LUNG FUNCTION TESTSIn SPORTS MEDICINE مرکز تحقیقات

پزشکی ورزشی

Outline

• PFT in Sports Medicine

• EIP (Intro & Tests)

• Lab challenge test

• Field challenge test

• Notes not to be forget

• PFT in Sports Medicine

• EIP (Intro & Tests)

• Lab challenge test

• Field challenge test

• Notes not to be forget

PFT in sports medicine

در • تنفسی ظرفیت تعیین برای آن تفسیر و اسپیرومتری انجامورزشکاران

اسپیرومتری 15 انجام•

آنها • اداره راهکارهای و ورزش از ناشی برونکواسپاسم و آسمورزش درحین

داخلی بیماری های و ورزش

گازها • انتشار و انتقال ریوی، خونرسانی تهویه، کنترل تهویه، فیزیولوژیریوی • بیماری به مبتال بیماران ارزیابیآنها • تفسیر و ریه پرتونگاری روش هایریوی • عملکرد آن (PFT)تست تفسیر وشریانی • خون گاز آن (ABG)آنالیز تفسیر وآن • تفسیر و اکسی متری پالسآسم • بیماری درمان و تشخیص نشانه ها، و عالئم پاتوفیزیولوژی،انسدادی • بیماری های درمان و تشخیص نشانه ها، و عالئم پاتوفیزیولوژی،

ریه (COPD)مزمنآسم • و ورزش متقابل اثراتو • ورزش متقابل COPDاثراتریه • کانسر به مبتال بیماران توانبخشی و پیشگیری در ورزش اثراتآن • درمان و پیشگیری تشخیص، روشهای و ورزش از ناشی برونکواسپاسمآن • انواع و پنوموتوراکسریوی • بیماران در ورزش تست

ریه( بخش الف

Lung Sports Medicine

• Most sports, even endurance sports, it is not the lungs that is the limiting factor to improvements

• Rowers??– due to the enormous absolute amounts of oxygen

required by their muscles,

Faulman et al Journal of Sports Sciences 1996, Vol. 14, No. 1, p 81

PPE

International SportMed Journal

The International Olympic Committee (IOC) Consensus Statement on periodic health

evaluation of elite athletes

Cambridge Sports & Exercise Medicine Unit

Performance Tests AvailableVO2 max testing

Lung Function

Exercise Induce Asthma

• The prevalence of asthma in athletes is high and varies – From 3-23% in summer sports – to 12-50% in winter sports

• An estimated 90% of individuals with asthma

Endurance versus nonendurance Olympic Summer Sports 1996 to 2004 mean percentage b2-agonists notified/approved.

DIRECT & INDIRECT CHALLENGES

• Indirect tests such as Exercise, EVH, inhaled powdered mannitol, nebulized hypertonic saline, or AMP appear to be

• more effective in identifying EIB in the elite athlete population

• than direct challenges such as methacholine or histamine

ASTHMA

Version 1.4 14.06.2009

Laboratory Testing The most objective indicator of asthma severity is the measurement of airflow

obstruction by spirometry.

Exercise Challenge Tests (field or laboratory) (10% fall of FEV1)

Many elite athletes have levels of lung function above normal predicted values and

therefore normal lung function may still represent a sign of airway obstruction.

ASTHMA

Version 1.4 14.06.2009

•The absence of a bronchodilator response does not exclude a diagnosis of asthma.

• A 12% increase in FEV1 following beta-2 agonist use is considered to be the standard diagnostic test for the reversibility of bronchospasm.

Bronchial provocation may be performed by the use of physiological (exercise or eucapnic voluntary hyperventilation tests) or pharmacological (metacholine, mannitol, hypertonic saline, histamine) challenge tests of hyperventilation.

Further reference should be made to the European Respiratory Society (ERS) and

American Thoracic Society (ATS) standards.

IOC Consensus Statement on Asthma in Elite AthletesLausanne ,2008

Diagnosis of asthma in elite athletesobjective tests are required to confirm the diagnosis.

The fall in FEV1 from the baseline value used to define abnormality is the meanplus 2 SDs of the fall documented in healthy subjects without asthma in response

to the maximum dose of the test stimulus.For exercise and EVH, a fall in FEV1 of 10% is consistent with EIB.

Exercise challenge test

• Lab test

• Field test

Lab test

Typical change in FEV1 in response to an 8-minute exercise challenge in EIB-positive individuals.

• Typical postprovocation spirometry times are at 5, 10, 15, and 30 minutes after the

completion of the challenge

EXERCISE CHALLENGE

Criterion for EIB in Exercise challenge

• Post-exercise ↓ in FEV1 >10% to 25% have been used.

• A 15% fall in FEV1 for field exercise challenges• A 10% fall in FEV1 for laboratory challenges

The American Thoracic Society and the European Respiratory Society

recommend a 10% ↓ in FEV1,

A standardized exercise test at a high enoughand standardized exercise load, breathing air of stable

temperature and humidity (20–25C and 40–50%relative humidity) should be employed, either in alaboratory or as a field test, demonstrating at least10% reduction in FEV1 from baseline after exercise.

The type of exercise may be varied in accordance withthe type of sport practiced, although running is most

often the best suited for provoking EIB.

Responsiveness to inhaled bronchodilators: Anincrease in FEV1 of 12% (in per cent of baseline

or of predicted value) before and after inhalation ofa bronchodilator, preferably an inhaled b2-agonist,

administered by a pressurized metered dose inhaler,dry powder inhaler or a nebulizer.

the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN

• Treadmill test , Exercised for 8 minutes.

• During the first 2 minutes, heart rate reaches at least 80% to 90% of predicted maximum.

• During the remaining 6 minutes, exercise should continue at this heart rate.

Exercise-induced asthmaJ Allergy Clin Immunol 2007

Exercise-induced asthmaJ Allergy Clin Immunol 2007

• At this level of exercise, ventilation should reach 40% to 60% of maximum.

• ↓ ≥ 10% in FEV1– Especially if symptoms accompany the drop in FEV1.

• It is important to recognize that the drop in FEV1 after exercise is normally distributed in large population studies, meaning that there is no absolute FEV1 cut off that can be used to make the diagnosis of EIA.

• FEV1 2.5, 5, 10, 15, and 30 minutes after exercise.

An exercise challenge,• free-run challenge sufficiently strenuous to increase the

baseline heart rate to 80% max for 4–6 minutes.

• the patient may simply undertake the task that previously caused the symptoms.

• A 15-percent decrease in PEF or FEV1 (with measurements taken before and after exercise at 5-minute intervals for 20–30 minutes) is compatible with EIB.

August 28, 2007

Filed test

Eighteen of 23 elite winter athletes who tested positive by a field-based sport-specific exercise challenge but tested negative by laboratory treadmill run in ambient conditions

of 218C, 60% RH. Med Sci Sports Exerc 2000;32:309-16.10 FEF25-75,

• Wilber et al used sports-specific tests (Nordic skiing, speed skating, ice hockey, ice skating) to identify EIB in Winter Olympic athletes

•Ogston and Butcher used a 15-minute ski exerciseto identify EIB in Nordic skiers.

Free running or a 6-minute run has often been used in screening large groups for EIB.

•Lack of control (e.g. stimulus and the varied environmental Conditions) , this type of testing may not be reliable

•It is not appropriate to use as a means of monitoring treatment.

Measurements prior to exercise and at 5-minute increments following a 15-minute cross-country skiing exercise session on a groomed ski trail.

They was instructed to perform the exercise challenge at “race pace,” with a specificheart rate range of >85% age-predicted maximum heart rate.

Clin J Sport Med 2002;12:291–295

rink-side (temperature 5 14°C, humidity 5 60%) spirometry before and 1, 5, 10, and 15 min after 5 min of intense skating

CHEST 1999; 115:649–6

After baseline lung function was measured, children underwent a 6 min run on a 100 m track on a flat, grassed oval marked with conesspaced 10 m apart.

Each subject wore a nose-clip to ensure mouth-breathing

Heart rate was recorded at one minute intervals ( a Polar Accurex )

Children were encouraged to run at an intensity which gave a heart rate of 85–90% of their predicted maximum

which is approximately 180–190 beats per minute (bpm) for 8–11 year olds, and to maintain a heart rate of 180±10 bpm for the final 4 min of exercise.

Eur Respir J, 1994, 7, 43–49

The exercise challenge was 6 minutes of outdoor, free-range running at 85–90% ofmaximum heart rate, measured by heart rate monitor. Nose clips were worn.

Notes

EXERCISE CHALLENGE

• The lack of using a standardized exercise challenge for EIB may explain the wide range in reported prevalence within specific sports,

• whereas the variety of exercise challenges at different intensities with no control over challenge minute ventilation (VE) or water content of inhaled air may result in poor test-retest reliability.

(20-258C; relative humidity [RH] <50%)

the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN

• EIB is heavily influenced by the– humidity – temperature of the inhaled air

• The use of inhaled cold air (–20C) during exercise testing markedly increased the sensitivity in diagnosing EIB

• Important items:– Strict environmental standardization– with a high enough exercise load

• Both ERS and ATS recommendations set a 10% reduction in FEV1 as criterion for EIB

Allergy 2008: 63: 387–403

Patients should stop all bronchodilator or anti-inflammatory therapy prior to the provocation test.

•for short acting Beta-2-agonists this will be for 8 hours • for long acting Beta-2- agonists and inhaled lucocorticosteroids (GCS) for 24 hours prior to testing.

Version 1.4 14.06.2009

Heart rate-based protocols for exercise challenge testing do not ensure sufficient exercise intensity for inducing exercise-induced bronchial

obstruction

Br J Sports Med 2009;43:429–431. doi:10.1136/bjsm.2007.041715

?

• No similar simple, efficient diagnostic exercise challenge exists for adults with EIA, because the risk of coronary heart disease requires cardiac monitoring and immediate availability of resuscitation resources.

During total expiration (slowly or forced) it is suggested to bend forward at the waist as this movement helps to force air out of the lungs.

The mouthpiece must be inserted well into the mouth (beyond the teeth)

FVC

If required (this is optional) before the test make several breaths at rest.

When ready inspire slowly as much air as possible (opening the arms helps)

and then expire all of the air as fast as possible.

Then, without removing the mouthpiece from the mouth, finish the test by inspiring again as fast as possible. This final inspiration is not necessary if the inspiratory parameters (FIVC, FIV1, FIV1%, PIF) are not required.

It is possible to repeat the cycle several times, (without removing the mouthpiece) and in this case Spirolab will automatically select the best test and will show the results.

To end the test press or wait 3 sec. after the last volume cycle.

Performance of FVC maneuver

• Give instructions and demonstrate:– Show nose clip and mouthpiece.– Demonstrate position of head with chin slightly

elevated and neck somewhat extended. – Inhale as much as possible, put mouthpiece in

mouth (open circuit), exhale as hard and fast as possible.

– Give simple instructions. (adapted from ATS, 1994)

Performance of FVC maneuver

• Patient performs the maneuver– Patient assumes the position– Puts nose clip on– Inhales maximally– Puts mouthpiece on mouth and closes lips around

mouthpiece (open circuit)– Exhales as hard and fast and long as possible– Repeat instructions if necessary –be an effective coach– Repeat minimum of three times (check for

reproducibility.)

(adapted from ATS, 1994)