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Spirometry in Primary Care

Dr Max Matonhodze FRCP (London)


M A Med Ed (Keele)
Objectives
• Need for performing spirometry
• Types of spirometers
• Spirometric indices
• Obstructive spirometry and severity scale
• Practical tips
• Quality control
• Illustrative examples
COPD NICE guidance 2010
The presence of airflow obstruction should be
confirmed by performing post-bronchodilator
spirometry. All health professionals involved in
the care of people with COPD should have
access to spirometry and be competent in the
interpretation of the results.
WHY?
• 3 million people are estimated to have COPD
in UK
• 900 000 are diagnosed
• 2 million are living with undiagnosed COPD
• About 70% of COPD remain undiagnosed
Spirometry
• Spirometry is the gold standard for COPD diagnosis
• Widespread uptake has been limited by:
• Concerns over technical performance of operators
• Difficulty with interpretation of results
• Lack of approved local training courses
• Lack of evidence showing clear benefit when spirometry
is incorporated into management
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.
Why Perform Spirometry?
• Measure airflow obstruction to help make a definitive
diagnosis of COPD
• Confirm presence of airway obstruction
• Assess severity of airflow obstruction in COPD
• Detect airflow obstruction in smokers who may have few
or no symptoms
• Monitor disease progression in COPD
• Assess one aspect of response to therapy
• Assess prognosis (FEV1) in COPD
• Perform pre-operative assessment
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
Volume Measuring Spirometer
Flow Measuring Spirometer
Desktop Electronic Spirometers
Small Hand-held Spirometers
Standard Spirometric Indicies
• 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
Additional Spirometric Indicies
• VC - Vital capacity:
A volume of a full breath exhaled in the patient’s own time
and not forced. Often slightly greater than the FVC,
particularly in COPD

• FEV6 – Forced expired volume in six seconds:


Often approximates the FVC. Easier to perform in older
and COPD patients but role in COPD diagnosis remains
under investigation

• MEFR – Mid-expiratory flow rates:


Derived from the mid portion of the flow volume curve
but is not useful for COPD diagnosis
Lung Volume Terminology

Inspiratory reserve Inspiratory


volume capacity

Total Tidal volume


lung
capacity Expiratory reserve
volume

Residual volume
Spirogram Patterns

• Normal

• Obstructive

• Restrictive

• Mixed Obstructive and Restrictive


Spirometry

Predicted Normal
Values
Predicted Normal Values
Affected by:
 Age
 Height
 Sex
 Ethnic Origin
Criteria for Normal
Post-bronchodilator Spirometry

• FEV1: % predicted > 80%

• FVC: % predicted > 80%

• FEV1/FVC: > 0.7 - 0.8, depending on age


Normal Trace Showing FEV1 and FVC

5 FVC
4
Volume, liters

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

1 2 3 4 5 6
Time, sec
SPIROMETRY

OBSTRUCTIVE
DISEASE
Spirometry: Obstructive Disease
Normal
5

4
Volume, liters

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

1 2 3 4 5 6
Time, seconds
Diseases Associated With
Airflow Obstruction

• COPD
• Asthma
• Bronchiectasis
• Cystic Fibrosis
• Post-tuberculosis
• Lung cancer (greater risk in COPD)
• Obliterative Bronchiolitis
Spirometric Diagnosis of COPD

• COPD is confirmed by post–bronchodilator


FEV1/FVC < 0.7 Plus
• FEV1 %pred >80%= Mild
• FEV1 %Pred 50-79% =moderate
• FEV1 % Pred 30-49% =Severe
• FEV1 %pred <30%= very severe
SPIROMETRY

RESTRICTIVE
DISEASE
Criteria: Restrictive Disease

• FEV1: normal or mildly reduced

• FVC: < 80% predicted

• FEV1/FVC: > 0.7


Spirometry: Restrictive Disease

5
Normal
4
Volume, liters

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

1 2 3 4 5 6
Time, seconds
Diseases Associated with a Restrictive Defect

Pulmonary Extrapulmonary
• Fibrosing lung diseases • Thoracic cage deformity
• Pneumoconioses • Obesity
• Pulmonary edema • Pregnancy
• Parenchymal lung tumors • Neuromuscular disorders
• Lobectomy or • Fibrothorax
pneumonectomy
Mixed Obstructive/Restrictive

• FEV1: < 80% predicted

• FVC: < 80% predicted

• FEV1 /FVC: < 0.7


SPIROMETRY

Flow Volume
Flow Volume Curve
• Standard on most desk-top spirometers

• Adds more information than volume time


curve

• Less understood but not too difficult to


interpret

• Better at demonstrating mild airflow


obstruction
Flow Volume Curve
Maximum
expiratory flow
(PEF)

Expiratory
flow rate
L/sec

TLC
FVC RV

Inspiratory
flow rate
L/sec

Volume (L)
Flow Volume Curve Patterns
Obstructive and Restrictive
Obstructive Severe obstructive Restrictive

Expiratory flow rate


Expiratory flow rate

Expiratory flow rate

Volume (L) Volume (L) Volume (L)


Reduced peak flow, Steeple pattern, Normal shape,
scooped out mid- reduced peak flow, normal peak flow,
curve rapid fall off reduced volume
Spirometry: Abnormal Patterns
Obstructive Restrictive Mixed

Volume
Volume

Volume
Time Time Time

Slow rise, reduced Fast rise to plateau Slow rise to reduced


volume expired; at reduced maximum volume;
prolonged time to maximum volume measure static lung
full expiration volumes and full PFT’s
to confirm
PRACTICAL SESSION

Performing Spirometry
Spirometry Training
• Training is essential for operators to learn correct performance
and interpretation of results
• Training for competent performance of spirometry requires a
minimum of 3 hours
• Acquiring good spirometry performance and interpretation skills
requires practice, evaluation, and review
• Spirometry performance (who, when and where) should be
adapted to local needs and resources
• Training for spirometry should be evaluated
Obtaining Predicted Values
• Independent of the type of spirometer
• Choose values that best represent the
• tested population
• Check for appropriateness if built into
• the spirometer
Optimally, subjects should rest 10 minutes
before performing spirometry
Performing Spirometry - Preparation
1. Explain the purpose of the test and demonstrate
the procedure
2. Record the patient’s age, height and gender and
enter on the spirometer
3. Note when bronchodilator was last used
4. Have the patient sitting comfortably
5. Loosen any tight clothing
6. Empty the bladder beforehand if needed
Performing Spirometry
• Breath in until the lungs are full
• Hold the breath and seal the lips tightly
around a clean mouthpiece
• Blast the air out as forcibly and fast as
possible. Provide lots of encouragement!
• Continue blowing until the lungs feel
empty
Performing Spirometry
• Watch the patient during the blow to
assure the lips are sealed around the
mouthpiece
• Check to determine if an adequate trace
has been achieved
• Repeat the procedure at least twice
more until ideally 3 readings within
100ml or 5% of each other are
obtained
Reproducibility - Quality of Results
Volume, liters

Time, seconds

Three times FVC within 5% or 0.15 litre (150 ml)


Spirometry - Possible Side Effects
• Feeling light-headed
• Headache
• Getting red in the face
• Fainting: reduced venous return or vasovagal
attack (reflex)
• Transient urinary incontinence

Spirometry should be avoided after recent


heart attack or stroke
Spirometry - Quality Control
• Most common cause of inconsistent readings is
poor patient technique
 Sub-optimal inspiration
 Sub-maximal expiratory effort
 Delay in forced expiration
 Shortened expiratory time
 Air leak around the mouthpiece
• Subjects must be observed and encouraged
throughout the procedure
Spirometry – Common Problems
 Inadequate or incomplete blow
 Lack of blast effort during exhalation
 Slow start to maximal effort
 Lips not sealed around mouthpiece
 Coughing during the blow
 Extra breath during the blow
 Glottic closure or obstruction of mouthpiece
by tongue or teeth
 Poor posture – leaning forwards
Equipment Maintenance
• Most spirometers need regular calibration to check
accuracy
• Calibration is normally performed with a 3 litre
syringe
• Some electronic spirometers do not require
daily/weekly calibration
• Good equipment cleanliness and anti-infection control
are important; check instruction manual
• Spirometers should be regularly serviced; check
manufacturer’s recommendations
Troubleshooting

Examples - Unacceptable Traces


Unacceptable Trace - Poor Effort

Normal
Volume, liters

Variable expiratory effort


Inadequate sustaining of effort

May be accompanied by a slow start

Time, seconds
Unacceptable Trace – Stop Early

Normal
Volume, liters

Time, seconds
Unacceptable Trace – Slow Start
Volume, liters

Time, seconds
Unacceptable Trace - Coughing

Normal
Volume, liters

Time, seconds
Unacceptable Trace – Extra Breath

Normal
Volume, liters

Time, seconds
Spirometry
• Mrs PZ 47 yrs
• FEV-1 = 0.8L (35% of pred)
• FVC = 2.4L (85% of pred)
• FEV-1/FVC Ratio = 30%
Spirometry
• Answer:
Spirometry
• Mr PY 83
• FEV-1 =0.6L (28%pred)
• FVC = 1.9 L (81% pred)
• FEV-1/FVC ratio =31.5%
Spirometry
• Answer:
Spirometry
• Mr BY 63
• FEV-1 = 1.6 L (63% pred
• FVC = 2.1 L (67% pred)
• FEV-1/FVC ratio = 76%
Spirometry
• Answer-
Spirometry
• Mrs TZ 56
• FEV-1 =1.1L (41% pred)
• FVC = 2.3 L (63%pred)
• FEV-1/FVC ratio =48%
Spirometry
• Answer?
Some Spirometry Resources
• Global Initiative for Chronic Obstructive Lung
Disease (GOLD) - www.goldcopd.org

• Spirometry in Practice - www.brit-thoracic.org.uk

• ATS-ERS Taskforce: Standardization of


Spirometry. ERJ 2005;29:319-338
www.thoracic.org/sections/publications/statements

• National Asthma Council: Spirometry Handbook


www.nationalasthma.org.au