Utilização da porcentagem e escore Z para avaliar resposta broncodilatadora em crianças asmáticas de idade pré-escolar
Use of percentage and Z-score to evaluate bronchodilator response in preschool asthmatic children
Sandra Lisboa; Luanda Dias da Silva Salviano; Ana Carolina Carioca da Costa; Alessandra L. Malafaia; Shandra L. Monteiro; Renata Wrobel Folescu Cohen
Resumo
Introdução: A resposta ao broncodilatador (RBD) é frequentemente utilizada no apoio diagnóstico e na tomada de decisões terapêuticas em crianças com sintomas respiratórios. Entretanto, não há um consenso do ponto de corte da RBD em crianças pré-escolares. Objetivo: Avaliar RBD através da porcentagem e do deslocamento do escore Z do volume expiratório forçado em relação ao tempo (VEFt ) de crianças asmáticas pré-escolares e propor novos pontos de corte. Métodos: Estudo transversal com 174 espirometrias de crianças asmáticas do ambulatório de alergia/imunologia de hospital de referência nacional no Rio de Janeiro (RJ), realizadas antes e após 15 minutos do uso do broncodilatador, expressas em escore Z e classificadas com padrão obstrutivo quando VEF1/capacidade vital (CV) < -1,645. O poder discriminatório para a RBD dos parâmetros espirométricos foi analisado por curvas ROC, e novos pontos de corte de RBD positiva foram calculados. Resultados: 23,4% apresentou padrão obstrutivo. O índice de Tiffeneau em crianças asmáticas com 3 anos é significativamente menor do que em crianças de 4-6 anos (p = 0,040). VEF0,75 apresentou maior poder discriminatório para RBD (variação > 11% e acurácia > 90%). Os pontos de corte encontrados para as variações percentuais na resposta positiva ao RBD foram 9,5 (VEF1); 13,8 (VEF0,75); 0,6 (escore Z VEF1) e 0,8 (escore Z VEF0,75). Tais pontos de corte refletem altos valores de sensibilidade e especificidade, com valores preditivos positivo e negativo variando em 90%. A conclusão pode ser estendida às variações nos escores Z de VEFt . Conclusões: O VEF0,75 > 11% apresentou melhor discriminação para RBD, demonstrando ser bom parâmetro para a clínica. Os valores encontrados no deslocamento do escore Z após o broncodilatador corroboram com a percepção de que seja um novo recurso para a interpretação da RBD.
Palavras-chave
Abstract
Introduction: Bronchodilator response (BDR) is often used to support diagnostic and therapeutic decision-making in children with respiratory symptoms. However, there is no consensus on the BDR cutoff in preschool children. Objective: To evaluate BDR through the percentage and displacement of Z-scores for forced expiratory volume over time (FEVt ) of preschool asthmatic children and to propose new cutoff points. Methods: Crosssectional study with 174 spirometry tests of asthmatic children from the allergy/immunology outpatient clinic of a national reference hospital in Rio de Janeiro, Brazil, performed before and after 15 min of bronchodilator use, expressed as Z-score and classified as obstructive pattern when forced expiratory volume in 1 minute (FEV1)/vital capacity (VC) < -1,645. The discriminatory power of spirometric parameters to assess BDR was analyzed by receiver operating characteristics (ROC) curves and new positive BDR cutoff points were calculated. Results: 23.4% presented obstructive pattern. The Tiffeneau index in asthmatic children aged 3 years is significantly lower than that found in children aged 4-6 years (p = 0.040). FEV0.75 presented higher discriminatory power for BDR (variation > 11% and accuracy > 90%). The cutoff points found for percentage changes in positive BDR were 9.5 (FEV1); 13.8 (FEV0.75); 0.6 (FEV1 Z-score) and 0.8 (FEV0.75 Z-score). Such cutoff points reflect high sensitivity and specificity values, with positive and negative predictive values ranging by 90%. The conclusion can be expanded to variations in FEVt Z-scores. Conclusions: FEV0.75 > 11% presented better discrimination for BDR, proving to be a good parameter for clinic practice. The values found in the Z-score displacement after use of bronchodilator corroborate the perception that it is a new resource for the interpretation of BDR.
Keywords
Referências
1. Tantisira KG, Fuhlbrigge AL, Tonascia JT, Van Nata M, Zeiger R, Strunc RC, et al. Bronchodilation and bronchoconstriction: predictors of future lung function in childhood asthma. J Allergy Clin Immunol. 2006;117:1264‑71.
2. Borrego LM, Stocks J, Almeida I, Stanojevic S, Antunes J, Leiria-Pinto P, et al. Bronchodilator responsiveness using spirometry in healthy and asthmatic preschool children. Arch Dis Child. 2013;98:112‑7.
3. Galant SP, Morphew T, Amaro S, Liao O. Value of the bronchodilator response in assessing controller naïve asthmatic children. J Pediatr. 2007;151:457‑62.
4. Lai CK, Beasley R, Crane J, Foliaki S, Shah J, Weiland S, et al. Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2009;64:476‑83.
5. Vilozni D, Livnat G, Hakim F, Bentur L. Detection of bronchodilator effect by spirometry in preschool asthmatic children. European Respiratory Journal. 2011;38:1117.
6. Busi LE, Restuccia S, Tourres R, Sly PD. Assessing bronchodilator response in preschool children using spirometry. Thorax. 2017;72:367-72.
7. Beydon N, Davis SD, Lombardi E, Allen JL, Arets HG, Aurora P, et al. An official American Thoracic Society/European Respiratory Society statement: pulmonary function testing in preschool children. Am J Respir Crit Care Med. 2007;175(12):1304-45.
8. Nystad W, Samuelsen SO, Nafstad P, Edvardsen E, Stensrud T, Jaakkola JJ. Feasibility of measuring lung function in preschool children. Thorax. 2002;57(12):1021-7.
9. Aurora P, Stocks J, Oliver C, Saunders C, Castle R, Chaziparasidis G, et al. Quality control for spirometry in preschool children with and without lung disease. Am J Respir Crit Care Med. 2004;169(10):1152‑9.
10. Burity EF, Pereira CA, Rizzo JÂ, Sarinho ES, Jones MH. Early termination of exhalation: effect on spirometric parameters in healthy preschool children. J Bras Pneumol. 2011;37(4):464-70.
11. Salviano LDS, Sad IR, Lisboa S. Avaliação do teste espirométrico em pré-escolares na unidade hospitalar. Rev Ped SOPERJ. 2017;17(2):30-5.
12. Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012;40(6):1324-43.
13. Global Initiative for Asthma – GINA- update 2018. Disponível em: www.ginasthma.org
14. Enright PL, Linn WS, Avol EL, Margolis HG, Gong H, Peters JM. Quality of spirometry test performance in children and adolescents: experience in a large field study. Chest. 2000;118:665-71.
15. Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J. 2012;19:127-64.
16. Iniciativa Global para o Relatório Asma GINA. Estratégia Global para o Manejo e Prevenção da Asma. 2019.
17. Yunginger J, Reed C, O’Connell E, Melton L, O’Fallon W, Silverstein M. A community-based study of the epidemiology of asthma incidence rates 1964-1983. Am Rev Resp Dis. 1992;146:888-94.
18. McGeachie MJ. Childhood asthma is a risk factor for the development of chronic obstructive pulmonary disease. Curr Opin Allergy Clin Immunol. 2017;17(2):104‑9.
19. Grad R, Morgan WJ. Long-term outcomes of early-onset wheeze and asthma. J Allergy Clin Immunol. 2012;130(2):299‑307.
20. Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26(5):948-68.
21. Borrego LM, Couto M, Almeida I, Morais-Almeida M. Espirometria em idade pré-escolar na prática clínica. Rev Port Imunoalergologia [Internet]. 2012 Jan [citado 2020 Mar 28];20(1):23-31.
22. Borsboom GJ, Van Pelt W, Quanjer PH. Pubertal growth curves of ventilatory function: Relationship with childhood respiratory symptoms. Am Rev Respir Dis. 1993;147:372‑8.
23. Quanjer PH, Stanojevic S, Stocks J, Hall GL, Prasad KVV, Cole TJ et al, on behalf of the Global Lung Initiative. Changes in the FEV1/ FVC ratio during childhood and adolescence: an intercontinental study. Eur Respir J. 2010;36(6):1391‑9.
24. Linares Passerini M, Meyer Peirano R, Contreras Estay I, Delgado Becerra I, Castro-Rodriguez JA. Utility of bronchodilator response for asthma diagnosis in Latino preschoolers. Allergol Immunopathol. 2014;42:553‑9.
25. Quanjer PH, Ruppel GL, Langhammer A, Krishna A, Mertens F, Johannessen A, et al. Bronchodilator Response in FVC Is Larger and More Relevant Than in FEV 1 in Severe Airflow Obstruction. Chest. 2017;151(5):1088‑98.
Submetido em:
16/11/2019
Aceito em:
30/04/2020
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email