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"tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "274" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Graphical Analysis Methods in Obstructive Spirometry: Does a Picture Speak More Than a Thousand Words?" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1673 "Ancho" => 2500 "Tamanyo" => 168367 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a)<span class="elsevierStyleHsp" style=""></span>Medición del ángulo β. b)<span class="elsevierStyleHsp" style=""></span>Método de área bajo la curva. c)<span class="elsevierStyleHsp" style=""></span>Concavidad central y periférica. Desarrollo de cada método en el texto.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao: área obstructiva; AR: área del rectángulo; At: área del triángulo; Au: área comprendida entre la hipotenusa del triángulo y la curva de espiración forzada espiratoria; AUC: área bajo la curva; FEF 50%: flujo espiratorio forzado al 50% de la capacidad vital; FEF 75%: flujo espiratorio forzado al 75% de la capacidad vital; L/s: litros por segundo; PEF: pico flujo espiratorio; Ref: referencia; RV: volumen residual; TLC: capacidad pulmonar total; Xp: extrapolación del PEF en las abscisas.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Gráficos adaptados de Dominelli et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a>, Lee et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> y Johns et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span 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array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Bilateral Lung Transplantation in a Patient With Severe Right Pleural Cavity Restriction" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "271" "paginaFinal" => "272" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante pulmonar bilateral en un paciente con una restricción severa de la cavidad pleural derecha" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 558 "Ancho" => 1300 "Tamanyo" => 142598 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT slices showing a collapsed right lung due to the presence of multiple bronchiectasis. Only the areas of emphysematous lung are aerated, with bullous changes. A small air-fluid level suggestive of superinfection over the bullous parenchyma can also be visualized. Moreover, major hyperinflation is present in the left lung with extensive areas of panacinar emphysema in the upper lobe. This hyperinflation, along with the collapse of the right lung, produces a significant shift in the mediastinum toward the contralateral side.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Luis Campo-Cañaveral de la Cruz, David Gómez de Antonio, Álvaro Sánchez Calle, Alejandra Romero Román" "autores" => array:4 [ 0 => array:2 [ "nombre" => "José Luis" "apellidos" => "Campo-Cañaveral de la Cruz" ] 1 => array:2 [ "nombre" => "David" "apellidos" => "Gómez de Antonio" ] 2 => array:2 [ "nombre" => "Álvaro" "apellidos" => "Sánchez Calle" ] 3 => array:2 [ "nombre" => "Alejandra" "apellidos" => "Romero Román" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289618303028" "doi" => "10.1016/j.arbres.2018.07.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289618303028?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212919300564?idApp=UINPBA00003Z" "url" => "/15792129/0000005500000005/v1_201905020905/S1579212919300564/v1_201905020905/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Graphical Analysis Methods in Obstructive Spirometry: Does a Picture Speak More Than a Thousand Words?" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "274" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Joaquín Maritano Furcada, César Ignacio Rodríguez, Esteban Javier Wainstein, Hernán Javier Benito" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Joaquín" "apellidos" => "Maritano Furcada" "email" => array:1 [ 0 => "joaquin.maritano@hospitalitaliano.org.ar" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "César Ignacio" "apellidos" => "Rodríguez" ] 2 => array:2 [ "nombre" => "Esteban Javier" "apellidos" => "Wainstein" ] 3 => array:2 [ "nombre" => "Hernán Javier" "apellidos" => "Benito" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumonología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Métodos de análisis gráfico de obstrucción espirométrica: ¿una imagen vale más que mil palabras?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1673 "Ancho" => 2500 "Tamanyo" => 166046 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Measuring angle <span class="elsevierStyleItalic">β</span>. (b) Area under the curve method. (c) Central and peripheral concavity. Each method is described in the text.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao: obstructive area; AR area: area of the rectangle; At: area of the triangle; Au: area between the hypotenuse of the triangle and the expiratory forced expiration curve; AUC: area under the curve; FEF50%: forced expiratory flow at 50% of vital capacity; FEF75%: forced expiratory flow at 75% of vital capacity; L/s: liters per second; PEF: peak expiratory flow; Ref: reference; RV: residual volume; TLC: total lung capacity; Xp: extrapolation of PEF in the abscissa.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Graphics adapted from Dominelli et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Lee et al.,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and Johns et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The evaluation of airway obstruction is fundamental in the management of asthma and COPD. Obstruction is usually quantified by spirometry, comparing FEV1 and FEV1/FVC with reference values.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> A reduced expiratory flow caused by obstruction of the small airways produces a concave pattern on the expiratory flow–volume curve (EFVC) in forced exhalation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> The standard practice of direct observation is subject to a certain degree of variability. As an alternative, if high quality maneuvers are obtained,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> the graphic properties of this curve can be measured objectively, although this method is relatively unknown in the literature and standard practice.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> The additional information provided by this method should increase the sensitivity of the diagnosis of obstruction, especially in patients with normal values on standard spirometry.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this study, we describe the different techniques for measuring bronchial obstruction using curvilinear graphical analysis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a non-systematic review of the literature in the Pubmed database using the terms “concavity”, “curvilinearity” and “spirometry”. Prospective and retrospective search techniques were then applied. Studies were selected that assessed the diagnostic and prognostic capacity of curvilinear analytical methods.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We retrieved 13 articles describing 4 methods of evaluating obstruction using EFVC analysis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The angle beta (Aβ) was created<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> in order to quantify the level of concavity of the EFVC. To this end, two straight lines were plotted: one from the point of residual volume to the EFVC at 50% of expiratory volume and one from 50% expiratory volume to the extrapolation of the peak expiratory flow on the vertical axis, corresponding to total lung capacity (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Aβ is measured at the point where these two straight lines intersect.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In adult patients, Aβ has been used to quantify obstruction in patients with asthma<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and COPD.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,5</span></a> Reference values for pediatric patients have been described.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> One study showed a 91% specificity for distinguishing patients with atopic asthma from healthy controls.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> A lower Aβ measured by <span class="elsevierStyleItalic">z</span>-score was observed in patients with wheezing and spirometric obstruction than in healthy patients.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">An improvement in the Aβ in adults with asthma was recorded after treatment with inhaled corticosteroids<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> and bronchodilators.<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 (<span class="elsevierStyleItalic">r</span>=−0.959) with the visual estimation of concavity by experts.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The degree of obstruction can be estimated by the area under the curve (AUC).<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">11,12</span></a> To achieve this, the area of a right-angled triangle (At) with one cathetus originating from the extrapolation of the peak expiratory flow (PEF) at the level of the abscissa (Xp) and the other running from this point to the point of residual volume, with the hypotenuse connecting both ends is calculated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). Specific software is used to determine expiratory AUC, which, when subtracted from the At can be used to quantify the area Au (between the hypotenuse of the triangle and the EFVC). Given that this area depends on the degree of concavity and the anthropometric characteristics of the subject, the obstructive area (Ao=Au/At), which is proportional to the degree of obstruction, is used.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Using the same catheti mentioned above, the area of the rectangle (AR) can be calculated from the ratio between a real and a predicted rectangle.</p><p id="par0050" class="elsevierStylePara elsevierViewall">By studying these variables and their ratios, both Ao/AR and Ao/PEF were found to correlate closely with RV/TLC (<span class="elsevierStyleItalic">r</span>=0.718 and <span class="elsevierStyleItalic">r</span>=0.780, respectively; <span class="elsevierStyleItalic">P</span>=.001 for both) and distance walked on a 6-minute walk test (<span class="elsevierStyleItalic">r</span>=−0.618 and <span class="elsevierStyleItalic">r</span>=−0.581, respectively; <span class="elsevierStyleItalic">P</span><.01 both).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Furthermore, in a study of AUC/At in the first 3<span class="elsevierStyleHsp" style=""></span>s of expiration,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> a strong correlation (<span class="elsevierStyleItalic">r</span>=0.88; <span class="elsevierStyleItalic">P</span><.001) was observed with obstruction measured by FEV1/FVC and a kappa of 0.72 for the diagnosis of COPD according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria.</p><p id="par0055" class="elsevierStylePara elsevierViewall">EFVC concavity can be quantified using mathematical models. 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. The greatest difference between functions is that in one, maximum curvature (Kmax) is estimated while in the other, the average curvature index (ACI) is determined.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A negative exponential relationship between Kmax and FEV1 has been found in a heterogeneous population of adults.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> In pediatric patients with asthma, moreover, a regular correlation (<span class="elsevierStyleItalic">r</span>=0.53; <span class="elsevierStyleItalic">P</span><.001) was observed between ACI and symptoms that was higher than that of the traditional spirometric variables (<span class="elsevierStyleItalic">r</span>=−0.22 for FEV1; <span class="elsevierStyleItalic">P</span>=.14).<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 (FEF50% and 75%) with the reference values (estimated by extrapolation of their points toward a straight line that joins PEF with the point of residual volume) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c).</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 (12%–14.6%) and peripheral (14.6%–17.9%) concavity compared with FEV1 (6.2%–8.0%), and FEV1/FVC (5.6%–8.3%) that was not associated with clinical outcomes, suggesting possible overdiagnosis. There was a high correlation (between <span class="elsevierStyleItalic">r</span>=−0.710 and −0.789) for concavity indices and FEV1/FVC.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Curvilinear analysis techniques showed variable usefulness in the diagnosis of obstruction, association with therapeutic response, and the presence of symptoms. The populations evaluated were heterogeneous in terms of etiology and age range. No comparisons were made between methods, and the methods for demonstrating diagnostic utility vary among the studies. The methods involve a risk of overdiagnosing obstruction, and standardized limits are not available for some. The pediatric population may benefit from the use of these techniques, since their standards of obstruction are less sensitive.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The wider dissemination of these methods could lead to new applications in medical practice. However, there is not enough evidence to recommend any method in a systematic way. 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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Maritano Furcada J, Rodríguez CI, Wainstein EJ, Benito HJ. Métodos de análisis gráfico de obstrucción espirométrica: ¿una imagen vale más que mil palabras?. Arch Bronconeumol. 2019;55:272–274.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1673 "Ancho" => 2500 "Tamanyo" => 166046 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Measuring angle <span class="elsevierStyleItalic">β</span>. (b) Area under the curve method. (c) Central and peripheral concavity. Each method is described in the text.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao: obstructive area; AR area: area of the rectangle; At: area of the triangle; Au: area between the hypotenuse of the triangle and the expiratory forced expiration curve; AUC: area under the curve; FEF50%: forced expiratory flow at 50% of vital capacity; FEF75%: forced expiratory flow at 75% of vital capacity; L/s: liters per second; PEF: peak expiratory flow; Ref: reference; RV: residual volume; TLC: total lung capacity; Xp: extrapolation of PEF in the abscissa.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Graphics adapted from Dominelli et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Lee et al.,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and Johns et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interpretative strategies for lung function tests" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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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
, César Ignacio Rodríguez, Esteban Javier Wainstein, Hernán Javier Benito
Corresponding author
Servicio de Neumonología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina