throughout life. For most COPDC, monitoring in specialized reference
centers by interdisciplinary teams leads to better outcomes.

• Spirometers versus peak flow meters
• PEF measured by a peak flow meter rather than by a spirometer
• is inaccurate and substantially overestimated in the range of
• 200–400L/min.52,53 Choi et al.54 reported that a peak flow meter
• underestimated the severity of airflow obstruction in acute
• asthma. Furthermore, in a study by Sly et al., peak flow meters
• were inaccurate in detecting changes in lung function in children
• which were detected by a spirometer.55 Therefore, when
• available, spirometers should be preferred to peak flow meters
• for measuring lung function in children

There are some 300 million alveoli in two adult
lungs, to provide a surface area of some 160 m2
(equal to that of a tennis court and 80 times the
area of our skin!).
EXPOSURE TO ENVIRONMENT
24X7X365!

Interactions of causes, effects, and clinical outcomes of chronic obstructive pulmonary
disease in children (COPDC).

ACUTE EXACERBATION OF OPD
Bacterial acute pulmonary exacerbations in chronic obstructive pulmonary
disease in children (COPDC) and pneumonia in previously healthy children.

COPDC
Control or non-control of Chronic Obstructive Airway Disease in children based on
diagnosis.

COPDC - SUMMARY
• COPDC have an environmental and/or genetic origin and its
manifestation has manifold genotypes, phenotypes, and
endotypes.
• Although COPDC has no cure, it can be clinically controlled.
• Chronic cough is the main symptom and bronchiectasis can
be present in several COPDC patients.
• The management of COPDC is more effective if based on
guidelines and when treatment regimen adherence is
promoted.
• Oral and inhaled corticosteroids, bronchodilators, inhaled
antibiotics, and treatment of pulmonary exacerbation (PE)
are the bases of COPDC management, and should be
individualized for each patient.

PFT IN CHILDREN
• During childhood, beyond the neonatal
period, lung function disorders are usually
of an obstructive nature, generally being
confined to the intrathoracic,
intrapulmonary airways. Hence,
measurements of Airway Patency
(Maximal Expiratory Flow Volume (MEFV)
curves, Spirometry, Resistance
measurements) are of most relevance for
these patients.

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