Letter to the Editor
Intra- and interobserver agreement of inspiratory capacity during cardio pulmonary exercise test
D. Mannée1,
, T. Berens1, B. van den Borst, H. van Helvoort
Corresponding author
denise.mannee@radboudumc.nl
Corresponding author at: Department of Pulmonary Diseases, Radboud University Medical Centre Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Netherlands.
Corresponding author at: Department of Pulmonary Diseases, Radboud University Medical Centre Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Netherlands.
Department of Pulmonary Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
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ACT, asthma control test; FEV<span class="elsevierStyleInf">1</span>, forced expiratory volume in one second; FeNO, fractional exhaled nitric oxide.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Hamada, E. Ogino, H. Yasuba" "autores" => array:3 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Hamada" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Ogino" ] 2 => array:2 [ "nombre" => "H." "apellidos" => "Yasuba" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S253104372100163X?idApp=UINPBA00004E" "url" => "/25310437/0000002800000001/v1_202201060713/S253104372100163X/v1_202201060713/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Intra- and interobserver agreement of inspiratory capacity during cardio pulmonary exercise test" "tieneTextoCompleto" => true "saludo" => "To the Editor" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "68" "paginaFinal" => "69" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Mannée, T. Berens, B. van den Borst, H. van Helvoort" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Mannée" "email" => array:1 [ 0 => "denise.mannee@radboudumc.nl" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0001" ] ] ] 1 => array:3 [ "nombre" => "T." "apellidos" => "Berens" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn1" ] ] ] 2 => array:2 [ "nombre" => "B." "apellidos" => "van den Borst" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "van Helvoort" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Pulmonary Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands" "identificador" => "aff0001" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0001" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Department of Pulmonary Diseases, Radboud University Medical Centre Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Netherlands." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0003" class="elsevierStylePara elsevierViewall">The most commonly used method to measure dynamic hyperinflation (DH) is serial inspiratory capacity (IC) manoeuvres during cardiopulmonary exercise tests (CPET). The manoeuvres have to be derived from the continuously measured breathing pattern recorded. Accounting for variations in breathing pattern prior to the IC manoeuvre is crucial in order to validly calculate serial ICs upon which DH can be diagnosed.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> This procedure of data interpretation is usually performed by a pulmonary function technician and the outcome should be independent of the individual technician.<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> The focus of this study is therefore to determine the intra- and interobserver agreement of IC measurements at rest and at peak exercise.</p><p id="para0004" class="elsevierStylePara elsevierViewall">In a single-centre cross-sectional cohort study, 11 technicians from the Radboud University Medical Centre (Nijmegen, The Netherlands) participated. The study was conducted according to the Declaration of Helsinki and was approved by the research ethics committee of the Radboudumc (2018-4357), the study does not fall within the ambit of the Medical Research Involving Human Subjects Act.</p><p id="para0005" class="elsevierStylePara elsevierViewall">40 CPET datasets were used from clinical practice. The technicians were all considered to be experienced assessors (+15 years) of IC measurements in the datasets (weekly assessment). To assess inter-observer agreement, 30 datasets were evaluated. The datasets were randomly chosen from a database containing all CPETs between May 2019 and December 2019. Characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>. The other 10 datasets were revaluated at a different time to determine intra-observer agreement. In all datasets, the technicians had to determine the correct breathing level prior to a rest and peak IC manoeuvre.</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0006" class="elsevierStylePara elsevierViewall">The intra-class correlation coefficient (ICC) was used to determine intra- and interobserver agreement. An ICC >0.8 was considered to be close to perfect agreement. We chose a two-way random model, absolute agreement (instead of consistency), and a single measures ICC. For the intra-observer agreement we calculated the ICC per observer and determined the mean with standard deviation (SD) or median with interquartile range (IQR), dependent on normality. Normality was tested with Q-Q plots.</p><p id="para0007" class="elsevierStylePara elsevierViewall">All the analyzed variables were normally distributed. The technicians scored a mean (SD) IC at rest of 2.33 L (0.68 L). The mean IC at peak exercise was 1.91 L (0.66 L). The ICC of the inter-observer agreement of IC rest and IC at peak exercise was 0.967 (95%CI: 0.948-0.982, p-value 0.00) and 0.976 (95%CI: 0.961-0.987, p-value 0.00), respectively.</p><p id="para0008" class="elsevierStylePara elsevierViewall">The intra-observer agreement ranged between 0.980-1.00 for IC at rest, and 0.976-0.996 for IC at peak exercise.</p><p id="para0009" class="elsevierStylePara elsevierViewall">In this study we determined the intra- and interobserver agreement of IC assessment by pulmonary function technicians. Guenette et al.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> suggested that the manual calculation is subjective and could introduce an observer bias. Despites all this, we found that interpretation of IC at rest and peak exercise is excellently done by technicians. Combined with earlier studies,<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> we can now conclude that both IC measurements can be used validly. The validity of IC measurement is of great importance in the assessment of (dynamic) hyperinflation and guidance of pharmacotherapeutic and non-pharmacotherapeutic disease management. Hyperinflation is known to be stronger correlated with symptoms of patients than FEV<span class="elsevierStyleInf">1</span> and is therefore more clinically relevant.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> To the best of our knowledge this is the first study that showed that assessment of IC is reliably done and thereby contributes to good clinical practice.</p><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Author contributions</span><p id="para0010" class="elsevierStylePara elsevierViewall">DM and TB contributed equally to this article. DM and TB made substantial contributions acquisition and analysis of the data. BvB, DM, HvH, and TB, made substantial contributions to interpretation of the data, the conception and design, drafted or revised the article critically, provided final approval of the version to be published and agreed to be accountable for all aspects of the work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0001" "titulo" => "Author contributions" ] 1 => array:2 [ "identificador" => "xack579693" "titulo" => "Acknowledgement" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-07-13" "fechaAceptado" => "2021-08-31" "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="notep0001">Authors contributed equally</p>" "identificador" => "fn1" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0001" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Age, years \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">62.3 (11.0) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0003"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Sex, males/females \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0004"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">16/14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0005"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0006"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">24.9 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0007"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">FEV1, L \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.46 (0.79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0009"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">FEV1, %pred \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">50 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0011"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">FEV1/FVC% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">49 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">COPD Gold I/II/III/IV \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1/4/15/5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0015"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Non COPD \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2796876.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics (n=30 tests), values are present as mean (SD). The non-COPD group comprises subjects referred for dyspnoe on exertion and restrictive pulmonary disease.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emerging concepts in the evaluation of ventilatory limitation during exercise: the exercise tidal flow-volume loop" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.D. Johnson" 1 => "I.M. Weisman" 2 => "R.J. Zeballos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1999" "volumen" => "116" "numero" => "2" "paginaInicial" => "488" "paginaFinal" => "503" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0002" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung volumes and forced ventilatory flows" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.H. Quanjer" 1 => "G.J. Tammeling" 2 => "J.E. 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Webb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.160.2.9901038" "Revista" => array:7 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1999" "volumen" => "160" "numero" => "2" "paginaInicial" => "542" "paginaFinal" => "549" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10430726" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0006" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dyspnea and activity limitation in COPD: mechanical factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.E. O'Donnell" 1 => "P. 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| 2022 April | 37 | 45 | 82 |
| 2022 March | 40 | 50 | 90 |
| 2022 February | 76 | 45 | 121 |
| 2022 January | 141 | 81 | 222 |
| 2021 December | 33 | 48 | 81 |
| 2021 November | 48 | 30 | 78 |
| 2021 October | 98 | 80 | 178 |
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