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at times it is necessary to measure the volume of the air that the lungs cannot displace &#40;static lung volumes&#41;&#46; Thus&#44; plethysmography remains an essential technique in the assessment of lung function&#46; It measures several gas volumes&#44; such as the intrathoracic gas volume &#40;TGV&#41; or the functional residual capacity &#40;FRC&#41;&#44; the residual volume &#40;RV&#41; and the total lung capacity &#40;TLC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#44;5</span></a> The addition of two or more lung volumes makes up a lung capacity &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; This technique also measures total airway resistance &#40;RawTOT&#41;&#44; specific airway resistance &#40;sRaw&#41;&#44; airway conductance &#40;Gaw&#41; and specific airway conductance &#40;sGaw&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Unlike other techniques like nitrogen washout or helium dilution that underestimate the FRC because they do not measure poorly ventilated or unventilated spaces &#40;bullae&#41;&#44; plethysmography measures the full volume of intrathoracic gas&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are three kinds of plethysmographs&#44; and the one used most commonly is the constant-volume plethysmograph&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Equipment</span><p id="par0025" class="elsevierStylePara elsevierViewall">It must include&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Airtight chamber &#40;2 models&#58; older children&#47;adults&#59; infants&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Pneumotachograph&#46; It must meet the standards for spirometric devices &#40;ATS&#47;ERS 2005<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a>&#41;&#58; capable of measuring volumes of 0&#46;5&#8211;8&#46;00<span class="elsevierStyleHsp" style=""></span>L with an accuracy of &#177;3&#37; as calibrated with a 3&#46;00<span class="elsevierStyleHsp" style=""></span>L syringe&#44; flows between 0 and 14<span class="elsevierStyleHsp" style=""></span>L&#47;s&#44; and recording durations of at least 30<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Shutter valve and pressure transducer to measure pressure changes at the mouth&#46; The pressure transducer must have a sensitivity greater than 50<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and a flat frequency response in excess of 8<span class="elsevierStyleHsp" style=""></span>Hz&#46; This depends on the breathing frequency during the TGV manoeuvre&#44; which should not be greater than 1&#46;5<span class="elsevierStyleHsp" style=""></span>Hz&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Pressure transducer inside the plethysmograph chamber &#40;constant-volume variable-pressure plethysmographs&#41;&#46; It measures the pressure within the chamber&#46; In some systems another pneumotachograph is placed on the plethysmograph wall to measure volume changes inside the chamber &#40;constant-pressure variable-volume plethysmographs&#41;&#46; It must be accurate to <span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Computer&#44; printer and weather station &#40;depending on the equipment&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Mouthpieces with disposable in-line filters 99&#37; effective in filtering out viruses&#44; bacteria and mycobacteria&#59; dead space of less than 100<span class="elsevierStyleHsp" style=""></span>mL and a resistance lower than 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O to a flow of 6<span class="elsevierStyleHsp" style=""></span>L&#47;s&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Calibration</span><p id="par0060" class="elsevierStylePara elsevierViewall">Flow metres should be calibrated following the protocol established by the manufacturer and adhering to the ATS&#47;ERS 2005 spirometry standards&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> Plethysmographs usually have automatic calibration systems &#40;chamber seal and transducer alignment&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Plethysmography manoeuvre procedure</span><p id="par0065" class="elsevierStylePara elsevierViewall">It is important to record the patient&#39;s age &#40;years&#41;&#44; weight &#40;kg&#41;&#44; ethnicity and height &#40;cm&#41;&#46; If the patient has difficulty standing up &#40;chest or neuromuscular malformations&#41; the arm span can be used instead of the height&#46; The patient is given detailed information about the test &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#46; The chamber door is shut&#44; letting 1<span class="elsevierStyleHsp" style=""></span>min elapse before starting for the temperature to stabilise&#46; The patient is instructed to breathe through the mouthpiece&#44; supporting his or her cheeks in both hands&#44; in small volumes and at a rate of 20&#8211;60 breaths per minute &#40;0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#46; A set of about 10 tidal breaths should be recorded&#44; seeking to achieve a stable FRC level &#40;variations<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mL&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">At this point&#44; the shutter is closed at the end of an expiration &#40;duration of occlusion&#44; 2&#8211;3<span class="elsevierStyleHsp" style=""></span>s&#41; and the patient continues to breathe while holding his or her cheeks to avoid leaks&#46; When the shutter is reopened&#44; the patient has to take two or three tidal breaths followed by the slow vital capacity manoeuvre&#44; which starts with a maximal inspiration to obtain the inspiratory capacity &#40;IC&#41;&#44; followed by a maximal expiration &#40;to measure the slow vital capacity&#41; and then a maximal inspiration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; If the manoeuvre fails&#44; the technician must explain and demonstrate the test procedure to the patient one more time&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Another standardised procedure&#44; albeit one used less frequently due to its technical difficulty&#44; consists in having the patient exhale to residual volume after occlusion&#44; followed by a maximal inspiration to TLC and then by a slow spirometry manoeuvre&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Plethysmography performance and quality assessment</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Test quality criteria</span><p id="par0080" class="elsevierStylePara elsevierViewall">A set of three to five technically satisfactory TGV-VC manoeuvres must be obtained&#46; The curves must be nearly straight and superimposable on one another&#44; and must be within the pressure calibration ranges of the transducers &#40;&#177;10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or 1&#46;3<span class="elsevierStyleHsp" style=""></span>kPa&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Acceptability criteria</span><p id="par0085" class="elsevierStylePara elsevierViewall">Individual plethysmography manoeuvres &#40;TGV-VC&#41; are acceptable if&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Tidal breathing shows a stable FRC &#40;at least 4 tidal breaths that agree within 100<span class="elsevierStyleHsp" style=""></span>mL&#41;&#46; This is corroborated by the graphs &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The difference in volume &#40;&#916;<span class="elsevierStyleItalic">V</span>&#41; between the FRC level and the occlusion level is less than 200<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The breathing frequency during shutter closure ranges between 30 and 60 breaths per minute&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The plethysmograph tracing shows 3&#8211;5 TGV manoeuvres&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">TGV loops have consistent patterns&#44; are free from artefacts&#44; and show minimal hysteresis between inspiration and expiration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The two ends of the curve can be observed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The slope of the measuring line should parallel the TGV loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The VC measurement is acceptable in relation to the highest IC or expiratory reserve volume values&#44; must achieve a plateau of at least 1 second in duration with changes in expiratory volume of less than 25<span class="elsevierStyleHsp" style=""></span>mL&#44; and must be greater or equal than the largest FVC value obtained in the previously performed forced spirometry&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Repeatability criteria</span><p id="par0130" class="elsevierStylePara elsevierViewall">In plethysmography&#44; these criteria should only be applied to decide when it is necessary to perform more than three acceptable manoeuvres &#40;a minimum of three acceptable manoeuvres and a maximum of eight manoeuvres should be performed&#41;&#46; The criteria are not to be used to exclude results from reports or subjects from a study&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The ATS&#47;ERS 2005<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> requires&#58; &#40;a&#41; that the three acceptable FRC<span class="elsevierStyleInf">pleth</span> manoeuvres agree within 5&#37;&#44; and &#40;b&#41; that the difference between the two largest values of the repeat VC measurements be less than 150<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Quality control</span><p id="par0140" class="elsevierStylePara elsevierViewall">The chamber and volume calibrations must be performed exactly as instructed by the manufacturer&#46; Testing of a biological control &#40;healthy nonsmoker&#41; should be performed at least once a month and whenever an error is suspected&#44; measuring the TGV&#44; RV and TLC&#46; Values that differ by more than 10&#37; for the FRC and TLC or more than 20&#37; for the RV compared to previous measurements on the same subject suggest errors&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Indications</span><p id="par0145" class="elsevierStylePara elsevierViewall">The main indication is the diagnosis and characterisation of restrictive ventilatory patterns &#40;assessment of disease severity&#44; course of disease&#44; and response to treatment&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It can also be used to assess the severity of restriction in diseases with a mixed ventilatory pattern&#44; and for the early detection of unventilated trapped gas compartments and airflow limitations&#46; It allows the measurement of unventilated air compartments &#40;subtracting the FRC measured by plethysmography from the FRC measured by helium dilution&#41; and risk assessment for surgery &#40;for instance&#44; for pneumonectomy&#41;&#46; It can be performed successfully starting at 6 years of age&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results and reference values</span><p id="par0155" class="elsevierStylePara elsevierViewall">First&#44; the acceptability and repeatability of the test should be assessed&#46; The results reported once the test is deemed acceptable are the TGV &#40;the mean of at least three TGV manoeuvres that agree within 5&#37;&#41;&#44; the CV &#40;the largest value in a minimum of 3 manoeuvres with values that agree within 5&#37;&#41;&#44; the TLC &#40;sum of the TGV and the highest IC value&#41;&#44; the RV and the RV&#47;TLC ratio&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Subsequently&#44; resistance and TGV curves are analysed&#44; checking that loops have a closed shape &#40;or&#44; if they are not&#44; assessing for potential underlying pathologies&#41;&#44; their angle&#44; slope&#44; etc&#46; Each manoeuvre is also analysed separately to assess lung volumes&#59; tidal volume should remain stable during the test&#44; with a stable end expiratory level volume &#40;EELV&#41;&#44; proper occlusion&#44; and correct performance of the manoeuvre consisting in an inspiration followed by a maximal expiration&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The results are reported as absolute values &#40;l&#41; at body temperature and barometric pressure at water vapour saturation &#40;BTPS&#41; conditions&#44; rounded to two decimals&#59; as relative values &#40;percentage relative to the reference or theoretical value&#41;&#59; and as z-scores &#40;distance from the predicted value in standard deviations&#41;&#46; Currently&#44; the upper and lower limit of normal &#40;LLN&#41; &#40;2&#46;5th and 97&#46;5th percentiles&#41; are calculated&#44; and measured values are considered clinically significant if they are outside these bounds&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">There are few reference data for the paediatric age group&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> The oldest references are those provided by Zapletal<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> and the most recent those by Rosenthal&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> Several studies have evinced the need to update these reference values to include children younger than 6 years and of non-Caucasian descent&#44; as ethnicity affects lung volumes and the equations derived from both studies were based on data for healthy white children&#46; Africans have smaller lung volumes&#44; probably because their limbs are long and their trunks short&#46; It has also been noted that previous equations have been derived from panting manoeuvres&#44; so they tend to overestimate FRC values&#44; something that has a lesser impact on the determination of RV and TLC&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Interpretation of results</span><p id="par0175" class="elsevierStylePara elsevierViewall">The recommendations of the ATS&#47;ERS for the interpretation of lung function tests<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> define restrictive abnormalities as reductions of VC and TLC below the LLN&#44; applying the reference values published in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> When relative values are used&#44; TLC&#44; FRC and RV are considered normal when they range between 80&#37; and 120&#37; of the predicted value&#44; and considered pathological when the TLC is below 80&#37;&#44; with the restrictive pattern being categorised depending on this percentage into mild &#40;70&#8211;80&#37;&#41;&#44; moderate &#40;60&#8211;69&#37;&#41; or severe &#40;&#60;59&#37;&#41;&#46; Furthermore&#44; the pattern is diagnosed as a mixed abnormality &#40;combination of obstructive and restrictive&#41; when the FEV1&#47;VC ratio and the TLC are below the LLN&#46; The possible causes of a restrictive pattern are neuromuscular disease&#44; kyphoscoliosis&#44; interstitial lung disease and pneumonectomy&#46; The ATS&#47;ERS recommendations<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> also classify patterns with a reduced VC&#44; a normal FEV1&#47;VC ratio and a normal TLC as obstruction&#44; although this algorithm has been disputed&#44; and patterns where the FRC&#44; RV and TLC are above 120&#37; and the RV&#47;TLC ratio is above 20&#8211;35&#37; as hyperinflation &#40;when the TLC is normal the pattern suggests air trapping&#41;&#46; In the paediatric age group&#44; variable parameters must be interpreted with caution&#44; such as the RV&#47;TLC ratio &#40;percentage of the TLC occupied by gas that cannot be exhaled&#44; the RV&#41;&#46; This variability results from the changes in respiratory tract characteristics that occur during growth&#44; such as the shape and size of the thoracic cage and respiratory muscle function&#46; Furthermore&#44; the rapid increase in height that occurs in adolescence is not proportional to increases in thorax dimensions or changes in respiratory mechanics&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurement of specific airway resistances</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introduction</span><p id="par0180" class="elsevierStylePara elsevierViewall">Airway resistance is defined as the relationship between airflow in the respiratory tract and the pressure required to generate this flow&#46; The RawTOT value comprises the resistance produced by the chest wall&#44; the lung tissue and the airway&#46; The specific airway resistance &#40;sRaw&#41; is the product of the airway resistance and the FRC&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Methodology and quality criteria</span><p id="par0185" class="elsevierStylePara elsevierViewall">Expressing the results as the specific resistance &#40;sRaw<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Raw<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>TGV&#41; or its reciprocal &#40;sGaw<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#47;sRaw&#41; can be advantageous if there is poor transmission of alveolar pressure&#44; as the TGV is overestimated in the same proportion as the Raw is underestimated&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The relationship between pressure changes in the chamber &#40;proportional to changes in alveolar pressure and airflow&#41; can be measured when the shutter is open&#46; This relationship &#40;&#916;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">box</span>&#47;<span class="elsevierStyleItalic">V</span>&#41; can be represented graphically as an S shape&#46; Once the shutter closes&#44; the relationship of the changes in chamber pressure and mouth pressure is calculated&#46; When the test is performed&#44; the technician watches the display in real time&#46; Since measurement of Raw involves inspiratory and expiratory flows&#44; the display allows the calculation of inspiratory and expiratory resistances&#44; which are the same in healthy individuals&#44; but may differ in patients with obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The chamber and pneumotachograph in the plethysmograph must be calibrated daily&#46; The parameters obtained must be adjusted under BTPS conditions&#46; The manoeuvre can be performed at tidal volume using a heated rebreathing bag&#44; which is considered the gold standard&#44; or automatically by electronic compensation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The flow-pressure curves are displayed in real time in the computer screen&#44; allowing the technician to eliminate curves that have artefacts&#46; The curves must have a similar size and shape&#44; be parallel&#44; and be close to zero flow&#46; The tangent selected automatically by the computer system must be used&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">To guarantee the reproducibility of the technique&#44; at least 3 FRC measurements must be acquired that agree within 5&#37;&#44; and the median of three technically acceptable sets of 10 breaths shall be reported&#46; The curves of as many breaths as possible must be obtained for the sRaw&#44; ideally between three and five sets of five to ten breaths&#44; depending on the software used&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Interpretation of results</span><p id="par0210" class="elsevierStylePara elsevierViewall">The sRaw is a parameter of airway obstruction&#46; The shape of the curve provides information on the location of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> If the patient has an expiratory obstruction&#44; the curve takes the shape of a golf club &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; A &#8220;cursive S&#8221; shape signals a mild diffuse obstruction&#59; an increased inspiratory resistance is indicative of extrathoracic obstruction&#59; an increased expiratory resistance denotes chronic obstructive pulmonary disease&#59; and the increase of both resistances is indicative of tracheal obstruction&#46; In generalised obstructive lung disease&#44; there is an increase in sRaw&#44; FRC and RV values accompanied by a reduced tidal flow&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> TLC changes may be very mild in mixed abnormalities&#44; so measurement of carbon monoxide diffusion capacity is useful in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Recently&#44; it has been reported that a 42&#37; reduction from baseline in the sRaw is statistically significant to assess the response to bronchodilators&#44; with a 55&#37; sensitivity and a 77&#37; specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> Furthermore&#44; the sGaw is very sensitive to changes in airway calibre&#44; and a 40&#8211;56&#37; increase has been established as the cut-off point for a positive response&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;17&#44;18</span></a> although sGaw has a lower specificity than the FEV1&#46; Furthermore&#44; an increase twice the baseline in the sRaw is considered a positive response to the bronchial challenge test&#44; as is a 35&#8211;40&#37; decrease in the sGaw&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Indications and clinical application</span><p id="par0220" class="elsevierStylePara elsevierViewall">The sRaw is the product of the airway resistance by the FRC&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> As children grow&#44; resistances decrease and volumes increase&#44; but specific resistance remains stable irrespective of age&#44; sex and height&#46; It is a sensitive and reproducible parameter for discriminating between normality and disease&#44; and also facilitates the longitudinal interpretation of different measurements in a single individual&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#8211;23</span></a> There is evidence of its usefulness in the clinical monitoring of cystic fibrosis and asthma&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> and also in diagnosing asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> In children with cystic fibrosis&#44; the sRaw is more sensitive than resistances measured with the interrupter technique or impulse oscillometry&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Some authors have noted its usefulness for monitoring the response to treatment of asthmatic children&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;27</span></a> It has also proven useful in the assessment of bronchodilator reversibility and bronchial hyperresponsiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The sGaw is more sensitive than the sRaw for detecting central obstruction&#44; and even more sensitive than the FEV1 obtained by means of forced spirometry&#46; However&#44; it is less reproducible than the sRaw&#44; so a larger number of measurements need to be acquired&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> It may be more sensitive than FEV1 in the detection of airflow limitation in bronchiolitis obliterans&#44; in which obstruction of the peripheral airways predominates&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">11&#44;28</span></a> and also in asthmatic patients with moderate obstruction&#46; It is also more sensitive in the assessment of the upper respiratory tract in vocal cord paralysis or dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Reference values</span><p id="par0235" class="elsevierStylePara elsevierViewall">Several published studies have provided sRaw reference values for children&#44; including preschoolers&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;14&#44;30</span></a> However&#44; most researchers recommend assessing normal values in each lung function laboratory to allow inter-centre comparison studies&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Measurement of static lung volumes&#46; Body plethysmography"
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            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Introduction"
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              "titulo" => "Equipment"
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          "identificador" => "sec0025"
          "titulo" => "Plethysmography manoeuvre procedure"
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            0 => array:3 [
              "identificador" => "sec0030"
              "titulo" => "Plethysmography performance and quality assessment"
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                  "identificador" => "sec0035"
                  "titulo" => "Test quality criteria"
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          "titulo" => "Measurement of specific airway resistances"
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              "titulo" => "Indications and clinical application"
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          "titulo" => "Conflicts of interest"
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    "fechaRecibido" => "2014-10-12"
    "fechaAceptado" => "2014-10-29"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec560877"
          "palabras" => array:5 [
            0 => "Whole body plethysmography"
            1 => "Intrathoracic gas volume"
            2 => "Functional residual capacity"
            3 => "Total airway resistance"
            4 => "Specific airway resistance"
          ]
        ]
      ]
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          "palabras" => array:5 [
            0 => "Pletismograf&#237;a corporal total"
            1 => "Volumen de gas intrator&#225;cico"
            2 => "Capacidad residual funcional"
            3 => "Resistencia total de la v&#237;a a&#233;rea"
            4 => "Resistencia espec&#237;&#64257;ca de la v&#237;a a&#233;rea"
          ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Whole body plethysmography is used to measure lung volumes&#44; capacities and resistances&#46; It is a well standardised technique&#44; and although it is widely used in paediatric chest diseases units&#44; it requires specific equipment&#44; specialist staff&#44; and some cooperation by the patient&#46; Plethysmography uses Boyle&#39;s law in order to measure the intrathoracic gas volume or functional residual capacity&#44; and once this is determined&#44; the residual volume and total lung capacity are extrapolated&#46; The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases&#46; Airway resistance is a measurement of obstruction&#44; with the total resistance being able to be measured&#44; which includes chest wall&#44; lung tissue and airway resistance&#44; as well as the specific airway resistance&#44; which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity&#46; The complexity of this technique&#44; the reference equations&#44; the differences in the equipment and their variability&#44; and the conditions in which it is performed&#44; has led to the need for its standardisation&#46; Throughout this article&#44; the practical aspects of plethysmography are analysed&#44; specifying recommendations for performing it&#44; its systematic calibration and the calculations that must be made&#44; as well as the interpretation of the results obtained&#46; The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results&#44; leading to improved management of the patient&#44; as well as a consensus among the speciality&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La pletismograf&#237;a corporal completa permite la medici&#243;n de vol&#250;menes&#44; capacidades y resistencias pulmonares&#46; Es una t&#233;cnica bien estandarizada y ampliamente utilizada en neumolog&#237;a pedi&#225;trica&#44; aunque requiere equipo espec&#237;fico&#44; personal especializado y cierta colaboraci&#243;n por parte del paciente&#46; La pletismograf&#237;a utiliza la ley de Boyle para determinar el volumen de gas intrator&#225;cico o capacidad residual funcional&#44; y una vez determinada esta&#44; se extrapolan el volumen residual y la capacidad pulmonar total&#46; La medici&#243;n de la capacidad pulmonar total es necesaria para el diagn&#243;stico de patolog&#237;a restrictiva&#46; La resistencia de la v&#237;a a&#233;rea es una medida de obstrucci&#243;n&#44; pudi&#233;ndose determinar la resistencia total&#44; que incluye la resistencia de la pared tor&#225;cica&#44; tejido pulmonar y v&#237;a a&#233;rea&#44; y la resistencia espec&#237;fica&#44; que es un par&#225;metro m&#225;s estable que corresponde al producto de la resistencia de la v&#237;a a&#233;rea por la capacidad residual funcional&#46; La complejidad de esta t&#233;cnica&#44; las ecuaciones de referencia&#44; las diferencias en el equipamiento&#44; la variabilidad de la misma y las condiciones en las que se realiza han hecho necesaria su estandarizaci&#243;n&#46; Se analizan a lo largo del art&#237;culo los aspectos pr&#225;cticos de esta t&#233;cnica&#44; especificando las recomendaciones para su realizaci&#243;n&#44; sistem&#225;tica de calibraci&#243;n y los c&#225;lculos que se deben llevar a cabo&#44; as&#237; como la interpretaci&#243;n de los resultados obtenidos&#46; El objetivo de esta publicaci&#243;n es favorecer una mejor comprensi&#243;n de los principios de la pletismograf&#237;a completa con el fin de optimizar la interpretaci&#243;n de los resultados favoreciendo un mejor manejo del paciente y un consenso en la especialidad&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de Mir Messa I&#44; Sard&#243;n Prado O&#44; Larramona H&#44; Salcedo Posadas A&#44; Villa Asensi JR&#44; Representing the Grupo de T&#233;cnicas de la Sociedad Espa&#241;ola de Neumolog&#237;a Pedi&#225;trica&#46; Pletismograf&#237;a corporal &#40;<span class="elsevierStyleSmallCaps">i</span>&#41;&#58; estandarizaci&#243;n y criterios de calidad&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;83&#58;136&#46;e1&#8211;136&#46;e7&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lung volume determination by plethysmography&#46; Graphic representation of results &#40;Jaeger plethysmography&#44; Care Fusion&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">From left to right&#44; normal pattern&#44; restrictive pattern&#44; air trapping and hyperinflation&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Determination of lung resistances and volumes by means of plethysmography&#46; Positive post-bronchodilator test&#58; decreased specific resistance &#40;&#8722;51&#37;&#41; and increased specific conductance &#40;&#43;105&#37;&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Capacities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air inspired after the end of expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiratory vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air expired after a full inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air inspired after a full expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Functional residual capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amount of air remaining in the lungs after expiration at tidal volume&#47;flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intrathoracic gas volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TGV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Plethysmography measurement equivalent to the FRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total lung capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TLC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total volume of air in the lungs after a full inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Volumes</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tidal volume&#47;flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Volume of air inspired or expired during relaxed breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiratory reserve volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ERV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air that can be forcibly exhaled after a normal expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Residual volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Volume of air that remains in the lungs after a full expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory reserve volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IRV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air that can be forcibly inhaled after a normal inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">a&#46;</span> Always use a new mouthpiece with a disposable in-line filter for each patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">b&#46;</span> The mouthpiece must be held with the teeth and sealed with the lips&#44; without obstructing it with the tongue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">c&#46;</span> Explain how to place the hands over the cheeks to prevent leaks during the manoeuvre&#46; Explain how to use the nose clip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">d&#46;</span> Instruct the patient on how to position him or herself in the box&#44; sitting with a straight chest and neck and with both feet resting on the floor&#46; Check that the patient is breathing in a relaxed manner at tidal volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">e&#46;</span> Demonstrate the IVC manoeuvre&#44; which must start with IC manoeuvres following occlusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the technician performing the test&#46;</p>"
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        "etiqueta" => "Table 3"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Assemble all components &#40;tubes&#44; sensors&#44; connectors&#44; etc&#46;&#41; following the directions of the manufacturer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clean the flow sensors according to specification&#44; removing potentially obstructing particles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Turn on equipment ahead of time to let it warm up &#40;approximately 30<span class="elsevierStyleHsp" style=""></span>min prior to the test&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Verify that the system has no leaks and airtight seal of door&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Verify that the shutter responds to activation with minimal resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">If the plethysmograph does not have a built-in thermometer&#44; measure the ambient temperature before calibration and before each test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Set up for the average relative humidity&#44; altitude or barometric pressure&#44; and temperature of the location where the test is performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Spanish Association of Paediatrics
Body plethysmography (i): Standardisation and quality criteria
Pletismografía corporal (i): estandarización y criterios de calidad
I. de Mir Messaa,
Corresponding author
, O. Sardón Pradob,c, H. Larramonad, A. Salcedo Posadase, J.R. Villa Asensif, en representación del Grupo de Técnicas de la Sociedad Española de Neumología Pediátrica
a Sección de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d¿Hebron, Barcelona, Spain
b Sección de Neumología Pediátrica, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
c Departamento de Pediatría, Facultad de Medicina y Odontología, UPV/EHU, San Sebastián, Spain
d Sección de Neumología Pediátrica, Consorci Hospitalari Parc Taulí, Sabadell, Barcelona, Spain
e Sección de Neumología, Hospital Maternoinfantil Gregorio Marañón, Madrid, Spain
f Sección de Neumología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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the shutter is closed at the end of an expiration &#40;duration of occlusion&#44; 2&#8211;3<span class="elsevierStyleHsp" style=""></span>s&#41; and the patient continues to breathe while holding his or her cheeks to avoid leaks&#46; When the shutter is reopened&#44; the patient has to take two or three tidal breaths followed by the slow vital capacity manoeuvre&#44; which starts with a maximal inspiration to obtain the inspiratory capacity &#40;IC&#41;&#44; followed by a maximal expiration &#40;to measure the slow vital capacity&#41; and then a maximal inspiration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; If the manoeuvre fails&#44; the technician must explain and demonstrate the test procedure to the patient one more time&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Another standardised procedure&#44; albeit one used less frequently due to its technical difficulty&#44; consists in having the patient exhale to residual volume after occlusion&#44; followed by a maximal inspiration to TLC and then by a slow spirometry manoeuvre&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Plethysmography performance and quality assessment</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Test quality criteria</span><p id="par0080" class="elsevierStylePara elsevierViewall">A set of three to five technically satisfactory TGV-VC manoeuvres must be obtained&#46; The curves must be nearly straight and superimposable on one another&#44; and must be within the pressure calibration ranges of the transducers &#40;&#177;10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or 1&#46;3<span class="elsevierStyleHsp" style=""></span>kPa&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Acceptability criteria</span><p id="par0085" class="elsevierStylePara elsevierViewall">Individual plethysmography manoeuvres &#40;TGV-VC&#41; are acceptable if&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Tidal breathing shows a stable FRC &#40;at least 4 tidal breaths that agree within 100<span class="elsevierStyleHsp" style=""></span>mL&#41;&#46; This is corroborated by the graphs &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The difference in volume &#40;&#916;<span class="elsevierStyleItalic">V</span>&#41; between the FRC level and the occlusion level is less than 200<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The breathing frequency during shutter closure ranges between 30 and 60 breaths per minute&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The plethysmograph tracing shows 3&#8211;5 TGV manoeuvres&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">TGV loops have consistent patterns&#44; are free from artefacts&#44; and show minimal hysteresis between inspiration and expiration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The two ends of the curve can be observed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The slope of the measuring line should parallel the TGV loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The VC measurement is acceptable in relation to the highest IC or expiratory reserve volume values&#44; must achieve a plateau of at least 1 second in duration with changes in expiratory volume of less than 25<span class="elsevierStyleHsp" style=""></span>mL&#44; and must be greater or equal than the largest FVC value obtained in the previously performed forced spirometry&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Repeatability criteria</span><p id="par0130" class="elsevierStylePara elsevierViewall">In plethysmography&#44; these criteria should only be applied to decide when it is necessary to perform more than three acceptable manoeuvres &#40;a minimum of three acceptable manoeuvres and a maximum of eight manoeuvres should be performed&#41;&#46; The criteria are not to be used to exclude results from reports or subjects from a study&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The ATS&#47;ERS 2005<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> requires&#58; &#40;a&#41; that the three acceptable FRC<span class="elsevierStyleInf">pleth</span> manoeuvres agree within 5&#37;&#44; and &#40;b&#41; that the difference between the two largest values of the repeat VC measurements be less than 150<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Quality control</span><p id="par0140" class="elsevierStylePara elsevierViewall">The chamber and volume calibrations must be performed exactly as instructed by the manufacturer&#46; Testing of a biological control &#40;healthy nonsmoker&#41; should be performed at least once a month and whenever an error is suspected&#44; measuring the TGV&#44; RV and TLC&#46; Values that differ by more than 10&#37; for the FRC and TLC or more than 20&#37; for the RV compared to previous measurements on the same subject suggest errors&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Indications</span><p id="par0145" class="elsevierStylePara elsevierViewall">The main indication is the diagnosis and characterisation of restrictive ventilatory patterns &#40;assessment of disease severity&#44; course of disease&#44; and response to treatment&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It can also be used to assess the severity of restriction in diseases with a mixed ventilatory pattern&#44; and for the early detection of unventilated trapped gas compartments and airflow limitations&#46; It allows the measurement of unventilated air compartments &#40;subtracting the FRC measured by plethysmography from the FRC measured by helium dilution&#41; and risk assessment for surgery &#40;for instance&#44; for pneumonectomy&#41;&#46; It can be performed successfully starting at 6 years of age&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results and reference values</span><p id="par0155" class="elsevierStylePara elsevierViewall">First&#44; the acceptability and repeatability of the test should be assessed&#46; The results reported once the test is deemed acceptable are the TGV &#40;the mean of at least three TGV manoeuvres that agree within 5&#37;&#41;&#44; the CV &#40;the largest value in a minimum of 3 manoeuvres with values that agree within 5&#37;&#41;&#44; the TLC &#40;sum of the TGV and the highest IC value&#41;&#44; the RV and the RV&#47;TLC ratio&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Subsequently&#44; resistance and TGV curves are analysed&#44; checking that loops have a closed shape &#40;or&#44; if they are not&#44; assessing for potential underlying pathologies&#41;&#44; their angle&#44; slope&#44; etc&#46; Each manoeuvre is also analysed separately to assess lung volumes&#59; tidal volume should remain stable during the test&#44; with a stable end expiratory level volume &#40;EELV&#41;&#44; proper occlusion&#44; and correct performance of the manoeuvre consisting in an inspiration followed by a maximal expiration&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The results are reported as absolute values &#40;l&#41; at body temperature and barometric pressure at water vapour saturation &#40;BTPS&#41; conditions&#44; rounded to two decimals&#59; as relative values &#40;percentage relative to the reference or theoretical value&#41;&#59; and as z-scores &#40;distance from the predicted value in standard deviations&#41;&#46; Currently&#44; the upper and lower limit of normal &#40;LLN&#41; &#40;2&#46;5th and 97&#46;5th percentiles&#41; are calculated&#44; and measured values are considered clinically significant if they are outside these bounds&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">There are few reference data for the paediatric age group&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> The oldest references are those provided by Zapletal<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> and the most recent those by Rosenthal&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> Several studies have evinced the need to update these reference values to include children younger than 6 years and of non-Caucasian descent&#44; as ethnicity affects lung volumes and the equations derived from both studies were based on data for healthy white children&#46; Africans have smaller lung volumes&#44; probably because their limbs are long and their trunks short&#46; It has also been noted that previous equations have been derived from panting manoeuvres&#44; so they tend to overestimate FRC values&#44; something that has a lesser impact on the determination of RV and TLC&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Interpretation of results</span><p id="par0175" class="elsevierStylePara elsevierViewall">The recommendations of the ATS&#47;ERS for the interpretation of lung function tests<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> define restrictive abnormalities as reductions of VC and TLC below the LLN&#44; applying the reference values published in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> When relative values are used&#44; TLC&#44; FRC and RV are considered normal when they range between 80&#37; and 120&#37; of the predicted value&#44; and considered pathological when the TLC is below 80&#37;&#44; with the restrictive pattern being categorised depending on this percentage into mild &#40;70&#8211;80&#37;&#41;&#44; moderate &#40;60&#8211;69&#37;&#41; or severe &#40;&#60;59&#37;&#41;&#46; Furthermore&#44; the pattern is diagnosed as a mixed abnormality &#40;combination of obstructive and restrictive&#41; when the FEV1&#47;VC ratio and the TLC are below the LLN&#46; The possible causes of a restrictive pattern are neuromuscular disease&#44; kyphoscoliosis&#44; interstitial lung disease and pneumonectomy&#46; The ATS&#47;ERS recommendations<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> also classify patterns with a reduced VC&#44; a normal FEV1&#47;VC ratio and a normal TLC as obstruction&#44; although this algorithm has been disputed&#44; and patterns where the FRC&#44; RV and TLC are above 120&#37; and the RV&#47;TLC ratio is above 20&#8211;35&#37; as hyperinflation &#40;when the TLC is normal the pattern suggests air trapping&#41;&#46; In the paediatric age group&#44; variable parameters must be interpreted with caution&#44; such as the RV&#47;TLC ratio &#40;percentage of the TLC occupied by gas that cannot be exhaled&#44; the RV&#41;&#46; This variability results from the changes in respiratory tract characteristics that occur during growth&#44; such as the shape and size of the thoracic cage and respiratory muscle function&#46; Furthermore&#44; the rapid increase in height that occurs in adolescence is not proportional to increases in thorax dimensions or changes in respiratory mechanics&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurement of specific airway resistances</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introduction</span><p id="par0180" class="elsevierStylePara elsevierViewall">Airway resistance is defined as the relationship between airflow in the respiratory tract and the pressure required to generate this flow&#46; The RawTOT value comprises the resistance produced by the chest wall&#44; the lung tissue and the airway&#46; The specific airway resistance &#40;sRaw&#41; is the product of the airway resistance and the FRC&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Methodology and quality criteria</span><p id="par0185" class="elsevierStylePara elsevierViewall">Expressing the results as the specific resistance &#40;sRaw<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Raw<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>TGV&#41; or its reciprocal &#40;sGaw<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#47;sRaw&#41; can be advantageous if there is poor transmission of alveolar pressure&#44; as the TGV is overestimated in the same proportion as the Raw is underestimated&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The relationship between pressure changes in the chamber &#40;proportional to changes in alveolar pressure and airflow&#41; can be measured when the shutter is open&#46; This relationship &#40;&#916;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf">box</span>&#47;<span class="elsevierStyleItalic">V</span>&#41; can be represented graphically as an S shape&#46; Once the shutter closes&#44; the relationship of the changes in chamber pressure and mouth pressure is calculated&#46; When the test is performed&#44; the technician watches the display in real time&#46; Since measurement of Raw involves inspiratory and expiratory flows&#44; the display allows the calculation of inspiratory and expiratory resistances&#44; which are the same in healthy individuals&#44; but may differ in patients with obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The chamber and pneumotachograph in the plethysmograph must be calibrated daily&#46; The parameters obtained must be adjusted under BTPS conditions&#46; The manoeuvre can be performed at tidal volume using a heated rebreathing bag&#44; which is considered the gold standard&#44; or automatically by electronic compensation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The flow-pressure curves are displayed in real time in the computer screen&#44; allowing the technician to eliminate curves that have artefacts&#46; The curves must have a similar size and shape&#44; be parallel&#44; and be close to zero flow&#46; The tangent selected automatically by the computer system must be used&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">To guarantee the reproducibility of the technique&#44; at least 3 FRC measurements must be acquired that agree within 5&#37;&#44; and the median of three technically acceptable sets of 10 breaths shall be reported&#46; The curves of as many breaths as possible must be obtained for the sRaw&#44; ideally between three and five sets of five to ten breaths&#44; depending on the software used&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">14&#44;15</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Interpretation of results</span><p id="par0210" class="elsevierStylePara elsevierViewall">The sRaw is a parameter of airway obstruction&#46; The shape of the curve provides information on the location of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> If the patient has an expiratory obstruction&#44; the curve takes the shape of a golf club &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; A &#8220;cursive S&#8221; shape signals a mild diffuse obstruction&#59; an increased inspiratory resistance is indicative of extrathoracic obstruction&#59; an increased expiratory resistance denotes chronic obstructive pulmonary disease&#59; and the increase of both resistances is indicative of tracheal obstruction&#46; In generalised obstructive lung disease&#44; there is an increase in sRaw&#44; FRC and RV values accompanied by a reduced tidal flow&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> TLC changes may be very mild in mixed abnormalities&#44; so measurement of carbon monoxide diffusion capacity is useful in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Recently&#44; it has been reported that a 42&#37; reduction from baseline in the sRaw is statistically significant to assess the response to bronchodilators&#44; with a 55&#37; sensitivity and a 77&#37; specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> Furthermore&#44; the sGaw is very sensitive to changes in airway calibre&#44; and a 40&#8211;56&#37; increase has been established as the cut-off point for a positive response&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;17&#44;18</span></a> although sGaw has a lower specificity than the FEV1&#46; Furthermore&#44; an increase twice the baseline in the sRaw is considered a positive response to the bronchial challenge test&#44; as is a 35&#8211;40&#37; decrease in the sGaw&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Indications and clinical application</span><p id="par0220" class="elsevierStylePara elsevierViewall">The sRaw is the product of the airway resistance by the FRC&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> As children grow&#44; resistances decrease and volumes increase&#44; but specific resistance remains stable irrespective of age&#44; sex and height&#46; It is a sensitive and reproducible parameter for discriminating between normality and disease&#44; and also facilitates the longitudinal interpretation of different measurements in a single individual&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#8211;23</span></a> There is evidence of its usefulness in the clinical monitoring of cystic fibrosis and asthma&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> and also in diagnosing asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> In children with cystic fibrosis&#44; the sRaw is more sensitive than resistances measured with the interrupter technique or impulse oscillometry&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Some authors have noted its usefulness for monitoring the response to treatment of asthmatic children&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;27</span></a> It has also proven useful in the assessment of bronchodilator reversibility and bronchial hyperresponsiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The sGaw is more sensitive than the sRaw for detecting central obstruction&#44; and even more sensitive than the FEV1 obtained by means of forced spirometry&#46; However&#44; it is less reproducible than the sRaw&#44; so a larger number of measurements need to be acquired&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> It may be more sensitive than FEV1 in the detection of airflow limitation in bronchiolitis obliterans&#44; in which obstruction of the peripheral airways predominates&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">11&#44;28</span></a> and also in asthmatic patients with moderate obstruction&#46; It is also more sensitive in the assessment of the upper respiratory tract in vocal cord paralysis or dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Reference values</span><p id="par0235" class="elsevierStylePara elsevierViewall">Several published studies have provided sRaw reference values for children&#44; including preschoolers&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;14&#44;30</span></a> However&#44; most researchers recommend assessing normal values in each lung function laboratory to allow inter-centre comparison studies&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Whole body plethysmography is used to measure lung volumes&#44; capacities and resistances&#46; It is a well standardised technique&#44; and although it is widely used in paediatric chest diseases units&#44; it requires specific equipment&#44; specialist staff&#44; and some cooperation by the patient&#46; Plethysmography uses Boyle&#39;s law in order to measure the intrathoracic gas volume or functional residual capacity&#44; and once this is determined&#44; the residual volume and total lung capacity are extrapolated&#46; The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases&#46; Airway resistance is a measurement of obstruction&#44; with the total resistance being able to be measured&#44; which includes chest wall&#44; lung tissue and airway resistance&#44; as well as the specific airway resistance&#44; which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity&#46; The complexity of this technique&#44; the reference equations&#44; the differences in the equipment and their variability&#44; and the conditions in which it is performed&#44; has led to the need for its standardisation&#46; Throughout this article&#44; the practical aspects of plethysmography are analysed&#44; specifying recommendations for performing it&#44; its systematic calibration and the calculations that must be made&#44; as well as the interpretation of the results obtained&#46; The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results&#44; leading to improved management of the patient&#44; as well as a consensus among the speciality&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La pletismograf&#237;a corporal completa permite la medici&#243;n de vol&#250;menes&#44; capacidades y resistencias pulmonares&#46; Es una t&#233;cnica bien estandarizada y ampliamente utilizada en neumolog&#237;a pedi&#225;trica&#44; aunque requiere equipo espec&#237;fico&#44; personal especializado y cierta colaboraci&#243;n por parte del paciente&#46; La pletismograf&#237;a utiliza la ley de Boyle para determinar el volumen de gas intrator&#225;cico o capacidad residual funcional&#44; y una vez determinada esta&#44; se extrapolan el volumen residual y la capacidad pulmonar total&#46; La medici&#243;n de la capacidad pulmonar total es necesaria para el diagn&#243;stico de patolog&#237;a restrictiva&#46; La resistencia de la v&#237;a a&#233;rea es una medida de obstrucci&#243;n&#44; pudi&#233;ndose determinar la resistencia total&#44; que incluye la resistencia de la pared tor&#225;cica&#44; tejido pulmonar y v&#237;a a&#233;rea&#44; y la resistencia espec&#237;fica&#44; que es un par&#225;metro m&#225;s estable que corresponde al producto de la resistencia de la v&#237;a a&#233;rea por la capacidad residual funcional&#46; La complejidad de esta t&#233;cnica&#44; las ecuaciones de referencia&#44; las diferencias en el equipamiento&#44; la variabilidad de la misma y las condiciones en las que se realiza han hecho necesaria su estandarizaci&#243;n&#46; Se analizan a lo largo del art&#237;culo los aspectos pr&#225;cticos de esta t&#233;cnica&#44; especificando las recomendaciones para su realizaci&#243;n&#44; sistem&#225;tica de calibraci&#243;n y los c&#225;lculos que se deben llevar a cabo&#44; as&#237; como la interpretaci&#243;n de los resultados obtenidos&#46; El objetivo de esta publicaci&#243;n es favorecer una mejor comprensi&#243;n de los principios de la pletismograf&#237;a completa con el fin de optimizar la interpretaci&#243;n de los resultados favoreciendo un mejor manejo del paciente y un consenso en la especialidad&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de Mir Messa I&#44; Sard&#243;n Prado O&#44; Larramona H&#44; Salcedo Posadas A&#44; Villa Asensi JR&#44; Representing the Grupo de T&#233;cnicas de la Sociedad Espa&#241;ola de Neumolog&#237;a Pedi&#225;trica&#46; Pletismograf&#237;a corporal &#40;<span class="elsevierStyleSmallCaps">i</span>&#41;&#58; estandarizaci&#243;n y criterios de calidad&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;83&#58;136&#46;e1&#8211;136&#46;e7&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lung volume determination by plethysmography&#46; Graphic representation of results &#40;Jaeger plethysmography&#44; Care Fusion&#41;&#46;</p>"
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      1 => array:7 [
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lung volumes and capacities&#46;</p>"
        ]
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">From left to right&#44; normal pattern&#44; restrictive pattern&#44; air trapping and hyperinflation&#46;</p>"
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      3 => array:7 [
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        "etiqueta" => "Figure 4"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Determination of lung resistances and volumes by means of plethysmography&#46; Positive post-bronchodilator test&#58; decreased specific resistance &#40;&#8722;51&#37;&#41; and increased specific conductance &#40;&#43;105&#37;&#41;&#46;</p>"
        ]
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Capacities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air inspired after the end of expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiratory vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air expired after a full inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory vital capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air inspired after a full expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Functional residual capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amount of air remaining in the lungs after expiration at tidal volume&#47;flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intrathoracic gas volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TGV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Plethysmography measurement equivalent to the FRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total lung capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TLC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total volume of air in the lungs after a full inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Volumes</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tidal volume&#47;flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Volume of air inspired or expired during relaxed breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiratory reserve volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ERV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air that can be forcibly exhaled after a normal expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Residual volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Volume of air that remains in the lungs after a full expiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiratory reserve volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IRV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maximum volume of air that can be forcibly inhaled after a normal inspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lung volumes and capacities&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">a&#46;</span> Always use a new mouthpiece with a disposable in-line filter for each patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">b&#46;</span> The mouthpiece must be held with the teeth and sealed with the lips&#44; without obstructing it with the tongue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">c&#46;</span> Explain how to place the hands over the cheeks to prevent leaks during the manoeuvre&#46; Explain how to use the nose clip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">d&#46;</span> Instruct the patient on how to position him or herself in the box&#44; sitting with a straight chest and neck and with both feet resting on the floor&#46; Check that the patient is breathing in a relaxed manner at tidal volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">e&#46;</span> Demonstrate the IVC manoeuvre&#44; which must start with IC manoeuvres following occlusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the technician performing the test&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Assemble all components &#40;tubes&#44; sensors&#44; connectors&#44; etc&#46;&#41; following the directions of the manufacturer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clean the flow sensors according to specification&#44; removing potentially obstructing particles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Turn on equipment ahead of time to let it warm up &#40;approximately 30<span class="elsevierStyleHsp" style=""></span>min prior to the test&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Verify that the system has no leaks and airtight seal of door&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Verify that the shutter responds to activation with minimal resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">If the plethysmograph does not have a built-in thermometer&#44; measure the ambient temperature before calibration and before each test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Set up for the average relative humidity&#44; altitude or barometric pressure&#44; and temperature of the location where the test is performed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab869324.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Preparation of the equipment before the test&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:31 [
            0 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A rapid plethysmographic method for measuring thoracic gas volume&#58; a comparison with a nitrogen washout method for measuring functional residual capacity in normal subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;B&#46; Dubois"
                            1 => "S&#46;Y&#46; Botelho"
                            2 => "G&#46;N&#46; Bedell"
                            3 => "R&#46; Marshall"
                            4 => "J&#46;H&#46; Comroe Jr&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1172/JCI103281"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Invest"
                        "fecha" => "1956"
                        "volumen" => "35"
                        "paginaInicial" => "322"
                        "paginaFinal" => "326"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13295396"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The birth of clinical body plethysmography&#58; it was a good week"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;B&#46; West"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1172/JCI22992"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Invest"
                        "fecha" => "2004"
                        "volumen" => "114"
                        "paginaInicial" => "1043"
                        "paginaFinal" => "1045"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15489948"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ATS&#47;ERS Task Force Standardisation of spirometry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;R&#46; Miller"
                            1 => "J&#46; Hankinson"
                            2 => "V&#46; Brusasco"
                            3 => "F&#46; Burgos"
                            4 => "R&#46; Casaburi"
                            5 => "A&#46; Coates"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00034805"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "319"
                        "paginaFinal" => "338"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16055882"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lung volumes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Wanger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "Pulmonary function testing&#58; a practical approach"
                        "paginaInicial" => "69"
                        "paginaFinal" => "112"
                        "edicion" => "3rd ed&#46;"
                        "serieFecha" => "2012"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "5"
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Idiomas
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