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was created<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> in order to quantify the level of concavity of the EFVC&#46; To this end&#44; two straight lines were plotted&#58; one from the point of residual volume to the EFVC at 50&#37; of expiratory volume and one from 50&#37; expiratory volume to the extrapolation of the peak expiratory flow on the vertical axis&#44; corresponding to total lung capacity &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; A&#946; is measured at the point where these two straight lines intersect&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In adult patients&#44; A&#946; has been used to quantify obstruction in patients with asthma<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3&#44;5</span></a> Reference values for pediatric patients have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> One study showed a 91&#37; specificity for distinguishing patients with atopic asthma from healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> A lower A&#946; measured by <span class="elsevierStyleItalic">z</span>-score was observed in patients with wheezing and spirometric obstruction than in healthy patients&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">An improvement in the A&#946; in adults with asthma was recorded after treatment with inhaled corticosteroids<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> and bronchodilators&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> A study in pediatric and adult patients<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> showed a significant correlation &#40;<span class="elsevierStyleItalic">r</span>&#61;&#8722;0&#46;959&#41; with the visual estimation of concavity by experts&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The degree of obstruction can be estimated by the area under the curve &#40;AUC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">11&#44;12</span></a> To achieve this&#44; the area of a right-angled triangle &#40;At&#41; with one cathetus originating from the extrapolation of the peak expiratory flow &#40;PEF&#41; at the level of the abscissa &#40;Xp&#41; and the other running from this point to the point of residual volume&#44; with the hypotenuse connecting both ends is calculated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#46; Specific software is used to determine expiratory AUC&#44; which&#44; when subtracted from the At can be used to quantify the area Au &#40;between the hypotenuse of the triangle and the EFVC&#41;&#46; Given that this area depends on the degree of concavity and the anthropometric characteristics of the subject&#44; the obstructive area &#40;Ao&#61;Au&#47;At&#41;&#44; which is proportional to the degree of obstruction&#44; is used&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Using the same catheti mentioned above&#44; the area of the rectangle &#40;AR&#41; can be calculated from the ratio between a real and a predicted rectangle&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">By studying these variables and their ratios&#44; both Ao&#47;AR and Ao&#47;PEF were found to correlate closely with RV&#47;TLC &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;718 and <span class="elsevierStyleItalic">r</span>&#61;0&#46;780&#44; respectively&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;001 for both&#41; and distance walked on a 6-minute walk test &#40;<span class="elsevierStyleItalic">r</span>&#61;&#8722;0&#46;618 and <span class="elsevierStyleItalic">r</span>&#61;&#8722;0&#46;581&#44; respectively&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;01 both&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Furthermore&#44; in a study of AUC&#47;At in the first 3<span class="elsevierStyleHsp" style=""></span>s of expiration&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> a strong correlation &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;88&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; was observed with obstruction measured by FEV1&#47;FVC and a kappa of 0&#46;72 for the diagnosis of COPD according to Global Initiative for Chronic Obstructive Lung Disease &#40;GOLD&#41; criteria&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">EFVC concavity can be quantified using mathematical models&#46; Hyperbolic<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> and quadratic<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> functions have been used to estimate the curve&#46; The greatest difference between functions is that in one&#44; maximum curvature &#40;Kmax&#41; is estimated while in the other&#44; the average curvature index &#40;ACI&#41; is determined&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A negative exponential relationship between Kmax and FEV1 has been found in a heterogeneous population of adults&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> In pediatric patients with asthma&#44; moreover&#44; a regular correlation &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;53&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; was observed between ACI and symptoms that was higher than that of the traditional spirometric variables &#40;<span class="elsevierStyleItalic">r</span>&#61;&#8722;0&#46;22 for FEV1&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;14&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Concavity indices are calculated by comparing forced expiratory flows &#40;FEF50&#37; and 75&#37;&#41; with the reference values &#40;estimated by extrapolation of their points toward a straight line that joins PEF with the point of residual volume&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A study of non-smokers<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> showed a higher prevalence of obstruction according to central &#40;12&#37;&#8211;14&#46;6&#37;&#41; and peripheral &#40;14&#46;6&#37;&#8211;17&#46;9&#37;&#41; concavity compared with FEV1 &#40;6&#46;2&#37;&#8211;8&#46;0&#37;&#41;&#44; and FEV1&#47;FVC &#40;5&#46;6&#37;&#8211;8&#46;3&#37;&#41; that was not associated with clinical outcomes&#44; suggesting possible overdiagnosis&#46; There was a high correlation &#40;between <span class="elsevierStyleItalic">r</span>&#61;&#8722;0&#46;710 and &#8722;0&#46;789&#41; for concavity indices and FEV1&#47;FVC&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Curvilinear analysis techniques showed variable usefulness in the diagnosis of obstruction&#44; association with therapeutic response&#44; and the presence of symptoms&#46; The populations evaluated were heterogeneous in terms of etiology and age range&#46; No comparisons were made between methods&#44; and the methods for demonstrating diagnostic utility vary among the studies&#46; The methods involve a risk of overdiagnosing obstruction&#44; and standardized limits are not available for some&#46; The pediatric population may benefit from the use of these techniques&#44; since their standards of obstruction are less sensitive&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The wider dissemination of these methods could lead to new applications in medical practice&#46; However&#44; there is not enough evidence to recommend any method in a systematic way&#46; It would be useful to evaluate these methods in symptomatic patients without spirometric obstruction with the aim of detecting a population who might benefit from treatment&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Maritano Furcada J&#44; Rodr&#237;guez CI&#44; Wainstein EJ&#44; Benito HJ&#46; M&#233;todos de an&#225;lisis gr&#225;fico de obstrucci&#243;n espirom&#233;trica&#58; &#191;una imagen vale m&#225;s que mil palabras&#63;&#46; Arch Bronconeumol&#46; 2019&#59;55&#58;272&#8211;274&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Measuring angle <span class="elsevierStyleItalic">&#946;</span>&#46; &#40;b&#41; Area under the curve method&#46; &#40;c&#41; Central and peripheral concavity&#46; Each method is described in the text&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao&#58; obstructive area&#59; AR area&#58; area of the rectangle&#59; At&#58; area of the triangle&#59; Au&#58; area between the hypotenuse of the triangle and the expiratory forced expiration curve&#59; AUC&#58; area under the curve&#59; FEF50&#37;&#58; forced expiratory flow at 50&#37; of vital capacity&#59; FEF75&#37;&#58; forced expiratory flow at 75&#37; of vital capacity&#59; L&#47;s&#58; liters per second&#59; PEF&#58; peak expiratory flow&#59; Ref&#58; reference&#59; RV&#58; residual volume&#59; TLC&#58; total lung capacity&#59; Xp&#58; extrapolation of PEF in the abscissa&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Graphics adapted from Dominelli et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Lee et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and Johns et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p>"
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Scientific Letter
Graphical Analysis Methods in Obstructive Spirometry: Does a Picture Speak More Than a Thousand Words?
Métodos de análisis gráfico de obstrucción espirométrica: ¿una imagen vale más que mil palabras?
Joaquín Maritano Furcada
Corresponding author
, César Ignacio Rodríguez, Esteban Javier Wainstein, Hernán Javier Benito
Servicio de Neumonología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

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