SPIROMETRY FOR DIAGNOSIS

OBSTRUCTIVE LUNG DISEASE

RATNAWATI
DEPARTMENT OF PULMONOLOGY AND RESPIRATORY
MEDICINE, FACULTY OF MEDICINE
UNIVERSITY OF INDONESIA
PERSAHABATAN HOSPITAL
JAKARTA
 Introduction

 Spirometry is Basic Pulmonary Function Test used

to screen for lung disease
 The key measurements are the forced expiratory
volume in the first second (FEV1) and the
maximum exhaled volume (vital capacity [VC]
 Using this measurement can diagnose the presence
and severity of airway obstruction
 What is Spirometry?

Spirometry is a method of assessing

lung function by measuring the total
volume of air the patient can expel
from the lungs after a maximal
inhalation.
 Spirometry
What is SPIROMETRY?
 Spiro = breath
 Metry = measurement

 What does SPIROMETRY measure ?

 VOLUME : amount of air expired (litres)

 FLOW : How fast the air was expired

(litres/second)

 TIME : How long it takes to empty the lung

(seconds)
 Types of Spirometers

 Bellows spirometers:
Measure volume; mainly in lung function
units
 Electronic desk top spirometers:
Measure flow and volume with real time
display
 Small hand-held spirometers:
Inexpensive and quick to use but no
print out
Small Hand-held Spirometers
 Measurements

Abbreviation Characteristic measured

FEV1 Forced expired volume in 1 second
FVC Forced vital capacity
FEV1 /FVC Ratio of the above
Ratio
PEFR Peak expiratory flow rate
FEF 25-75% Forced expiratory flow between 25-75% of the vital
capacity
 Standard Spirometric Indices
 FEV1 - Forced expiratory volume in one
second:
The volume of air expired in the first second of the
blow
 FVC - Forced vital capacity:
The total volume of air that can be forcibly exhaled in
one breath
 FEV1/FVC ratio:
The fraction of air exhaled in the first second relative
to the total volume exhaled
 SPIROMETRY
Used to evaluate ventilation
function of the lung which
measure static and dynamic
lung function
 Static and Dynamic
SPIROMETRY

 Static  volume-base slow

maneuver  slow vital
capacity
 Dynamic  based on time
Forced vital capacity
 Static Volume (1)
 Tidal Volume (TV)
volume that is inhaled or exhaled with each
respiratory cycle.
 Inspiratory reserve volume (IRV)
maximal volume of air that can be inhaled from TV
end-inspiratory level.
 Expiratory reserve volume (ERV)
maximal volume of air that can be exhaled after
normal tidal exhalation.
 Residual volume (RV)
Volume of gas remaining in the lung at the end of a
maximal expiration
STATIC VOLUME (2)
Inspiratory capacity (IC)
maximal volume of air that can be inhaled from tidal
volume end-expiratory level (IC=TV+IRV)

Vital capacity (VC)

volume change that occurs between maximal
inspiration and maximal expiration (VC=IRV+TV+ERV)

Functional residual capacity (FRC)

volume of air in the lung at the average TV end-
expiratory level (FRC=ERV+RV)

Total lung capacity (TLC)

Volume of air in the lung at the end of a maximal
inspiration (TLC=RV+VC or TLC=FRC+IC)
LUNG VOLUME
 DYNAMIC VOLUME
Forced vital capacity (FVC)
 maximum volume of air which can be exhaled
 or inspired during a forced maneuver.
Forced expiratory volume in 1 second (FEV1)
 volume expired in the first second of maximal
 expiration after a full inspiration.
 Maximal voluntary ventilation (MVV)
 total volume of air exhaled during 12 seconds of
 rapid, deep breathing.
SPIROMETRY

Flow Volume
 The flow-volume curve
The F-V curve was
peak flow
invented to make
the recognition of
spirometry patterns
easier.

• You can’t
FVC measure the FEV1
from F-V curves.

• The blue Xs mark

predicted values.
The exhalation
starts here
Hyatt and Black popularized the F/V curve in 1971.
Common “Acceptability
Acceptability““Issues
Cough

Early stop
G t!
Great!

Poor effort
Hesitant
Start
Acceptable and Unacceptable
Spirograms (from ATS, 1994)
 cALIBRATION

 Daily calibration with a calibrated syringe with

a volume of at least 3 litres (ATS/ERS).
 Check syringe for leaks and damage.
 Store the syringe next to the spirometer.
 Reinforce the criteria for an
acceptable maneuver
1. Take in the deepest breath possible
(lung completely full)
2. Blast out as hard and fast as possible
(maximal effort without hesitation)
3. Keep blowing out until completely empty
(at least 6 seconds or a one second plateau)
3 Phases of the FVC maneuver

Phase 2 Phase 3
Blast out! Keep blowing

End

Phase 1
Inhale deeply Start
 Good test session
1. Obtain 3 acceptable maneuvers
Look at graphs individually to make sure there
are no errors on at least 3

2. Check repeatability (or reproducibility)

Look at values of the acceptable maneuvers
(the 2 largest FVC`s and 2 largest FEV1`s should not
vary > 150 ml. (2005 ATS/ERS Spirometry
standards)
(If the FVC is 1.0 L or less, they both need to be
within 100 ml)
3 acceptable with 2 repeatable

Trial FVC (L) FEV1 (L)

1 4.81 4.09
2 4.74 4.07
3 4.87 4.14
Repeatability 0.06 0.05
4.87 - 4.81 = 0.06 4.14 - 4.09 = 0.05
 Basic of Interpretation

Obstruction = reduced flow rates

Restriction = reduced lung volumes

Methods to determine if spirometry is
abnormal:

 Fixed tresholds:
 FVC %Predicted < 80%
 FEV1 %Predicted < 80%
 Observed FEV1/FVC% < 75%
 Spirogram Patterns

 Normal

 Obstructive

 Restrictive

 Mixed Obstructive and Restrictive

 Predicted Normal Values

Affected by:
 Age
 Height

 Sex
 Ethnic Origin
 Normal Trace Showing FEV1 and FVC

5 FVC
Volume, liters

4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1

1 2 3 4 5 6
Time, sec
 Criteria for Normal
Post-bronchodilator Spirometry

 FEV1: % predicted > 80%

 FVC: % predicted > 80%

 FEV1/FVC: > 0.7 - 0.8,

depending on age
 Bronchodilator Reversibility Testing

 Provides the best achievable FEV1

(and FVC)
 Helps to differentiate COPD from
asthma
Must be interpreted with clinical history -
neither asthma nor COPD are diagnosed
on spirometry alone
 Bronchodilator Reversibility Testing
 Can be done on first visit if no diagnosis has
been made
 Best done as a planned procedure: pre- and
post-bronchodilator tests require a minimum
of 15 minutes
 Post-bronchodilator only saves time but does
not help confirm if asthma is present
 Short-acting bronchodilators need to be
withheld for at least 4 hours prior to test
 Bronchodilator Reversibility Testing

Bronchodilator* Dose FEV1 before

and after
Salbutamol 200 – 400 µg via large 15 minutes
volume spacer
Terbutaline 500 µg via Turbohaler® 15 minutes

Ipratropium 160 µg** via spacer 45 minutes

* Some guidelines suggest nebulised bronchodilators can be given but the doses
are not standardised. “There is no consensus on the drug, dose or mode of
administering a bronchodilator in the laboratory.” Ref: ATS/ERS Task Force :
Interpretive strategies for Lung Function Tests ERJ 2005;26:948
** Usually 8 puffs of 20 µg
 Measurements

Definition of reversibility
 Pre-Bronchodilator
- FEV1/FVC <70% of predicted
 Post-Bronchodilator
- Increase 12% AND at least 200 cc

Reversibility = Asthma!
 Measurements
Severity of obstruction
FEV1 % of predicted
Mild >80
Moderate 50 to 79
Severe 30 to
Very severe <30

Severity of restriction
FVC % of predicted
Mild >65 to 80
Moderate >50 to 65
Severe <50
SPIROMETRY

OBSTRUCTIVE
DISEASE
 Spirometry: Obstructive Disease

5 Normal
Volume, liters

3
FEV1 = 1.8L
2
FVC = 3.2L Obstructive
1
FEV1/FVC = 0.56

1 2 3 4 5 6

Time, seconds
 Obstructive Airway Disease

 Obstruction
FEV1 < 80%
predicted
FEV1/FVC < 75%
 Spirometric Diagnosis of COPD

 COPD is confirmed by post–

bronchodilator FEV1/FVC < 0.7

 Post-bronchodilator FEV1/FVC
measured 15 minutes after 400µg
salbutamol or equivalent
 Bronchodilator Reversibility Testing
in COPD

Preparation
•Tests should be performed when patients are clinically stable
and free from respiratory infection
• Patients should not have taken:
 inhaled short-acting bronchodilators in the previous six
hours
 long-acting bronchodilator in the previous 12 hours
 sustained-release theophylline in the previous 24 hours
 Bronchodilator Reversibility Testing
in COPD
Results
•An increase in FEV1 that is both greater than 200 ml
and 12% above the pre-bronchodilator FEV1 (baseline
value) is considered significant

•It is usually helpful to report the absolute change (in

ml) as well as the % change from baseline to set the
improvement in a clinical context
Spirometry Classification for COPD
Stage FEV1:FVC FEV1
1: Mild ≥80% of predicted value
2: Moderate 50% to 79% of predicted value
3: Severe 30% to 49% of predicted value
<0.70
<30% of predicted value
4: Very OR
severe <50% of predicted value with
chronic respiratory failure

Adapted from GOLD, 2018

 Measurements
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 2.66 1.32 50 1.26 47 -4
FEV1 2.02 0.54 26 0.50 25 -6
FEV1/FVC 76 41 -35 39 -37 -2
PEF 315 114 36 120 38 5
FEF 25 4.96 0.40 8 0.30 6 -28
FEF 50 2.85 0.20 7 0.20 7 -----
FEF 75 0.78 0.10 13 ----- ----- 198
FEF 25-75 1.02 0.19 10 0.18 10 -6
SPIROMETRY

RESTRICTIVE
DISEASE
 Criteria: Restrictive Disease

 FEV1: normal or mildly reduced

 FVC: < 80% predicted

 FEV1/FVC: > 0.7

Spirometry: Restrictive Disease

Normal
5
Volume, liters

3
Restrictive
FEV1 = 1.9L
2
FVC = 2.0L
1
FEV1/FVC = 0.95

1 2 3 4 5 6
Time, seconds
 Mixed Obstructive/Restrictive

 FEV1: < 80% predicted

 FVC: < 80% predicted

 FEV1 /FVC: < 0.7

 Mixed Obstructive and Restrictive

Normal
Volume, liters

FEV1 = 0.5L
Obstructive - Restrictive FVC = 1.5L
FEV1/FVC = 0.30

Time, seconds
Restrictive and mixed obstructive-restrictive are difficult to diagnose by spirometry alone; full
respiratory function tests are usually required (e.g., body plethysmography, etc)
Normal vs. Obstructive vs.
Restrictive

(Hyatt, 2003)
Unacceptable spirometry
 FEV1/FVC
<LLN Normal

FEV1 FVC

Low WNL WNL Low

Obstruction Normal Restriction

 ATS/ERS INTERPRETATION ALGORITHM

 Identify presence or
absence of obstruction
 Assess Vital Capacity
 Grade severity of
obstruction or restriction
 Assess gas exchange
abnormality
 Consider other factors:
 Performance
 Chest wall or
neuromuscular
 Central airways
 PROJEct PNEUMOBILE INDONESIA

Aim: Values of lung function in normal people

Collaboration between Univ. Indonesia and
Univ. Airlangga
Year 1989
6000 subjek
Age 15 – 70 y.o
Students, workers, social workers, public
organizations
Thank you