EDUCATIONAL MATERIAL · EDUCATIONAL MATERIAL Meet the expert 10 ... access, annotate, store and...
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ERS Annual Congress Amsterdam
26–30 September 2015
EDUCATIONAL MATERIAL
Meet the expert 10
Paediatric lung function tests reference values
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Tuesday, 29 September 2015 13:00 – 14:00
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Paediatric Lung Function Tests: Reference Values
Dr Sanja Stanojevic Division of Respiratory Medicine
Hospital for Sick Children 555 University Avenue
M5G 1X8 Toronto CANADA
AIMS: To review the key points regarding the use of appropriate reference values for lung function testing in children and their correct interpretation. The session will focus on both spirometry and the reference values for lung function techniques in preschool children. TARGET AUDIENCE: Caretakers who use lung function testing to manage paediatric patients, paediatric pulmonologists, paediatric nurses, and paediatric lung function technicians.
AIMS
Describe why reference equations are important and relevant to daily practice Describe the Global Lung Function Initiative and its advantages Discuss interpretation of lung function results in different ethnic groups Discuss different approaches to interpreting lung function test results Review several examples of paediatric lung function tests and how to interpret results
SUMMARY
Lung function results can help with establishing a diagnosis, with assessment of treatment effects and with making a prognosis. However, arbitrary differences in the way lung function is expressed and interpreted may result in mismanagement of patients as well as hindering our understanding of the global burden of lung disease. In this session I will summarise the Global Lung Function Initiative spirometry reference equations and dispel some common myths related to the use and interpretation of spirometry results. REFERENCES 1. Kirkby J, Aurora P, Spencer H, Rees S, Sonnappa S, and Stocks J, Stitching and switching: the impact
of discontinuous lung function reference equations. Eur Respir J, 2012. 39(5): p. 1256-7. 2. Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, Enright PL, Hankinson JL, Ip MS,
Zheng J, Stocks J, ERS Global Lung Function Initiative. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J 2012: 40(6): 1324-1343.
3. Stanojevic, S., Qunajer, P., Miller, M.R., Stocks, J. The Global Lung Function Initiative: dispelling some myths of lung function test interpretation. Breathe: 2013: 9(6): 462-474
4. Quanjer PH, Pretto JJ, Brazzale DJ, Boros PW. Grading the severity of airways obstruction: new wine in new bottles. European Respiratory Journal 2014. 43(2):505-12
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5. Quanjer PH, Weiner DJ. Interpretative consequences of adopting the global lungs 2012 reference equations for spirometry for children and adolescents. Pediatr Pulmonol 2014: 49(2):118-25:
EVALUATION
1. If the pulmonary function test is done according to the ATS/ERS guidelines, does it not matter what reference equation is use.
a. No, it is only necessary to evaluate the absolute lung function results b. No, every reference equation produces the same percent predicted results c. Yes, reference equations should be representative of the study population, based on a large
representative sample of the study population and developed using appropriate methods to consider how the lungs grow and develop
d. Yes, you should always use reference equations derived at your centre, as long as there are more than 20 patients included in the sample
2. Before performing a lung function test, a patients height should be:
a. Measured at each visit b. Measured once at the first visit c. Measured in children, but adults can self-report their height d. Self-reported in children, but measured in adults
3. When can you start using the Global Lung Function Initiative Reference Equations a. As soon as I buy new equipment for my laborartory b. As soon as the GLI equations are available for all lung function tests (i.e. TLCO, lung volumes). c. As soon as I confirm the equations are in my equipment d. As soon as GLI equations are available for the ethnic group represented in my country
4. In addition to the appropriate reference equations, interpretation of a lung function test results should include (select all that apply):
a. A good effort, that meets current ATS/ERS standards b. An assessment of the patients clinical symptoms and other clinical findings c. Whether the lung function results is within the normal range d. The change in lung function from the previous visit
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Paediatric Lung Function Tests: Reference Values
Sanja Stanojevic PhD
Division of Respiratory MedicineHospital for Sick Children
Toronto, Canada66
Disclosures
• I have no conflicts to disclose
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Reference Equations and Zzzzzzzz-Scores
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Aims
• Describe why reference equations are important and relevant to daily practice
• Describe the Global Lung Function Initiative and its advantages
• Discuss interpretation of lung function results in different ethnic groups
• Discuss different approaches to interpreting lung function test results
• Review several examples of paediatric lung function tests and how to interpret results
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How big should my lungs be?
Ethnicity
Age
Photos courtesy of www.london2012.com 1010
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Choice of 34 equations for spirometry in same commercial equipment!
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Switched and stitched into 14 different modules to cover various age ranges and
all possible outcomes
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Switched and stitched into 14 different modules to cover various age ranges and
all possible outcomes
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Why is this important?
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Lack of Universal Reference Equations and Limits of Normal hinders our
understanding of the global burden of lung disease
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Tracking of Individual Results
Kirkby et al ERJ 2012
% Predicted
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Kirkby et al ERJ 2012
Absolute Values
Tracking of Individual Results
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Spirometry from Cradle to the Grave
International GuidelinesLum et al AJRCCM 2005Beydon et al AJRCCM 2007Pellegrino et al. AJRCCM 2005 1919
Ideally Reference Ranges should span All-Ages
2020
The GLI-2012 equations based on collated results from ~74,000 healthy non-smokers aged 3-95 years to create the 1st multi-ethnic all-age lung growth charts
www.lungfunction.org
The Global Lung Function Initiative
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GLI Objectives
• Derive internationally valid ‘all-age’ spirometry reference equations
• Specific focus on defining normal ranges
– During early life
– Transition through adolescence
– Shift from growth to plateau
– Age related decline
• Accurate representation of ethnic differences
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Eur Resp J 2012; 40, 1324-1343 2323
GLI are endorsed by:
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GLI 2012
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Ethnic differences in lung function
4.1 Litres 5.9 Litres 6.8 Litres
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Ethnicity and spirometry
• Ethnic differences in FEV1 and FVC (shown as % reductions) when compared to white subjects
Quanjer et al ERJ 20122727
FEV1/FVC vs Age
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What about the LLN?
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What is the LLN?
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The ATS/ERS Recommends the 5th Centile
5th Centile-1.64 SDS/z-score
5% of healthy subjects will have values below the 5th centile
The 5% is also called the Lower Limit of Normal (LLN)
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Why do we use 80% predicted as a cut-off?
80%
This assumes 1 SD of the between-subject variability is 10%
120%
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Between-subject variability varies with age and sex.
CV = 15% ~ LLN of 70%Normal = 70-130%
CV = 10% ~ LLN of 80%Normal = 80-120%
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Does it make a difference?
Only 5% of observations should be <LLN in population of healthy subjects.
If use <80% FEV1 as cut off, clear age-related bias.
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65
70
75
80
85
0 20 40 60 80 100
FEV
1%
Pre
dic
ted
Age (yr)
Males
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Reference Equations and Zzzzzzzz-Scores
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What do Z-scores translate to?
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Relationship Between Z-scores and % Predicted
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Does it make a difference?
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Kirkby et al ERJ 2012
Percent Predicted
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Kirkby et al ERJ 2012
Absolute Values
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GLI Equations Track Continuity
Add 3rd graph
Percent Predicted
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Advantages to GLI
In contrast to other commonly used equations, GLI-2012 equations allow appropriate interpretation:
– In very young children– During adolescence– During the transition from paediatric to adult care– In different ethnic groups
GLI-2012 also provides accurate LLN rather than fixed cut-offs for detecting abnormality – relevant throughout the life course
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How to use the GLI?
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Practical Recommendations
• Express results in relation to lower limit of normal not fixed thresholds
• Measure age and height to ≥ 1 decimal point accuracy to maximise accuracy of predicted values.
• Calibrate stadiometer at least annually and whenever suspect
• Do not use self reported height!
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• Altruistic international collaboration to improve diagnosis and management of lung disease
• First reference equations to cover different ethnicities over the entire life span
• International endorsement will streamline interpretation of lung function results
• Provides patients with a far more consistent record of their own lung health
Benefits of the GLI
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What about other PFTs?
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Acknowledgements
• Those who submitted spirometry data to the GLI
• ATS, TSANZ, ACCP, ANZSRS, APSR
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Discussion Slides
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Practicalities of Switching Equations
• Educate physiologists & clinicians– Reports must show which reference equation used
– Information sheets
• Educate patients and families– Liaise with Nurses and clinicians, patient representatives
– Information sheets on the website & in clinics
• Trend graphs– Display serial results using same equations
• Improve report format to show normal range
• for5151
Education Leaflets
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Practical Examples
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5555
5656
5757
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5959
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6161
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Faculty disclosures There are no faculty disclosures for this session.
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Answers to evaluation questions
Please find all correct answers in bold below
Paediatric Lung Function Tests: Reference Values - Dr Sanja Stanojevic
1. If the pulmonary function test is done according to the ATS/ERS guidelines, does it not matter
what reference equation is use.
a. No, it is only necessary to evaluate the absolute lung function results
b. No, every reference equation produces the same percent predicted results
c. Yes, reference equations should be representative of the study population, based on a
large representative sample of the study population and developed using appropriate
methods to consider how the lungs grow and develop
d. Yes, you should always use reference equations derived at your centre, as long as there are
more than 20 patients included in the sample
2. Before performing a lung function test, a patients height should be:
a. Measured at each visit
b. Measured once at the first visit
c. Measured in children, but adults can self-report their height
d. Self-reported in children, but measured in adults
3. When can you start using the Global Lung Function Initiative Reference Equations
a. As soon as I buy new equipment for my laborartory
b. As soon as the GLI equations are available for all lung function tests (i.e. TLCO, lung
volumes).
c. As soon as I confirm the equations are in my equipment
d. As soon as GLI equations are available for the ethnic group represented in my country
4. In addition to the appropriate reference equations, interpretation of a lung function test results
should include (select all that apply):
a. A good effort, that meets current ATS/ERS standards
b. An assessment of the patients clinical symptoms and other clinical findings
c. Whether the lung function results is within the normal range
d. The change in lung function from the previous visit