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continuing professional development

Spirometry in primary care


PHC180 Booker R (2008) Spirometry in primary care.
Primary Health Care. 18, 10, 37-47. Date of acceptance: August 7 2008.

reference values for these parameters


Summary in various patient groups.
}} Describe spirometry procedures and
An evaluation of lung function is an essential part of the diagnosis and management of
evaluate the technical acceptability
respiratory disease but spirometry was, until recently, rarely available in primary care.
The emphasis in national chronic obstructive pulmonary disease (COPD) and asthma of a patient’s spirometry reading.
guidelines on spirometry for diagnosis and monitoring, together with its inclusion in }} Identify the typical spirometry
the quality and outcomes framework (QOF) for COPD in the General Medical Services readings associated with the more
contract, has led to its wider availability in this setting. Spirometry is a relatively easy common respiratory conditions.
test, but is unreliable and confusing if not performed and interpreted correctly. The first spirometer, invented by John
Hutchinson, a 19th century surgeon, consisted
Authors of a calibrated bell inverted in water. Air,
Rachel Booker RGN, DN (Cert), HV is an independent specialist respiratory nurse and exhaled from fully inflated lungs, was captured
freelance medical writer in the bell, and Hutchinson termed this volume
the ‘vital capacity’, theorising that its reduction
Keywords was associated with reduced life expectancy. It
was 150 years before his ideas gained credence.
Respiratory system and disorders; Spirometry; Primary care
A large epidemiological study (Kannel et
These keywords are based on the subject headings from the British Nursing Index. al 1980) demonstrated that reduced vital
This article has been subject to double-blind review. For related articles and author capacity is a powerful predictor of premature
guidelines visit our online archive at www.primaryhealthcare.net and search using death from respiratory and cardiac disease
the keywords. and a further study found that abnormal
spirometry is associated with an increase
in ‘all cause’ mortality (Hole et al 1996).
Despite evidence of its value, spirometry
was, until recently, rarely used in primary
Aims and learning outcomes care settings. National, evidence-based
This article aims to describe the types of guidelines for the management of asthma
spirometry equipment suitable for use in (British Thoracic Society (BTS) and
primary care, their correct maintenance Scottish Intercollegiate Guidelines Network
and use, and how to obtain reliable, 2007) and chronic obstructive pulmonary
technically acceptable recordings from disease (COPD) (BTS 1997, National
patients. The essential parameters of Collaborating Centre for Chronic Conditions
lung function are defined and the effect (NCCCC) 2004), recommend spirometry
of various types of ventilatory defect for diagnosis and disease monitoring, and
on these parameters explained. the inclusion of spirometry in the Quality
After studying this article you will be able to: and Outcomes Framework (QOF) of the
}}Review the types of spirometer General Medical Services Contract (British
available and discuss their usefulness Medical Association 2003) have led to an
in various healthcare settings. increase in its availability in this setting.
}}Describe spirometer maintenance and In the 21st century health care is driven
infection prevention procedures. by objective measurements and clinical
}}Summarise the indications and evidence. We would not diagnose and
contraindications for spirometry. manage hypertension without measuring
}}Identify the main parameters of lung the blood pressure, and it is equally
function measured with a spirometer inappropriate to diagnose and manage
and discuss the determination of respiratory disease without measurements

primary health care | Vol 18 No 10 | December 2008 37


respiratory disease

Figure 1
taking six to 12 seconds to move its full
The bellows spirometer
distance of travel, depending on the model
of spirometer. Thus, the stylus moves
vertically while the recording paper moves
Recording stylus horizontally, producing a trace of volume
Bellows exhaled against time – the volume time trace.
(expanded)
Bellows spirometers are very accurate, but
Chart paper
are quite large. They can be fitted on to a
stand and moved from room to room, but
are not suitable for taking out to a patient’s
Paper motor device home or transporting from site to site. A
wide range of flow measuring spirometers
are now available and these smaller, more
portable devices have largely superseded the
bellows spirometer in primary care settings.
Bellows (collapsed) Expired air from subject

Flow measuring spirometers


of lung function. Spirometers should be Three types of flow measuring spirometer are
as available as sphygmomanometers. in common use in primary care settings:
}} Differential pressure pneumotachographs.
Types of spirometer }} Turbine/rotary vane.
There are two basic types of spirometer: }} Ultrasonic.
Volumetric – measuring the volume
}} They range in size from ‘hand held’ to desk-top
of exhaled air directly. models.
Flow measuring – measuring airflow
}} When air is blown down a partially
and extrapolating volume from flow. obstructed tube there is a pressure drop
beyond the obstruction. The extent of the
Volumetric spirometers drop is dependent on the airflow rate. A
The volumetric spirometer that is differential pressure pneumotachograph
occasionally used in general practice is instantaneously measures air pressure
the bellows spirometer (Figure 1). Other before and after a partial obstruction and
types are almost exclusively confined to calculates airflow rate and volume from the
the pulmonary function laboratory. pressure drop. The two most commonly used
Air exhaled into the bellows spirometer differential pressure pneumotachographs
causes the bellows to inflate. The stylus, are the Lilly and the Fleisch (Figure 2).
attached to the bellows, moves downwards as In a turbine/rotary vane spirometer
the bellows inflates, pressing on the pressure- (Figure 3) air blown into the spirometer spins
sensitive recording paper on the front of a low inertia vane. Each rotation of the vane
the spirometer. At the same time a motor interrupts a light signal emitted from two
moves the recording paper horizontally, diodes, producing a digital pulse. The volume

Figure 2 Figure 3
Differential pressure pneumotachographs Turbine/rotary vane spirometer

Lilly Fleisch
Mouthpiece
Light source

Wire mesh Capillary


tubes

Swirl plate Moving vane


Differential pressure transducer Optical sensor

Differential pressure transducer

38 primary health care | Vol 18 No 10 | December 2008


table 1
of air is calculated from the number of pulses
Spirometer features to consider
and the flow rate from their frequency.
Ultrasonic spirometers use a piezoelectric Essential Real-time graphic display of patient’s effort
}}
Hard copy of results, including volume/time and flow/volume graphics
}}
crystal to generate an ultrasonic beam. In Memory facility that will save all the patient’s efforts
}}
one type of ultrasonic spirometer partial Proven reliability and accuracy
}}
obstructions in the air tube break the airflow
Desirable Easy-to-use software
}}
into waves. Each wave passing through the Facility to download to the practice computer/patient database
}}
beam produces a pulse proportional to its Free ‘helpline’ and good technical support services
}}
volume. The second type sends ultrasonic Calibration syringe sold with the spirometer
}}
signals between two piezoelectric crystals Training provided
}}
within the airflow through the spirometer.
The speed of the signal passing from one may not be a good investment in terms of
crystal to another is reduced or increased capital outlay and staff training. Spirometry
depending on the speed of the airflow. also requires co-operation and effort from
patients. Poorly trained or untrained staff are
Choosing a spirometer unlikely to obtain high quality, meaningful
The purchase of a spirometer entails capital spirometry recordings from them (Eaton
and continuing costs. There are several et al 1999, Ponsioen et al 2002). This can
‘essential’ and ‘desirable’ features of a lead to confusion and potentially dangerous
spirometer (Table 1) and many practical misdiagnosis. All healthcare personnel using
points to be thought through. It is a good idea a spirometer must be trained in the safe use of
to obtain your preferred model for a trial, the equipment, and must be able to recognise
to ensure it fulfils all your requirements. and correct poor technique. Those responsible
Where will the spirometer be used? If it for interpreting results and supervising others
does not need to be moved or taken out into should be trained to at least diploma level
the community, then a bellows spirometer and preferably certified as competent.
may be suitable. A small hand-held spirometer Spirometers are precision instruments
may be an attractive option for monitoring that need regular maintenance. Technical
patients in their home, but some have serious support is also sometimes necessary. Cheap,
limitations. Lack of a real-time graphic display imported models may not come with access
makes it impossible to verify the adequacy of to a free ‘helpline’ and servicing may be
the patient’s technique and correct errors as difficult and costly. The cost and availability
they are performing the test. Some need to of disposables, such as recording paper and
be downloaded onto a computer at the end mouthpieces, can also vary considerably.
of the test to view graphs and lung function Now do Time out 1
data. Spirometers that only give a digital
display of the lung function parameters are Infection prevention
unsuitable for diagnostic spirometry and It is vital that you are conversant with and
the inability to ensure adequate technique follow infection prevention policies for
limits their usefulness. A small, desk-top your place of work. Cross infection from
Time out 1
spirometer, or hand-held spirometer and spirometry equipment is rare (Rutula et al What type of
laptop computer may overcome difficulties 1991, Leeming et al 1993), but the rising spirometer do you use
and be suitable for use in the community. incidence of multidrug-resistant bacterial in your place of work?
Most desk-top spirometers produce ‘real infection makes this an important issue. One Compile a list of the
advantages and disadvantages
time’ digital graphics and hard copy printouts. of the most effective methods of preventing
of this spirometer. Are there any
However, some use heat sensitive paper and infection is to make sure that you wash
additional features that would
the graphs will need to be photocopied for your hands between patients and before be useful?
long-term storage. The pressure sensitive and after handling spirometry equipment.
recording paper of a bellows spirometer Disposable mouthpieces and nose clips If you do not use a spirometer
is similarly difficult to store. A facility to should be used. One-way, ‘valved’ disposable compile a list of the desirable
download results, including graphs, to the mouthpieces can prevent cross infection features of a spirometer for your
practice computer system can be particularly from accidental inhalation through the particular place of work and
useful. It will allow you to email spirometry spirometer. Use of disposable gloves for construct a business case for
results for quality control or a second option. handling mouthpieces will further reduce the the purchase of a spirometer,
Training, practice and continual use makes cross infection risk. In primary care settings bearing in mind all the issues
that have been discussed.
perfect. A spirometer that is used infrequently inspiratory manoeuvres are rarely needed, but

primary health care | Vol 18 No 10 | December 2008 39


respiratory disease

disposable viral and bacterial filter mouthpieces to be performed on each new batch of sensors,
Time out 2 are available to prevent contamination of in addition to the routine daily checks.
Find out what equipment if these are required (Kendrick et If there is a significant change in temperature
infection prevention al 2003). Spirometer parts in direct contact during a spirometry session calibration should
policies are applicable with the patient must be washed in hot, be rechecked. A spirometer that is transported
to spirometry in your place of soapy water to remove saliva and mucus to a patient’s home must be allowed to ‘settle’
work. prior to disinfection and sterilisation. for at least ten minutes. It needs to be left to
If you do not already have a log Unless spirometry measurements are urgently reach room temperature and humidity, and
of cleaning procedures construct needed for medical reasons, patients with its calibration checked before it is used. A
a template for recording:
known, active respiratory infection should spirometer carried in the boot of a car on a cold
 Cleaning procedures.
not be tested. If spirometry is necessary, tests day and used straight away will be inaccurate.
 Which patients are tested on
the spirometer. should be carried out at the end of the day and The spirometer and the calibration syringe
the equipment dismantled and sterilised after must be routinely serviced and maintained
use. Immunocompromised individuals, such according to the manufacturer’s instructions.
Time out 3 as chemotherapy patients or those with HIV, For most models this is required annually and
Determine the AIDS or post transplant, should be tested at the may necessitate the spirometer being sent away.
normal range for a start of the day on newly sterilised equipment. The accuracy of the spirometer should
‘biological control’. It is extremely important to adhere to the also be verified on a regular basis, using a
 Record your own spirometry manufacturer’s instructions for methods of ‘biological control’, for example, an individual
every day (or that of a disinfection and sterilisation. Inappropriate with no respiratory disease and known lung
colleague if you have a methods can destroy expensive equipment. function values. Once the normal range of
respiratory condition) at the Cleaning and disinfection of spirometry the biological control is known a spirometry
same time of day, on the same equipment should be routine and a log kept. recording from that individual can be used
spirometer for 14 days. You
It is also helpful to keep a log of the date, to verify the spirometer’s accuracy.
will need a minimum of ten
time and details of the patients tested on the Now do Time out 3
recordings.
 Calculate the mean (average) equipment to assist in risk assessment and
contact tracing, should it become necessary. Indications and contraindications
for each spirometry
parameter. Now do Time out 2 Spirometry should be a routine for any patient
 Add up all the readings for presenting with cardio-respiratory symptoms;
that parameter and divide by Calibration and verification cough, wheeze or breathlessness. Spirometry is
the number of recordings. Modern spirometers are generally robust also used for routine occupational surveillance
 Now calculate 5 per cent of and reliable, but it is still important to of people exposed to hazardous substances at
each of these values. check that they are recording accurately. work. It is also being increasingly requested
 Finally, calculate the normal Calibration checks must be done as a during routine medical checks for insurance
range for each of these values
daily routine, using a calibration syringe, or diving. Spirometry is vital for any patient
by adding and subtracting this
and a log kept. This is the only method of suspected of having COPD. Early COPD
5 per cent.
You can now use yourself (or demonstrating that the equipment is reliable. is asymptomatic and airflow obstruction
your colleague) to verify the A calibration syringe injects an exact volume can only be detected with spirometry.
accuracy of your spirometer on of air (one or three litres) into the spirometer. Another important role for spirometry
a weekly basis, in addition to the It must be accurate to within 0.5 per cent; testing is to monitor patients with chronic
daily calibration check. 15ml for a three litre syringe and 5ml for a respiratory conditions, such as asthma and
one litre syringe. It must be serviced at the COPD. Spirometry can be used to assess
recommended intervals and kept next to the response to therapy and to monitor for
spirometer, so that it is at the same temperature any rapid, or unexpected deterioration.
and humidity. Calibration syringes are Now do Time out 4
delicate; if one is dropped you should assume
it is inaccurate until it has been serviced. Spirometry is generally safe and there are
The spirometer must record within 3 per cent no absolute contraindications. There are,
of the syringe volume. The calibration of however a few relative contraindications
some spirometers, for example, ultrasonic, (Table 2). It is important to assess each patient
turbine and bellows spirometers, can only be and, in cases of doubt, to seek advice from
adjusted by an engineer. Others, for example, your local pulmonary function laboratory.
some models of Fleisch pneumotachograph,
can be updated on a daily or sessional basis Spirometry measurements
if necessary. Spirometers using disposable, A spirometer will give you some
single-patient-use flow sensors will need checks essential information:

40 primary health care | Vol 18 No 10 | December 2008


table 2
Relative contraindications to spirometry Time out 4
Relative contraindication Rationale
Discuss with
Haemoptysis of unknown origin Exacerbation of the problem and possible major haemorrhage. your colleagues the
Possible active pulmonary tuberculosis leading to clinical situations where
contamination of equipment and cross infection risk. spirometry may be useful.
Pneumothorax Aggravation of the condition. How could you incorporate
spirometry into your normal,
Unstable cardiovascular status: recent (within Forced expiration can worsen angina or cause potentially daily clinical practice and use
one month) myocardial infarction, uncontrolled dangerous blood pressure changes. it to best advantage for early
hypertension or pulmonary embolism diagnosis of respiratory disease?
Uncontrolled hypertension or history of Precipitation of cerebral bleed. Spirometry is vital for the early
haemorrhagic cerebrovascular event detection of COPD. ‘The primary
care face of COPD’ (Booker
Recent thoracic, abdominal or eye surgery Pain or incisional hernias. Raised intraocular pressure post
2008) discusses which people
ophthalmic surgery undesirable.
are at particular risk and may
Nausea, vomiting or pain Effect on patient’s ability to co-operate and perform the test. help you develop strategies for
identifying and monitoring these
Measurements of volume – vital capacity
}} flow meter. The PEF recorded with a flow individuals.
(relaxed and forced) and forced expired measuring spirometer will be different from
volume in one second (FEV1). that recorded with a PEF meter because the
Measurements of airflow – ratio of
}} blowing technique is different. The reference
FEV1 to forced and relaxed vital values for PEF recorded with a spirometer
capacity, peak expiratory flow. (Quanjer et al 1993) are also different from
These measurements are defined in Box 1. those for PEF recorded with a peak flow
meter (Nunn and Gregg 1989) and it is
Volume measurements important to compare the patient’s readings
Vital capacity represents the total amount of with the appropriate reference value.
air an individual can breathe in and out of The ratio of FEV1 to VC (FEV1 /VC) should
their lungs in a single maximum breath and, be used if the VC is greater than the FVC.
in primary care, is most commonly measured The FEV1 /FVC is also referred to as the
as an expired volume. Expired vital capacity is FEV1% or FER, depending on the model of
measured as a relaxed and a forced expiration.
FVC is reached after a maximum of 15 seconds
forced expiration, or when the expiratory Box 1
flow rate has fallen below 0.05 L/sec. Definitions of essential spirometry parameters (Miller et al 2005)
The abbreviation VC conventionally refers
Vital capacity
to the expired relaxed vital capacity. It is
The volume, measured at the mouth, between the positions of full inspiration and full expiration.
important to record this. In patients with
Expired relaxed vital capacity (VC)
obstructive airways disease the narrowed The maximum volume of air that can be expired from the lungs during a relaxed, but complete
airways can collapse, trapping air in the lungs, expiration from a position of full inspiration.
during forced expiration. This reduces the Forced expired vital capacity (FVC)
volume of the FVC and, in patients with severe The maximum volume of air that can be expired from the lungs during a forced and complete
airflow obstruction, the VC will be greater and expiration from a position of full inspiration.
a more accurate measure of vital capacity. Forced expired volume in one second (FEV1)
Measurement of FEV1 is simple to do The maximum volume of air that can be expelled from the lungs in the first second of a forced
expiration from a position of full inspiration.
and there are clearly defined reference
(predicted) values. It is affected in Peak expiratory flow (PEF)
The highest flow achieved from a maximal forced expiratory manoeuvre started without
all patterns of lung disease. hesitation from a position of maximal lung inflation.
The ratio of FEV1 to VC (FEV1/VC)
Measurement of airflow The amount of air expired during the first second of a forced expiration from a position of
Airflow is only measured directly with a maximal inspiration expressed as a percentage of the total amount expired during a relaxed vital
flow measuring spirometer. Volumetric capacity manoeuvre.
spirometers calculate flow from volume. The ratio of FEV1 to FVC (FEV1/FVC)
Peak expiratory flow (PEF) can be measured The amount of air blown out in the first second of a forced expiration from a position of maximal
with a flow measuring spirometer, but is inspiration expressed as a percentage of the total amount expired (regardless of time) during
that forced manoeuvre.
most commonly measured with a peak

primary health care | Vol 18 No 10 | December 2008 41


respiratory disease

Box 2
spirometer. These abbreviations all refer to the
Time out 5 same measurement. Box 2 gives examples of
Calculation of ratio of FEV1 to VC and FVC

Devise an how to calculate FEV1 /VC and FEV1 /FVC. The FEV1/VC is calculated:
information and Measured FEV1
Reference values X 100
instruction sheet to give Measured VC
to patients when they make The normal lung function value (reference
an appointment for spirometry, value) for any individual depends on their The FEV1/FVC is calculated:
using the information in Box 3 age, height, gender and ethnic group. Lung Measured FEV1
and Table 4. volumes increase during childhood and X 100
This can help patients to prepare Measured FVC
adolescence, reach a peak at around 25 years
for the test, will reinforce the
and decline into old age. Tall individuals
verbal instructions you give, and
can save you time. have larger thoraces and hence greater lung Actual data from population surveys
volumes than short people. Males have are limited for adolescents and the elderly.
larger lung volumes in relation to their Data from the 18-70 year old age group are
height than females and anthropometric extrapolated to cover these groups and the
differences between different racial groups resulting reference values are therefore less
also influence lung function. For example, robust. This needs to be borne in mind when
negro racial groups tend to have longer legs interpreting spirometry from these individuals.
and shorter torsos than white Europeans,
and hence smaller lung volumes in relation Patient preparation
to their overall height. Large population Spirometry can be performed
surveys in different populations have been opportunistically, but it is helpful to do this
conducted to determine the reference as a planned procedure and give patients
values for spirometry and tables of the instructions to enable them to prepare
results, showing the mean reference value (Box 3). Any bronchodilators the patient
for individuals within a range of age and is taking will need to be withheld for
height, and either gender, are available. diagnostic spirometry (Table 3) but this is
The reference values recommended for use not necessary for routine, monitoring of
in European populations are those developed patients with known respiratory disease.
for the European Community for Coal and Now do Time out 5
Steel (Quanjer et al 1993). Charts of these
reference values are widely available and Height, without shoes, must be accurately
they are incorporated in the software of measured. A proxy height measurement can
all electronic spirometers sold for use in be used for individuals unable to stand or
the UK. Correction factors can be applied with a kyphoscoliosis that prevents them
to these to adjust for ethnicity. However, from standing upright. Measure across the
it can be difficult to determine whether to back from middle finger tip to middle finger
apply a correction factor if the individual is tip with the arms outstretched at 90o. The
of mixed ethnic background. If correction patient should also be weighed and body
is applied it must be recorded and applied mass index calculated since this can help
consistently in subsequent tests and in cases in later interpretation of the spirometry.
of doubt the advice of your local pulmonary
function laboratory should be sought. Box 3
Preparation for spirometry
table 3
DO:
Withholding bronchodilators prior to diagnostic spirometry
Wear loose and comfortable clothing
}}
Drug Class Example Withhold prior to spirometry that does not restrict breathing.
Arrive for your appointment in time to empty
}}
Short acting beta2 agonists salbutamol, terbutaline Two to four hours
your bladder and relax before testing.
Short acting anticholinergics ipratropium bromide Four to six hours DO NOT:
Long acting beta2 agonists salmeterol, formoterol 12 to 24 hours Eat a substantial meal within two hours of the test.
}}
Smoke within one hour of the test or consume
}}
Long acting anticholinergics tiotropium bromide 24 to 36 hours alcohol within four hours of the test.
Sustained release theophyllines Slo-phyllin, Neulin SA, 24 to 36 hours Take vigorous exercise within
}}
Uniphyllin continuus 30 minutes of the test.

42 primary health care | Vol 18 No 10 | December 2008


Figure 4
Technically acceptable, normal volume time and flow volume traces

Volume trace time Flow volume trace

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Performing the test they are unable to exhale any further. Once
Spirometry must be performed with the again, active, verbal encouragement to keep
patient sitting down. Forced expiratory blowing as hard as they can is absolutely
manoeuvres can cause dizziness or syncope essential. Allow the patient to rest for
and patients are unsafe standing up. They at least one minute between efforts.
should be comfortably seated with both
feet on the floor, in a chair that gives them Reproducibility and technical errors
good support. False teeth should be left in. To ensure reproducibility you need a minimum
of three relaxed vital capacity measurements.
Relaxed expiratory manoeuvres There should be less than 150ml difference
These should be performed first and a nose clip between the two best efforts. If necessary
used to prevent air leak. Instruct the patient to further efforts, up to a maximum of four, can
take a rapid, but unforced, maximum breath be attempted. The highest reading is recorded.
in, and to place the mouthpiece in their mouth, A minimum of three forced manoeuvres
so that their teeth and tongue do not obstruct with less than 5 per cent difference between
it, making a good seal with their lips. With the best two, technically acceptable FVC
the minimum of delay between inhalation and and FEV1 readings are required. If the first
the start of exhalation, they should exhale three attempts do not produce reproducible
gently and steadily into the mouthpiece, until results further efforts, up to a maximum of
they have completely emptied their lungs. You eight, can be attempted, unless the patient
will need to encourage them to ‘squeeze’ out is becoming distressed. The highest FVC
every last drop of air, but exhalation should and FEV1 are recorded and these can be
not be forced and there is no need for them taken from different efforts if necessary.
to empty their lungs within any particular A technically acceptable effort
timeframe. Some electronic spirometers will is where the individual has:
give an audible signal when airflow through }} Exhaled completely from maximum
them has ceased. Allow the patient to rest inhalation to maximum expiration.
for at least one minute between efforts. }} Exhaled immediately from the
position of maximal inspiration.
Forced expiratory manoeuvres }} Used maximum effort for the
Nose clips are not essential, but can be forced manoeuvre.
used if there are difficulties obtaining }} Used maximum effort from the
reproducible tests. You will need to stress start of the forced manoeuvre.
the need for absolutely maximum effort. }} Has not coughed.
Ask the patient to make a rapid, but The volume time trace needs to be smooth,
unforced, maximum breath in and place upwardly curving, free from irregularity and
the mouthpiece into their mouth, as before, should plateau for at least one second. The flow
making a tight seal around it. They should volume trace needs to rise almost vertically
then immediately, using maximum effort, to a peak and should merge smoothly with
exhale as hard and as fast as possible until the horizontal axis of the graph (Figure 4).

primary health care | Vol 18 No 10 | December 2008 43


respiratory disease

Figure 5
Slow start

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Figure 6
Failure to exhale to FVC

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There are a number of technical errors that At the start of the patient’s effort a loud,
render a test invalid. Coughing during the verbal instruction to ‘BLOW’ and a forceful
forced expiratory manoeuvre Gi\[`Zk\[
will invalidate
Gi\[`Zk\[ gesture such as G\Xb\og`iXkfip]cfn
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G\Xb\og`iXkfip]cfn
=cfnc`ki\j&j\Zfe[
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the FVC recording. It is a common problem, A common cause of reduced VC and FVC
Mfcld\c`ki\j

and will be apparent from observing the is a failure to exhale completely. The volume
Mfcld\c`ki\j

patient during the test. The volume time time trace will fail to plateau and the flow
trace will be irregular. Several minutes’
D\Xjli\[
D\Xjli\[ rest volume trace will not merge smoothly with
between efforts can help, but if necessary the horizontal axis (Figure 6). It is hard work
the relaxed manoeuvre can be used to assess to squeeze every last drop of air out the lungs
the vital capacity. If the patient has managed and it is vital that you continually encourage
to blow for one second without coughing the patient throughout the manoeuvre.
K`d\j\Zfe[j
K`d\j\Zfe[j Mfcld\c`ki\j
Mfcld\c`ki\j
and produced a reproducible, good quality Spirometry technique needs to be learned
FEV1, the ratio of FEV1 to VC can be used. and, while some individuals will grasp what
A slow or delayed start to the forced is needed quickly, others will need several
expiratory manoeuvre is another common practice attempts before they get it right. A
problem. This can be detectedGi\[`Zk\[
in the graphic
Gi\[`Zk\[ poor effort from the patient will result in
=cfnc`ki\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
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display and print out. The volume time failure to meet reproducibility criteria. The
Mfcld\c`ki\j
Mfcld\c`ki\j

trace will have an ‘S’ shape at the start role of the health professional as the patient’s
and the flow volume trace will show a ‘coach’ cannot be stressed strongly enough.
D\Xjli\[
slower, more sloping rise (Figure 5). It can
D\Xjli\[ Spirometry requires a great deal of effort and
be overcome by further explanation to the co-operation from them, so it is vital that
patient, using phrases such as: ‘I need you to your instructions are clear and you give plenty
really blast the air out right from the start of encouragement. If possible you should
– almost like you wereK`d\j\Zfe[j
going to cough.’
K`d\j\Zfe[j demonstrate what Mfcld\c`ki\j
you want the patient to
Mfcld\c`ki\j

44 primary health care | Vol 18 No 10 | December 2008

Gi\[`Zk\[
Gi\[`Zk\[ Gi\[`Zk\[efidXcZlim\
Gi\[`Zk\[efidXcZlim\
&j\Zfe[
j\Zfe[
c`ki\j
c`ki\j
Box 4
do, as well as giving a verbal explanation.
Calculating lung volumes as a percentage of the reference value
Now do Time out 6
Measured lung volume
Interpretation x 100
Reference value for that lung volume
Normal ventilatory function
The VC, FVC and FEV1 are expressed in
terms of the volume, in litres, and as a obstruction. Caution does however need
percentage of the reference value (Box 4). A to be exercised when applying this rule Time out 6
healthy individual will have lung volumes to adolescents and the elderly. Lungs lose Consistent, verbal
over 80 per cent of the reference value. The elasticity as part of the normal ageing process. encouragement to
FEV1 /VC and FEV1 /FVC are expressed as In a young person with elastic, compliant lungs ‘keep blowing’ is vital to
a ratio, or as a percentage, for example, exhalation will be rapid and the FEV1 and ensure technically acceptable
0.75 or 75 per cent (Box 2). An individual ratio of FEV1 to VC are likely to be high. In spirometry.
with unobstructed airways will be able to an older person natural loss of lung elasticity Record the VC from a colleague,
or patient who is not familiar
exhale three quarters of their vital capacity will slow exhalation and produce a relative
with spirometry. Explain what
+
in the first second of a forced expiration. reduction in FEV1 and ratio of FEV1 to VC.
you want them to do, but do not
In other words, the FEV1 should be around Thus, an FEV1 /FVC of 0.73 may be abnormal continually encourage them to
75 per cent of* the vital capacity, giving a in a symptomatic adolescent and an FEV1 /FVC
=cfniXk\c`ki\j&j\Zfe[

continue blowing. Then repeat


ratio of FEV1 to VC or FVC of around 0.75. of 0.69 may be normal in an asymptomatic the test with the same person
Mfcld\c`ki\j

The time taken to exhale to FVC is normally older person. It is therefore vital to consider while continually encouraging
)
four to six seconds. Figure 4 shows normal the clinical presentation and other diagnostic them to ‘…blow, blow … Keep
volume time and flow volume traces. tests, as well as the lung function, in all cases. blowing’.
( =<M ( The volume time trace will be ‘flattened’ and Is there a difference between
Obstructive ventilatory defects the time taken to reach FVC and for the trace the two recordings?
Obstructive airways diseases are common. to plateau extended. The flow volume trace
' ( ) * + , -
There are more than five million people with
K`d\j\Zfe[j will still rise rapidlyMfcld\c`ki\j
to a peak, but obstruction
asthma and around one million diagnosed of airflow will produce a typical ‘scooped out’
cases of COPD in the UK (BTS 2006). The concave shape to the trace (Figure 7). The
feature of these conditions is difficulty flow volume trace can be particularly useful
with expiration. Inhalation is unaffected in identifying early airflow obstruction.
and vital capacity in mild to moderate
KiXZ\]X`cjkfgcXk\Xl
airflow obstruction is usually normal; over Severe obstruction
80 per cent of the reference value. However, Severe obstructive airways disease can cause
=cfnc`ki\j&j\Zfe[

airway obstruction reduces the speed of air trapping. Small airways are normally
Mfcld\c`ki\j

exhalation. Thus, the volume of FEV1 falls KiXZ\Ê[ifgjf]]Ë


‘squeezed’ during forced expiration and will
to less than 80 per cent of the reference value narrow slightly. When airways are already
and the ratio of FEV1 to vital capacity drops. narrowed, or where they are unsupported, such
A ratio of less than 0.7 (70 per cent) is as occurs in emphysema, forced expiration
generally considered diagnostic of airflow can cause collapse of the airways; so-called

Figure 7 K`d\j\Zfe[j Mfcld\c`ki\j


Obstructive volume time and flow volume traces

Gi\[`Zk\[ G\Xb\og`iXkfip]cfn
=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j

D\Xjli\[

K`d\j\Zfe[j Mfcld\c`ki\j

primary health care | Vol 18 No 10 | December 2008 45

Gi\[`Zk\[
i\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
c`ki\j
+

=cfniXk\c`ki\j&j\Zfe[
* Gi\[`Zk\[ G\Xb\og`iXkfip]cfn

=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j
Mfcld\c`ki\j
)
respiratory disease
D\Xjli\[
( =<M (

Figure 8
' ( ) * + , -
Severely obstructedK`d\j\Zfe[j
volume time and flow volume traces
K`d\j\Zfe[j
Mfcld\c`ki\j
Mfcld\c`ki\j

Gi\[`Zk\[

=cfnc`ki\j&j\Zfe[
KiXZ\]X`cjkfgcXk\Xl Gi\[`Zk\[efidXcZlim\
Mfcld\c`ki\j

=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j

D\Xjli\[ KiXZ\Ê[ifgjf]]Ë

K`d\j\Zfe[j Mfcld\c`ki\j

K`d\j\Zfe[j
dynamic airway collapse. This reduces }} Thoracic spine Mfcld\c`ki\j
deformity –
the volume of the vital capacity. Thus, in scoliosis or kyphoscoliosis.
Gi\[`Zk\[
severe obstructive airways disease the FVC, }} NeuromuscularGi\[`Zk\[efidXcZlim\
disease – muscular

=cfnc`ki\j&j\Zfe[
FEV1 and FEV1 /FVC are all reduced. The dystrophy, motor neurone disease,
Mfcld\c`ki\jMfcld\c`ki\j

VC may be well preserved since this does Guillan Barre syndrome, paralysis
not involve forced expiratory effort. The
Gi\[`Zk\[ of the diaphragmG\Xb\og`iXkfip]cfn
and so on.

=cfnc`ki\j&j\Zfe[
volume time trace will be markedly flattened
D\Xjli\[ }} Obesity – excess fat on the thorax
and the flow volume trace will show a restricts respiratory muscle movement
dramatic drop in flow through the latter and excess fat within the abdomen
part of the expiration, producingD\Xjli\[
a ‘church restricts movement of the diaphragm.
steeple’ silhouette to K`d\j\Zfe[j
the trace (Figure 8). Respiratory causes Mfcld\c`ki\j
for restrictive spirometry
are comparatively rare. A common cause of
Restrictive ventilatory defects apparent restrictive defects is poor spirometry
The cause of a restrictive defect can be technique; failure to exhale to FVC.
K`d\j\Zfe[j Mfcld\c`ki\j
respiratory or non-respiratory. Intra- The feature of restrictive ventilatory defects
pulmonary causes include diseases that cause is reduced lung volume; VC, FVC and FEV1
fibrosis of lung tissue reducing the ability of will all be less than 80 per cent of the reference
the lung tissue to expand, such as fibrosing value and the FEV1 and FVC will be reduced
Gi\[`Zk\[
alveolitis or sarcoidosis. Pulmonary oedema in proportion to each other. Airways are not
=cfnc`ki\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
‘stiffens’ lung tissue producing a restrictive obstructed and the ratio of FEV1 to VC will
Mfcld\c`ki\j

ventilatory defect. Any condition that prevents be normal. Indeed, when lung volumes are
full expansion of the thoracic cavity can significantly reduced the FEV1 /FVC may be
also cause restrictive spirometry, such as:
D\Xjli\[ abnormally high and the time taken to reach

Figure 9
Restrictive volume K`d\j\Zfe[j
time and flow volume traces Mfcld\c`ki\j

Gi\[`Zk\[ Gi\[`Zk\[efidXcZlim\
=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j

D\Xjli\[

K`d\j\Zfe[j Mfcld\c`ki\j

46 primary health care | Vol 18 No 10 | December 2008


table 4
Normal spirometry parameters and how these are affected in various ventilatory defects
Normal Obstruction Severe Obstruction Restriction

FVC More than 80 per cent of More than 80 per cent of Often less than 80 per cent of reference Less than 80 per cent of reference
reference value reference value value but less reduced than FEV1 value. Reduced in proportion to FEV1
VC Same as FVC May be higher than FVC Greater than FVC Same as FVC

FEV1 More than 80 per cent of Less than 80 per cent of Less than 30 per cent of reference value Less than 80 per cent of reference
reference value reference value value
FEV1/FVC Around 75 per cent (0.75) Less than 70 per cent (0.7) Usually less than 70 per cent (0.7) and In excess of 75 per cent (0.75) and
and more than 80 per cent of and less than 80 per cent 80 per cent of reference value – but may more than 80 per cent of reference
reference value of reference value be higher if there is significant air trapping value

FVC reduced to two to four seconds. A ratio appropriately trained for the task. Once
of greater than 0.85 in an adult is highly taught they also need to continually practice
Time out 7
suggestive of a restrictive defect, although their skills in order to maintain them. Now that you have
it may be normal in a child or adolescent. When these requirements are met primary completed the article
The volume time trace will be a normal care spirometry can provide a reproducible and you might like to write a
shape, but will be small and, in a severe meaningful test that enables accurate diagnosis practice profile. Guidelines to
restrictive defect, will plateau early. The and rational treatment of respiratory disease n help you are on page 48.
flow volume trace will appear narrow Now do Time out 7
and ‘domed’. The ‘scooping’ typical of
obstruction will not be present (Figure 9). Resources and further reading
One day short courses and a diploma level module
}}
The spirometry parameters affected in
in spirometry (accredited with the Open University)
the types of ventilatory defect discussed are available from Education for Health www.
here are summarised in Table 4. educationforhealth.org.uk Successful graduates
of the diploma level module are also awarded the
Conclusion BTS/ARTP certificate of competence in spirometry.
There are many indications for spirometry Training in spirometry, culminating in the award
}}
of the BTS/ARTP certificate of competence, is
and a wide variety of different spirometers
available from The Association for Respiratory
available, many of which are suitable for use Technology and Physiology.
in general practice and community settings. http://fp.artpweb2.f9.co.uk/
However, all spirometers require regular One day short courses and academic modules in
}}
maintenance, disinfection and calibration spirometry (accredited with Edge Hill University)
checks. Most importantly, the healthcare available from Respiratory Education UK
staff responsible for obtaining recordings www.respiratoryeduk.com
from patients and those interpreting Booker R (2008) Vital Lung Function.
}}
Class Health. London.
the results need to be adequately and

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Booker R (2008) The primary Network (2007) British et al (1980) The value of of spirometry. European hand held spirometer by
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