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1、XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,4-PHASE-RHINOMANOMETRY IMPROVES THE DIAGNOSTICAL INFORMATION ABOUT THE NASAL AIR STREAM,Klaus VogtRendsburg/Germany and Riga/Latvia,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Consensus conference April 2003:Publications,XIX IFOS WORLD CONGRESS,SAO
2、 PAULO,JUNE 1-5,2009,Essentials of Nasal Air Stream Physiology,The relation between differential pressure and flow is the RESISTANCEThis relation is non-linear and depends on the actual flow,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Essentials of Nasal Air Stream Physiology,The feeling of obst
3、ruction or patency depends not only on the resistance of the nose,but also on the effective duration!PERFORMANCE DEPENDS ON TIME!,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Essentials of Nasal Air Stream Physiology,During the rhinomanometricmeasurement the nasal airflow changesVelocity Accelera
4、tionDirection,Rhinomanometric standard methods measure a limited number of breathes without expiratory break and with alternating directions of pressure and flow!,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Essentials of Nasal Air Stream Physiology,The geometry of the nasal air channel can be ch
5、anged during and by the effect of the measurement process by the onset of valve phenomena 4 different conditions of the nasal air streamIncreasing in inspirationDecreasing in inspirationIncreasing in expirationDecreasing in expiration,Consider 4 phases separately!,XIX IFOS WORLD CONGRESS,SAO PAULO,J
6、UNE 1-5,2009,Essentials of Nasal Air Stream Physiology 4 phases of the nasal air stream,1.Ascending inspiratory flow may generate BERNOUILLI-effects with aspiration of movable valve parts:reduced cross-section area,increased resistance.2.Descending inspiratory flow releases the movable valve parts t
7、o rest conditions.3.Ascending expiratory flow widens the nasal entrance in a small extend.4.Descending expiratory airflow leads to rest conditions.,The phase of clinical interest depends on the diagnostical task!,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,IMAGING OF THE RELATION BETWEEN DIFFERE
8、NTIAL PRESSURE AND FLOW:THE STANDARD DIAGRAM OF ISOANA,“CLASSIC”,FPR,HRR,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,3 Preconditions for a New Standard,Correct physical and mathematical analysis and confirmation by model experimentsAdequate and practicable techniqueComprehensive statistical anal
9、ysis,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,RELIABLE TECHNOLOGY?,Hardware problems of the past are solved nowadaysThe dynamic properties of the transducers allow to gain more information about the nasal air stream,The quality of a rhinomanometer in 2009 depends on the software and its relat
10、ions to the really existing physiology of the nasal ventilation.,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Physics and technical models,Hysteresis as technical error has to be excluded by DYNAMICAL testing and calibration of the equipment,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Compari
11、ng results of model simulation and real measurements,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Confirmation of the 4-Phase-Theory by MathematicalModel Simulation of the Nasal Airstream(Dr.Alexander Steinmann,Berlin 2007),XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Technique,1998 Developmen
12、t of the worlds smallest rhinomanometer HRR 2 using high integrated sensor technique by VOGT and HASSE,patented 2002,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Practical Improvement by preserving the new algorithm:HRR 3,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Parameters and Statistics,S
13、tandard parameters should represent the work or performance of breathing of an ENTIRE BREATH.They should also consider the parameter TIME!,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Numeric Evaluation-The Problem of Standard Parameters-,Presently used standard parameters(flow values at a given
14、pressure)are remnants of the historical graphical evaluation.They are not related to the patients feeling of obstruction.Data loss in Nasal Provocation Tests and studies.Reduced applicability in Asian races,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Valve phenomena,slight,moderate,heavy,Pattern
15、:Remarkable distance between phase 1 and phase 2(inspiration),XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Diagnosis of Valve Phenomena,Valve phenomena can be seen in the 4PR“view-diagnosis”The onset of valve closure can be quantified by x/t-imaging of pressure and flow,XIX IFOS WORLD CONGRESS,SA
16、O PAULO,JUNE 1-5,2009,Consensus conference April 2003:Results concerning evaluation of measurements 1,Consider the 4 phases of the breathing cycle separately!,HYSTERESIS occurs as part of nasal air stream physiology and can be used diagnostically!,Physical Background:Hoffrichters equation 1994Grzank
17、a 2002Womersley Parameter(Hirsch 2005),Addendum Rhinology 43,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Using Data Processing for Evaluation of Described Variables and Models,BROMS Polar Coordinate SystemOther single variablesk1 and k2 coefficient of Rohrers model,coefficient and hydraulic diam
18、eter according to Mlynski-Korabljew(see above).Coefficient of acceleration change(Naito et al.,1993,1995)Maximum flow or maximum peak flow point(depending of lung function),peak flow resistance.VERTEX RESISTANCE(Vogt et al.)Variables using more than one measuring pointEFFECTIVE RESISTANCE(Vogt&Hoffr
19、ichter 1998)Resistometry(Mlynski et al.)Resistance increase,flow percentage increase(Bachmann et al.,1983)Coefficient of nasal resistance(Van Arentsschild,1966)Surface under tracing(Guillerm et al.,1967,Naito)Work per minute,work coefficient(Cottle,1968)Nasal quotient(Feenstra,1972)Lateralistion per
20、centage(Postema et al.,1980,Bachmann 1983),XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Evaluated Parameters,Peak Flow Resistance PFR=Vertex Resistance(VR)McCaffrey&Kern(1979)Sipil(1991)Naito(1989)Pallanch(1997),Linear Effectice Resistance REFF Vogt&Hoffrichter(1993),XIX IFOS WORLD CONGRESS,SAO P
21、AULO,JUNE 1-5,2009,VERTEX RESISTANCE VR(Peak Flow Resistance),Linear relation between differential pressure and flow during maximal flow within a steady airstream,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,VERTEX RESISTANCEPooled Data,N=5292,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Linea
22、r Effectice Resistance(Reff),XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Correlation with the feeling of obstruction,The correlation of the parameters VR and REFF with data obtained by a Visual Analogue Scale(VAS)was found higher than with any other parameter!AFTER LOGARITHMIC TRANSFORMATION STI
23、LL BETTER CORRELATION!R=0.59,N=810(Vogt et al.2000)R=0.65,N=72(Vogt&Shiraz 2005)R=0.62,N=1580(Vogt,Shah,Moesges 2009),XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,Development in progress.,Determination of the nasal cycle“of an individual patient by long-term observationDetermination of the intraindividual influence of body position and sleep on the nasal ventilation Equipment of Somnomedics already exists to fulfill these tasks!,XIX IFOS WORLD CONGRESS,SAO PAULO,JUNE 1-5,2009,SUMMARY,ACCEPTING 4 PHASES IN NASAL BREATHING PHYSIOLOGY=THE STEP FROM STATIC TO DYNAMIC RHINOMANOMETRY,
