COPD:

Spirometry

Clare Hawkins, MD, MS

Program Director, San Jacinto Methodist Hospital Family Medicine Residency,
Baytown, TX

Isaac M. Goldberg, MD
Faculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown,
TX
 Educational Objectives
At the end of this presentation, the
learner should be able to …
• Utilize spirometry to diagnose and stage
COPD
• Overcome barriers to the use of office
spirometry
• Achieve confidence with spirometry
interpretation
 Background
Objective measure of airway function for accurate
diagnosis of Chronic Obstructive Pulmonary
Disease (COPD)
 World Health Organization Global Obstructive Lung
Disease Consensus/ Evidence guideline (GOLD)
 American Thoracic Society (ATS)
 European Respiratory Society (ERS)
 National Committee for Quality Assurance (NCQA)
 Background
Alternate ways to diagnose COPD
 Clinical Findings Late
- Increased AP diameter, tympanitic chest
- Signs of respiratory distress
 Peak flow reading not adequately sensitive or specific
 Radiographic findings occur late in disease
 CT scanning more accurate, but findings also occur
late in disease
 Background
Who should receive spirometry?
 Early diagnosis relies on the recognition of the clinical
features
- Persistent cough
- Chronic sputum production
- Breathlessness on exertion
- Reduction in activity (often attributed to natural aging)

 About 20% of COPD patients identified in NHANES

study with obstruction never smoked
- Only 1/5 were explained by asthma
 Background
Other testing considerations
 Recurrent or chronic respiratory symptoms
 Occupational exposure to respiratory irritants
 Family history of respiratory diseases and symptoms
 NCQA established use of spirometry as required
quality measure for accurate COPD diagnosis
 Routine periodic use not recommended
 Background
Screening
 Not recommended in the absence of respiratory
symptoms (dyspnea, cough)
 No threshold amount of smoking pack-years for
screening in the absence of respiratory symptoms
 Not recommended by USPSTF or ACP 2011
Guideline
 Background
 Family physicians able to do quality spirometry
 Quality of care increases with use of spirometry
- To prevent overdiagnosis of COPD, attention to quality
spirometry is important
 Suggestions to maintain quality of spirometry
- Know technique
- Have staff coach the patient
- Do sufficient numbers of tests
- Maintain and calibrate the equipment
- Understand interpretative algorithms
 Background
Why do office spirometry?
 Diagnostic accuracy. 30% of time diagnosis changes.
- Was not COPD; heart failure or asthma
- Was COPD rather than asthma
- If spirometry normal, then expensive meds discontinued
 Respect. Patients respect physicians who use
technology (Future of Family Medicine)
 Patient convenience. You can avoid an unnecessary
referral and additional visit
 Diagnostic power: You can connect diagnostic
information with rest of clinical encounter
 Financial benefit to practice.
 Equipment
 Older volume/time loop
- Drum technique from John
Hutchinson 1844

 Newer flow/volume loop

using flow transducer
- Smaller Machines, Mobile
- Disposable Mouthpiece
 No other infection
transmission
precautions necessary
 Equipment
 Numerous manufacturers produce quality instruments
 Reviews conducted by National Lung Health Education
Program (NLHEP) regarding appropriateness of
spirometers for office practice
- http://www.nlhep.org/spirometer-review-process.html
- Simplicity (fewer numbers)
- Reliability
 Equipment
Calibration
 Daily calibration must be done with 3 L syringe
 Syringe must have accuracy of at least 15 ml
 Spirometer must have accuracy of ±105 mL or
0.105 L (calibration volume = 2.90 to 3.11)
 Calibration log/printouts must be kept
- Date and time of calibration
- Individual performing
- Comments
 Technique
Forced expiratory maneuver
 Coach patient to get a maximal effort
 Six seconds of effort required though most of air pushed
out in the first second
 Pace of expired air is most important variable; therefore
it should be released with explosive force
 Technique
 Minimum 6 second exhalation with 2 second plateau
 Tracing should have no artifacts
 At least 3 acceptable maneuvers (<5 % variation)
- ATS criteria
 Empty bladder for females (concern if incontinence)
 Can be seated or standing
 Nose plug optional
 Technique
None of the following should occur:
 Unsatisfactory start, with excessive hesitation or false start
 Air leak
 Coughing during the first second
 Early termination of forced expiration
 Glottis closure
 Obstructed mouthpiece
- Tongue
- False teeth
- Chewing gum
 Technique
Reliability
 Spirometry overdiagnoses COPD if insufficient effort
 Concerns that family physicians will not perform
quality testing and overdiagnose people with
obstructive lung disease
 Imperative that patients be coached on robust, forced
expiratory maneuver
 Technique
Contraindications
 Hemoptysis of unknown origin
 Pneumothorax
 Unstable cardiovascular status or recent MI or PE
 Thoracic, abdominal, or cerebral aneurysms
 Recent eye, thorax or abdomen surgery
 Technique
Barriers
 Inaccessibility of Equipment
 Concern patient effort and cooperation are insufficient
 Difficulty remembering interpretive algorithm
 Frustration by ambiguous results
 Difficulty working 30-minute spirometry into office flow
 Central location for spirometry versus going room to
room
 Lack of staff training
 Poor integration with electronic health record
 Lack of adequate reimbursement
 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
 Measurements
Normal values
 Individual variation according to age, height, ethnicity
and gender
- Height - Tall people have larger lungs
- Age - Respiratory function declines with age
- Sex - Lung volumes smaller in females
- Race - Studies show Blacks and Asians have smaller lung
volumes (-12%)
- Posture - Little difference between sitting and standing;
reduced in supine position
 Measurements
Bronchodilator reversibility testing
 Beta-agonist
- Short-acting – wait 20 minutes before retesting
- Long-acting – wait 2 hours before retesting
 Do not take bronchodilator the day of testing
- Measured reversibility will be limited if the patient is
bronchodilated for the pretest.
 Measurements
Definition of reversibility
 Pre-Bronchodilator
- FEV1/FVC <70% of predicted
 Post-Bronchodilator
- Increase 12% AND at least 200 cc

Reversibility = Asthma!
 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
 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
 Case Study 1
A 53-year-old white male presents for annual
visit. Although he quit 10 years ago he is a
previous cigarette smoker with a 20 pack-year
history. During the past 12 months, he has had
3 episodes of bronchitis. His history of tobacco
use and recent episodes of acute bronchitis lead
you to perform spirometry.
 Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 4.65 4.65 100 4.95 106 6
FEV1 3.75 3.13 83 3.34 89 6
FEV1/FVC 80 67 -13 67 -13 0
PEF 511 462 90 522 102 12
FEF 25 7.86 5.7 73 6.00 76 5
FEF 50 4.46 2.3 52 2.10 47 -9
FEF 75 1.75 .5 29 0.60 35 18
FEF 25-75 3.76 1.77 47 1.78 47 0
 Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 4.65 4.65 100 4.95 106 6
FEV1 3.75 3.13 83 3.34 89 6
FEV1/FVC 80 67 -13 67 -13 0

Is there obstruction?
FEV1/FVC = 67% of predicted; therefore, obstruction present

Is there restriction?
FVC = 100% of predicted; therefore, no restriction present
 Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 4.65 4.65 100 4.95 106 6
FEV1 3.75 3.13 83 3.34 89 6
FEV1/FVC 80 67 -13 67 -13 0

What is the severity of obstruction?

FEV1 is 83% of predicted; therefore, the obstruction is mild

Is the obstruction reversible (is reversibility present)?

FEV1 increases from 83% to 89% (6% increase) and increases from 3,130
cc to 3,340 cc (increase of 210 cc)

Interpretation: Mild Obstruction with minimal reversibility: Mild COPD

 Common Obstructive
Pulmonary Disorders

Diffuse Airway Disease Upper-Airway Obstruction

Asthma Foreign body
COPD Neoplasm
Bronchiectasis Tracheal stenosis
Cystic fibrosis Tracheomalacia
Vocal cord paralysis
Diagnostic Flow Diagram for Obstruction
Is FEV1 / FVC Ratio Low? (<70%)
Yes
Obstructive Defect

Is FVC Low? (<80% pred)

Yes No

Combined Obstruction & Pure Obstruction

Restriction /or Hyperinflation

Improved FVC with Reversible Obstruction

ß-agonist with ß-agonist

No Yes Yes No
Further Testing with Suspect Suspect
Full PFT’s Asthma COPD

Adapted from Lowry.

 Case Study 2
A 33 year old female presents to the office
complaining of dyspnea and cough for the past 2
days. Her cough is productive of a white mucous.

Her past medical history is significant for asthma

since childhood, obesity, gastroesophageal reflux
disease (GERD), and an occasional migraine
headache. She is a nonsmoker and has no known
allergies.
 Case Study 2 (cont)
Her current medications include the following:
 Albuterol 2 puffs po qid prn wheezing, cough,
or dyspnea
 Fluticasone 110 micrograms 2 puffs po bid
 Ranitidine 150 mg po bid
Her father recently died secondary to advanced
COPD.
Due to her symptoms, you order spirometry.
 Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 3.78 1.92 51 2.7 71 34
FEV1 3.24 1.11 34 1.61 50 36
FEV1/ FVC 86 58 -28 60 -26 3

Obstruction?
FEV1/FVC = 60%; therefore, obstruction present

Restriction?
FVC = 51% of predicted; therefore, restriction present
 Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured % Measured % % change
FVC 3.78 1.92 51 2.7 71 34
FEV1 3.24 1.11 34 1.61 50 36
FEV1/ FVC 86 58 -28 60 -26 3

What is the severity of obstruction?

60%; therefore, moderate obstruction
Is the obstruction reversible (is reversibility present)?
FEV1 increases from 34% to 50% (16% increase) and increases by 500 cc
What is the severity of restriction?
71% of predicted; therefore, mild restriction
Interpretation: Moderate obstruction with reversibility (Moderate obstruction)
 Common Restrictive Pulmonary
Disorders
Parenchymal Pleural
 Interstitial Lung Diseases  Effusion
- Fibrosis
 Fibrosis
- Granulomatosis (TB)
- Pneumoconiosis Chest Wall
- Pneumonitis (lupus)  Kyphoscoliosis
 Loss of Functioning Tissue  Neuromuscular Disease
- Atelectasis
 Trauma
- Large Neoplasm
- Resection Extrathoracic
 Obesity
 Abdominal Trauma
Diagnostic Flow Diagram for Restriction
Is FEV1 / FVC Ratio Low? (<70%)

No

Is FVC Low?(<80% pred)

Yes No

Restrictive Defect Normal Spirometry

Further Testing with

Full PFT’s; consider
referral if moderate to
severe Adapted from Lowry, 1998
Results

Lowry 1998
 Results
“Full” Pulmonary Function Testing (PFT’s)
 Assessment of Oxygenation
- Transcutaneous oxygen saturation
- Arterial blood gasses
 Diffusion test to evaluate alveolar exchange (DLCO)
 Plethysmography
- To objectively assess lung volumes
- Delineate air-trapping versus restriction
 May also include Spirometry
 Spirometry and Smoking Cessation

 Lung age calculation

- Use to motivate smoking cessation.
 Mixed results
- Normal results may give the impression that it’s
acceptable to continue smoking.
- Avoid fatalism with abnormal results.
 Research results recently favor use
- ACP and AHRQ advise only if symptomatic.
Spirometry and Smoking Cessation
Spirometry and Smoking Cessation
Coding and Reimbursement
Diagnosis ICD-9 Code
Cough 786.2
Simple chronic bronchitis 491.0
Mucopurulent chronic bronchitis 491.2
Acute bronchitis 466.0
Chronic obstructive pulmonary disease 496.0
Shortness of breath 786.5
Restrictive lung disease 515
Asthma 493.91
 Coding and Reimbursement
Procedure CPT Code Reimbursement*
Single spirometry 94010 $32.82
Pre-post spirometry 94060 $57.71
Pulmonary stress test simple 94620 $71.77
Medication administration 94640 $13.34
bronchodilator supply separate
Demonstration / instruction 94664 $14.79
Smoking Cessation <8x/ yr 99406 $12.98
Equipment Cost
Office spirometer $1,000 – 2,500

*Reimbursement based upon Medicare payments 2009

Estimated Return on Investment

Tests /week (#) Reimbursement/year* ROI $1,995 in weeks

4 $6,864 15
6 $10, 296 10
8 $13,728 7
10 $17,160 6
15 $25,740 4
20 $34,320 3
25 $42,900 2

*Based upon CPT code 94010

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