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Abstract
Protocol
Results
Discussion
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Tilt Test med Kombineret Underkroppen Negativ Pressure: en "Gold Standard" til måling af Ortostatisk Tolerance

Published: March 21, 2013
doi:
10.3791/4315
, , ,
1Department of Biomedical Physiology and Kinesiology,Simon Fraser University

Summary

Vi beskriver en "gold standard" for evaluering ortostatisk tolerance (OT) ved hjælp af tilt test med kombineret nederste del af kroppen negativt tryk (LBNP). Dette kan kombineres med ikke-invasive evalueringer af kardiovaskulære refleks kontrol. Normale og unormale reaktioner er defineret.

Abstract

Ortostatisk tolerance (OT) er evnen til at opretholde kardiovaskulær stabilitet i oprejst mod de hydrostatiske virkningerne af tyngdekraften, og derved fastholdes cerebral perfusion og forhindre synkope (besvimelse). Forskellige teknikker er tilgængelige til at vurdere OT og virkningerne af tyngdekraft stress på omsætning, typisk ved at gengive en presyncopal begivenhed (nær-besvimelse episode) i et kontrolleret laboratoriemiljø. Den tid og / eller graden af ​​stress påkrævet for at fremkalde denne reaktion giver målet for OT. Enhver teknik, der anvendes til at bestemme OT bør: muliggøre skelnen mellem patienter med ortostatisk intolerance (af forskellige årsager) og asymptomatiske kontrolpersoner, være meget reproducerbar, hvilket muliggør vurdering af terapeutiske interventioner, undgå invasive procedurer, som er kendt for at forringe OT 1.

I slutningen af 1980'erne head-opretstående tilt test blev først udnyttet til diagnosticering synkope 2. Since da det er blevet anvendt til at vurdere OT hos patienter med synkope af ukendt årsag, og hos raske individer at undersøge posturale kardiovaskulære reflekser 2-6. Vippe protokoller omfatter tre kategorier: passiv tilt, passive tilt ledsaget af farmakologisk provokation, og passiv vip med kombineret nederste del af kroppen negativt tryk (LBNP). Men virkningen af hældning test (og andre ortostatisk stress test modaliteter) er ofte dårligt reproducerbare, med lav sensitivitet og specificitet til at diagnosticere ortostatisk intolerance 7.

Typisk en passiv tilt omfatter 20-60 min for ortostatisk stress fortsatte indtil indtræden af præsynkope i patienter 2-6. Men den største ulempe ved denne procedure er dens manglende evne til at påberåbe sig præsynkope i alle enkeltpersoner, som gennemfører testen, og tilsvarende lav følsomhed 8,9. Således blev forskellige metoder udforskes for at øge ortostatisk stress og forbedre følsomheden.

Farmakologisk provokation er blevet anvendt til at øge ortostatisk udfordring, for eksempel ved anvendelse isoprenalin 4,7,10,11 eller sublingual nitrat 12,13. Men den væsentligste ulempe ved disse metoder er stigninger i følsomhed på bekostning af uacceptable fald i specificitet 10,14, med en høj positiv svarprocent umiddelbart efter administration 15. Desuden invasive procedurer i forbindelse med nogle farmakologiske provokationer i høj grad øge den falsk positiv rate 1.

En anden metode er at kombinere passiv tilt test med LBNP, hvilket giver en stærkere ortostatisk stress uden invasive procedurer eller narkotika bivirkninger, anvendelse af teknikken udviklet af professor Roger Hainsworth i 1990'erne 16-18. Denne tilgang provokerer præsynkope i næsten alle fag (hvilket muliggør symptom anerkendelse hos patienter med synkope), mens diskriminere mellem patieNTS med synkope og sunde kontroller, med en specificitet på 92%, sensitivitet på 85%, og gentagelsesnøjagtighed på 1,1 ± 0,6 min 16,17. Dette giver ikke blot diagnose og patofysiologiske vurdering 19-22, men også evaluering af behandlinger for ortostatisk intolerance grund af dets høje repeterbarhed 23-30. Af disse årsager argumenterer vi dette skulle være "gold standard" for ortostatisk stresstest, og derfor vil dette være den metode der er beskrevet i dette dokument.

Protocol

Gennem afprøvning, kontinuerlig slag-til-slag blodtryk og elektrokardiogram (EKG) overvågning er altafgørende. Dette sikrer emne sikkerhed, og hurtig afslutning af testen med debut af præsynkope. Beat-to-beat blodtrykket optagelser kan opnås gennem arteriel kateterisering, eller finger plethysmografi 31-33. Sidstnævnte anvendes i denne protokol, fordi det er ikke-invasiv og kan vurdere indtræden af præsynkope med samme nøjagtighed som kateterisering 31,34, uden de skadelige virkninger af i…

Representative Results

Ved hjælp af denne protokol, alle fag erfaring præsynkope, og definitionen af ​​normale eller unormale reaktioner sker i vid udstrækning baseret på den tid, det tager at fremkalde denne reaktion. OT er defineret som tiden til præsynkope i minutter fra indtræden af ​​opretstående vipning. Typiske værdier for OT i raske frivillige efter alder og køn kan ses i tabel 1. Patienter med ortostatisk intolerance udviser præsynkope tidligere i testen, med 85% slutter testen i -20 mmHg fase samme…

Discussion

Denne teknik er særdeles reproducerbar, har evnen til at skelne normale og unormale reaktioner med høj følsomhed og specificitet, og kan fremprovokere præsynkope i alle fag, der giver mulighed for symptom anerkendelse hos patienter med tilbagevendende synkope. I en klinisk indstilling, kan forskellige typer af synkope skelnes, så skræddersyet behandling og forvaltning. Virkningen af ​​interventioner let kan vurderes. Med yderligere kardiovaskulær monitorering, kan refleks respons også evalueres.

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Disclosures

The authors have nothing to disclose.

Acknowledgements

Vi vil gerne anerkende professor Roger Hainsworth, der har udviklet denne teknik. Vi er taknemmelige for Mr. King Hang Chao og Mr. Wang-Joe Woo for deres assistance med fotografering.

Dette arbejde understøttes af Simon Fraser University og Heart and Stroke Foundation of Canada.

Materials

Equipment Manufacturer Location
Tilt Table Custom-build Leeds, United Kingdom
Finometer Finapres Medical Systems Amsterdam, The Netherlands
Doppler Box Compumedics Singen, Germany
Doppler software The DWL Doppler Company Singen, Germany
Aquasonic Ultrasound gel Parker Laboratories, Inc. Fairfield, USA
Headbands Lululemon Burnaby, Canada
Headset Canadian Tire Burnaby, Canada
ECG Finapres ECG Module, Finapres Medical Systems Amsterdam, The Netherlands
Electrodes Red Dot Ontario, Canada
Antiseptic Isopropyl Alcohol Pads Lernapharm Quebec, Canada
O2Cap-Oxygen Analyser Oxigraph Inc. California, USA
Airlife Nasal Oxygen Cannula Cardinal Health Mountainview, USA
Powerlab 16/30 AD Instruments Colorado Springs, USA
DOWNLOAD MATERIALS LIST

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Tags

Tilt TestingCombined Lower Body Negative PressureOrthostatic ToleranceCardiovascular StabilitySyncopePresyncopal EventGravitational StressOrthostatic IntoleranceReproducibilityTherapeutic InterventionsInvasive ProceduresHead-upright Tilt TestingSyncope DiagnosisPostural Cardiovascular ReflexesTilting ProtocolsPharmacological ProvocationLBNP
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Protheroe, C. L., Ravensbergen, H. (. J., Inskip, J. A., Claydon, V. E. Tilt Testing with Combined Lower Body Negative Pressure: a “Gold Standard” for Measuring Orthostatic Tolerance. J. Vis. Exp. (73), e4315, doi:10.3791/4315 (2013).
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