Expiratory Flow Limitation and Its Relation to Dyspnea and Lung Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease: Analysis Using the Forced Expiratory Flow-Volume Curve and Critique
Background: Tidal expiratory flow limitation (tEFL) is defined as absence of
increase in air flow during forced expiration compared to tidal breathing and
is related to dyspnea at rest and minimal exertion in patients with chronic
airflow limitation (CAL). Tidal EFL has not been expressed as a continuous
variable (0% - 100%) in previous analyses. Objective: To relate the
magnitude of tEFL to spirometric values and Modified Medical Research Council
(MMRC) score and Asthma Control Test (ACT). Methods: Tidal EFL was computed as percent of the tidal
volume (0% - 100%) spanned (intersected) by the forced expiratory-volume curve. Results: Of 353 patients
screened, 192 (114 M, 78 F) patients (136 with COPD, 56 with asthma) had CAL.
Overall characteristics: (mean ± SD) age 59 ± 11 years, BMI 28 ± 7, FVC (%
pred) 85 ± 20, FEV1 (% pred) 66 ± 21, FEV1/FVC 55% ± 10%, RV (% pred) 147 ± 42.
Tidal EFL in patients with tEFL was 53% ± 39%. Using univariate analysis,
strongest correlations were between tEFL and FVC and between tEFL and RV in
patients with BMI < 30 kg/m2. In patients with nonreversible CAL,
tEFL was positively associated with increasing MMRC, negatively with
spirometric measurements, and positively with RV/TLC. In asthmatics, ACT scores
were higher in patients with mean BMI ≥ 28 kg/m2 (p < 0.00014)
and RV/TLC values > 40% (p < 0.03). Conclusions: Dyspnea is strongly associated with tEFL and
lung function, particularly in patients with nonreversible CAL. Air trapping
and BMI contribute to tEFL.
References
[1]
Tantucci, C. (2013) Expiratory Flow Limitation: Definition, Mechanisms, Methods, and Significance. Pulmonary Medicine, 2013, Article ID: 749860. https://doi.org/10.1155/2013/749860
[2]
Koulouris, N.G., Valta, P., Lavoie, A., et al. (1995) A Simple Method to Detect Expiratory Flow Limitation during Spontaneous Breathing. European Respiratory Journal, 8, 306-313. https://doi.org/10.1183/09031936.95.08020306
[3]
Eltayara, L., Becklake, M.R., Volta, C.A., et al. (1996) Relationship between Chronic Dyspnea and Expiratory Flow Limitation in Patients with Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine, 154, 1726-1734. https://doi.org/10.1164/ajrccm.154.6.8970362
[4]
Koulouris, N.G., Retsou, S., Kosmas, E., et al. (2003) Tidal Expiratory Flow Limitation, Dyspnoea and Exercise Capacity in Patients with Bilateral Bronchiectasis. European Respiratory Journal, 21, 743-748. https://doi.org/10.1183/09031936.03.00301103
[5]
O’Donnell, D.E. and Laveneziana, P. (2006) The Clinical Importance of Dynamic Lung Hyperinflation in COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease, 3, 219-232. https://doi.org/10.1080/15412550600977478
[6]
Pride, N.B. and Milic-Emili, J. (1995) Lung Mechanics. In: Calverley, P. and Pride, N.B., Eds., Chronic Obstructive Lung Disease, Chapman Hall, London, 135-160. https://doi.org/10.1007/978-1-4899-4525-9_7
[7]
Fry, D.L. and Hyatt, R.E. (1960) Pulmonary Mechanics. A Unified Analysis of the Relationship between Pressure, Volume and Gas Flow in the Lungs of Normal and Diseased Human Subjects. The American Journal of Medicine, 29, 672-689. https://doi.org/10.1016/0002-9343(60)90100-5
[8]
Pellegrino, R., Viegi, G., Brusasco, V., et al. (2005) Interpretative Strategies for Lung Function Tests. European Respiratory Journal, 26, 948-968. https://doi.org/10.1183/09031936.05.00035205
[9]
Crapo, R.O., Morris, A.H., Clayton, P.D., et al. (1982) Lung Volumes in Healthy Nonsmoking Adults. Bulletin Européen de Physiopathologie Respiratoire, 18, 419-425.
[10]
Crapo, R.O. and Morris, A.H. (1981) Standardized Single Breath Normal Values for Carbon Monoxide Diffusing Capacity. The American Review of Respiratory Disease, 123, 185.
[11]
Fletcher, C.M., Elmes, P.C., Fairbairn, M.B., et al. (1959) The Significance of Respiratory Symptoms and the Diagnosis of Chronic Bronchitis in a Working Population. British Medical Journal, 2, 257. https://doi.org/10.1136/bmj.2.5147.257
[12]
Global Initiative for Chronic Obstructive Lung Disease (2018) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Report. Goldcopd.org. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf
[13]
Nathan, R.A., Sorkness, C.A., Kosinski, M., et al. (2004) Development of the Asthma Control Test: A Survey for Assessing Asthma Control. The Journal of Allergy and Clinical Immunology, 113, 59-65. https://doi.org/10.1016/j.jaci.2003.09.008
[14]
Graham, B.L., Steenbruggen, I., Miller, M.R., et al. (2019) Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement. American Journal of Respiratory and Critical Care Medicine, 200, e70-e88. https://doi.org/10.1164/rccm.201908-1590ST
[15]
Johnson, B. and Weisman, I. (1999) Emerging Concepts in the Evaluation of Ventilatory Limitation during Exercise: The Exercise Tidal Flow-Volume Loop. Chest, 116, 488-503. https://doi.org/10.1378/chest.116.2.488
[16]
Dixon, W.J. and Massey Jr., F.J. (1983) Introduction to Statistical Analysis. 4th Edition, McGraw-Hill, New York, 385-414.
[17]
Diaz, O., Villafranca, C., Ghezzo, H., et al. (2000) Role of Inspiratory Capacity on Exercise Tolerance in COPD Patients with and without Tidal Expiratory Flow Limitation at Rest. European Respiratory Journal, 16, 269-275. https://doi.org/10.1034/j.1399-3003.2000.16b14.x
[18]
Holland, A.E., Denehy, L. and Wilson, J.W. (2006) Does Expiratory Flow Limitation Predict Chronic Dyspnoea in Adults with Cystic Fibrosis? European Respiratory Journal, 28, 96-101. https://doi.org/10.1183/09031936.06.00122105
[19]
Martin, J.G. (1993) Respiratory Mechanics in Asthma. The European Respiratory Review, 14, 444-447.
[20]
Gold, W.M., Kaufman, M.S. and Nadel, J.A. (1967) Elastic Recoil of the Lungs in Chronic Asthmatic Patients before and after Therapy. Journal of Applied Physiology, 23, 433-438. https://doi.org/10.1152/jappl.1967.23.4.433
[21]
Peress, L., Sybrecht, G. and Macklem, P.T. (1976) The Mechanism of the Increase in Total Lung Capacity during Acute Asthma. The American Journal of Medicine, 61, 165-168. https://doi.org/10.1016/0002-9343(76)90165-0
[22]
Higgenbottam, T. (1980) Narrowing of the Glottis Opening in Humans Associated with Experimentally Induced Bronchoconstriction. Journal of Applied Physiology, 49, 403-407. https://doi.org/10.1152/jappl.1980.49.3.403
[23]
Collette, P.W., Brancatisano, T. and Engel, L.A. (1986) Upper Airway Dimensions and Movements in Bronchial Asthma in Bronchial Asthma. The American Review of Respiratory Disease, 133, 1143-1149.
[24]
McCarthy, D.S. and Milic-Emili, J. (1973) Closing Volume in Asymptomatic Asthma. The American Review of Respiratory Disease, 107, 559-570. https://doi.org/10.1164/arrd.1973.107.4.559
[25]
Shee, C.D., Ploy-Song-Sang and Milic-Emili, J. (1985) Decay of Inspiratory Muscle Pressure during Expiration in Conscious Humans. Journal of Applied Physiology, 58, 1859-1865. https://doi.org/10.1152/jappl.1985.58.6.1859
[26]
Mortola, J.P., Magnante, D. and Saetta, M. (1985) Expiratory Pattern of Newborn Mammals. Journal of Applied Physiology, 58, 528-533. https://doi.org/10.1152/jappl.1985.58.2.528
[27]
Eissa, N.T., Ranieri, V.M., Corbeil, C., et al. (1991) Analysis of Behavior of the Respiratory System in ARDS Patients: Effects of Flow, Volume, and Time. Journal of Applied Physiology, 70, 2719-2729. https://doi.org/10.1152/jappl.1991.70.6.2719
[28]
Guerin, C., Coussa, M.-L., Eissa, N.T., et al. (1993) Lung and Chest Wall Mechanics in Mechanically Ventilated COPD Patients. Journal of Applied Physiology, 74, 157-1580. https://doi.org/10.1152/jappl.1993.74.4.1570
[29]
Nadel, J.A. and Tierney, D.F. (1961) Effect of a Previous Deep Inspiration on Airway Resistance in Man. Journal of Applied Physiology, 16, 717-719. https://doi.org/10.1152/jappl.1961.16.4.717
[30]
Gump, A., Haughney, L. and Fredberg, J. (2001) Relaxation of Activated Airway Smooth Muscle: Relative Potency of Isoproterenol vs. Tidal Stretch. Journal of Applied Physiology, 90, 2306-2310. https://doi.org/10.1152/jappl.2001.90.6.2306
[31]
Lavoie, T.L., Ramaswamy, K., Siegel, H.R., et al. (2012) Dilatation of the Constricted Human Airway by Tidal Expansion of Lung Parenchyma. American Journal of Respiratory and Critical Care Medicine, 186, 225-232. https://doi.org/10.1164/rccm.201202-0368OC
[32]
Koulouris, N.G. and Hardavella, G. (2011) Physiological Techniques for Detecting Expiratory Flow Limitation during Tidal Breathing. The European Respiratory Review, 20, 147-155. https://doi.org/10.1183/09059180.00001911
[33]
Boczkowski, J., Murciano, D., Pichot, M.-H., et al. (1997) Expiratory Flow Limitation in Stable Asthmatic Patients during Resting Breathing. American Journal of Respiratory and Critical Care Medicine, 156, 752-757. https://doi.org/10.1164/ajrccm.156.3.9609083
[34]
Filippelli, M., Pacini, F., Romagnoli, I., et al. (2000) Airway Obstruction and Chronic Exertional Dyspnea in Patients with Persistent Bronchial Asthma. Respiratory Medicine, 94, 694-701. https://doi.org/10.1053/rmed.2000.0803
[35]
Melissinos, C.G., Webster, P., Tien, Y.K., et al. (1979) Time Dependence of Maximum Flow as an Index of Nonuniform Emptying. Journal of Applied Physiology, 47, 1043-1050. https://doi.org/10.1152/jappl.1979.47.5.1043
[36]
Liistro, G., Veritier, C., Dury, M., et al. (1999) Expiratory Flow Limitation in Awake Sleep-Disordered Breathing Subjects. European Respiratory Journal, 14, 185-190. https://doi.org/10.1034/j.1399-3003.1999.14a31.x
[37]
Baydur, A., Wilkinson, L., Mehdian, R., et al. (2004) Extrathoracic Flow Limitation in Obesity and Obstructive and Restrictive Disorders: Effects of Increasing Negative Expiratory Pressure. Chest, 125, 98-105. https://doi.org/10.1378/chest.125.1.98
[38]
Ninane, V., Leduc, D., Kafi, S.A., et al. (2001) Detection of Expiratory Flow Limitation by Manual Compression of the Abdominal Wall. American Journal of Respiratory and Critical Care Medicine, 163, 1326-1330. https://doi.org/10.1164/ajrccm.163.6.2004150
[39]
Ingram, R.H. and Schilder, D.P. (1966) Effect of Gas Compression on Pulmonary, Flow, and Volume Relationship. Journal of Applied Physiology, 21, 1821-1826. https://doi.org/10.1152/jappl.1966.21.6.1821
[40]
Shore, S., Milic-Emili, J. and Martin, J.G. (1982) Reassessment of Body Plethysmographic Technique for the Measurement of Thoracic Gas Volume in Asthmatics. The American Review of Respiratory Disease, 126, 515-520.
[41]
Rodenstein, D.O., Stanescu, D.C. and Francis, C. (1982) Demonstration of Failure of Body Plethysmography in Airway Obstruction. Journal of Applied Physiology Respiratory Environmental and Exercise Physiology, 52, 949-954. https://doi.org/10.1152/jappl.1982.52.4.949
[42]
Jaeger, M.J. (1982) Effect of the Cheeks and the Compliance of Alveolar Gas on the Measurement of Respiratory Variables. Respiration Physiology, 47, 325-340. https://doi.org/10.1016/0034-5687(82)90061-5
