Pulmonary Function Study
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1 The Belgian Pulmonary Function Study: the Belgian Thoracic Society
2 Steering committee UZLeuven (M. Decramer, W. Janssens) Middelheim Antwerpen (L. Bedert) UZ Antwerpen (W. De Backer) Universiteit Liège (JL. Corhay) AZ Kortrijk (R. Deman) UZ Gent (E. Derom, G. Joos) St Pierre Bruxelles (V. Ninane) AZ Brugge (D. Van Renterghem) UCL Bruxelles (G. Liistro) Charleroi (R. Peché, A. Van Meirhaeghe)
3 Inclusion criteria yrsold New patients with respiratory symptoms: dyspnea cough sputum but without firm diagnosis Seen by pulmonologist Able to perform pulmonary function tests Written informed consent
4 New outpatients with respiratory symptoms but without diagnosis History Clinical Data Spirometry with flow-volume curve Absolute volumes Resistance Diffusion capacity LOK/GLEM meeting Frequency: 4/year Diagnosis 1 addition of spirometry with flow-volume curve Diagnosis 2 addition of absolute volumes Diagnosis 3 addition of resistance Diagnosis 4 addition of diffusion capacity Pneumologist of the patient Laboratory results and imaging Final diagnosis Gold standard
5 Terminology diagnoses Differential diagnoses Preferential diagnosis after each step Differential diagnoses Preferential diagnosis Side diagnosis after four steps Final diagnosis pulmonologist Final diagnosis corrected by LOK at the end
6 Outcomes Primary outcome 1/ n differential diagnoses (correctie 1/28, 27/28) Secondary outcomes % correct preferential diagnoses (GEE) 1/n differential diagnoses, with correct preferential diagnosis Sensitivity analysis: all analyses, with preferential diagnosis also correct if corresponding to side diagnosis Subgroup analyses: COPD, asthma, ILD, and no respiratory abnormality
7 List of differential diagnosis (checklist) COPD Asthma Upper airway obstruction Other obstructive diseases including Bronchiectasis, Cystic fibrosis and Bronchiolitis. Neuromuscular disease Thoracic deformity Lung function abnormalities due to obesity* Interstitial lung disease Systemic sclerosis and other vasculitis Cardiac failure* Pulmonary vascular disease* No primary pulmonary abnormality Hyperventilation syndrome* Other diagnosis * Only if clinical evidence is present
8 1000+ patients two periods: June 6 th -August 31 st January 16 th May 28 th
9 Participating Hospitals 1 UZ Gasthuisberg Leuven 19 O.L. Vrouwziekenhuis Aalst 2 Middelheim Antwerpen 20 Algemeen Stedelijk Ziekenhuis Aalst 3 UZA Antwerpen 21 Clinique Louis Caty-Baudour Baudour 4 CHU Liège 22 Hopital de la Citadelle Liège 5 AZ Groeninge Kortrijk 23 Clinique Saint-Pierre Ottignies 6 UZ Gent 24 ZOL Genk 7 AZ Maria Middelares Gent 25 Ziekenhuis Ronse 8 UCL, Bruxelles 26 CHR de Namur 9 St. Pierre Bruxelles 27 St. Elisabeth Namur 10 St. Jean Bruxelles 28 Heilig Hart Ziekenhuis Roeselare 11 CHU Brugman Bruxelles 29 AZ Sint Blasius, Dendermonde 12 Université Libre de Bruxelles 30 Ziekenhuis Jolimont 13 IRIS SUD Bruxelles 31 Virga Jesse Hasselt 14 CHU Charleroi 32 Imelda Bonheiden 15 Grand hopital de Charleroi 33 Jan Yperman ziekenhuis Ieper 16 AZ St. Jan Brugge 34 St. Maarten Duffel 17 UCL Mont-Godinne 35 St. Maarten Mechelen 18 AZ St. Jozef Turnhout
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11 Baseline characteristics Patient Characteristic Value Number 79 Age(yrs) 53 ±17 Gender(M/F) 1.19 Weight (kg) 75 ±19 Height(cm) 169 ± 10 BMI (kg.m -2 ) 26 ±6 Allergy/atopy(%) 22 Previous Pulmonary Disease(%) 11 Reflux(%) 18 Nose-Throat-Ear problems(%) 22
12 Baseline characteristics History Value (Ex-) Smoker(%) 63 Pack yrs 25 ±19 Cough(%) 71 Wheezing(%) 9 Dyspnea(%) 78 Fatigue(%) 18 Sputum production(%) 34 Thoracic pain (%) 13 Hemoptoe(%) 4 CAT score 14 ±7
13 History Complaints since Value few months(%) 46 1yearormore (%) 38 1 month(%) 9 others(few weeks, 1week, few days) (%) All < 5 Previous consultation GP (%) 49 Pulmonary function by GP (%) 7 Referral Pulmonary Function Study Baseline characteristics GP (%) 60 own initiative(%) 23 other specialist (%) 18
14 Baseline characteristics Pulmonary function variable Value FVC (L) 3.6 ±1.1 FEV1 (L) 2.6 ±1.0 FEV1/VC 72 ± 11 PEF (L.s -1 ) 6.4 ±2.3 MMEF (L.s -1 ) 2.2 ±1.3 MEF75%FVC (L.s -1 ) 5.3 ±2.2 MEF50%FVC (L.s -1 ) 2.8±1.5 MEF25%FVC (L.s -1 ) 0.9±0.8 TLC (L) 6.0±1.3 RV (L) 2.4±0.9 FRC (L) 3.4 ±1.0 VC (L) 3.6 ±1.1
15 Baseline characteristics Pulmonary function variable Value Raw(kPa.L.s -1 ) 0.4 ±0.6 Raw(cmH2O.L.s -1 ) 3.1 ±1.4 sgaw(s.kpa -1.L) 1.7 ±6.2 sgaw(s.cmh20-1.l -1 ) 12 ±9.1 TL,CO (mmol.min -1.kPa -1 ) 7.2 ±3.3 TL,CO (ml.mmhg -1.min -1 ) 9.8 ±20.1 KCO (mmol.min -1.kPa -1.L -1 ) 1.4 ±0.5 KCO (ml.mmhg -1.min -1.L -1 ) 4.3 ±1.4
16 Differential diagnosis COPD(%) Asthma(%) Upper airway(%) Other obstructive(%) Neuromuscular(%) Thoracic/Pleural(%) Obesity(%) ILD (%) Systemic sclerosis(%) Cardiac failure(%) Pulmonary vascular(%) No abnormality(%) Hyperventilation(%) Other(%)
17 Preferential diagnosis COPD(%) Asthma(%) Upper airway(%) Other obstructive(%) Neuromuscular(%) Thoracic/Pleural(%) Obesity(%) ILD (%) Systemic sclerosis(%) Cardiac failure(%) Pulmonary vascular(%) No abnormality(%) Hyperventilation(%) Other(%)
18 Additional tests Top 10 additional tests Value Chestx-ray(%) 62 Reversibility(%) 53 CT-scan chest(%) 34 Provocation test (%) 29 ExhaledNO (%) 25 Othertest (%) 25 Skin prick test (%) 19 Endoscopy(%) 11 BAL (%) 9 Biopsy(%) 8
19 Most contributing additional tests Top 10 most contributing additional tests Value Chestx-ray(%) 15 Reversibility(%) 17 CT-scan chest(%) 34 Provocation test (%) 28 ExhaledNO (%) 9 Ergospirometry(%) 1 ECG(%) 1 Endoscopy(%) 1 BAL (%) 1 Biopsy(%) 7
20 Primary analysis using LOK preferential diagnosis Test Transformed score Back-transformed score P value Spirometry ± Lung volumes ± < Resistance ± < Diffusing capacity ± <
21 Sensivity analysis using LOK preferential and side diagnosis Test Transformed score Back-transformed score P value Spirometry ± Lung volumes ± < Resistance ± < Diffusing capacity ± <
22 Secondary analysis using LOK preferential diagnosis GEE analysisnumberdifferentialdiagnoses in patients with correct final diagnosis N Median P-value Spirometry Lung volumes Resistance Diffusing capacity
23 Sensitivity analysis using LOK preferential and side diagnosis GEE analysisnumberdifferentialdiagnoses in patients with correct final diagnosis N Median P-value Spirometry Lung volumes < Resistance < Diffusing capacity <
24 Secondary analysis using LOK preferential diagnosis GEE analysis number differential diagnoses in patientswithcorrect final diagnosis Median P-value Lung volumes vs. spirometry < Resistance vs. spirometry < Resistance vs. lung volumes Diffusing capacity vs. spirometry < Diffusing capacity vs. lung volumes < Diffusing capacity vs. resistance
25 Sensivity analysis using LOK preferential and side diagnosis GEE analysis number differential diagnoses in patientswithcorrect final diagnosis Median P-value Lung volumes vs. spirometry < Resistance vs. spirometry < Resistance vs. lung volumes < Diffusing capacity vs. spirometry < Diffusing capacity vs. lung volumes < Diffusing capacity vs. resistance <
26 Secondary analysis using LOK preferential diagnosis GEE analysis% correct final diagnoses Proportion % P-value Spirometry 42/79 53 Lung volumes 46/ Resistance 47/ Diffusing capacity 54/
27 Sensivity analysis using LOK preferential and side diagnosis GEE analysis% correct final diagnoses Proportion % P-value Spirometry 52/79 66 Lung volumes 58/ Resistance 60/ Diffusing capacity 62/
28 Conclusions Each test contributed significantly to the 1/n differential diagnoses score, correctedforthe accuracyof the diagnosis. Each test significantly reduced the number of differential diagnoses. These differenceswereeven more pronounced, ifalsoa correct side diagnosis was taken into account.
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