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Summary  摘要

4-Phase-Rhinomanometry (4PR) Basics and Practice 2010
2010 年 4 相鼻压计 (4PR) 基础与实践

Klaus Vogt*, Alfredo A. Jalowayski, W. Althaus, C. Cao,
克劳斯-沃格特*、阿尔弗雷多-A-贾洛维斯基、W-阿尔特豪斯、C-曹、
D. Han, W. Hasse, H. Hoffrichter, R. Mösges,
D.Han, W. Hasse, H. Hoffrichter, R. Mösges、
J. Pallanch, K. Shah-Hosseini, K. Peksis,
J.Pallanch, K. Shah-Hosseini, K. Peksis、
K.-D. Wernecke, L. Zhang*, P. Zaporoshenko
K.-D. Wernecke, L. Zhang*, P. ZaporoshenkoWernecke, L. Zhang*, P. Zaporoshenko

The last comprehensive publications about the theory and practice of rhinomanometry appeared more than 20 years ago. Since the 1980 's, the general progress of sensor techniques, fluid physics and data processing was accompanied by the permanent work of the authors to analyze the errors of rhinomanometry and to create a fundament for a contemporary and practical method that can be used in functional diagnostics of the nasal air stream.
上一本关于鼻测量理论与实践的综合性出版物出版于 20 多年前。自 20 世纪 80 年代以来,伴随着传感器技术、流体物理学和数据处理技术的全面进步,作者们一直致力于分析鼻测量法的误差,并为可用于鼻气流功能诊断的现代实用方法奠定基础。
In this special document, the objectives and measurement principles, as well as the history of rhinomanometry are described in the first three chapters. It is pointed out, that the key parameters are not only intranasal pressure and flow, but also the factor time. The technical requirements as following from the dynamics of breathing are described.
在这份特别文件的前三章中,介绍了鼻测量仪的目标、测量原理和历史。文件指出,关键参数不仅包括鼻内压和鼻流量,还包括时间因素。此外,还介绍了呼吸动力学的技术要求。
The process of averaging of rhinomanometric data lead to a separate and time-dependent analysis of the changes of pressure and flow and implicated the introduction of the 4 breathing phases (ascending and descending curve part in inspiration and expiration) into rhinomanometry and is therefore called 4Phase-Rhinomanometry (4PR). Chapter 4 is containing a comprehensive analysis of the practical errors, which may follow neglecting the 4 breathing phases.
鼻测量数据的平均化过程导致对压力和流量的变化进行单独和随时间变化的分析,并将 4 个呼吸阶段(吸气和呼气时的上升和下降曲线部分)引入鼻测量法,因此被称为 4 阶段鼻测量法(4PR)。第 4 章全面分析了忽视 4 个呼吸阶段可能导致的实际错误。
The in chapter 5 described mathematical-physical concept of 4PR is based on the introduction of the terms "steady" and "unsteady" flow, in addition to the up to now used terms of laminarity and turbulence. After the derivation of the HOFFRICHTER-equation as explaining the loops around the intersection point of the -axis and -axis, a clinical classification of the rhinomanometric findings is given and confirmed by physical experiments with "artificial noses". Finally, testing the rhinomanometric method by CFD (Computational Fluid Dynamics), lead to the same conclusions as to the importance of 4 phases of the breathing cycle.
第 5 章描述了 4PR 的数学物理概念,除了目前使用的层流和湍流术语外,还引入了 "稳定 "和 "非稳定 "流动术语。在推导出解释 轴和 轴交点周围环流的 HOFFRICHTER 方程后,给出了鼻测量结果的临床分类,并通过 "人工鼻 "物理实验加以证实。最后,通过 CFD(计算流体力学)测试鼻测量法,得出了关于呼吸周期 4 个阶段重要性的相同结论。
The precondition for the worldwide introduction of new parameters into the 4PR is a comprehensive statistical analysis. The disadvantages of the present recommended standard values are described in chapter 6. Following previous studies in 5800 cases, the parameters Vertex Resistance (VR), Effective Resistance (Reff) and their logarithmic transformations have been investigated in 1580 rhinograms of different degrees of obstructions, also including the correlations to a VAS. It could be confirmed, that the parameters VR and Reff after logarithmic transformation, have a significant and high correlation to the sensation of obstruction. The new clinical classification of obstruction and conductance of the nose is proposed in Table 1 for Caucasian noses.
在全球范围内将新参数引入 4PR 的先决条件是进行全面的统计分析。第 6 章介绍了目前推荐标准值的缺点。根据之前对 5800 个病例的研究,我们对 1580 张不同阻塞程度的鼻图进行了顶点阻力(VR)、有效阻力(Reff)参数及其对数变换的研究,其中也包括与 VAS 的相关性。结果表明,经过对数变换后的 VR 和 Reff 参数与阻塞感具有显著的高度相关性。表 1 针对白种人鼻子的阻塞和鼻传导性提出了新的临床分类。
Table 1. Clinical classification of obstruction and conductance for Causcasian noses.
表 1.高加索人鼻子阻塞和传导性的临床分类。
Log10R(VR, REFF) Log10R(VR、REFF) Obstruction, Resistance 阻碍、阻力 Conductance 电导
1 very low 非常低 very high 非常高
2 low high 
3 moderate 温和派 moderate 温和派
4 high  low
5 very high 非常高 very low 非常低
Chapter 7 is dedicated to the advantages of in the functional diagnosis of nasal valve problems. Graphical as well as numerical solutions are available by the fact, that the motions of the nasal entrance as caused by the breathing process are now visible from the shape of the 4PR-curve.
第 7 章主要介绍 在鼻瓣膜功能诊断方面的优势。事实上,从 4PR 曲线的形状中可以看到呼吸过程引起的鼻腔入口运动,因此可以用图形和数值来解决。
Discussing practical aspects in chapter 8 , the start point of proposals and discussions are the standard recommendations of the ISOANA and the results of its consensus conference in 2003. In particular the calibration processes, hygiene, the correct attachment of the pressure tube at the nostril ("tape method") and the different measurement procedures (AAR, APR), decongestion and provocation tests are extensively described.
第 8 章讨论了实用方面的问题,建议和讨论的出发点是 ISOANA 的标准建议及其 2003 年共识会议的结果。特别是校准过程、卫生、压力管在鼻孔处的正确连接("胶带法")、不同的测量程序(AAR、APR)、减充血和激惹试验,都有广泛的描述。
Both the final chapters are clinical contributions from mainland China, which are of high importance because of the racial differences in nasal respiratory function. In chapter 9 , tests of the assessment of normal nasal airway in adult Chinese by , rhinomanometry and acoustic rhinometry are presented. This investigation lead to the conclusion that 4PR is an important supplement to classic rhinomanometry and acoustic rhinometry, if the classification of obstruction is adapted to the higher basic resistance of the Chinese population.
最后两章都是来自中国大陆的临床研究成果,由于鼻呼吸功能的种族差异,这两章具有非常重要的意义。第 9 章介绍了通过 、鼻量计和声学鼻量计评估中国成人正常鼻气道的测试。这项调查得出的结论是,如果鼻阻塞的分类适应中国人口较高的基本阻力,4PR 是经典鼻测量法和声学鼻测量法的重要补充。
Chapter 10 is dealing with and acoustic rhinometry in the functional evaluation of septal deviations and concludes, that both methods are valuable objective instruments for the evaluation of nasal obstruction.
第 10 章讨论了鼻中隔偏曲功能评估中的 和声学鼻测量法,并得出结论,这两种方法都是评估鼻阻塞的重要客观工具。

1. The Objective and Measurement Principles of Rhinomanometry
1.鼻测量的目标和测量原理

Klaus Vogt, Alfredo A. Jalowayski
克劳斯-沃格特、阿尔弗雷多-A-贾洛维斯基

1-1 Introduction 1-1 引言

The beginnings of functional diagnostic rhinology go back to 1894, when Zwaardemaker recommended holding a refrigerated metal plate under the nose during exhalation in order to estimate the degree of airflow obstruction from the relative amounts of condensed vapour. Glatzel attempted to further quantify this method by engraving a series of equidistant arcs to the mirror. The Glatzel Mirror can occasionally be found in medical-historical collections. Further modifications of this method have been described by Jochims in 1938 by the fixation of the condensed pattern with Gummi Arabicum.
功能诊断鼻科的起源可以追溯到 1894 年,当时 Zwaardemaker 建议在呼气时将一块冷冻金属板放在鼻下,以便根据冷凝蒸汽的相对数量来估计气流阻塞的程度。格拉泽尔 试图通过在镜子上雕刻一系列等距弧线来进一步量化这种方法。格拉泽尔镜偶尔会出现在医学历史藏品中。Jochims 在 1938 年描述了对这种方法的进一步改进,即用阿拉伯树胶固定凝结的图案。
Later, the hygrometric methods described above were replaced by methods characterizing the nasal airflow by its physical parameters of flow and pressure; thus rhinology as well as pneumonology were following methods based on physics and general fluid dynamics. Methods of estimation have now been replaced by measuring and calculation.
后来,上述湿度测量方法被通过流量和压力等物理参数来描述鼻腔气流特征的方法所取代;因此,鼻科和肺科都采用了基于物理学和一般流体动力学的方法。现在,估算方法已被测量和计算方法所取代。
The goal of rhinomanometry in the past has been either:
过去鼻测量的目标是:
a. to measure how much pressure is required to move a given volume of air through the nose during respiration, or
a. 测量在呼吸过程中,一定量的空气通过鼻腔所需的压力,或
b. to determine the airflow that can pass through the nose at a given pressure.
b. 确定在给定压力下可通过鼻腔的气流。
During the transition from graphical to computerized rhinomanometry it became apparent that the most important parameter is neither the pressure nor the airflow velocity; instead, it is the relation between these two parameters, which allow us to describe more completely the physics of the nasal air stream. The basis of these relations became the accepted standard for evaluating the degree of nasal obstruction in the field of rhinology in .
在从图形鼻测量法向计算机鼻测量法过渡的过程中,我们发现最重要的参数既不是压力,也不是气流速度,而是这两个参数之间的关系,它使我们能够更完整地描述鼻腔气流的物理特性。 这些关系的基础成为鼻科领域评估鼻阻塞程度的公认标准。
During the development of computerized rhinomanometry, it was necessary to consider how pressure and flow vary during a breathing cycle. We had to analyze the dynamics of both measurement channels and to eradicate methodical errors. It became apparent, that another factor played a significant role: this factor was time, which had not been taken into consideration previously. Time is an important physiological factor, because it is essential that the amount of oxygen required by the body reach the lung within a period corresponding to its oxygen needs. In cases of elevated nasal obstruction, this time limit is exceeded and mouth breathing becomes necessary. For example, during vigorous exercise or physical work, this transition is physiologically predetermined. However, when a person at rest feels compelled to breathe through the mouth, this indicates that sufficient amounts of conditioned air cannot flow under those conditions through the nose. Therefore, the pres- sure difference between the nasal opening and the epipharynx has to be maintained for a longer period to allow the transport of sufficient oxygen to the lungs. Therefore, the diagnostic aim of 4-phase-rhinomanometry is to measure the intranasal pressure, flow and time variables necessary for maintaining an adequate oxygen supply through the nose.
在开发计算机鼻测量仪的过程中,有必要考虑呼吸周期中压力和流量的变化情况。我们必须分析两个测量通道的动态变化,并消除方法上的误差。很明显,另一个因素也起着重要作用:这就是以前从未考虑过的时间因素。时间是一个重要的生理因素,因为人体所需的氧气量必须在与肺部氧气需求量相应的时间内到达肺部。在鼻腔阻塞加重的情况下,就会超过这个时间限制,这时就需要用口呼吸。例如,在剧烈运动或体力劳动时,这种转变是生理上预先决定的。然而,当一个人在休息时感到不得不用口呼吸时,这表明在这种情况下,鼻子无法提供足够的调节空气。因此,鼻腔开口和会咽之间的预压差必须保持更长的时间,才能将足够的氧气输送到肺部。因此,四相血压计的诊断目的是测量鼻内压力、流量和时间变量,这些都是通过鼻腔维持充足氧气供应所必需的。

1-2 Methodology of Rhinomanometry
1-2 鼻测量方法

The principles applied during the past few decades for measuring the relationship between pressure difference and airflow volume through the nose can be described as follows:
在过去几十年中,用于测量压力差与鼻腔气流体积之间关系的原理可描述如下:

1-2-1 External airflow methods (Passive Rhinomanometry)
1-2-1 外部气流测量法(被动式鼻测量法)

External airflow methods consist of pumping a constant, predefined amount of air through a nasal olive into or out of the nose. The resultant pressure difference generated can thus be measured. The basis of this method, so called "passive rhinomanometry", can be traced to Kayser in 1895, and it has been used in children, especially when active rhinomanometry testing was not possible .
外部气流法包括通过鼻橄榄将预定量的恒定空气泵入或泵出鼻腔。由此产生的压力差可以被测量出来。这种方法的基础,即所谓的 "被动鼻测量法",可追溯到 1895 年的 Kayser ,它一直被用于儿童,尤其是在无法进行主动鼻测量测试时
Passive rhinomanometry had been the only available method used to study nasal ventilatory functions until the development of pneumotachography . The passive rhinomanometry has several critical drawbacks that one should be aware when using this procedure, or when analysing and comparing data.
在气动描记术 问世之前,被动测鼻法一直是研究鼻通气功能的唯一可用方法。被动测鼻法有几个关键的缺点,在使用这种方法或分析和比较数据时应注意。
During passive rhinomanometry:
在被动测鼻过程中:
  • The patient must hold his/her breath during the recording
    记录时患者必须屏住呼吸
  • The positioning of the soft palate affects airflow resistance significantly and can be deliberately altered only by trained subjects. Airflow from an external source is often reported to cause discomfort and causes reflex movements by the soft palate
    软腭的位置对气流阻力有很大影响,只有受过训练的受试者才能有意识地改变软腭的位置。据报道,来自外部的气流通常会引起不适,并导致软腭反射性运动
  • When using alternating airflows, significant differences have been measured between the pumping and suction phases.
    在使用交替气流时,测量到抽气和吸气阶段之间存在显著差异。
Passive rhinomanometry is a "one-value" method. It means that the diagnostic information is only one number/value for the pressure at a given flow level and reveals little about the dynamics of nasal airflow. When using nasal olives, the risk exists that at each "breath" the airflow is channelled in a different direction, thereby altering the geometry of the nose and affecting the measurement at each reading. Moreover, the nasal openings, including the nasal valve, cannot be assessed when nasal olives are used. This circumstance further restricts the diagnostic value of passive rhinomanometry.
被动测鼻法是一种 "单值 "方法。这意味着诊断信息只是给定流量下压力的一个数字/数值,对鼻腔气流的动态变化揭示甚少。在使用鼻橄榄时,每次 "呼吸 "时气流都有可能流向不同的方向,从而改变鼻子的几何形状,影响每次读数的测量结果。此外,使用鼻橄榄时,包括鼻瓣在内的鼻腔开口也无法评估。这种情况进一步限制了被动式鼻测量仪的诊断价值。
The oscillatory measurement of nasal resistance assumes a special status and is likewise classified as an external airflow
鼻阻力的振荡测量具有特殊地位,同样被归类为外部气流测量。

procedure . Here, an alternating current is superimposed on the patient's spontaneous breathing by an airflow generator. This gas flow spreads throughout the entire respiratory tract as well as into adjacent tissues. The total resistance in all respiratory passages is determined. Analogous to the theory of alternating current, the assessed resistance is a complex resistance and results from the series and parallel circuits of real, inductive and capacitive sub-resistances found in the respiratory tract.
在这里,气流发生器将交流电叠加到患者的自主呼吸上。气流遍布整个呼吸道以及邻近组织。所有呼吸通道的总阻力由此确定。与交流电理论类似,评估的电阻是一种复合电阻,由呼吸道中的实性、感性和容性子电阻的串联和并联电路产生。
With the oscillation method, a reference resistance of known magnitude is connected in parallel with respiratory tract resistance . A current generator device produces an alternating current of . The alternating pressure produced by oscillation is measured. Analogous to the theory of alternating current, the following relationship set remains valid:
在振荡法中,已知大小的基准电阻 与呼吸道电阻 并联。电流发生装置产生 的交变电流。测量振荡产生的交变压力 。与交流电理论类似,以下关系组仍然有效:
and
can be calculated, where and are given and is measured. An x-y plotter is used to make a recording in a special diagram, which depicts a graphical solution to the specific equation. Respiratory resistance value can be read directly from the diagram.
可以计算,其中 是给定的, 是测量的。使用 x-y 绘图仪在特殊图表中进行记录,描绘出特定方程的图解。呼吸阻力值 可直接从图表中读取。
Resistance in the entire respiratory tract is determined with this method. Nasal resistance can be obtained by subtracting the resistance measured through the mouth from the total resistance. It is a quick and practical method of measurement. However, the oscillation method for assessing nasal airflow resistance is a "one-value" method also, which does not permit further statements to be made about the nasal airflow pattern. No accurate result can be obtained where resistance values exceed . Special technical equipment (FD5/Siemens) is necessary to carry out this procedure. In the course of earlier work, we have adapted this technique to the specific requirements of rhinology . Berdel and Koch have recommended using this method particularly for functional diagnostics in children; however, the method is generally not widely used in rhinology.
整个呼吸道的阻力都是通过这种方法测定的。从总阻力中减去通过口腔测得的阻力,即可得出鼻腔阻力。这是一种快速实用的测量方法。不过,评估鼻腔气流阻力的振荡法也是一种 "单值 "法,无法进一步说明鼻腔气流模式。如果阻力值超过 ,则无法获得准确结果。执行此程序需要特殊的技术设备(FD5/西门子)。在早先的工作中,我们已根据鼻科的具体要求调整了这一技术 。Berdel 和 Koch 建议将此方法特别用于儿童的功能诊断;不过,该方法一般未在鼻科广泛使用。

1-2-2 Spontaneous flow method (Active Rhinomanometry)
1-2-2 自发流量法(主动鼻测量法)

Due to the drawbacks of external flow methods described above, a general consensus has been reached worldwide that the patient's own physiological airflow should be used for assessing nasal ventilatory functions whenever possible. Not only the natural dynamics of nasal breathing can be measured, but nasal symptoms can also be correlated to the pulmonary physiological parameters.
由于上述外部气流方法的缺点,全世界已达成普遍共识,即应尽可能使用患者自身的生理气流来评估鼻通气功能。不仅可以测量鼻腔呼吸的自然动态,还可以将鼻腔症状与肺部生理参数联系起来。

According to Semarak , these methods can even be traced to Brünings and have been mentioned in the description summarized by Zwaardemaker . In 1958, Semarak described the first "Nasal Patency Assessment Device" that enabled simultaneous assessment of nasal respiratory flow and pressure difference between the nasal entrance and choanae.
根据 Semarak ,这些方法甚至可以追溯到 Brünings ,并在 Zwaardemaker 总结的描述中有所提及。1958 年,Semarak 描述了第一个 "鼻腔通畅评估装置",该装置可同时评估鼻腔呼吸流量以及鼻腔入口和咽喉之间的压力差。
Along with the development of functional nasal surgery in the US, Cottle and his school in particular embarked on a search for an objective diagnostic procedure for assessing nasal obstruction and introduced rhinomanometry to clinical rhinology. During that time, in Germany such scholars as Masing , Bachmann , Fischer , von Arentsschild , Schumann and later Eichler , Mlynski , Bachert , Vogt and many others have contributed significantly to the development of theoretical and practical conditions for a meaningful rhinology diagnostics, particularly so for active rhinomanometry testing.
随着功能性鼻腔手术在美国的发展,Cottle 和他的学派尤其开始寻找评估鼻腔阻塞的客观诊断程序,并将鼻测量法引入临床鼻科。在此期间,德国的学者如 Masing 、Bachmann 、Fischer 、von Arentsschild 、Schumann 以及后来的 Eichler 、Mlynski 、Bachert 、Vogt 和其他许多人都为发展有意义的鼻科诊断的理论和实践条件做出了重要贡献,特别是在主动鼻测量测试方面。
Rapid development of microelectronics within last two decades has not only made space flight possible, but it has also ensured that digital measuring technologies, originally possible only using large mainframe computers, have found their way into many areas of everyday life. In rhinomanometry, this particularly pertains to the accurate measurement of very low pressures and flow rates. Thus, new pathways have opened up in rhinology for the implementation of precise and manageable measurement technologies, which can be readapted to suit the needs of practical medicine.
过去二十年来,微电子技术的飞速发展不仅使太空飞行成为可能,而且还确保了原本只能使用大型计算机主机才能实现的数字测量技术进入日常生活的许多领域。在鼻测量领域,这尤其体现在对极低压力和流速的精确测量上。因此,在鼻科领域开辟了新的途径,可以采用精确、易于管理的测量技术,以适应实际医疗的需要。
Active Rhinomanometry distinguishes in turn between two measurement techniques after deriving the pressure difference between nasal entrance and choanae: the anterior and posterior methods. Active Anterior Rhinomanometry (AAR) involves closing one nostril with a measuring pressure probe, the other nostril thereby serving as an extension of the probe, while Active Posterior Rhinomanometry (APR) measures pressure difference via a tube in the mouth, with or without a mouthpiece, and held by the lips. In order to accurately measure total nasal resistance by APR, the soft palate and the tongue must be relaxed. Since pressure is deflected by the soft palate, the resistance of the anatomical structures between the oropharynx and choanae become effective in addition to the nasal resistance. Thus, rhinomanometric results obtained by AAR and APR are not always comparable. Typical examples for such differences are found in children with enlarged adenoids, in cleft palate patients and patients with nasopharyngeal fibromas or choanal polyps.
在得出鼻腔入口和咽鼓管之间的压力差后,主动鼻腔测量法又分为两种测量技术:前部测量法和后部测量法。前部主动测鼻法(AAR)是用测压探针关闭一个鼻孔,另一个鼻孔作为探针的延伸,而后部主动测鼻法(APR)则是通过口中的一根管子(带或不带吹口管),用嘴唇固定来测量压力差。为了通过 APR 准确测量鼻腔总阻力,软腭和舌头必须放松。由于软腭会使压力发生偏转,因此除了鼻腔阻力外,口咽部和咽喉之间解剖结构的阻力也会产生作用。因此,AAR 和 APR 所获得的测鼻结果并不总是具有可比性。腺样体肥大的儿童、腭裂患者和鼻咽纤维瘤或咽喉息肉患者就是这种差异的典型例子。

2. Technical aspects of rhinomanometry
2.鼻测量技术

Klaus Vogt, Wolfgang Hasse, Alfredo A. Jalowayski
克劳斯-沃格特、沃尔夫冈-哈斯、阿尔弗雷多-A-贾洛维斯基

2-1 Introduction 2-1 引言

From a technical point of view, rhinomanometry is the simultaneous measurement of the volume flow through the nose and of the differential narinochoanal pressure required for the generation of this airflow and the calculation of relevant physiological parameters. Presently, this task can be completed at different quality levels by several commercially available instruments. Therefore, the following section attempts to present a summary account of currently used measuring technology, which should enable the user to critically assess the quality characteristics of different equipment.
从技术角度看,鼻流量计是同时测量通过鼻腔的气流量和产生该气流量所需的鼻腔咽鼓管压差,并计算相关的生理参数。目前,市场上销售的几种仪器都能以不同的质量水平完成这项任务。因此,下文将对目前使用的测量技术进行简要介绍,以便用户对不同设备的质量特性进行严格评估。

2-2 Measurement of volume flow and differential pressure
2-2 流量和压差测量

Most rhinomanometers in practice have applied the measurement principle of pneumotachography for recording volume flow. This principle requires an introduction of a defined resistance force to the respiratory airflow. The drop in pressure caused by this hindrance is proportional to the flow velocity (Bernoulli's principle). This obstacle is generally referred to as a "spiroceptor", and various technical models of this device exist. Its classic design resembles a so-called "Fleisch' Head" that is comprised of several metal tubes in parallel arrangement. Decrease of pressure occurring in such "heads" is linear within a specific range. Hence, the size of the spiroceptor must correspond to the anticipated flow. In prolonged testing, the spiroceptor must be warmed up to prevent water condensation inside
在实际应用中,大多数鼻毛测量仪都采用气动描记法的测量原理来记录体积流量。这一原理要求在呼吸气流中引入一个确定的阻力。这种阻力造成的压力下降与流速成正比(伯努利原理)。这种障碍物通常被称为 "螺旋受体",这种装置有各种技术模型。其经典设计类似于所谓的 "弗莱施头",由多根平行排列的金属管组成。这种 "头 "中发生的压力下降在特定范围内是线性的。因此,螺纹吸附器的尺寸必须与预期流量相符。在长期测试中,必须对螺套进行预热,以防止水在螺套内凝结。
So-called "lamellar spiroceptors," consisting of plastic foils arranged in parallel, have a much greater range of linearity . The same authors have also described another device called a "diaphragm spiroceptor," where a diaphragm functions as a curtain blowing in response to airflow changes to such a degree that a linear relationship results between a decrease in pressure and airflow . This formerly essential requirement for such a strictly linear relationship no longer exists today, if this non-linearity can be levelled via utilisation of appropriate analogue modules or by computer calculation. To illustrate, the information gathered by a ring-diaphragm spiroceptor is initially represented in quadratic terms with subsequent electronic root extraction of outcome data.
所谓的 "片状螺线管 "由平行排列的塑料薄膜组成,其线性范围更大 。同一作者还描述了另一种称为 "膜片螺旋受体 "的装置,其中的膜片可作为帘幕对气流变化做出响应,从而使压力下降和气流之间形成线性关系 。如果可以通过利用适当的模拟模块或计算机计算来消除这种非线性关系,那么这种严格的线性关系的基本要求在今天就不复存在了。举例说明,环形隔膜螺旋感受器收集的信息最初用二次方表示,随后用电子根提取结果数据。
The critical drawback of this measurement technology is that it possesses a high degree of inaccuracy near zero values (square root of small numbers) and inevitably leads to a distortion of measurement results in this important range.
这种测量技术的主要缺点是在零值(小数的平方根)附近误差较大,不可避免地会导致在这一重要范围内的测量结果失真。

From the hygiene point of view, a common risk involved with the use of all pneumotachographs, and therefore all rhinomanometers based on this principle, is the fact that respiratory flow passing through the lamellae is not filtered for bacteria and appropriate and regular disinfection measures rarely take place. No publications have yet focused on this problem.
从卫生的角度来看,使用所有气压计以及基于此原理的所有鼻流量计的一个共同风险是,通过薄片的呼吸气流没有经过细菌过滤,而且很少采取适当的定期消毒措施。目前还没有任何出版物关注这一问题。

2-3 Technical problems following the dynamics of the nasal air flow
2-3 遵循鼻腔气流动态的技术问题

Flow sensors and sensors for measuring differential pressure must meet rigid standard requirements if the primary measurement results are to be accurate. In this respect, the precision of flow and pressure measurements is not the only important criterion. It is just as essential that the speed of the recording is adjusted to time-dependent physiological changes in respiration. The demands placed on measurement technology by the dynamics of respiration have been considered the greatest challenge in the development of rhinomanometry.
流量传感器和压差测量传感器必须满足严格的标准要求,才能保证主要测量结果的准确性。在这方面,流量和压力测量的精度并不是唯一重要的标准。同样重要的是,记录速度必须适应呼吸中随时间变化的生理变化。呼吸动态对测量技术的要求被认为是鼻搏动测量技术发展过程中的最大挑战。
The most important parameters that can provide information about the dynamic properties of a rhinomanometer are:
能提供鼻压计动态特性信息的最重要参数是
  • resolution 决议
  • offset drift 偏移漂移
  • gain drift 增益漂移
  • cut-off frequency. 截止频率。
In this respect, resolution designates the smallest change of a signal that can still be registered. Above all, the noise level of a sensor puts restrictions on the highest possible resolution. Signal changes within the magnitude of a given noise level cannot be distinguished from general noise. These facts are well known in audiometry and are applied in the same sense in general information technology.
在这方面,分辨率指的是仍能记录的信号的最小变化。最重要的是,传感器的噪音水平会对最高分辨率造成限制。在给定噪声级范围内的信号变化无法与一般噪声区分开来。这些事实在听力测量中众所周知,在一般信息技术中也同样适用。
Primary signal resolution in digital processing of the measurements is closely related to quantization. For instance, a peak value of is generated by an electromechanical pressure transducer and a serially connected primary electronic device with full-scale output (F.S.O.) of 1200 Pa. Subsequently, this signal is quantized into steps by a 12-bit analogue digital converter. In this case, the noise voltage of a sensor must not exceed , otherwise the output is falsified.
测量数字处理中的主信号分辨率与量化密切相关。例如, 的峰值由机电压力传感器和串行连接的一次电子装置产生,其满量程输出(F.S.O.)为 1200 Pa。随后,该信号被一个 12 位模拟数字转换器量化为 步。在这种情况下,传感器的噪声电压不得超过 ,否则输出将被伪造。
Such a quality, to some extent comparable with CD quality sound in stereo systems, can be attained only by a small number of pressure transducers that register lower range pressures generated by a spiroceptor. The measurement of differential narinochoanal pressure in a pressure range of does not pose such technological challenges.
这种音质在某种程度上可与立体声系统中的 CD 音质相媲美,但只有通过少量的压力传感器才能实现,这些压力传感器可记录螺旋感受器产生的较低范围的压力。在 的压力范围内测量 narinochoanal 压差不会带来这样的技术挑战。
Sensor offset drift is a quite disagreeable characteristic, which played a significant role in early pneumotachography technology using valve amplifiers. In spite of the absence of any physiological signal, a measuring device will produce a signal. At each measurement, this offset drift is added on to the signal measured. In this respect, temperature sensitivity of a measurement system is of crucial importance. Stable sensors have an offset drift of / 10K. Superior quality sensors produce results in which offset drift is largely negligible, thereby eliminating the need for verification procedures prior to each measurement.
传感器偏移漂移是一个相当令人不快的特性,它在早期使用阀式放大器的气动照相技术中发挥了重要作用。尽管没有任何生理信号,测量设备仍会产生信号。每次测量时,偏移漂移都会加到测量信号上。在这方面,测量系统的温度灵敏度至关重要。稳定的传感器具有 / 10K 的偏移漂移。质量上乘的传感器所产生的结果,偏移漂移基本上可以忽略不计,因此无需在每次测量前进行验证程序。
Gain drift, on the contrary, cannot be identified as easily as offset drift. This is a multiplicating error, which can be easily avoided by assessing and correcting the calibration of total measuring channel. Yet, it must first be identified. In modern sensor technology, which is also applied in rhinomanometry, high stability of gain is also generally a prerequisite since it permits the use of the electronic components. Therefore, various factors such as transportation, clogging of a spiroceptor or extreme atmospheric changes implement the necessity of recalibration of the total system.
相反,增益漂移不像偏移漂移那样容易识别。这是一种倍增误差,可以通过评估和校正总测量通道的校准来轻松避免。但是,必须首先识别它。在现代传感器技术中,增益的高稳定性通常也是一个先决条件,因为它允许使用电子元件。因此,运输、螺线管堵塞或极端的大气变化等各种因素都会导致整个系统需要重新校准。
Cut-off-frequency of a sensor or, to be more precise, of the entire measuring section is an exceptionally important factor that is decisive for the quality of rhinomanometric testing. It characterises the dynamic behaviour of a measured section. At the same time, some knowledge of physics is necessary in order to understand it. Depending on the activity level, the normal breathing rate is between 0.3 and . Harmonics, however, are superimposed on this cyclical process. The results obtained in Fourier analyses prove that these harmonics can reach a frequency range of . In practical terms of transmission technology, this means that rhinomanometric equipment should be capable of registering frequencies up to precisely. For a long time, though, this has been a scarcely imaginable breakthrough.
传感器的截止频率,更准确地说,是整个测量截面的截止频率,是一个非常重要的因素,对鼻测量仪的质量起着决定性的作用。它描述了测量截面的动态特性。同时,要理解它还需要一定的物理知识。根据活动水平的不同,正常呼吸频率在 0.3 到 之间。 然而,谐波会叠加在这一周期性过程中。傅立叶分析的结果证明,这些谐波的频率范围可达 。从传输技术的实际角度来看,这意味着测鼻设备应能精确记录高达 的频率。但长期以来,这一直是一个难以想象的突破。
Simulation of human breathing processes to test airflow diagnostic devices can be carried out with a slowly running piston pump with a capacity of , which can generate sinusoidal respiration cycles. Maximal airflow velocity is assumed to be . Similar airflow velocity can be generated with a piston pump having a capacity and driven with a revolution per minute (rpm) rate that is thirty times greater. It remains questionable whether the precalculated airflow value can actually be assessed. In the lower rpm range, a linear relationship develops between velocity and measured flow, whereas the indicated flow value does not increase anymore, when a specific velocity rate is reached. The cut-off frequency of the flow-channel is thus attained. In physical terms, the cut-off frequency of a sensor is reached when the signal response of measurement system is calculated to 0.707 of the real value. This corresponds to an attenuation effect of .
模拟人类呼吸过程以测试气流诊断设备,可以使用一个缓慢运行的活塞泵,其容量为 ,可以产生正弦呼吸周期。最大气流速度假定为 。如果使用容量为 、驱动速度为每分钟转数 (rpm) 30 倍的活塞泵,也能产生类似的气流速度。预计算的气流值是否可以实际评估仍然是个问题。在较低的转速范围内,速度与测量流量之间呈线性关系,而当达到特定速度时,指示流量值不再增加。这样就达到了流道的截止频率。从物理角度讲,当测量系统的信号响应计算到实际值的 0.707 时,传感器的截止频率就达到了。这相当于 的衰减效应。

Highest harmonics of the respiration frequency are found around the phase of changing of the flow direction, because the real breathing curve is more similar to a trapezoid than to a sinusoidal curve. This cannot be measured with a cut-off frequency of , but it is precisely there and this has invoked critical questions regarding the interpretation of the results.
呼吸频率的最高谐波出现在气流方向变化的相位附近,因为真实的呼吸曲线更类似于梯形,而不是正弦曲线。这一点无法用 的截止频率来测量,但它恰恰存在,这引发了对结果解释的关键问题。
In a series of relevant Fourier analysis tests, Mlynski established that time-dependent changes in respiratory pressure and airflow values fall within the range of . Similar results have been reported by Versnick and Clement . In general terms of transmission techniques, this implies that the cut-off frequency in a rhinomanometric system needs to be above .
在一系列相关的傅立叶分析测试中,Mlynski 确定呼吸压力和气流值随时间变化的范围为 。Versnick 和 Clement 也报告了类似的结果。就一般传输技术而言,这意味着测鼻系统的截止频率必须高于
In this respect, confusion between the terms "respiratory frequency" and "frequency content" in respiratory activity has farreaching consequences. At the time when respiratory frequency itself is predominantly below ( 20 breaths per minute), the frequency content of respiration is determined by acceleration and deceleration processes taking place within the same inspiration. The changes occur fastest at the transition from inspiration to expiration.
在这方面,混淆呼吸活动中的 "呼吸频率 "和 "频率含量 "会产生深远的影响。当呼吸频率本身主要低于 (每分钟 20 次呼吸)时,呼吸的频率含量由同一吸气过程中的加速和减速过程决定。这种变化在从吸气到呼气的转换过程中发生得最快。
Today, rhinomanometers based on the measurement principles of pneumotachography should have a cut-off frequency of about in the flow channel as well as in the pressure channel that no longer poses a serious technological problem. Users of such devices should be aware of the fact that the technological characteristics of a given pressure converter are not the only factors able to determine the frequency response behaviour of a rhinomanometer. Thus, caution must be exercised when modifying the length and strength parameters of the connecting tubes, which can also affect the cut-offfrequency.
如今,基于气动照相法测量原理的鼻曼仪在流量通道和压力通道中应具有 左右的截止频率,这不再是一个严重的技术问题。此类设备的用户应该意识到,特定压力转换器的技术特性并不是决定鼻压计频率响应特性的唯一因素。因此,在修改连接管的长度和强度参数时必须谨慎,因为这也会影响截止频率。
The number of possible airflow measurement procedures is far greater. For anemometry, the use of thermistors, or hot wire thermal resistors, is fundamentally practicable; alternatively, airflow measurement can be carried out with Venturi tubes or Pitot tubes as used for aviation purposes. However, all of these methods are either designed for application in areas other than rhinomanometry and cannot satisfy its diagnostic requirements at a reasonable cost.
可能的气流测量程序要多得多。就风速测量而言,使用热敏电阻或热线热敏电阻基本上是可行的;另外,还可以使用文丘里管或用于航空目的的皮托管进行气流测量。然而,所有这些方法要么是为鼻流量计以外的应用而设计的,要么是无法以合理的成本满足鼻流量计的诊断要求。
The evolution of sensor technology brought along by semiconductors has not only been instrumental in developing semiconductor-based pressure sensors but has also produced so-called "mass flow sensors" (Figure 1). These relatively new devices contain all required equipment in a miniature case, which eliminates the need for an extensive tube connecting the nasal cavity with a pressure sensor. The measurement principle consists in the microelectronic evaluation of heat transmission between two thermo-electrical measuring elements.
半导体带来的传感器技术的发展不仅有助于开发基于半导体的压力传感器,而且还产生了所谓的 "质量流量传感器"(图 1)。这些相对较新的设备将所需的所有设备都装在一个微型盒中,因此不需要连接鼻腔和压力传感器的庞大管道。测量原理是对两个热电测量元件之间的热传递进行微电子评估。
mass: approx.  质量:约
Figure 1. Mass Airflow Sensor (Datasheet from the Honeywell company).
图 1.质量气流传感器(霍尼韦尔公司数据表)。
This type of sensors offers high stability performance and compact construction. In combination with laptop computers, these devices provide a high level of mobility and open up entirely new perspectives for rhinological research and practice, especially in allergological and environmental studies. Such miniature measurement technology was first installed in the HRR 2 rhinomanometer (RhinoLab GmbH, Rendsburg, Germany). Earlier hygienic issues have been solved by implementing appropriate filtering elements.
这种传感器稳定性能高,结构紧凑。这些设备与笔记本电脑相结合,具有很高的移动性,为鼻科学研究和实践,特别是过敏症和环境研究开辟了全新的前景。HRR 2 鼻压计(RhinoLab GmbH,德国伦茨堡)首次采用了这种微型测量技术。早期的卫生问题已通过采用适当的过滤元件得到解决。
As an example (Figure 2), such a device may consist of the following components:
举例来说(图 2),这种装置可由以下部件组成:
  1. sensor case 传感器外壳
  2. airflow sensor case 气流传感器外壳
  3. differential pressure sensor
    差压传感器
  4. diffusor 扩散器
  5. bacteria and humidity filter
    细菌和湿度过滤器
  6. hose connections 软管连接
  7. mask (sterilisable) 面罩(可消毒)
  8. fixing element for pressure hose
    压力软管固定件
  9. electronic circuit 电子电路
  10. computer interface 电脑接口
(B)
Figure 2. Rhinomanometer HRR 3 (RhinoLab, Rendsburg,Germany)*. (A) Schematic picture and (B) in a set with a netbook computer.
图 2.HRR 3 鼻压计(RhinoLab,德国伦茨堡)*。(A) 原理图;(B) 与上网本电脑配套使用。

3. Recording technology in rhinomanometry
3.鼻测量仪的记录技术

Klaus Vogt, Wolfgang Hasse, Alfredo A. Jalowayski
克劳斯-沃格特、沃尔夫冈-哈斯、阿尔弗雷多-A-贾洛维斯基

3-1 Introduction 3-1 引言

The evolution of rhinomanometry into "4-Phaserhinomanometry" is the result of a 20 -year error analysis conducted in rhinomanometric diagnostic technology, both on the side of theoretical research and technical feasibility of the procedure. While fundamental technical approaches as described above have spurred rapid developments in recording possibilities, documentation process of the obtained data and computer data interpretation remain a matter of discussion until today.
从理论研究和技术可行性两方面对鼻测量诊断技术进行了长达 20 年的误差分析,最终将鼻测量演变为 "4-Phaserhinomanometry"。尽管上述基本技术方法推动了记录技术的快速发展,但直到今天,所获数据的记录过程和计算机数据解读仍是一个需要讨论的问题。

3-2 Rhinomanometry devices and set-ups
3-2 鼻测量设备和装置

Earlier pioneers in pneumotachography and rhinomanometry recorded the results of their measurements with a so-called kymograph. Change-sensitive stylus records any deflections on a revolving drum wrapped with a sheet of soot-blackened paper. The founder of functional nasal surgery Cottle aimed to incorporate into clinical rhinology the physiological findings on a relationship between nasal flow volume and the pressure required to move it. To this end, he recorded both of these parameters simultaneously on an ECG device and later evaluated them by reading the corresponding values of pressure and flow curves at the same point in time. The difficulties accompanying this methodology inevitably arise at zero points, inasmuch as accurate meter-reading is no longer possible due to curve steepness. Therefore, Cottle resorted to measuring parameters at their peak values; unfortunately, though, this methodology failed to gain acceptance with time. We will return to the meaningfulness of this procedure below.
早期的气动测速仪和鼻测量仪先驱使用所谓的气压计记录测量结果。对变化敏感的测针可记录缠有烟灰黑纸的旋转鼓上的任何偏转。功能性鼻腔手术的创始人科特尔 (Cottle) 的目标是将鼻腔流量与移动鼻腔所需的压力之间关系的生理学研究成果应用于临床鼻科。为此,他在心电图设备上同时记录了这两个参数,随后通过读取同一时间点的压力和流量曲线的相应值对其进行评估。这种方法在零点时不可避免地会遇到困难,因为由于曲线陡峭,精确读表已不再可能。因此,Cottle 采用了在峰值时测量参数的方法;但遗憾的是,随着时间的推移,这种方法未能得到认可。我们将在下文再次讨论这一程序的意义。
Bachmann recommended recording the relationship between both variables on an - recorder in a direct manner a procedure that later became the basis of today's international standard. Representation of data interdependencies inevitably caused certain technical problems, which could be immediately discerned by every professional. First and foremost, this has to do with the fact that different elements of a measurement chain respond at different rates to changes in the measured variables. Individual elements in a given measurement setup have differing cut-off frequencies. The "cut-off frequency" of a measurement system is the highest frequency at which this system can analyse dynamic processes without loss of accuracy and to treat them as if they were static processes. A measurement system that registers two interdependent variables must align frequency response characteristics in its channels first. Precisely this was not the case with analogue data representation, since the flow channel responded sluggishly due to a considerably slower transducer.
巴赫曼 建议在 记录仪上直接记录两个变量之间的关系,这一程序后来成为当今国际标准的基础。数据相互依存关系的表示不可避免地会产生一些技术问题,每个专业人员都能立即发现这些问题。首先,这与测量链中的不同元素对测量变量变化的响应速度不同有关。特定测量装置中的各个元件具有不同的截止频率。测量系统的 "截止频率 "是指该系统在分析动态过程时可以不损失精度并将其视为静态过程的最高频率。测量系统在记录两个相互依存的变量时,必须首先调整其通道的频率响应特性。模拟 数据表示的情况恰恰不是这样,因为流量通道的响应速度由于传感器的速度大大降低而变得迟缓。

According to Figure 3, the two weakest elements in an analogue recording system were none other than the flow transducer and the recorder.
根据图 3,模拟记录系统中最薄弱的两个元件非流量传感器和 记录器莫属。
Figure 3. Analogue measurement chain in rhinomanometric procedure by Bachmann .
图 3.巴赫曼 鼻毛测量法中的模拟测量链。
In 1980 with the aid of spacecraft engineering pressure converters and extremely short connecting hoses, a research group at the ENT department of the Charité University Hospital in Berlin, Germany; K. Vogt and team members) managed to attain a cut-off- frequency of in a given flow measuring section (unpublished data). Obtained data were temporarily saved in a storage oscilloscope designed for observation in an intensive care unit and subsequently read from an -y plotter (Figures 4 and 5). This allowed recording data in the critical zero-point area with sufficient accuracy. Even at a lower diagram recording speed, however, loop curves have been detected, thus questioning the reliability of graphical curve interpretation. Besides that, it was possible to obtain truly trustworthy measurements only with cooperative patients who were able to produce a series of steady and constant breathing cycles.
1980 年,借助航天器工程压力转换器和极短的连接软管,德国柏林夏里特大学医院耳鼻喉科的一个研究小组(K. Vogt 和小组成员)成功地在给定的流量测量部分达到了 的截止频率(未发表数据)。获得的数据暂时保存在专为重症监护室观察设计的存储示波器中,随后从 -y 绘图仪中读取(图 4 和图 5)。这样就能足够精确地记录关键零点区域的数据。不过,即使在较低的图表记录速度下,也能检测到循环曲线,因此对图形曲线解释的可靠性提出了质疑。此外,只有合作的患者才能获得真正可信的测量结果,因为他们能够进行一系列稳定和持续的呼吸循环。
Further small-scale experimenting with the aid of piston pump-generated airflow ("artificial nose") has yielded significant findings on how various technical aspects of rhinomanometric measurement - setup can contribute to error generation, i.e., what impact can have hose dimensions, mask size, etc. on cut-off- frequency .
借助活塞泵产生的气流("人工鼻")进行的进一步小规模实验取得了重要发现,了解了鼻测量的各种技术方面--设置如何导致误差的产生,即软管尺寸、面罩大小等对截止频率 的影响。
Figure 4. Rhinomanometric workstation, 1985, HNO-Clinic Charité in Berlin (ENT Department at the Charité University-Hospital). The pressure converters are mounted on a stand. Flow measurement takes place with the aid of a lamellar spiroceptor. Data are recorded using a storage oscilloscope monitor; analogue results are written by an x-y recorder.
图 4.鼻测量工作站,1985 年,柏林 HNO-Clinic Charité(Charité 大学医院耳鼻喉科)。压力转换器安装在支架上。流量测量借助一个片状螺线管进行。数据由存储示波器监视器记录;模拟结果由 x-y 记录器写入。
Figure 5. Hybrid system with data digitalisation, an interim stage on the route to computer-assisted rhinomanometry.
图 5.数据数字化混合系统,实现计算机辅助鼻测量的过渡阶段。
In 1982, during the ERS-Congress in Stockholm, the first results of the so-called "computer rhinomanometry" were presented. These were the interpretations of digital curves designed to produce a general mathematical model of curve progression. Similar procedures have been developed independently by research groups in East Berlin, Tbilisi and Rochester (26-28). This development was performed on large workstations typical for that time, where measurement data were recorded in analogue form, digitally stored on magnetic tape and subsequently exported to a computer memory.
1982 年,在斯德哥尔摩召开的 ERS 大会上,首次展示了所谓的 "计算机鼻测量 "成果。这是对数字曲线的解释,旨在建立一个曲线发展的通用数学模型。东柏林、第比利斯和罗切斯特的研究小组也独立开发了类似的程序 (26-28)。这项开发工作是在当时典型的大型工作站上进行的,测量数据以模拟形式记录,以数字形式存储在磁带上,随后输出到计算机存储器中。

The introduction of computer technology into rhinomanometry has brought along some substantial errors attributable to direct importation of calculation methods from other scientific spheres. The initial fundamental error was the calculation of the regression between flow and pressure difference without taking notice of the individual data that arise in the process and, thereon, the analysis of an presumed function instead of the interpretation of actual measurements. On the basis of digital computation technology a new generation of microprocessor rhinomanometers has been developed. Devices of similar construction are still popular today thanks to their user-friendliness.
在鼻测量学中引入计算机技术后,由于直接引进了其他科学领域的计算方法,导致出现了一些重大错误。最初的根本性错误是在计算流量和压差之间的回归时,没有考虑到过程中出现的各种数据,因此分析的是假定函数,而不是对实际测量结果的解释。在数字计算技术的基础上,新一代微处理器鼻压计应运而生。由于使用方便,类似结构的设备至今仍很受欢迎。
In the 1980s, computer technologies have also paved the way for the development of the first commercial software-based rhinomanometers, one of which was produced and released by the research group at HNO-Klinik Charité in Berlin (29). Initially named "Carima", this system was later renamed to "Rhinodat". For over five years, it had been widely used for rhinomanometric measurements in many clinics. Different companies took over this technology after 1990 and many of those systems are still in use.
20 世纪 80 年代,计算机技术也为开发首批基于软件的商业鼻毛测量仪铺平了道路,其中之一就是由柏林 HNO-Klinik Charité 研究小组生产并发布的(29)。该系统最初名为 "Carima",后更名为 "Rhinodat"。五年多来,该系统在许多诊所广泛用于鼻测量。1990 年后,不同的公司接管了这项技术,其中许多系统仍在使用。
Figure 6. Carima System (1989). The first PC-controlled rhinomanometer in the world, produced by Heyer, Bad Ems, Germany. Due to a still existing problem of sensor relocation sensitivity, the case is vertically mounted onto a stand.
图 6.Carima 系统(1989 年)。这是世界上第一台由电脑控制的鼻压计,由德国巴德埃姆斯的 Heyer 公司生产。由于仍存在传感器定位灵敏度的问题,该系统的外壳是垂直安装在支架上的。
Despite continuous improvements in the quality and operational speed of the measurement system, the careful review of the results constantly showed the presence of loops in rhinomanometric curves, an error previously attributed to the deficiencies of the equipment. After ensuring that technical errors were excluded, the loops could only reflect phenomena as characteristic for the nasal airflow physiology. A new basic mathematical and physical concept was needed. The practical conclusion of this concept, as described in Chapter 4, was "High-Resolution Rhinomanometry". In 2003, the "International Standardization Committee on the Objective Assessment of the Nasal Airway" (ISOANA) recommended to rename this term "4-Phase-Rhinomanometry" (30).
尽管测量系统的质量和运行速度不断提高,但在对结果进行仔细审查后发现,鼻气流测量曲线中不断出现回路,而这一误差之前被归咎于设备的缺陷。在确保排除技术误差后,循环只能反映鼻腔气流生理特征的现象。因此需要一个新的基本数学和物理概念。正如第 4 章所述,这一概念的实际结论就是 "高分辨率鼻测量法"。2003 年,"鼻气道客观评估国际标准委员会"(ISOANA)建议将这一术语更名为 "4 相鼻流测量法"(30)。

4. Averaging in computerised rhinomanometry the key to 4-Phase-Rhinomanometry
4.计算机鼻测量中的平均值是 4 相鼻测量的关键

Klaus-Dieter Wernecke, Klaus Vogt, Alfredo A. Jalowayski
克劳斯-迪特尔-韦内克、克劳斯-沃格特、阿尔弗雷多-A-贾洛维斯基

4-1 Introduction 4-1 导言

The International Standardization Committee on Objective Assessment of the Nasal Airway (ISOANA) published recommendations of standards for rhinomanometry in . The recommended physical units as well as parameters have been used worldwide and become an essential part of commercial rhinomanometers. These recommendations were based upon the manual graphical evaluation of rhinomanometric findings, which had been recorded on x-y recorders or plotters. In 1990, after completing extensive physical and technical studies, Vogt et al. described the first PC-based commercial rhinomanometric system. An essential part of the software used in that system was the independent and time-related recording of data points for differential pressure and flow and the averaging of data via spline interpolation . When introducing this procedure into computerized rhinomanometry, they observed that the increasing and decreasing phases of the airflow followed different aerodynamic conditions and that the -y-imaging of pressure and flow, as recommended by the standards from 1984, generated loops instead of a simple curved line. At the conference held by the European Rhinologic Society in Copenhagen in 1994, Vogt and Hoffrichter proposed the term "High-Resolution Rhinomanometry" for the analysis of four different phases of breathing to underline the difference in the quality of the new procedure. During the Consensus Conference of the ISOANA in Brussels in , the committee recommended changing this term into "Four-Phase Rhinomanometry."
鼻气道客观评估国际标准化组织(ISOANA)在 中公布了鼻流量计的标准建议。推荐的物理单位和参数已在全球范围内使用,并成为商用鼻压计的重要组成部分。这些建议是基于对鼻测量结果的手动图形评估,这些结果记录在 X-Y 记录仪或绘图仪上。1990 年,在完成了大量的物理和技术研究后,Vogt 等人 描述了第一个基于 PC 的商用鼻测量系统。该系统软件的一个重要部分是独立并与时间相关地记录压差和流量的数据点,并通过样条插值 对数据进行平均。在将这一程序引入计算机鼻畸形测量法时,他们发现气流的上升和下降阶段遵循不同的空气动力学条件,而且 1984 年标准所建议的压力和流量 -y-imaging 会产生环路,而不是简单的曲线。1994 年,在哥本哈根举行的欧洲鼻科学会会议上,Vogt 和 Hoffrichter 提出了 "高分辨率鼻测量 "这一术语,用于分析四个不同的呼吸阶段,以强调新程序在质量上的差异。在 布鲁塞尔举行的 ISOANA 共识会议上,委员会建议将这一术语改为 "四相鼻测量法"。
After the introduction of computerized rhinomanometry into clinical practice, two different phenomena became visible in determining the shape of the loops:
在临床实践中引入计算机鼻测量技术后,在确定鼻环形状时出现了两种不同的现象:
  1. A remarkable number of curves did not pass the intersection of the -axis and -axis.
    许多曲线没有通过 轴和 轴的交点。
  2. The opening of the loops was frequently observed to be much wider in inspiration than in expiration.
    经常观察到吸气时襻的开口比呼气时大很多。
The first observation is caused by the influence of the inertia of the air. The mathematical and physical interpretation will be described in detail in Chapter 5. The theoretical concept has been confirmed by many model experiments using an "artificial nose" and in recent times by Computational Fluid Dynamics (CFD). The second observation is based on the physiological behaviour of the nasal valve (see Chapter 7 for details). nomanometry
第一个观测结果是由空气惯性的影响引起的。第 5 章将详细介绍数学和物理解释。许多使用 "人工鼻 "进行的模型实验以及最近的计算流体动力学(CFD)都证实了这一理论概念。第二个观察结果基于鼻瓣膜的生理行为(详见第 7 章)。
Figure 7. Averaging of rhinomanometric data by regression lines. Flow; DP Differential Pressure; Regression Line
图 7.用回归线平均鼻压计数据。 流量;DP 压差; 回归线
The differences between classic rhinomanometry and 4PR originate from the data acquisition process and the method of data averaging. Classic computerized rhinomanometers sequentially collect alternating values for flow and pressure and place the obtained data points in a xy-Cartesian system. Subsequently, a regression line is constructed representing the pressure-flow relationship, which starts at the origin of the axis (Figure 7).
传统鼻压计与 4PR 的区别在于数据采集过程和数据平均方法。传统的计算机鼻压计按顺序交替采集流量和压力值,并将获得的数据点置于 xy-Cartesian 系统中。随后,以轴的原点为起点,构建一条代表压力-流量关系的回归线(图 7)。
Two important errors are generated by the above procedure that are not easily recognized by the user of these systems
上述程序会产生两个重要的错误,而这些系统的用户并不容易识别这些错误
  • The correlation coefficient as a parameter for the reliability of the regression line is not necessarily given in the printouts
    作为回归线可靠性参数的相关系数不一定在打印输出中给出
  • The rhinomanometric curve meets always the intersection point of the -axis and -axis
    鼻测量曲线总是与 轴和 轴的交点相交。
A better way of acquiring and averaging the data from different breaths is to separately and visually control the uptake of the flow and pressure data and then to construct a "representative breath" as a real-time procedure (Figure 8).
获取和平均不同呼吸数据的更好方法是分别目视控制流量和压力数据的吸收,然后构建 "代表性呼吸 "作为实时程序(图 8)。
Breaths differ both in time and in the amplitude of pressure and flow recordings. The uptake process can be followed by both the patient and investigator on the screen. If the differences in length and amplitude between the single breaths are too high, the computer is instructed to discontinue the averaging procedure. The limits of such discrimination can be determined by software. After the recording process, the "representative breath" is constructed by interpolating data points up to
呼吸的时间以及压力和流量记录的振幅都不同。患者和研究人员都可以在屏幕上看到吸气过程。如果单次呼吸在时间和振幅上的差异过大,计算机会被指示停止平均程序。这种辨别的限度可通过软件确定。记录过程结束后,"代表性呼吸 "将通过内插数据点构建,直至
Figure 8. (A) Time-related averaging of rhinomanometric data.
图 8. (A) 鼻测量数据的时间平均值。
Step 1: Breaths of different lengths (B1, B2, B3) are "stretched" to a standard length of 2000 data points by spline interpolation (B1', )
步骤 1:通过样条插值将不同长度的呼吸(B1、B2、B3)"拉伸 "到 2000 个数据点的标准长度(B1', )
Figure 8. (B) Time-related averaging of rhinomanometric data. Step 2: Averaging of the time-standardized breaths.
图 8. (B) 与时间相关的鼻测量数据平均化。步骤 2:对时间标准化的呼吸进行平均。
Figure 8. (C) Time-related averaging of rhinomanometric data.
图 8. (C) 与时间相关的鼻测量数据平均值。
Step 3: Transferring of the data for differential pressure and flow in a Cartesian System.
步骤 3:在直角坐标系中传输压差和流量数据。
a unified length of 2000 points for pressure and flow and a following calculation of the arithmetic means. This time-related standardization preserves the full information of the course of pressure and flow. The pressure and flow curves are saved separately as files along with the patients identification data and
压力和流量的统一长度为 2000 点,然后计算算术平均值。这种与时间相关的标准化保留了压力和流量过程的全部信息。压力和流量曲线与患者身份识别数据和其他数据一起单独保存为文件。
Figure 9. General shape of rhinomanometric graphs in four-phase rhinomanometry (right nasal cavity).
图 9.四相鼻腔测量法中鼻腔测量图的一般形状(右侧鼻腔)。
can be preserved for later numerical analysis of the pressureflow relationship as well as for statistical analysis.
可以保留下来,以便日后对压力流关系进行数值分析和统计分析。
By using this procedure and transferring the data in a Cartesian system, a double-loop instead of a simple line is generated, which means that the pressure-flow relationship in the increasing airflow is different from the decreasing airflow. The analysis of clinical material below shows the importance of this different behaviour.
通过使用该程序并在笛卡尔系统中传输数据,会产生一个双环而不是简单的线,这意味着气流增加时的压力-流量关系与气流减少时不同。下面的临床材料分析表明了这种不同行为的重要性。
After transferring these results in a Cartesian system, the shape of Figure 9 appears.
将这些结果转换到直角坐标系后,就出现了图 9 的形状。
The four phases depicted in the graph are:
图中描述的四个阶段是
Phase 1: Ascending inspiratory phase. The airflow is accelerated up to the inspiratory peak flow. The airflow in this phase is an exponential function of the pressure. The accelerating flow causes Bernouilli effects, which may reduce the crosssectional area preferably at the nasal entrance by generating so-called "valve effects." Flow is instationary from the starting point of the breathing cycle up to the peak flow, but from the moment of the attained peak flow to the beginning of the decreasing phase, the airflow is stationary and almost turbulent. Under peak flow conditions the relationship between pressure and flow is linear: Depicting the relationship between the pressure-curve and the flow-curve in xt imaging shows parallel curves.
第 1 阶段:上升吸气阶段。气流加速至吸气峰值流量。该阶段的气流是压力的指数函数。加速的气流会产生伯努利效应,通过产生所谓的 "阀门效应",缩小鼻腔入口处的横截面积。从呼吸周期的起点到峰值流量,气流都是静止的,但从达到峰值流量的时刻到下降阶段的开始,气流是静止的,几乎是湍流。在峰值流量条件下,压力与流量之间呈线性关系:在 xt 成像中,压力曲线和流量曲线之间的关系显示为平行曲线。
Phase 2: Descending inspiratory phase. The second phase is the phase from the highest inspiratory flow to the end of the inspiration. The pressure-flow relationship depends on the course of the pressure drop due to the exponential function between pressure and flow, the whirling of the airflow and the causative anatomical conditions, and on the mechanical properties of the elastic compartments determining the behaviour of the nasal entrance. When the pressure difference is zero (0), airflow may still occur if the kinetic energy of the streaming
第二阶段:下降吸气阶段。第二阶段是从最高吸气流量到吸气结束的阶段。压力-流量关系取决于压力和流量之间的指数函数所导致的压力下降过程、气流的旋涡和解剖条件,以及决定鼻腔入口行为的弹性区块的机械特性。当压差为零(0)时,如果气流的动能为 0,则气流仍会发生。

volume is sufficient. This is the case if the shape of the nasal channel approximates a tube instead of a diaphragm. At the same pressure level as in the first phase, the flow is lower than in the ascending phase. This important fact determines the subjective feeling of obstruction.
体积就足够了。如果鼻腔通道的形状近似于管道而不是隔膜,就会出现这种情况。在与第一阶段相同的压力水平下,流量低于上升阶段。这一重要事实决定了主观上的阻塞感。
Phase 3: Ascending expiratory phase. After the air flow changes its direction, the instationary airflow accelerates up to the peak expiratory flow. The relationship between pressure and flow is again exponential. The increasing expiratory airflow widens the flow channel to a small extent. During the short period of the expiratory peak flow, the pressure-flowrelation is again found to be linear. The variability of the pressure-flow relationship is higher than in Phase 4.
第 3 阶段:呼气上升阶段。气流改变方向后,吸入气流加速达到呼气峰值。压力和流量之间的关系再次呈指数关系。呼气气流的增加在很小程度上拓宽了气流通道。在呼气峰值流量的短时间内,压力-流量关系再次呈线性。压力-流量关系的变异性高于第 4 阶段。
Phase 4: Descending expiratory phase. The last phase of the nasal breathing cycle is characterized by the return to resting conditions. Under physiological conditions it is followed by an expiratory break. This pause is not reproducible under the conditions of rhinomanometry.
第四阶段:呼气下降阶段。鼻呼吸周期最后一个阶段的特点是恢复到静息状态。在生理条件下,这之后是呼气暂停。在鼻测量仪的条件下,这一停顿无法重现。
The flow is higher than in the first expiratory phase when comparing the respective pressure levels.
比较各自的压力水平,流量要高于第一呼气阶段。
Figure 10. Incorrect averaging and depicting of results in a graph leads to severe diagnostic errors in particular in elastic deformations of the nasal air channel
图 10.在图表中对结果进行不正确的平均和描述会导致严重的诊断错误,尤其是在鼻腔气道的弹性变形方面
Phase 1 and Phase 4 are determined preferably by the anatomical structures of the nose. The parameters in Phase 2 and
第 1 和第 4 阶段最好由鼻子的解剖结构决定。第 2 和第 4 阶段的参数

Phase 3 depend to a great extent on the generated flow.
第 3 阶段在很大程度上取决于所产生的流量。
During one nasal breathing cycle, the relationship changes between the causative narinochoanal pressure and the resulting flow. That is the reason why it is impossible to calculate or define a single pressure-flow relationship with one equation. Furthermore, the variability of the pressure-flow relationship is different within the four phases of nasal breathing.
在一个鼻呼吸周期中,引起鼻腔回声的压力和由此产生的流量之间的关系会发生变化。这就是为什么不可能用一个等式来计算或定义单一的压力-流量关系。此外,在鼻腔呼吸的四个阶段中,压力-流量关系的变化也各不相同。

4-3 The clinical impact of loops in rhinomanometry
4-3 环路对鼻测量的临床影响

Presently, users of rhinomanometry use the flow at different pressure levels as parameters of clinical importance. This is also the procedure recommended by the international standard of ISOANA. The flow at a differential pressure of is the main value, which is substituted by lower pressures if the 150 level cannot be reached ( ). Other investigators are accustomed to using the linear resistance at the same pressure level, which can be calculated by dividing the pressure by flow.
目前,鼻测量仪的使用者将不同压力水平下的流量作为临床重要参数。这也是 ISOANA 国际标准推荐的程序。 压差下的流量是主要数值,如果无法达到 150 的水平( ),则用更低的压力代替。其他研究人员习惯于使用相同压力水平下的线性阻力,该阻力可通过压力除以流量计算得出。
If the resolution of the breathing cycle in four phases is accepted as being correct and representing the fluid dynamics of the nasal airflow, the question arises as to whether the separate analysis of the ascending and descending phases of inspiration and expiration is really of clinical importance, or whether or not averaging of the flow values for the same pressure level of the ascending and descending curve parts can be accepted for clinical purposes.
如果认为将呼吸周期分为四个阶段是正确的,并代表了鼻腔气流的流体动力学,那么问题就来了,对吸气和呼气的上升和下降阶段进行单独分析是否真的具有临床意义,或者是否可以将上升和下降曲线部分同一压力水平的流量值平均用于临床目的。
To arrive at an answer to these questions, a statistical analysis of 1377 non-classified rhinomanometric measurements of patients who visited the author (KV) because of different rhinologic problems was conducted. The material consisted of measurements of all possible degrees of nasal obstruction. A bilateral active anterior rhinomanometry before and after decongestion with xylometazoline was carried out in any case observed. The differences between the flow values at clinically important pressure levels were calculated. The mean values are noted in Table 1.
为了回答这些问题,我们对作者(KV)因不同鼻病就诊的 1377 名患者的非分类鼻测量数据进行了统计分析。材料包括所有可能的鼻阻塞程度的测量值。在使用甲氧甲唑啉减充血前后,对观察到的任何病例都进行了双侧主动前鼻测量。计算了在临床重要压力水平下流量值之间的差异。平均值见表 1。
Table 1. Mean values of flow in each of the 4 breathing phases at different pressure levels.
表 1.不同压力水平下 4 个呼吸阶段中每个阶段的流量平均值。
-300 -250 -200 -150 -100 -75 -50 0 50 75 100 150 200 250 300
Before decongestion 减员前
Inspiration 1 灵感 1 119 165 201 256 297 323 344
Inspiration 2 灵感 2 99 136 169 224 268 298 323
Difference  差异 16.8 17.6 15.9 12.5 9.8 7.7 6.1
Expiration 1 有效期 1 -330 -305 -273 -228 -169 -133 -68
Expiration 2 有效期 2 -345 -324 -296 -259 -211 -180 -144
Difference  差异 4.3 5.9 7.8 12.0 19.9 26.1 52.8
After decongestion 解除充血后
Inspiration 1 灵感 1 - 157 223 275 354 411 452 469
Inspiration 2 灵感 2 136 190 239 319 381 425 446
Difference  差异 13.4 14.8 13.1 9.9 7.3 6.0 4.9
Expiration 1 有效期 1 -455 -434 -392 -327 -238 -185 -102
Expiration 2 有效期 2 -485 -455 -419 -365 -292 -274 -195
Difference  差异 6.2 4.6 6.4 10.4 18.5 32.5 47.7
Table 2. Relationship between pressure level and the number of unacceptable rhinomanometric measurements obtained by averaging the ascending and descending curve parts.
表 2.压力水平与通过平均上升和下降曲线部分获得的不可接受的鼻测量次数之间的关系。
Before decongestion 减员前 After decongestion 解除充血后
Inspiration 灵感 Expiration 到期 Inspiration 灵感 Expiration 到期
The values in Table 1 and 2 show that the greatest differences between the ascending and descending phases are found at low pressure levels and that they are smaller at higher pressures. When one considers only the mean values, it could lead to the wrong conclusion. For example, a statistical mean difference of at between Phase 1 and Phase 2 would not be of high clinical importance, because the deviation from the averaged value would be only , an even acceptable figure for
表 1 和表 2 中的数值表明,升压阶段和降压阶段的差异在低压水平时最大,而在高压水平时则较小。如果只考虑平均值,可能会得出错误的结论。例如,第一阶段和第二阶段在 处的统计平均差 在临床上的重要性并不高,因为与平均值的偏差仅为 ,这甚至是一个可以接受的数字。
Figure 12. Relationship between pressure level and resistance values in
图 12.图 12 中压力水平与电阻值之间的关系
750 measurements in which a pressure level of was obtained.
750 次测量,其中获得 的压力水平。

Figure 11. Relationship between pressure level and the number of unacceptable rhinomanometric measurements obtained by averaging the ascending and descending curve parts.
图 11.压力水平与通过平均上升和下降曲线部分获得的不可接受的鼻测量次数之间的关系。

such measurements. Therefore, much more important is the information obtained by histograms showing the statistical distribution of the differences in the entire data set. The histogram in Figure 11 shows the distribution of flow differences between the ascending and descending inspiratory curve parts at a differential pressure level of . Even if the range of differences between and were accepted, of the population show flow differences higher than