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From the Authors

Dept Pediatric Respiratory Diseases, University Medical Center Utrecht, Utrecht, the Netherlands.

From the authors:

We thank W. Kozlowska and colleagues for their worthy comments to our paper on the use of computer animation programs. We concluded that the use of incentives can be helpful in training young infants how to blow and how to perform a flow/volume manoeuvre. However, we were not able to prove that the routine use of these programs is helpful in the improvement of reproducibility and maximal effort 1. We agree that the use of a tailor-made combination of different programs might improve the performance of young children, provided the use of envelop flow/volume curves. Thus, nonroutine use of incentives should be further investigated and the use of envelop curves for young children should be standardised in the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines.

In our study we used the reference values of Zapletal et al. 2 and the animation target was achieved at 120% of the predicted value of peak expiratory flow (PEF) and forced vital capacity (FVC). These reference values are indeed back-extrapolations from older children, which might result in underestimation for several lung function parameters in younger children. Comparison of back-extrapolated values with actual values in younger children from the same authors reveals that overestimation is especially a problem for forced expiratory volume in one second (FEV₁), but not for FVC 3. Extrapolated PEF values are even higher compared to the actual values in younger children. Back-extrapolated predicted values for FEV₁ (L), FVC (L) and PEF (L·s^–1) in a 100 cm male are 0.76, 0.89 and 2.05, respectively 2, while actual values are 0.85, 0.88 and 2.02, respectively 3. So, we do not think that the use of back-extrapolated values in our study resulted in understimulation. Whether an eventual raise in animation target to 130 or 140% will result in higher values should be studied.

We agree with W. Kozlowska and colleagues that the reproducibility results largely depend on the criteria which are chosen. For this reason we did not study only the 5% and 100 mL criteria as recommended by the ATS/ERS but also a 7% and 10% criterion. Both using these latter criteria and the coefficient of variation (in table 2) the use of incentives did not result in better reproducibility.

With Kozlowska and colleagues we think that incentives should not be dismissed from the lung function lab for young children, but we plead for a well-considered (nonroutine) use and uniform guidelines. We are happy that the American Thoracic Society/European Respiratory Society Task Force has initiated their development.

References

1. Gracchi V, Boel M, Van der Laag J, Van der Ent CK. Spirometry in young children: should computer-animation programs be used during testing?. Eur Respir J 2003;21:872–875.[Abstract/Free Full Text]
2. Zapletal A, Samenek M, Paul T. Lung function in children and adolescents: methods, reference values. Basel, Karger, 1987.
3. Zapletal A, Chalupova J. Forced expiratory Parameters in healthy preschool children (3–6 years of age). Pediatr Pulmonol 2003;35:200–207.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

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