呼气负压技术在慢性阻塞性肺疾病（COPD）患者中的应用
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摘要
目的探讨呼气负压技术检测呼气流速受限(EFL)在慢性阻塞性肺病(COPD)患者中的临床价值。
方法采用呼气负压技术(NEP)检测59例COPD患者在坐位及卧位EFL'隋况。
结果59例患者中49例顺利完成了各项指标的检测,其中10例患者因严重呼吸困难或剧烈咳嗽无法完成本次常规肺功能测定。在49例COPD患者中22例在坐位及卧位均出现EFL,20例仅在卧位出现,坐位无EFL,有7例在坐位及卧位均无EFL；中度EFL组、重度EFL组、极重度EFL组的FEV1占预计值%均显著低于无EFL组(P均<0.000),极重度EFL组的FEV1占预计值%最低,与轻度、中度、重度EFL组比较差异有统计学意义(P<0.05)。5分法EFL评分与MRC呼吸困难评分呈显著正相关(r=0.903,P<0.005)；5分法EFL评分与FEV1呈负相关(r=-0.934,P<0.001)。多元回归分析结果表明,性别、年龄、身高、体重、FEV1、6min步行距离及5分法EFL评分7个变量中,6min步行距离、FEV1及5分法EFL评分与MRC呼吸困难评分有显著相关,其中5分法EFL评分相关性最强。
结论1、五分法EFL评分与COPD患者呼吸困难分级有很好的相关性,是评价COPD患者呼吸困难可靠的客观指标。2、呼气负压技术是一种操作简单、非侵袭性、不需患者主动配合的肺功能检查方法,可用于不能完成常规肺功能检查患者的检测。
Objective To evaluate the relationship between expiratory flow limitation (EFL) and chronic dyspnea in patients with chronic obstructive pulmonary disease (COPD).
Methods EFL was detected by using negative expiratory pressure technique(NEP) in 59 patients with COPD at the sitting and the supine position.
Results 49 cases of 59 patients successfully completed each target tests, of which 10 patients with severe dyspnea or severe cough can not accomplish the routine pulmonary function test. EFL was detected in 22 (44.9%) of the 49 COPD patients in both seated and supine positions and in 20 (40.8%) only in supine position. And 7 patients were not flow-limted either seated or supine. The values of FEV1% of the patients in the moderate, severe and very severe EFL group were all significantly lower than that of them in NO EFL group(P< 0.000). And the values of FEV1% of them in very severe EFL group were the lowest, which is significantly different with that of the patient in the mild, the moderate, severe EFL group(P<0.005).five-point EFL were significantly correlated with FEV1 (r=-0.934, P<0.000). There was a significant correlation between MRC dyspnea score and five-point EFL score (r=0.903, P<0.01). the multiple regression analysis showed that 6-min walking distance, FEV1% and five-point EFL score were correlated with MRC dyspnea score among the variables of sexes, age, height, body weight,FEV1%,6-min walking distance and five-point EFL score, and five-point EFL score showed the best correlativity with MRC dyspnea score. (regression coefficient was 0.47,P<0.005).
Conclusions There was a significant relationship between expiratory flow limitation (EFL) and chronic dyspnea in patients with chronic obstructive pulmonary disease (COPD). EFL are measured by negative expiratory pressure (NEP) technique may be more reliable in the evaluation of dyspnea in COPD. Negative expiratory pressure technique is a is simple, non-invasive test, which dos not require any initiative cooperation from the patients, it can be applied in the patients who can not accomplish routine pulmonary function tests.
方法采用呼气负压技术(NEP)检测59例COPD患者在坐位及卧位EFL'隋况。
结果59例患者中49例顺利完成了各项指标的检测,其中10例患者因严重呼吸困难或剧烈咳嗽无法完成本次常规肺功能测定。在49例COPD患者中22例在坐位及卧位均出现EFL,20例仅在卧位出现,坐位无EFL,有7例在坐位及卧位均无EFL；中度EFL组、重度EFL组、极重度EFL组的FEV1占预计值%均显著低于无EFL组(P均<0.000),极重度EFL组的FEV1占预计值%最低,与轻度、中度、重度EFL组比较差异有统计学意义(P<0.05)。5分法EFL评分与MRC呼吸困难评分呈显著正相关(r=0.903,P<0.005)；5分法EFL评分与FEV1呈负相关(r=-0.934,P<0.001)。多元回归分析结果表明,性别、年龄、身高、体重、FEV1、6min步行距离及5分法EFL评分7个变量中,6min步行距离、FEV1及5分法EFL评分与MRC呼吸困难评分有显著相关,其中5分法EFL评分相关性最强。
结论1、五分法EFL评分与COPD患者呼吸困难分级有很好的相关性,是评价COPD患者呼吸困难可靠的客观指标。2、呼气负压技术是一种操作简单、非侵袭性、不需患者主动配合的肺功能检查方法,可用于不能完成常规肺功能检查患者的检测。
Objective To evaluate the relationship between expiratory flow limitation (EFL) and chronic dyspnea in patients with chronic obstructive pulmonary disease (COPD).
Methods EFL was detected by using negative expiratory pressure technique(NEP) in 59 patients with COPD at the sitting and the supine position.
Results 49 cases of 59 patients successfully completed each target tests, of which 10 patients with severe dyspnea or severe cough can not accomplish the routine pulmonary function test. EFL was detected in 22 (44.9%) of the 49 COPD patients in both seated and supine positions and in 20 (40.8%) only in supine position. And 7 patients were not flow-limted either seated or supine. The values of FEV1% of the patients in the moderate, severe and very severe EFL group were all significantly lower than that of them in NO EFL group(P< 0.000). And the values of FEV1% of them in very severe EFL group were the lowest, which is significantly different with that of the patient in the mild, the moderate, severe EFL group(P<0.005).five-point EFL were significantly correlated with FEV1 (r=-0.934, P<0.000). There was a significant correlation between MRC dyspnea score and five-point EFL score (r=0.903, P<0.01). the multiple regression analysis showed that 6-min walking distance, FEV1% and five-point EFL score were correlated with MRC dyspnea score among the variables of sexes, age, height, body weight,FEV1%,6-min walking distance and five-point EFL score, and five-point EFL score showed the best correlativity with MRC dyspnea score. (regression coefficient was 0.47,P<0.005).
Conclusions There was a significant relationship between expiratory flow limitation (EFL) and chronic dyspnea in patients with chronic obstructive pulmonary disease (COPD). EFL are measured by negative expiratory pressure (NEP) technique may be more reliable in the evaluation of dyspnea in COPD. Negative expiratory pressure technique is a is simple, non-invasive test, which dos not require any initiative cooperation from the patients, it can be applied in the patients who can not accomplish routine pulmonary function tests.
引文
[1]中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南(2007年修订版).中华结核和呼吸杂志,2007,30(1)：8-17.
[2]Donaid A, Mahler M.D. F. C. C. P. Evaluation of clinical methods for rating dyspnea. Chest,1988,93:580-585.
[3]Gosker HR. Engelen MP,vall Mameren H. et al.Muscle fiber type ⅡⅩ atrophy is involved in the lOSS of fat. free mass in chronic obstructive pulmonary disease. Am J Clin Nutr2002; 76:113-119.
[4]Hyatt RE. The interrelationship of pressure, flow and volume during various respiratory maneuvres in normal andemphysematous patients. Am Rev Respir Dis 1961; 83:676-683.
[5]穆魁津,林友华主编.肺功能测定原理与临床应用.北京医科大学、中国协和医科大学联合出版社,1992；66.
[6]Mead J, Turner JM, Macklem PT, Little JB. Significance of the relationship between lung elastic recoil and maximum expiratory flow. J Appl Physiol 1967; 22:95-108.
[7]Melissinos CG, Webster P, Tien YK, Mead J. Time dependence of maximum flow as an index of nonuniformemptying. J Appl Physiol 1979; 47:1043-1050.
[8]D'Angelo E, Prandi E, Marazzini L, Milic-Emili J.Dependence of maximal flow-volume curve on time-course of preceding inspiration in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 150: 1581-1586.
[9]Valta P, Corbeil C, Lavoie A, et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med,1994, 150:1311-1317
[10]Jones MH, Davis SD, Kisling JA, et al. Flow limitation in infants assessed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[11]Dourado VZ, Antunes LC, Tanni SE, et al. Relationship of upper-limb and thoracic muscle strength to 6-min walk distance in COPD patients. Chest,2006, 129:551-557.
[12]PapirisS A,D aniitZ D,M alagariK,et al. The Medical research council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis. Respir Med,2005,99:755-761.
[13]Jones MH, Davis SD, Kisling JA, etal.Flow limitation in infants assesed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[14]Eltayara L, Becklake MR, Volta CA, Milic-Emili J.Relationship between chronic dyspnea and expiratory flowlimitation in patients with chronic obstructive pulmonarydisease. Am J Respir Crit Care Med 1996; 154: 1726-1734.
[15]Boni E, Corda L, Franchini D, et al. Volume effect and exertional dyspnoea after bronchodilator in patients with COPD with and without expiratory flow limitation at rest.Thorax 2002; 57:528-532.
[16]Donald A,Mahler M.D.F.C.C.P. Evaluation of clinical methods of rating dyspnea.Chest,1988,93:580-585.
[17]Takashi H, Koichi N, Mitsuhiro T, etal. Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med.1998.158:1185-1189.
[18]Weaver T E, Richmond T S,N arsavage G L. An explanatory model of functional status in chronic obstructive pulmonary disease. Nurs Res,1997,46:26-31.
[19]Bestall JC, Paul EA, Garrod R, et al. Usefulness of the medical research council(M RC) dyspnea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax,1999,54:581.
[20]Eltayara L, Becklake MR, Volta CA, et al. Relationship between chronic dyspnea and expiratory flow limitation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med,1996,154(6Pt1):1726-1734.
[1]施焕中编.慢性阻塞性肺疾病人民卫生出版社,2006；76
[2]Hyatt RE. The interrelationship of pressure, flow and vol-ume during various respiratory maneuvres in normal andemphysematous patients. Am Rev Respir Dis 1961; 83:676-683.
[3]穆魁津,林友华主编.肺功能测定原理与临床应用.北京医科大学、中国协和医科大学联合出版社,1992；66.
[4]Mead J, Turner JM, Macklem PT, Little JB. Significance of the relationship between lung elastic recoil and maxi-mum expiratory flow. J Appl Physiol 1967; 22:95-108.
[5]Melissinos CG, Webster P, Tien YK, Mead J. Time dependence of maximum flow as an index of nonuniformemptying. J Appl Physiol 1979; 47:1043-1050.
[6]D'Angelo E, Prandi E, Marazzini L, Milic-Emili J.Dependence of maximal flow-volume curve on time-course of preceding inspiration in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 150:1581-1586.
[7]Valta P, Corbeil C, Lavoie A, et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med,1994, 150:1311-1317.
[8]Jones MH, Davis SD, Kisling JA, et al. Flow limitation in infants assessed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[9]Koulouris NG,Valta P, Corbel C, et al. [J]. Eur Respir J,1995,8:306-313.
[10]中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南(2007年修订版).中华结核和呼吸杂志,2007,30(1)：8-17.
[11]Eltayara L, Becklake MR, Volta CA, Milic-Emili J. Relationship between chronic dyspnea and expiratory flow-limitation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996;154: 1726-1734.
[12]Koulouris NG, Dimopoulou I, Valta P, Finkelstein R, Cosio MG,Milic-Emili J. Detection of expiratory flow limitation during exercise in COPD patients. J Appl Physiol 1997;82:723-731.
[13]D'iaz 0, Villafranca C, Ghezzo H, et al. Role of inspiratory capacity on exercise tolerance in COPD patients with and without tidal expiratory flow limitation at rest. Eur Respir J 2000; 16:269-275.
[14]O'Donnell DE, Webb KA. Exertional breathlessness in patients with chronic airflow limitation. The role of lung hyperinflation. Am Rev Respir Dis 1993; 148:1351-1357.
[15]Donald A,Mahler M.D.F.C.C.P. Evaluation of clinical methods of rating dyspnea.Chest,1988,93:580-585.
[16]Eltayara L, Becklake MR, Volta CA, Milic-Emili J.Relationship between chronic dyspnea and expiratory flowlimitation in patients with chronic obstructive pulmonarydisease. Am J Respir Crit Care Med 1996; 154: 1726-1734.
[17]Boni E, Corda L, Franchini D, et al. Volume effect and exertional dyspnoea after bronchodilator in patients with COPD with and without expiratory flow limitation at rest.Thorax 2002; 57:528-532.
[18]Niekolaos GK, Epaminondas NK. Negative expiratory pressure:a new diagnostic tool in chest medicine. Pneumonia,2002,15:254-262.
[19]Tantucci C,Mehiri S,Duguet A et al. Application of negative expiratory pressure during expiration and activity of genioglossus in humans. J Appl Physiol,1998, 84:1076-1082.
[20]Bestall JC, Paul EA, Garrod R, et al. Usefulness of the Medical Research Council(MRC) dyspnea scale as a measure of disability in patient with chronic obstructive pulmonary disease[J]. Thorax,1999。54(7):581-586.
[21]Boczkowski J, Murciano D, Pichot MH, et al. Expiratory flow limitation in stable asthmatic patients during resting breathing. Am J Respir Crit Care Med, 1997,156:752-757.
[22]Baydur A.Milic-Emili J.Expiratory flow limitation during spontaneous breathing:comparison of patient with restrictive and obstructive respiratory disorders.Chest,1997.112(4):1017-1023.
[23]Tantucci C, Ellaffi M, Duguet A etal.Dynamic hyperinflation and flow limitation during methacholine induced broncho- constriction in asthma. Eur Respir J,1999,14:295-301.
[24]Wang PH, Kuo, p H, Hsu C L, et al. Diagnostic value of negative expiratory pressure for airway hyperreactictivity. Chest,2003,124:1762-1767.
[25]Stauffer JL, Buick MK, Bixler EO, et al. Morphology of the Uvula in Obstructive Sleep Apnea. Am Rev Respir Dis,1989,140:724.
[26]Verin Eric; Tardif C; Portier F; Similowski T; Pasquis P; Muir JF et al. Evidence for expiratory flow limitation of extrathoracic origin in patient with obstructive sleep apnea,thorax,2002,57(5),423-428.
[27]Liistro G, Veriter C, Dury M, et al. Expiratory flow limitation in awake sleep-disordered breathing subjects. Eur Respir J,1999,14:185-190
[28]KoutsoukouA, ArmaganidisA, Stavrakaki KallergiC, etal.Expiratory flow limitation and intrinsic positive end expiratory pressure at zero positive end expiratory pressure in patients with adult respiratory distress syndrome.Am J Respir Crit Care Med.2000,161:1590-1596.
[29]Goetghebeur D, Sarni D, Grossi Y, et al. Tidal expiratory flow limitation and chronic dyspnoea in patients with cystic fibrosis. Eur Respir J,2002,19: Koulouris NG, Retsou S, Kosmas E, et al. Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis. Eur Respir J,2003,21:743—748.
[30]Tauber E.Fazekas T.Delwiche JP,et al.Negative expiratory pressure:a new tool for evaluating lung function in children? Pediatr Pulmonol,2003,35(3):162-168.
[31]陈爱欢,陈荣昌,李俊梅,等.呼气流速受限在儿童支气管哮喘气道高反应性评价中的应用.中华结核和呼吸杂志,2007,30：950-951
[32]Vanpee D,Swine C,Delwiche JP, et al.Evaluation of flow limitation in elderly patients unable to perform a forced expiratory maneuver. Aging Clin Exp Res,2002,14(3):208-211.
[2]Donaid A, Mahler M.D. F. C. C. P. Evaluation of clinical methods for rating dyspnea. Chest,1988,93:580-585.
[3]Gosker HR. Engelen MP,vall Mameren H. et al.Muscle fiber type ⅡⅩ atrophy is involved in the lOSS of fat. free mass in chronic obstructive pulmonary disease. Am J Clin Nutr2002; 76:113-119.
[4]Hyatt RE. The interrelationship of pressure, flow and volume during various respiratory maneuvres in normal andemphysematous patients. Am Rev Respir Dis 1961; 83:676-683.
[5]穆魁津,林友华主编.肺功能测定原理与临床应用.北京医科大学、中国协和医科大学联合出版社,1992；66.
[6]Mead J, Turner JM, Macklem PT, Little JB. Significance of the relationship between lung elastic recoil and maximum expiratory flow. J Appl Physiol 1967; 22:95-108.
[7]Melissinos CG, Webster P, Tien YK, Mead J. Time dependence of maximum flow as an index of nonuniformemptying. J Appl Physiol 1979; 47:1043-1050.
[8]D'Angelo E, Prandi E, Marazzini L, Milic-Emili J.Dependence of maximal flow-volume curve on time-course of preceding inspiration in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 150: 1581-1586.
[9]Valta P, Corbeil C, Lavoie A, et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med,1994, 150:1311-1317
[10]Jones MH, Davis SD, Kisling JA, et al. Flow limitation in infants assessed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[11]Dourado VZ, Antunes LC, Tanni SE, et al. Relationship of upper-limb and thoracic muscle strength to 6-min walk distance in COPD patients. Chest,2006, 129:551-557.
[12]PapirisS A,D aniitZ D,M alagariK,et al. The Medical research council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis. Respir Med,2005,99:755-761.
[13]Jones MH, Davis SD, Kisling JA, etal.Flow limitation in infants assesed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[14]Eltayara L, Becklake MR, Volta CA, Milic-Emili J.Relationship between chronic dyspnea and expiratory flowlimitation in patients with chronic obstructive pulmonarydisease. Am J Respir Crit Care Med 1996; 154: 1726-1734.
[15]Boni E, Corda L, Franchini D, et al. Volume effect and exertional dyspnoea after bronchodilator in patients with COPD with and without expiratory flow limitation at rest.Thorax 2002; 57:528-532.
[16]Donald A,Mahler M.D.F.C.C.P. Evaluation of clinical methods of rating dyspnea.Chest,1988,93:580-585.
[17]Takashi H, Koichi N, Mitsuhiro T, etal. Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med.1998.158:1185-1189.
[18]Weaver T E, Richmond T S,N arsavage G L. An explanatory model of functional status in chronic obstructive pulmonary disease. Nurs Res,1997,46:26-31.
[19]Bestall JC, Paul EA, Garrod R, et al. Usefulness of the medical research council(M RC) dyspnea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax,1999,54:581.
[20]Eltayara L, Becklake MR, Volta CA, et al. Relationship between chronic dyspnea and expiratory flow limitation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med,1996,154(6Pt1):1726-1734.
[1]施焕中编.慢性阻塞性肺疾病人民卫生出版社,2006；76
[2]Hyatt RE. The interrelationship of pressure, flow and vol-ume during various respiratory maneuvres in normal andemphysematous patients. Am Rev Respir Dis 1961; 83:676-683.
[3]穆魁津,林友华主编.肺功能测定原理与临床应用.北京医科大学、中国协和医科大学联合出版社,1992；66.
[4]Mead J, Turner JM, Macklem PT, Little JB. Significance of the relationship between lung elastic recoil and maxi-mum expiratory flow. J Appl Physiol 1967; 22:95-108.
[5]Melissinos CG, Webster P, Tien YK, Mead J. Time dependence of maximum flow as an index of nonuniformemptying. J Appl Physiol 1979; 47:1043-1050.
[6]D'Angelo E, Prandi E, Marazzini L, Milic-Emili J.Dependence of maximal flow-volume curve on time-course of preceding inspiration in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 150:1581-1586.
[7]Valta P, Corbeil C, Lavoie A, et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med,1994, 150:1311-1317.
[8]Jones MH, Davis SD, Kisling JA, et al. Flow limitation in infants assessed by negative expiratory pressure. Am J Respir Crit Care Med,2000,161:713-717.
[9]Koulouris NG,Valta P, Corbel C, et al. [J]. Eur Respir J,1995,8:306-313.
[10]中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南(2007年修订版).中华结核和呼吸杂志,2007,30(1)：8-17.
[11]Eltayara L, Becklake MR, Volta CA, Milic-Emili J. Relationship between chronic dyspnea and expiratory flow-limitation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996;154: 1726-1734.
[12]Koulouris NG, Dimopoulou I, Valta P, Finkelstein R, Cosio MG,Milic-Emili J. Detection of expiratory flow limitation during exercise in COPD patients. J Appl Physiol 1997;82:723-731.
[13]D'iaz 0, Villafranca C, Ghezzo H, et al. Role of inspiratory capacity on exercise tolerance in COPD patients with and without tidal expiratory flow limitation at rest. Eur Respir J 2000; 16:269-275.
[14]O'Donnell DE, Webb KA. Exertional breathlessness in patients with chronic airflow limitation. The role of lung hyperinflation. Am Rev Respir Dis 1993; 148:1351-1357.
[15]Donald A,Mahler M.D.F.C.C.P. Evaluation of clinical methods of rating dyspnea.Chest,1988,93:580-585.
[16]Eltayara L, Becklake MR, Volta CA, Milic-Emili J.Relationship between chronic dyspnea and expiratory flowlimitation in patients with chronic obstructive pulmonarydisease. Am J Respir Crit Care Med 1996; 154: 1726-1734.
[17]Boni E, Corda L, Franchini D, et al. Volume effect and exertional dyspnoea after bronchodilator in patients with COPD with and without expiratory flow limitation at rest.Thorax 2002; 57:528-532.
[18]Niekolaos GK, Epaminondas NK. Negative expiratory pressure:a new diagnostic tool in chest medicine. Pneumonia,2002,15:254-262.
[19]Tantucci C,Mehiri S,Duguet A et al. Application of negative expiratory pressure during expiration and activity of genioglossus in humans. J Appl Physiol,1998, 84:1076-1082.
[20]Bestall JC, Paul EA, Garrod R, et al. Usefulness of the Medical Research Council(MRC) dyspnea scale as a measure of disability in patient with chronic obstructive pulmonary disease[J]. Thorax,1999。54(7):581-586.
[21]Boczkowski J, Murciano D, Pichot MH, et al. Expiratory flow limitation in stable asthmatic patients during resting breathing. Am J Respir Crit Care Med, 1997,156:752-757.
[22]Baydur A.Milic-Emili J.Expiratory flow limitation during spontaneous breathing:comparison of patient with restrictive and obstructive respiratory disorders.Chest,1997.112(4):1017-1023.
[23]Tantucci C, Ellaffi M, Duguet A etal.Dynamic hyperinflation and flow limitation during methacholine induced broncho- constriction in asthma. Eur Respir J,1999,14:295-301.
[24]Wang PH, Kuo, p H, Hsu C L, et al. Diagnostic value of negative expiratory pressure for airway hyperreactictivity. Chest,2003,124:1762-1767.
[25]Stauffer JL, Buick MK, Bixler EO, et al. Morphology of the Uvula in Obstructive Sleep Apnea. Am Rev Respir Dis,1989,140:724.
[26]Verin Eric; Tardif C; Portier F; Similowski T; Pasquis P; Muir JF et al. Evidence for expiratory flow limitation of extrathoracic origin in patient with obstructive sleep apnea,thorax,2002,57(5),423-428.
[27]Liistro G, Veriter C, Dury M, et al. Expiratory flow limitation in awake sleep-disordered breathing subjects. Eur Respir J,1999,14:185-190
[28]KoutsoukouA, ArmaganidisA, Stavrakaki KallergiC, etal.Expiratory flow limitation and intrinsic positive end expiratory pressure at zero positive end expiratory pressure in patients with adult respiratory distress syndrome.Am J Respir Crit Care Med.2000,161:1590-1596.
[29]Goetghebeur D, Sarni D, Grossi Y, et al. Tidal expiratory flow limitation and chronic dyspnoea in patients with cystic fibrosis. Eur Respir J,2002,19: Koulouris NG, Retsou S, Kosmas E, et al. Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis. Eur Respir J,2003,21:743—748.
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