Clinical update - asthma
Jo Riley Lead for Respiratory Nursing Service - Oxfordshire
Asthma is a chronic inflammatory disorder of the airways In susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.
International consensus report
A Lot Going On Beneath The Surface
Bronchial hyperresponsiveness Airway inflammation
response to allergen In atopic individual excess of IgE attaches to mast cells
.Sensitisation to an allergen
Initial exposure to allergen Production of IgE in .
Mediator release (2)
Allergen reexposure bridges IgE (1)
.Re-exposure to an allergen
Bronchus in early asthmatic response
Goblet Cells (with mucus) Basement membrane Nerve Fibres
Smooth Muscle Cells
Peak Expiratory Flow
Time Scale (hours)
education for health
Late response to an allergen
III II IIIIII
Microvascular leakage and inflammation
Bronchus in late asthmatic response
Eosinophil Lumen with mucus. cellular debris. plasma exudate Macrophage
Desquamated epithelial cells
Nerve fibres partly exposed by epithelial damage
Basement membrane Eosinophils
Smooth muscle fibre
0 hrs 3 hrs
L.Peak Expiratory Flow
6 hrs 9 hrs
Time scale (hours)
education for health
Muscles around airway
Very tight muscles Mucus blocking airway
Inflammed lining of airway wall
Very small airway
Inflammed swollen airway wall
Asthma often has an atopic component
particularly aeroallergens.What is atopy?
A genetic tendency to overproduce IgE (sometimes called hypersensitivity) in response to common allergens.
A predisposition to develop allergic disease
What is allergy?
Allergy is the clinical manifestation of the genetic predisposition to atopy. Allergic symptoms are expressed upon reexposure to a specific allergen. The symptoms are a result of the release of inflammatory mediators. 66-80% of children have allergic asthma and 15-25% of adults
hormones.no identifiable trigger
. some industrial chemicals Exercise. food hypersensitivity.stress. smoking. drugs.Asthma triggers
Animals. respiratory infections Chronic symptoms . pollens and spores. house dust mite.
rm?id=18 [AccessedJune 2008].2 million people in the UK have asthma1
Among patients treated for their asthma.asthma.html. Eur Respir J 2007:30 (supple 51):249s 3. Where do we stand? Asthma in the UK today.asthma.700 people were admitted to hospital experiencing an asthma attack in England in 20043 – It is estimated that 75% of all admissions for asthma are avoidable4 Somebody dies from asthma every 7 hours4 – Nearly 90% of these deaths are preventable4
1. Date accessed July 2008
. http://www.org. The Asthma Divide.uk/document. Asthma UK. 2. Desfougeres JL et al.org. Key facts and statistics.org.uk/news_media/media_resources/for_1.uk/how_we_help/world_asthma_day/index.Asthma UK. Available at: www.The impact of asthma
An estimated 5. http://www.html Date accessed: July 2008 4. 55% are not well controlled 2
live guidelines updated on the Web – latest update published May 2008
.BTS/SIGN asthma guidelines – published 2003.
Reconsider the diagnosis Consider further tests or referral
Reconsider probable diagnosis Further investigation
Asthma diagnosis confirmed Continue Rx
Manage according to 18 alternative diagnosis
.ADULT with symptoms that may be due to asthma
Clinical History and examination Spirometry (or PEF if spirometry not available)
High Probability Intermediate Probability Obstructive
Low Probability Investigate and treat alternative diagnosis Response? No Yes
Trial of Treatment
Response? Yes No
Assess compliance and inhaler technique.
allergen exposure and cold air • after taking aspirin or beta blockers 2) History of atopic disease 3) Family history of asthma or atopic disease 4) Widespread wheeze 5) Evidence of airway narrowing
(NB Normal spirometry when free of symptoms does not exclude asthma)
. wheeze. SOB or chest tightness): • worse at night and in the morning • in response to exercise.Patient with symptoms that may be due to asthma
Clinical History and examination Spirometry (or PEF if spirometry not available)
High Probability 1)Symptoms (cough.
peripheral tingling 3) Repeatedly normal clinical examination even when Trial of Treatment symptomatic 4) No evidence of Assess airwaycompliance narrowing when symptomatic and inhaler technique.Patient with symptoms that may be due to asthma
Clinical History and examination Spirometry (or PEF if spirometry not available)
Low Probability Highprobability Probabilityequals: Low 1) Cough in the absence of wheeze or breathlessness 2) Prominent dizziness. light headedness. 5) Voice disturbance Response? Reconsider the diagnosis 6) Yes Symptoms colds only No with Consider further tests or referral 7) Chronic productive cough 8) Significant smoking history (>20 pack years) Asthma diagnosis confirmed 20 9) Cardiac disease Continue Rx
Spirometry in asthma
Spirometry is the preferred test to confirm diagnosis of asthma
– Clearer identification of airflow obstruction – Less dependant on effort – Useful where history and examination leave doubt about diagnosis – Dependant on level of training of operator
If spirometry shows obstruction – patient will need inhaled treatment – what? will depend on diagnosis
Differential diagnosis in adults
Without airflow obstruction
– – – – – – – Chronic cough syndrome Hyperventilation syndrome Vocal cord dysfunction Rhinitis GORD Heart failure Pulmonary fibrosis
With Airflow obstruction
– – – – – – – COPD Bronchiectasis Inhaled foreign body Obliterative bronchiolitis Large airways stenosis Lung Cancer Sarcoidosis
CHILD with symptoms that may be due to asthma
High Probability Intermediate Probability Low Probability
Consider tests of lung function and atopy
Trial of Treatment
Investigate/treat other condition
Response? Yes No
Assess compliance and inhaler technique. Consider further investigation and/or referral
Asthma diagnosis confirmed Continue Rx and find minimum effective dose
Further investigation Consider referral
Response? No Yes Continue Rx
Further investigations if intermediate probability of asthma
Treatment trials and reversibility testing
– >400ml improvement in FEV1 – Pre and post 400mcg inhaled salbutamol – Steroid trial
200mcg BD inhaled beclometasone for 6-8 weeks 30mg prednisolone for 2 weeks
Peak flow monitoring
– 2-4 times a day best of 3 blows (if highest within 40 l/min of each other) – >20% variability if 4 times a day monitoring
Assessment of airways responsiveness
– E.g. methacholine challenge – specialist centres only
Aims of asthma Treatment - 2008
No daytime symptoms No Night time waking due to asthma No exacerbations No need for rescue β2 agonist No activity limitation Normal lung function (FEV1 >80%) Minimal/no adverse effects for medication
. lung and blood institute. including exercise – Maintain lung function as close to normal levels as possible
1. British Thoracic Society et al. BTS/SIGN guidelines.Most people with asthma should not need to feel like asthmatics
People with asthma should expect to 1-3
– Achieve and maintain control of symptoms – Prevent asthma exacerbations – Maintain normal activity levels. World Health Organisation 1998 3. Thorax 1997 2.National heart.
Progression of asthma therapy
ICS treatment introduced 1972
Salbutamol introduced 1968
High use of short-acting b2 -agonists
Increased use of ICS
AMD Combination products introduced
Fixed Dose Combination products introduced
1990 Launch of long-acting b2 -agonists
Introducing inhaled steroids
Adults or children
– using inhaled beta 2 agonist 3 times a week or more – having symptoms 3 times a week or more – Waking at night once a week or more
Consider in adults and children who have had an exacerbation requiring oral steroids in the last 2 years
Fear of steroids!
While the use of inhaled corticosteroids may be associated with adverse effects (including the potential to reduced bone mineral density) with careful inhaled steroid dose adjustment this risk is likely to be outweighed by their ability to reduce the need for multiple bursts of oral corticosteroids.771
before stepping up.Stepping up treatment?
If patient not controlled. consider the following: Check compliance with existing therapies Check understanding Check Inhaler technique Eliminate trigger factors where possible
British Thoracic Society.Step 3: Initial add-on therapy
The first choice as add-on therapy to inhaled steroids in adults and children(5-12 years) is an inhaled long-acting beta2 agonist (LABA) Adding a LABA should be considered before going above a dose of 400 mcg BDP or equivalent and certainly before going above 800mcg Long-acting beta2 agonists are effective at providing bronchodilation over a sustained period. British
Guideline on the Management of Asthma: A National Clinical Guideline . improve symptoms and reduce incidence of exacerbation LABAs are not licensed as monotherapy in the treatment of asthma
1. Revised Edition. They increase lung function. Scottish Intercollegiate Guidelines Network. 2008.
. Patients should discuss any concerns regarding their asthma treatment with their doctor. and it is important that patients take their asthma medicine as prescribed to them.mhra.gov.MHRA advice on LABA‟s
At present the benefits of long-acting β2 agonists outweigh the risks.uk/Safetyinformation/Generalsafetyi nformationandadvice/Productspecificinformationandadvice/Asthma/index.
3. BTS 2008 “there is no difference in efficacy in giving inhaled steroid and long-acting ß2 agonist in combination or in separate inhalers” “Once a patient is on stable therapy. combination inhalers have the advantage of guaranteeing that the long-acting ß2 agonist is not taken without inhaled steroid” Supported by Oxfordshire guidance in prescribing “Points Bulletin Oxfordshire PCT Vol 17(1) 09 May 2008”
LABA AT STEP 2 OR 3 – Optimal inhaler technique – Compliance – Understanding
.Can we gain control of asthma?
Vast majority of asthmatics seen in primary care should achieve guideline level control (total control)
– Appropriate dose of inhaled steroid +/.
Children age 5-12 yrs
Children Less than 5 yrs
regular review 2.Stepping down
Patients who have been stable and asymptomatic for 3 months could consider stepping down treatment – one study recommends halving ICS dose every 3 months Some children with milder asthma and a clear seasonal pattern to their symptoms may have a more rapid dose reduction during their “good” season Key issues –
1. maintain on lowest dose possible of ICS
Allergen avoidance Breast feeding Avoidance of pollutants – stop smoking/support parents to stop smoking Family therapy in difficult childhood asthma
Cochrane Review: Dust Mite Control Measures for asthma. Goetzsche PC. •No evidence to support current methods of dust mite control in reducing asthma symptoms or severity
. Cochrane Systematic Review 2001 •23 studies – 6 chemical. 4 combined. 13 physical.
Have we sorted Asthma? .Asthma management today
• The majority of patients accept limitations in their lives due to asthma
Going to work Playing with children Socialising Walking Going up or down stairs Sport Sleeping 0% 10% 20% 30% 40% 50% 60% 70%
27% 35% 42% 49%
53% 63% 71%
Gruffydd Jones et al. Int J Clin Pract 2002 (ACE survey)
National Asthma Campaign.Asthma compromises lifestyles in the UK
• 27% feel that asthma totally controls their life or
has a major effect on it1
• 44% say that at least one activity is „totally or
very limited‟ by asthma2
• Only 40% usually feel well3
• Two-thirds of patients who say their asthma is
„well controlled‟ use reliever twice a day4
1. Int J Clin Pract 2002.
. Asthma J 1999. 4. Asthma J 2000. National Asthma Campaign & Allen and Hanburys. 3. 1996. Gruffydd Jones et al. The Impact of Asthma Survey. 2. Price et al.
Prim Care Resp J 2004.After being shown international guidelines. 13: 28-35
. significantly fewer patients thought their asthma was under control
% respondents who thought that their asthma was under control before and after being shown international guidelines
“That can‟t be right. My treatment doesn‟t do that”
Haughney J et al.
Asthma monitoring in primary care
Symptomatic asthma control – RCP3 or ACQ (following slides) Lung function Spirometry or PEFR Exacerbations. oral corticosteroid use and time off work or school since last assessment Inhaler technique Compliance .which can be assessed by reviewing prescription refill frequency Possession of and use of self management plan/personal action plan
.which can be assessed by reviewing prescription refill frequency Bronchodilator reliance .
Ask & Tell
ZERO TOLERANCE FOR SYMPTOMS • Simple questions are needed to gain an insight how patients really are:
• Have you had any asthma symptoms recently? • Have you needed your blue inhaler recently?
• Do you ever wake up in the night due to your asthma?
• Have you had an attack or needed an emergency visit recently? • Do you ever avoid doing things because of your asthma?
Tell them that the aim of asthma management is zero symptoms
During the past 4 weeks. how much of the time did your asthma keep you from getting as much done at work. how often have you had shortness of breath?
Patient Total Score
. chest tightness or pain) wake you up at night. Asthma Control Test Is a Trademark of QualityMetric Incorporated. QualityMetric Incorporated. school or at home?
2. In the past 4 weeks. how often did your asthma symptoms (wheezing. How would you rate your asthma control during the past 4 weeks?
Copyright 2002. shortness of breath. or earlier than usual in the morning?
During the past 4 weeks. how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)? 5.
During the past 4 weeks.Asthma Control Test™ (ACT)
© Imperial College London
Outcomes and audit. Thorax 2003. school. etc)?” Date / / /
Applies to all patients with asthma aged 16 and over.Assessment: Royal College of Physicians of London three questions
IN THE LAST WEEK / MONTH
“Have you had difficulty sleeping because of your asthma symptoms (including cough)?”
“Have you had your usual asthma symptoms during the day (cough. work.g. chest tightness or breathlessness)?”
“Has your asthma interfered with your usual activities (e. wheeze. 58 (Suppl I): i1-i92
. housework. Only use after diagnosis has been established.
Can we control Asthma?
Asthma control is achievable in the majority of patients
– Have you got them on the correct treatment step? – Does your patient understand what and when to take and when to seek help? – Have you checked inhaler technique? – Does your patient have a self management plan?
Acute exacerbation management
1 million (of the 2.2 million people with asthma in the UK.000 people) 20% of people with severe asthma are seriously concerned that the next asthma attack will be the one that kills them (>500.6 million have severe symptoms. 2. 2.6 million) are suffering unnecessarily because of a failure of asthma management.000)
. 1 in 6 people with severe asthma symptoms report weekly attacks so severe that they cannot speak (430.“Living on a knife edge” Asthma UK 2004
Of the 5.
Lessons from studies of Asthma deaths and near-fatal asthma – Who is at risk?
A combination of asthma :Severe And Adverse behavioural or psychological features:– Non compliance with treatment or monitoring – Failure to attend appointments – Fewer GP contacts – Frequent home visits – Self discharge from hospital – Psychosis. depression. in the past year – 3 or more classes of asthma medication – Heavy use of ß2 agonists – Repeated attendances for asthma to the ED department – “brittle” asthma
. marital or legal stress – Previous near fatal asthma (requiring ventilation or acidotic) – Previous admission for asthma esp. other psychiatric illness or self harm – Current or recent major tranquiliser use – Denial – Alcohol or drug abuse – Obesity – Learning difficulties – Employment or income problems – Social isolation – Childhood abuse – Severe domestic.
Deaths continue to be reported following inappropriate prescription of β-blockers and NSAIDs. all asthma patients should be asked about past reactions to these agents Patients with acute asthma should not be sedated unless this is to allow anaesthetic or intensive care procedures
. Thorax 2008.Lessons learnt from studies of asthma deaths
Many deaths from asthma are preventable – 88-92% of attacks requiring hospitalisation develop over 6 hours Factors include: • inadequate objective monitoring • failure to refer earlier for specialist advice • inadequate treatment with steroids
Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitely Respiratory specialist should follow up patients admitted with severe asthma for at least a year after admission
Management of acute asthma.
Type 2: sudden severe attacks on a background of apparently well controlled asthma
.Type 1: wide PEF variability (>40% diurnal variation for >50% of the time over a period >150 days) despite intense therapy .
Moderate asthma exacerbation
Increasing symptoms PEF>50-75% best of predicted No features of acute severe asthma
heart rate ≥110/min .inability to complete sentences in one breath
.Acute severe asthma
Any one of: .PEF 33-50% best or predicted .respiratory rate ≥25/min .
0 kPa) Cyanosis Silent chest Poor respiratory effort
.6–6.Life threatening asthma
Any one of the following in a patient with severe asthma:
Clinical signs Measurements Altered conscious level PEF <33% best or predicted Exhaustion SpO2 <92% Arrhythmia PaO2 <8 kPa Hypotension “normal” PaCO2 (4.
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
respiratory and cardiovascular signs helpful but non-specific for severity. symptoms. absence does not exclude severe attack Measurement of severity and guide for treatment. Aim to maintain sats >92% Necessary for patients with SaO2 < 92% or if features of life threatening asthma Not routinely recommended in the absence of :•Suspected pneumomediastinum or pneumothorax •Suspected consolidation •Life threatening asthma •Failure to respond to treatment as expected •Requirement for ventilation Systolic paradox (pulsus paradox)is an inadequate indicator of the severity of an attack and should not be used
. PEF more convenient.Patient assessment
Clinical features PEF or FEV1 Pulse oximetry Blood gasses Chest X-ray Clinical features. (PEF as %age previous best or predicted) Determines adequacy of oxygen therapy and need for ABG.
(PEF >50% pred. p<110)
High dose bronchodilator (Neb or inhaler) If peak flow >50 – 75% give 40 – 50mg prednisolone Continue or step up usual treatment If pulse and respiratory rate settling and peak flow >50% predicted continue treatment at home Admit if
– Features of life threatening attack – Features of acute severe asthma after initial treatment – Previous near fatal asthma
. resps<25. Speech normal.
Continue high dose bronchodilators via nebuliser and oxygen in ambulance
.Acute severe asthma
(PEF 33-50% pred. can‟t complete sentence. pulse>110)
Consider admission High flow oxygen if available High dose bronchodilators Prednisolone 40 – 50mg (or hydrocortisone 100mg) If no response – ADMIT If admitting. send written assessment. Resp>25. stay with patient.
high dose bronchodilators can be delivered via large volume spacers or nebulisers The absence of supplemental oxygen should not prevent nebulised therapy being given if indicated
. ambulance and primary care. nebulisers should be driven by high flow oxygen (minimum 6l/min flow) Outside hospital.Treatment of acute asthma in adults
Oxygen : Oxygen saturations should be above 92% Give high flow oxygen to all patients with acute severe asthma In hospital.
sats <92%. etc)
Arrange immediate admission Whilst waiting for ambulance – Oxygen 40-60% to keep sats >92% High dose bronchodilators – salbutamol and ipratropium via nebuliser driven by oxygen Prednisolone 40 – 50mg (or hydrocortisone 100mg) Follow up after admission to hospital: GP review in 48 hours Check inhaler technique Written asthma management plan Modify treatment if underlying poor control
.Life threatening asthma (PEF <33%
best or predicted.
Acute asthma in pregnancy Give drug therapy as for the non pregnant patient Deliver oxygen immediately to maintain saturations above 95% Always treat as an emergency Asthma in children Alter drug doses for younger children All over 12‟s receive adult therapy
<130 in 2-5’s Resp rate <30 in >5’s. <50 in 2-5’s SpO2>92% In over 5’s peak flow >50% predicted/best
.Moderate asthma exacerbation – children 2-12 years
Able to talk No features of acute severe asthma Pulse <120 in >5’s.
Children aged >5years Moderate exacerbation
ß2 agonist (salbutamol or terbutaline) 4 – 6 puffs via spacer Consider soluble prednisolone 30 .40mg Increase dose of ß2 agonist by 2 puffs every 2 minutes up to 10 puffs according to response Arrange admission if poor response Good response – Continue ß2 agonist via spacer prn but not exceeding 4 hourly Continue Prednisolone for 3 days Arrange follow up in clinic
Asthma 2 – 5 years Moderate exacerbation
ß2 agonist (salbutamol or terbutaline) 4 – 6 puffs via spacer Consider soluble prednisolone 20mg Increase dose of ß2 agonist by 2 puffs every 2 minutes up to 10 puffs according to response Arrange admission if poor response Good response – Continue ß2 agonist via spacer prn but not exceeding 4 hourly Continue Prednisolone for 3 days Arrange follow up in clinic
>130 in 2-5’s Resp rate >30 in >5’s. >50 in 2-5’s SpO2 <92% In over 5’s. peak flow <50% predicted/best
.Acute severe asthma – children 2-12 years
Unable to complete sentences in one breath or too breathless to talk or feed Use of accessory muscles Pulse >120 in >5’s.
send written assessment. Continue high dose bronchodilators via neb and oxygen in ambulance
.Children aged >5years Acute Severe exacerbation
Oxygen via face mask ß2 agonist (salbutamol or terbutaline) 4 – 6 puffs via spacer at intervals of 10-20 mins or nebulised salbutamol 2.40mg Assess response to treatment 15 mins after ß2 agonist If poor response – repeat ß2 agonist and arrange admission If admitting.55mcg or terbutaline 5 – 10 mg Soluble prednisolone 30 . stay with patient.
Continue high dose bronchodilators via neb and oxygen in ambulance
. stay with patient.5mg Soluble prednisolone 20mg Assess response to treatment 15 mins after ß2 agonist If poor response – repeat ß2 agonist and arrange admission If admitting.Children 2 .5years Acute Severe exacerbation
Oxygen via face mask ß2 agonist (salbutamol or terbutaline) 4 – 6 puffs via spacer at intervals of 10-20 mins or nebulised salbutamol 2. send written assessment.
Life threatening asthma – children 2-12 years
Silent chest Cyanosis Poor respiratory effort Hypotension Exhaustion Confusion/agitation Coma SpO2 <92% In over 5’s peak flow <33% predicted/best
Children aged >5years Life threatening asthma
Oxygen via face mask High dose bronchodilators – salbutamol 5mg or terbutaline 10mg and ipratropium 0.25mg via nebuliser driven by oxygen Soluble prednisolone 30 - 40mg or IV hydrocortisone 100mg Repeat ß2 agonist via oxygen driven nebuliser whilst arranging immediate admission to hospital
Children 2 - 5years Life threatening asthma
Oxygen via face mask High dose bronchodilators – salbutamol 2.5mg or terbutaline 5mg and ipratropium 0.25mg via nebuliser driven by oxygen Soluble prednisolone 20mg or IV hydrocortisone 50mg Repeat ß2 agonist via oxygen driven nebuliser whilst arranging immediate admission to hospital
Moderate asthma exacerbation – children under 2 years
SpO2 >92% Audible wheezing Using accessory muscles Still feeding
Acute severe asthma – children under 2years
SpO2 <92% Cyanosis Marked respiratory distress Too breathless to feed
Life threatening asthma in children under 2 years
Apnoea Bradicardia Poor respiratory effort
.Asthma treatment in the under 2‟s
2-4 Puffs Salbutamol initial treatment For mild to moderate acute asthma. a pMDI + spacer is the optimal drug delivery device. Consider steroid tablets in infants early in the management of severe episodes of acute asthma – 10mg of soluble prednisolone for 3 days Consider inhaled ipratropium bromide in combination with an inhaled β2 agonist for more severe symptoms.
Lower threshold for admission for all children if:
Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home NB always treat according to most severe features
Criteria for admission
Any patient with any feature of a life threatening or near fatal attack Any patient with any feature of a severe attack persisting after initial treatment Any patient who after initial treatment:
– – – – – – – – – Still has significant symptoms Concerns about compliance Lives alone/socially isolated Psychological problems Physical disability or learning difficulties Previous near fatal or brittle asthma Exacerbation despite already being on oral steroids Presentation at night Pregnancy
or severe attack persisting after initial treatment
• Measure oxygen saturation • Use steroid tablets • Primary care follow up required promptly after acute asthma
Management of acute asthma. 58 (Suppl I): i1-i92
. Thorax 2003.Overview: Management of acute asthma
• Assess and act promptly in acute asthma • Admit patients with any feature of a life threatening or near
•Check inhaler technique •Tailor inhaler device to the patients needs
Do your hospitals use a discharge checklist? Peak flow should be at least 75% or best or predicted with less than 20% diurnal variation pre discharge ALL PATIENTS SHOULD HAVE A SELF MANAGEMENT PLAN BEFORE BEING DISCHARGED Patient must be prescribed preventative therapy Inhaler technique must be checked All patients should have their own peak flow meter Advise to see GP within 2 working days – can they get an Refer for chest OPD within 4 weeks
how often and for how long How to use inhaler effectively What to do if they have another asthma attack Are there any triggers and can they avoid them in future? Smoking cessation How often to make an appointment to have asthma reviewed The importance of carrying a reliever inhaler at all times
.Education / written information
How to recognise that asthma is deteriorating How to take medicines.
Why do spirometry?
More informative than peak flow To detect presence or absence of lung disease where there is a history or pulmonary symptoms To confirm findings of other investigations e.g.chest x-ray or blood gasses To establish extent of lung impairment in respiratory disease and monitor progression e.bronchodilator reversibility tests
. smokers. cardiac disease or neuromuscular disease Occupational / environmental monitoring e. asbestos To determine effects of an intervention e.g.COPD / Fibrosis To investigate impact of other diseases on lung function e.g. dust.g.g.
Spirometry cannot Define the full extent of the disease e.g. In COPD many systemic as well as pulmonary effects Define the response to therapy Define the extent of disability that the patient experiences
Smoking for 24 hours Alcohol for 4 hours Vigorous exercise for 30 minutes Tight clothing Food for 2 hours Query Using Inhalers
angina Ear infection Pregnancy
MI / CVA Recent operations Spontaneous pneumothorax Aneurysm Uncontrolled hypertension.
Record patients date of birth. height. ethnic origin Note if the patient is currently unwell or has had a recent exacerbation Ensure the patient is comfortable Sit the patient in a chair with arms Explain the purpose of the test You may need to demonstrate the correct technique Allow the patient practice attempts
To withhold or not to withhold medication? If you are doing reversibility testing:
No short acting bronchodilators for 4 hours No long acting bronchodilators for 12 hours No sustained release oral bronchodilators for 24 hours
For routine monitoring of COPD patients:
Take all medication as usual
Lung volume terminology
Inspiratory capacity Inspiratory reserve vol
Expiratory reserve vol
The percentage of the VC that is produced in the first second
. should be the same volume as VC but is sometimes reduced due to air trapping in COPD FEV1 – Forced expiratory volume in one second from full inspiration FEV1/FVC or FEV1% or FEV1/FVC ratio –The percentage of the FVC that is produced in the first second FEV1/VC .Terminology
VC – Vital capacity. the total amount of air that acn be expelled from the lungs from full inspiration to full expiration FVC – Forced vital capacity.
Measuring vital capacity (VC)
The VC is a non vorced measurement. It is often measured at the start of a session. Patient breathes in as deeply as is comfortable Seals lips around mouthpiece Breathes out steadily at a comfortable pace Continue until expiration complete May need a nose clip Repeat
until there is nothing left to dispell
– Encourage patient to keep blowing – For some COPD patients this can take up to 15 seconds! – Spirometer may bleep to say manoeuvre complete
Repeat the procedure twice or until reproducible results
. as hard and fast as possible.Measuring FEV1 and FVC
Ask the patient to take a deep breath in – full inspiration Patient to blow out forcibly.
The most common reason for inacurate results is patient technique Common problems include:
Inadaquate or incomplete inhalation Additional breath taken during manoeuvre Lips not sealed around mouthpiece A slow start to the forced exhalation Some exhalation through the nose Coughing
Interpreation of results
Take the best of the 3 consistent readings of FEV1 and of FVC Find the predicted normals for your patient – Your machine may do this for you! Get out your calculators!!
Depends on . – Age – Sex – Height – Race
ERS93.Predicted Normal values
Based on large population surveyse.g. ECCS83 Predicted values are the mean values obtained from the survey No surveys conducted in elderly populations
Normal ventilatory function
80 – 120% of predicted
80 – 120% of predicted
FEV1/FVC ratio >70%
Normal Obstructive Restrictive Combined
Obstructive Restrictive Combined
Flow volume trace
Peak expiratory flow Flow (l/second)
FVC Volume (litres)
Normal Flow Volume curve
Maximum expiratory flow (PEF)
Expiratory flow rate L/sec TLC Inspiratory flow rate L/sec
Patterns of abnormality in spirometry
Obstruction Restriction Mixed
Slow rise. prolonged time to full expiration
Fast rise to plateau at reduced maximum volume
Slow rise to reduced maximum volume
. reduced volume expired.
rapid fall off
Volume (L) Normal shape. normal peak flow. reduced peak flow.Patterns of flow volume curves in obstruction and restriction
Expiratory flow rate
Severe obstruction Expiratory flow rate
Expiratory flow rate
Volume (L) Reduced peak flow. scooped out midcurve
Volume (L) Steeple pattern. reduced volume
COPD Asthma Bronchial carcinoma Bronchiectasis
Fibrosing lung disease (CFA. rheumatiod) Byssinosis Pulmonary oedema
Pneumoconiosis (coal workers. EAA. UIP. asbestosis. silicosis. siderosis)
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