Spirogram při obstrukci

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1 Spirogram při obstrukci
Normální spirogram Normal spirogram and lung volumes. ERV = FRC - RV; VC = TLC - RV; RV ~= 25% of TLC; FRC ~= 40% of TLC; FEV1 >= 75% of FVC. Spirogram and lung volumes in obstructive disease. RV and FRC are increased.TLC is also increased but to a lesser degree, so that VC is decreased. Expiration is prolonged. FEV1 <= 75% of FVC. Note the emphysematous notch. Spirogram při obstrukci

2 Spirogram restrikce Spirogram and lung volumes in restrictive disease. Lung volumes are all diminished, the RV less so than the FRC, FVC, and TLC. FEV1 %FVC is normal or greater than normal. Tidal breathing is rapid and shallow.

3 Ventilační křivky Fyziologická Restrikce Flow-volume loops.
(Fyziologická) Inspiratory limb of loop is symmetric and convex. Expiratory limb is linear. Flow rates at midpoint of VC are often measured. MIF 50%FVC is > MEF 50%FVC because of dynamic compression of the airways. Peak expiratory flow is sometimes used to estimate degree of airway obstruction but is very dependent on patient effort. Expiratory flow rates over lower 50% of FVC (ie, approaching RV) are sensitive indicators of small airways status. (Restrikční vada) Restrictive disease (eg, sarcoidosis, kyphoscoliosis). Configuration of loop is narrowed because of diminished lung volumes, but shape is basically as in (Fyz). Flow rates are normal (actually greater than normal at comparable lung volumes because increased elastic recoil of lungs and/or chest wall holds airways open).

4 Obstrukční vady Fixovaná obstrukce horních cest dýchacích Asthma, COPD
(tracheální stenoza, oboustranná paralýza hlasivek…) Asthma, COPD (Obstrukce: C) COPD, asthma. Though all flow rates are diminished, expiratory prolongation predominates, and MEF is < MIF. (Obstrukce: D) Fixed obstruction of upper airway (eg, tracheal stenosis, bilateral vocal cord paralysis, goiter). Top and bottom of loop are flattened so that the configuration approaches that of a rectangle. The fixed obstruction limits flow equally during inspiration and expiration, and MEF = MIF. (Obstrukce: E) Variable extrathoracic obstruction (eg, vocal cord paralysis). When a single vocal cord is paralyzed, it moves passively in accordance with pressure gradients across the glottis. During a forced inspiration, it is drawn inward, resulting in a plateau of decreased inspiratory flow. During a forced expiration, it is passively blown aside and expiratory flow is unimpaired, ie, MIF 50%FVC is < MEF 50%FVC. (Obstrukce: F) Variable intrathoracic obstruction (eg, tracheomalacia). During a forced inspiration, negative pleural pressure holds the "floppy" trachea open. With forced expiration, the loss of structural support results in narrowing of the trachea and a plateau of diminished flow (a brief period of maintained flow is seen before airway compression occurs). Variabilní extrathorakální obstrukce Variabilní intrathorakální obstrukce

5 Vztah chronické obstrukční bronchopulmonární choroby (COPD)
chronické bronchiridy a asthmatu. FIG Interrelationships of chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, and asthma. Subset areas in this Venn diagram are not proportional to actual subset size. The three overlapping circles represent patients with chronic bronchitis, emphysema, or asthma. The shaded area represents those with COPD. Patients with asthma whose airflow obstruction is completely reversible (subset 9) are not considered to have COPD. Often, patients with asthma whose airflow obstruction does not remit completely are almost impossible to differentiate from those who have chronic bronchitis and emphysema with partially reversible airflow obstruction and airway hyperreactivity. Therefore, patients with unremitting asthma are classified as having COPD (subsets 6, 7, and 8). Chronic bronchitis and emphysema with airflow obstruction usually occur together (subset 5), and some patients also have asthma (subset 8). Patients with asthma who are exposed to chronic irritation, as from cigarette smoke, may develop chronic productive cough, a feature of chronic bronchitis (subset 6). In the USA, such patients are often said to have asthmatic bronchitis or asthmatic COPD. Patients with chronic bronchitis or emphysema without airflow obstruction (subsets 1, 2, and 11) are not classified as having COPD. Patients with airway obstruction due to diseases with known etiology or specific pathology, such as cystic fibrosis or bronchiolitis fibrosa obliterans (subset 10), are not included in this definition. Modified from the American Thoracic Society: "Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease." American Journal of Respiratory and Critical Care Medicine, 1995;152:S77-S120; used with permission. 1, 2, 11: Pacienti s chronickou bronchitidou nebo emfyzémem bez obstrukce DC 3. Chronická bronchitida 4. Emfyzém 5. Pacienti s chronickou bronchitidou a emfyzémem 6. Pacienti s Asthma b. a chronickým produktivním kašlem (asthmatická bonchitida) 7. Pacienti s Asthma b. a emfyzémem 8. Pacienti s chronickou bronchitidou, emfyzémem a asthma b. 9. Asthma bronchiále s kompletně reverzibilní obstrukcí DC 10. Pacienti jejichž nemoc známé etiologie způsobuje obstrukci (cystická fibroza)

6 Vztah kouření, FEV1 a věku
Smoking status, FEV 1 , and age. Three matched cohorts, followed from age 45 to 85 yr, are depicted. The nonsmokers (top curve) show a decline in FEV1 along a curvilinear path; at age 85, FEV1 has not declined to 0.8 L (shown as a horizontal line), the level at which dyspnea generally occurs during activities of daily living (ADL). The FEV1 of smokers (bottom curve) declines at a steeper rate than that of nonsmokers, to 0.8 L before age 70. In their late 60s and 70s, smokers become dyspneic on mild effort and begin to populate chest clinics and intensive care units and to die of COPD. In ex-smokers (middle curve) who smoked at least 20 cigarettes per day for >= 25 yr and who stopped smoking at age 45 yr, FEV1 does not decline for 5 yr, then declines at a rate parallel to that of nonsmokers. FEV1 does not decline to 0.8 L until age 85 yr. Smoking cessation at age 45 yr delays the onset of dyspnea by about 15 yr. Modified from Snider GL: "Chronic obstructive pulmonary disease," in Stein JH, editor: Internal Medicine, ed. 5, St. Louis, 1998, Mosby-Year Book, Inc.; used with permission.