Obizatelno,vecherom, posli Raboti dam link. (rabochi den tolko nachalsa).Кира писал(а):Откуда цитата? Можно ссылку на первоисточник? Ощущение, что это рекомендации именно для спортсменов.
Речь не идет о том, что не надо делать тест с нагрузкой, а том, что его сложнее организовать. И что нагрузка не заменяет фармакологические пробы для диагностики астмы в целом. Что косвенно видно даже из Вашей цитаты - большинство лабораторий проводят метахолиновый тест, и только некоторые - нагрузочный. Моя цитата про чувствительность метахолинового теста из аптудейта. Примерно о том же говорят на лекциях по пульмонологии для американских врачей-интернистов. Проблемы нагрузочного теста с ложноотрицательными результатами, то есть с чувствительностью, у метахолинового - со ложноположительными, то есть со специфичностью.
Диастолическая трикуспидальная регургитация
Модератор: Pyankov Vasily
Основная причина начинать с нагрузочного теста, а не фармакологического - не низкая чувствительность метахолинового теста, а существующая вероятность пропустить альтернативный диагноз, симптомы которого также возникают именно при физической нагрузке. "The following exercise-associated airway processes may be missed on routine pulmonary function testing. Diagnosis may require direct visualization or a high index of suspicion:
●Central airway obstruction – Features that suggest central airway obstruction include a lack of response to inhaled bronchodilator, associated hemoptysis, and risk factors for lung cancer or metastasis to the airway. (See "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults".)
●Paradoxical vocal fold motion – The hallmark of PVFM is inspiratory stridor accompanied by respiratory distress. However, a portion of patients have expiratory stridor due to expiratory adduction of the vocal folds. PVFM is often brought on by exercise. (See "Paradoxical vocal fold motion".)
●Exercise-induced laryngomalacia – Exercise-induced laryngomalacia is associated with inspiratory stridor during exercise caused by abnormal movement of the aryepiglottic folds into the endolarynx, resulting in subtotal glottic obstruction [47-50]. It is distinct from tracheomalacia. The diagnosis is made by flexible laryngoscopy during exercise. Exercise-induced laryngomalacia and PVFM are both forms of exercise-induced laryngeal obstruction. (See "Paradoxical vocal fold motion", section on 'Differential diagnosis'.)
●Exercise-induced anaphylaxis – Exercise-induced anaphylaxis is characterized by the abrupt onset of signs and symptoms of anaphylaxis during exercise. Prodromal symptoms may include generalized pruritus, warmth, urticaria, and fatigue. A food co-factor may be implicated. Some patients develop laryngeal angioedema as a component, although hypotension and/or cardiovascular collapse are more common. (See "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis", section on 'Clinical manifestations'.)
●Exercise-associated reflux – Laryngopharyngeal reflux during exercise can mimic mild symptoms of EIB and exercise-induced anaphylaxis, including flushing, throat discomfort, dysphonia, and chest tightness/cough. However, it is not associated with severe dyspnea, pruritus, or urticaria. (See "Laryngopharyngeal reflux", section on 'Diagnosis'.)
The differential diagnosis of EIB is similar among children. In one retrospective review, treadmill exercise testing was performed in 142 children referred to a pediatric allergy and pulmonology clinic with exercise-induced dyspnea who had no other signs of asthma or in whom treatment with beta-2-agonists had failed [51]. Symptoms of exercise-induced dyspnea were reproduced in 82 percent. Among these 117 children, only 11 (9 percent) had EIB (defined by reproduction of symptoms and ≥15 percent decrease in FEV1 from baseline). Other diagnoses included normal physiologic exercise limitation (63 percent), restrictive abnormalities (13 percent), vocal cord dysfunction (11 percent); laryngomalacia (2 percent), and hyperventilation and supraventricular tachycardia, each in one patient."
●Central airway obstruction – Features that suggest central airway obstruction include a lack of response to inhaled bronchodilator, associated hemoptysis, and risk factors for lung cancer or metastasis to the airway. (See "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults".)
●Paradoxical vocal fold motion – The hallmark of PVFM is inspiratory stridor accompanied by respiratory distress. However, a portion of patients have expiratory stridor due to expiratory adduction of the vocal folds. PVFM is often brought on by exercise. (See "Paradoxical vocal fold motion".)
●Exercise-induced laryngomalacia – Exercise-induced laryngomalacia is associated with inspiratory stridor during exercise caused by abnormal movement of the aryepiglottic folds into the endolarynx, resulting in subtotal glottic obstruction [47-50]. It is distinct from tracheomalacia. The diagnosis is made by flexible laryngoscopy during exercise. Exercise-induced laryngomalacia and PVFM are both forms of exercise-induced laryngeal obstruction. (See "Paradoxical vocal fold motion", section on 'Differential diagnosis'.)
●Exercise-induced anaphylaxis – Exercise-induced anaphylaxis is characterized by the abrupt onset of signs and symptoms of anaphylaxis during exercise. Prodromal symptoms may include generalized pruritus, warmth, urticaria, and fatigue. A food co-factor may be implicated. Some patients develop laryngeal angioedema as a component, although hypotension and/or cardiovascular collapse are more common. (See "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis", section on 'Clinical manifestations'.)
●Exercise-associated reflux – Laryngopharyngeal reflux during exercise can mimic mild symptoms of EIB and exercise-induced anaphylaxis, including flushing, throat discomfort, dysphonia, and chest tightness/cough. However, it is not associated with severe dyspnea, pruritus, or urticaria. (See "Laryngopharyngeal reflux", section on 'Diagnosis'.)
The differential diagnosis of EIB is similar among children. In one retrospective review, treadmill exercise testing was performed in 142 children referred to a pediatric allergy and pulmonology clinic with exercise-induced dyspnea who had no other signs of asthma or in whom treatment with beta-2-agonists had failed [51]. Symptoms of exercise-induced dyspnea were reproduced in 82 percent. Among these 117 children, only 11 (9 percent) had EIB (defined by reproduction of symptoms and ≥15 percent decrease in FEV1 from baseline). Other diagnoses included normal physiologic exercise limitation (63 percent), restrictive abnormalities (13 percent), vocal cord dysfunction (11 percent); laryngomalacia (2 percent), and hyperventilation and supraventricular tachycardia, each in one patient."
С уважением, Кира Далгатова.
itot post govorit o tom routine pulmonary function testing ( both direct & indirect challenge tests) mogut ni obnaruzit perecheslinii vami pathology, i nuzno dopolnitelni testi.Кира писал(а):Основная причина начинать с нагрузочного теста, а не фармакологического - не низкая чувствительность метахолинового теста, а существующая вероятность пропустить альтернативный диагноз, симптомы которого также возникают именно при физической нагрузке. "The following exercise-associated airway processes may be missed on routine pulmonary function testing. Diagnosis may require direct visualization or a high index of suspicion:
●Central airway obstruction – Features that suggest central airway obstruction include a lack of response to inhaled bronchodilator, associated hemoptysis, and risk factors for lung cancer or metastasis to the airway. (See "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults".)
●Paradoxical vocal fold motion – The hallmark of PVFM is inspiratory stridor accompanied by respiratory distress. However, a portion of patients have expiratory stridor due to expiratory adduction of the vocal folds. PVFM is often brought on by exercise. (See "Paradoxical vocal fold motion".)
●Exercise-induced laryngomalacia – Exercise-induced laryngomalacia is associated with inspiratory stridor during exercise caused by abnormal movement of the aryepiglottic folds into the endolarynx, resulting in subtotal glottic obstruction [47-50]. It is distinct from tracheomalacia. The diagnosis is made by flexible laryngoscopy during exercise. Exercise-induced laryngomalacia and PVFM are both forms of exercise-induced laryngeal obstruction. (See "Paradoxical vocal fold motion", section on 'Differential diagnosis'.)
●Exercise-induced anaphylaxis – Exercise-induced anaphylaxis is characterized by the abrupt onset of signs and symptoms of anaphylaxis during exercise. Prodromal symptoms may include generalized pruritus, warmth, urticaria, and fatigue. A food co-factor may be implicated. Some patients develop laryngeal angioedema as a component, although hypotension and/or cardiovascular collapse are more common. (See "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis", section on 'Clinical manifestations'.)
●Exercise-associated reflux – Laryngopharyngeal reflux during exercise can mimic mild symptoms of EIB and exercise-induced anaphylaxis, including flushing, throat discomfort, dysphonia, and chest tightness/cough. However, it is not associated with severe dyspnea, pruritus, or urticaria. (See "Laryngopharyngeal reflux", section on 'Diagnosis'.)
The differential diagnosis of EIB is similar among children. In one retrospective review, treadmill exercise testing was performed in 142 children referred to a pediatric allergy and pulmonology clinic with exercise-induced dyspnea who had no other signs of asthma or in whom treatment with beta-2-agonists had failed [51]. Symptoms of exercise-induced dyspnea were reproduced in 82 percent. Among these 117 children, only 11 (9 percent) had EIB (defined by reproduction of symptoms and ≥15 percent decrease in FEV1 from baseline). Other diagnoses included normal physiologic exercise limitation (63 percent), restrictive abnormalities (13 percent), vocal cord dysfunction (11 percent); laryngomalacia (2 percent), and hyperventilation and supraventricular tachycardia, each in one patient."
Это я понимаю, но нагрузочный тест даст возможность наблюдать характерную симптоматику во время приступа, и, таким образом, заподозрить альтернативный диагноз, что, разумеется невозможно при проведении фармакологических тестов, которые способны только исключить астму в случае отрицательного результата.
Ну, и еще раз о чувствительности и специфичности. А также о том, что нагрузочный тест - это не просто "побегал и дунул в спирометр".
METHACHOLINE CHALLENGE
The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results.15,17 A positive methacholine challenge result is defined as a greater than 20% reduction in FEV1 at or before administration of 4 mg per mL of inhaled methacholine.15 The result is considered borderline if the FEV1 drops by 20% at a dose between 4 and 16 mg per mL.15
MANNITOL INHALATION CHALLENGE
The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the methacholine challenge, but has a higher specificity for the diagnosis of asthma.16,17 A positive mannitol inhalation challenge result is defined as a greater than 15% decrease from baseline in FEV1 at a cumulative dose of 635 mg or less of inhaled mannitol, or a 10% decrease between any two consecutive doses.16,17
EXERCISE TESTING
A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only modest sensitivity and specificity for the diagnosis of asthma.17 In this test, baseline spirometry is measured, followed by exercise on a treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight minutes.17 Inhaled medical-grade dry air or an air-conditioned room, with air temperature between 60°F and 77°F (20°C and 25°C) and humidity level less than 50%, is recommended. The patient must wear a nose clip.
Postchallenge FEV1 testing takes place at 1- to 3-, 5-, 10-, 15-, 20-, and 30- to 45-minute time points. The test is considered positive if a 10% or greater decline from baseline in FVC or FEV1 occurs over any two consecutive time points in the 30 minutes following the cessation of exercise.15,18
http://www.aafp.org/afp/2014/0301/p359.html
Полагаю, при соблюдении протокола, проведение нагрузочного теста для выявления бронхиальной обструкции должно быть в разы дороже, чем метахолиновый тест. Отчасти, думаю, это и является причиной того, что метахолин у них практически везде, а вот нагрузка только в некоторых лабораториях. Умеют считать деньги.
Ну, и еще раз о чувствительности и специфичности. А также о том, что нагрузочный тест - это не просто "побегал и дунул в спирометр".
METHACHOLINE CHALLENGE
The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results.15,17 A positive methacholine challenge result is defined as a greater than 20% reduction in FEV1 at or before administration of 4 mg per mL of inhaled methacholine.15 The result is considered borderline if the FEV1 drops by 20% at a dose between 4 and 16 mg per mL.15
MANNITOL INHALATION CHALLENGE
The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the methacholine challenge, but has a higher specificity for the diagnosis of asthma.16,17 A positive mannitol inhalation challenge result is defined as a greater than 15% decrease from baseline in FEV1 at a cumulative dose of 635 mg or less of inhaled mannitol, or a 10% decrease between any two consecutive doses.16,17
EXERCISE TESTING
A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only modest sensitivity and specificity for the diagnosis of asthma.17 In this test, baseline spirometry is measured, followed by exercise on a treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight minutes.17 Inhaled medical-grade dry air or an air-conditioned room, with air temperature between 60°F and 77°F (20°C and 25°C) and humidity level less than 50%, is recommended. The patient must wear a nose clip.
Postchallenge FEV1 testing takes place at 1- to 3-, 5-, 10-, 15-, 20-, and 30- to 45-minute time points. The test is considered positive if a 10% or greater decline from baseline in FVC or FEV1 occurs over any two consecutive time points in the 30 minutes following the cessation of exercise.15,18
http://www.aafp.org/afp/2014/0301/p359.html
Полагаю, при соблюдении протокола, проведение нагрузочного теста для выявления бронхиальной обструкции должно быть в разы дороже, чем метахолиновый тест. Отчасти, думаю, это и является причиной того, что метахолин у них практически везде, а вот нагрузка только в некоторых лабораториях. Умеют считать деньги.
С уважением, Кира Далгатова.
"Полагаю, при соблюдении протокола, проведение нагрузочного теста для выявления бронхиальной обструкции должно быть в разы дороже, чем метахолиновый тест. Отчасти, думаю, это и является причиной того, что метахолин у них практически везде, а вот нагрузка только в некоторых лабораториях. Умеют считать деньги."
Vi Obsoletno Pravi,
link to the article
http://www.aafp.org/afp/2011/0815/p427.html
Vi Obsoletno Pravi,
link to the article
http://www.aafp.org/afp/2011/0815/p427.html