Ole F. Pedersen

Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction.

Aim: The prevalence of airway obstruction varies widely with the definition used. Objectives: To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four regression equations. Methods: We collected predicted values for forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) and its lower limit of normal (LLN) from the literature. FEV1/FVC from 40 646 adults (including 13 136 asymptomatic never smokers) aged 17–90+years were available from American, English and Dutch population based surveys. The prevalence of airway obstruction was determined by the LLN for FEV1/FVC, and by using the Global Initiative for Chronic Obstructive Lung Disease (GOLD), American Thoracic Society/European Respiratory Society (ATS/ERS) or British Thoracic Society (BTS) guidelines, initially in the healthy subgroup and then in the entire population. Results: The LLN for FEV1/FVC varied between prediction equations (57 available for men and 55 for women), and demonstrated marked negative age dependency. Median age at which the LLN fell below 0.70 in healthy subjects was 42 and 48 years in men and women, respectively. When applying the reference equations (Health Survey for England 1995–1996, National Health and Nutrition Examination Survey (NHANES) III, European Community for Coal and Steel (ECCS)/ERS and a Dutch population study) to the selected population samples, the prevalence of airway obstruction in healthy never smokers aged over 60 years varied for each guideline: 17–45% of men and 7–26% of women for GOLD; 0–18% of men and 0–16% of women for ATS/ERS; and 0–9% of men and 0–11% of women for BTS. GOLD guidelines caused false positive rates of up to 60% when applied to entire populations. Conclusions: Airway obstruction should be defined by FEV1/FVC and FEV1 being below the LLN using appropriate reference equations.

Acoustic rhinometry: Evaluation of the nasal cavity with septal deviations, before and after septoplasty

We introduce acoustic rhinometry as a new, objective method to assess the geometry of the nasal cavity. The cross‐sectional area of the nasal cavity as a function of distance from the nostrils was obtained. A group of 21 patients with septal deformities was examined with acoustic rhinometry preoperatively and postoperatively. These values were compared with those of 21 normal control subjects.

Human reactions to a mixture of indoor air volatile organic compounds

Abstract A controlled experimental study of human reactions to a mixture of 22 volatile organic compounds often found in indoor air was performed in a climate chamber. Twenty-one healthy subjects were compared with a group of 14 subjects suffering from the ‘sick building syndrome’ (SBS subjects), i.e. having symptoms related to the indoor environment (irritated mucous membranes, headache, etc.) as defined by WHO in 1982. In groups of 4 these subjects were exposed during two successive periods to either 0 and 0 mg m −3 , 25 and 0 mg m −3 , or 0 and 25 mg m −3 ; 25 mg m −3 is equivalent to the highest concentrations expected in a new building. The study was double blinded, and a latin square design was used to balance out effects of day in the week and season. Both groups reacted subjectively to the air reporting worse odor, worse indoor air quality as defined by the subject, and more irritated mucous membranes in eye, throat and nose than in the clean environment. A tendency to a stronger response was seen among the SBS subjects. Objective measures indicated among others an exposure related reduction in lung function among SBS subjects. Both groups had an increased number of polymorphonuclear leucocytes in tear fluid as a result of exposure. This was not seen for nasal secretions. Psychological performance tests indicated an exposure related diminished ability to learn. In conclusion, the experiment indicates that exposure to volatile organic compounds in low concentrations as seen in new houses causes both subjective complaints and objective signs in normal healty subjects; but more so in subjects from the sick building syndrome.

Dust exposure, eye redness, eye cytology and mucous membrane irritation in a tobacco industry

SummaryIn a study of 75 workers employed in a tobacco factory producing cheroots we measured cellular contents of tear fluid, redness of eyes, discomfort, total (0–5.7 mg/m3) and respirable dust in the breathing zone and total ambient dust by stationary sampling (0.08–1.0 mg/m3). A matched group of 50 office workers in a telephone company (total ambient dust concentration between 0.08–0.13 mg/m3) was similarly examined as referents. We found a difference between the two companies with regard to cell counts, with tobacco workers having the largest numbers except for lymphocytes. Among tobacco workers we furthermore found that the number of cuboidal and columnar epithelial cells increased during the day. The increase of cuboidal cells, however, occurred mainly in a small group of tobacco workers exposed to the highest concentrations of tobacco dust (mean =1.26 mg/m3). No difference in the sensation of eye irritation was found between companies, but increased irritation in the morning was associated with increased exposure to total dust during the work-shift among tobacco workers. A dose-dependent difference in photographically measured eye redness was found among the tobacco workers. It could not be explained by differences in tobacco smoking, sex, age, sleeping habits or use of glasses. Irritation of lips and upper airways as reported by questionnaire were more common in tobacco workers than in referents. In conclusion the tobacco workers, more often than the referents, had complaints and objective changes in the mucous membranes of the eyes. These may be related to tobacco dust exposure.

Posture and Nasal Patency: Evaluation by Acoustic Rhinometry

Nasal passage geometry was measured by acoustic rhinometry in 8 healthy medical students (5 males and 3 females, 21-29 years old; mean age 24 years) after 6 min in different postures of head and body. The minimum cross-sectional area (A-min) and volume between the nostril and 7 cm posteriorly were measured on both sides. When changing from sitting to horizontal the total airway dimension (i.e., the sum of A-min for the two sides) decreased by about 16% (Mean +/- SD = 0.19 +/- 0.14 cm2), and when standing up it increased by about 12% (0.14 +/- 0.13 cm2). A-min seemed more sensitive than volume to detecting postural changes. Including the variation between the cavities, the coefficient of variation (CV = SD/Mean) for area was 24.8 +/- 6.7 and for volume 22.4 +/- 6.4 for the 8 subjects. For the total nasal airway passage the corresponding figures were 12.9 +/- 3.9 and 10.9 +/- 5.5. These figures are considerably higher than for subjects measured only in the sitting position under comparable circumstances. In conclusion, our findings indicate a composite response of the nasal cavity mucosa to both systemic (hydrostatic) and local conditions, probably induced by vascular and cutaneous reflexes. These factors must be taken into account in studies of environmental, clinical, and pharmacological conditions.

Nasal histamine challenge in nonallergic and allergic subjects evaluated by acoustic rhinometry

Nasal patency shows spontaneous variations but is influenced by a number of factors like exercise and allergic conditions. Nasal histamine challenge has been used to define nasal hypersensitivity. We have applied acoustic rhinometry as a new objective method to study the spontaneous variations of the nasal mucosa and its response to histamine challenge in 12 nonallergic subjects and 12 subjects with nasal allergy to pollen, but out of the pollen season. Measurements of the minimum cross‐sectional area and the volume of the nasal cavities were done every 15 min for 6 h. More pronounced spontaneous variations, defined by the coefficient of variation of the measurements, were encountered in the allergic than in the nonallergic subjects, especially with regard to the minimum cross‐sectional areas in the nasal cavities (P < 0.02). Allergic subjects showed increased sensitivity to histamine, as compared with nonallergic subjects, during low‐concentration (0.1%) challenge (P < 0.05) and a prolonged effect of histamine challenge (P = 0.01). Antihistamine (cetirizine) had a significant effect on the histamine‐induced symptoms and decrease of nasal dimensions during histamine challenge, but no significant effect on pollen‐induced changes. In the allergic group, the decrease in minimum area during allergen provocation correlated with the level of specific IgE (r = 0.81; P = 0.0015).

Debating the definition of airflow obstruction: time to move on?

The clinical practice of medicine involves accurate history taking and appropriate clinical examination, followed by the formulation of possible diagnoses to account for the patients condition. This usually leads to investigations being undertaken to confirm or refute the possible diagnoses. These investigations may be of a visual nature, such as imaging (radiology, magnetic resonance imaging or ultrasound) or endoscopy, or may be the measurement of physiological indices, such as blood pressure, height, weight, lung function or measurements from blood tests. For most measurements, clinicians are used to the concept of accepted normal ranges, which may be different for males and females. These ranges may be quite distinct and relatively invariable. For other measurements the situation is less clear, e.g. blood pressure, for which the acceptable ranges may be defined by their relationship to survival and risk of adverse outcome 1. In lung function tests, the normal ranges have usually been obtained from healthy nonsmoking subjects and are dependent on a number of other aspects related to the individual subject in question, namely their age, sex, height and ethnic background 2. This complicates the way in which a clinician can quickly interpret whether a subjects result is abnormal. The American Thoracic Society/European Respiratory Society task force on the standardisation of lung function testing has recommended that a given test is said to be abnormal when the measured value is below the lower limit of normality (LLN), defined as 1.645 standard deviations below predicted 3. However, an alternative way to define a lower limit for deciding on the presence of airflow obstruction for chronic obstructive pulmonary disease (COPD), based on the ratio of forced expiratory volume in 1 s (FEV1) to forced …

Long-term performance of a hand held spirometer.

BACKGROUND: A study was undertaken to test the long term performance of a small hand held spirometer for self-administered serial spirometric testing. METHODS: Thirty turbine pocket spirometers (MicroMedical DiaryCard) were used in a clinical trial on 22 emphysematous patients with severe alpha 1-antitrypsin deficiency. The spirometers were able to store the date, time, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), and flow-volume loop for each blow. Every four weeks when the patients came for alpha 1-antitrypsin infusions the performance of their spirometer was checked before and after retrieval of the data from the spirometer. Calibration checks were threefold and included volume calibration with a 1.0 litre and 3.0 litre syringe, and flow calibration with a decompression calibrator. RESULTS: After two years of study the mean number of spirometric recordings performed per spirometer was 693 (range 237-1178), and the mean number of calibration checks was 33 (range 2-57). The coefficient of variation of the calibration signal was 1-2% for syringes and 0.5-1% for the decompression calibrator. The bearings of one turbine exhibited excessive friction after 17 months. None of the other 29 instruments showed drift, and a general drift of all spirometers towards larger or smaller readings could not be shown. However, unforeseen problems in the stability of the calibrating devices were observed. CONCLUSIONS: The small hand held turbine spirometers are suitable for long term patient-administered serial spirometric testing. The two year durability is acceptable and the long term reproducibility excellent.

Peak expiratory flow and the resistance of the mini-wright peak flow meter.

The purpose of this study was to examine whether the resistance of the peak flow meter influences its recordings. One hundred and twelve subjects, (healthy nonsmokers and smokers and subjects with lung diseases) performed three or more peak expiratory flow (PEF) manoeuvres through a Fleisch pneumotachograph with and without a mini-Wright peak flow meter added in random order as a resistance in series. The results were as follows. In comparison with a pneumotachograph alone, peak flow measured with an added mini-Wright meter had a smaller within-test variation, defined as the difference between the highest and second highest values of PEF in a series of blows. The mean (SE) variation was 14 (1.3) L.min-1 and 19 (1.5) L.min-1 with and without meter added, respectively. In comparison with the pneumotachograph alone, the addition of the mini-Wright meter caused PEF to be underread, especially at high flows. The difference (PEF with meter minus PEF without meter) = -0.064 (average PEF) -8 L.min-1; R2 = 0.13. The mean difference was -7.8 (1.1) %, and increased numerically for a given PEF, when maximal expiratory flow when 75% forced vital capacity remains to be exhaled (MEF75%FVC) decreased. The reproducibility criteria for repeated measurements of peak flow are more appropriately set at 30 L.min-1 than the commonly used 20 L.min-1, because a within-test variation of less than 30 L.min-1 was achieved in 76% of the subjects without PEF meter inserted and in 88% with meter inserted, with no difference between healthy untrained subjects and patients. The resistance of the peak expiratory flow meter causes less variation in recordings but reduces peak expiratory flow, especially at high values and when the peak is large as compared with the rest of the maximal expiratory flow-volume curve.

Nasal reaction to changes in whole body temperature

The changes in nasal patency following a 1.5 degrees C decrease or increase in whole body temperature were measured in 8 healthy young males, during and after 30 min of immersion in a 15 degrees C cold or a 40 degrees C warm bath, breathing air at the same temperature, in a cross-over experimental design. The nasal reactions were traced by consecutive measurements of changes in nasal cavity volumes by acoustic rhinometry. Swelling of the mucosa during cooling and an almost maximal shrinkage of the mucosa during heating were indicated by respectively a decrease and an increase in nasal cavity volumes. The reactions were determined predominantly by the whole body thermal balance, but were also influenced by the temperature of the inhaled air, either enhanced, reduced or temporarily reversed. The greatest change occurred in the nasal cavity, left or right, which differed most from the final state at the beginning of exposure due to the actual state of nasal cycle.