SPIROMETRY

CONTRAINDICATIONS FOR SPIROMETRY

Absolute
 postoperative conditions after chest operation
 month after myocardial infarction
 serious instability of air passages – emphysema
 bronchial non-specifically marked
hypersensitiveness
 serious difficulties during gas exchange – total
or partial respiratory insufficiency
 CONTRAINDICATIONS FOR SPIROMETRY

Relative
• spontaneous condition after pneumothorax
• arterial- venous aneurysm
• severe arterial hypertension
• pregnancy with complications in 3rd month
• pro test in MVV profile: hyperventilation
syndrome
Lung Volumes and Capacities
• 4 volumes: inspiratory
reserve volume, tidal
volume, expiratory reserve
volume, and residual
volume
• 2 or more volumes
comprise a capacity.
• 4 capacites: vital capacity,
inspiratory capacity,
functional residual capacity,
and total lung capacity
 Lung Volumes
• Tidal Volume (TV): volume of air
inhaled or exhaled with each
breath during quiet breathing
• Inspiratory Reserve Volume (IRV):
maximum volume of air inhaled
from the end-inspiratory tidal
position
• Expiratory Reserve Volume (ERV):
maximum volume of air that can
be exhaled from resting end-
expiratory tidal position
 Lung Volumes

• Residual Volume
(RV):
– Volume of air
remaining in lungs
after maximium
exhalation
– Indirectly measured
(FRC-ERV) not by
spirometry
 Lung Capacities
• Total Lung Capacity (TLC): Sum of
all volume compartments or
volume of air in lungs after
maximum inspiration
• Vital Capacity (VC): TLC minus RV
or maximum volume of air exhaled
from maximal inspiratory level
• Inspiratory Capacity (IC): Sum of
IRV and TV or the maximum
volume of air that can be inhaled
from the end-expiratory tidal
position
 Lung Capacities (cont.)
• Functional Residual
Capacity (FRC):
– Sum of RV and ERV or the
volume of air in the lungs at
end-expiratory tidal position
– Measured with multiple-
breath closed-circuit helium
dilution, multiple-breath
open-circuit nitrogen
washout, or body
plethysmography (not by
spirometry)
What information does a spirometer yield?

• A spirometer can be used to measure the following:

– FVC and its derivatives (such as FEV1, FEF 25-75%)
– Forced inspiratory vital capacity (FIVC)
– Peak expiratory flow rate
– Maximum voluntary ventilation (MVV)
– Slow VC
– IC, IRV, and ERV
– Pre and post bronchodilator studies
 RECOMMENDED TEST SEQUENCE

• forced spirometry – FVC, PEF

• relaxed spirometry – SVC, MVV
• medicine inhalation (if used)
• repeating of forced spirometry – post-medical
examination
SPIROMETER
 Performance of FVC maneuver
• Check spirometer calibration.
• Explain test.
• Prepare patient.
– Ask about smoking, recent illness, medication use,
etc.
(adapted from ATS, 1994)
Performance of FVC maneuver (continued)

• Give instructions and demonstrate:

– Show nose clip and mouthpiece.
– Demonstrate position of head with chin slightly
elevated and neck somewhat extended.
– Inhale as much as possible, put mouthpiece in
mouth (open circuit), exhale as hard and fast as
possible.
– Give simple instructions.
(adapted from ATS, 1994)
Performance of FVC maneuver (continued)
• Patient performs the maneuver
– Patient assumes the position
– Puts nose clip on
– Inhales maximally
– Puts mouthpiece on mouth and closes lips around
mouthpiece (open circuit)
– Exhales as hard and fast and long as possible
– Repeat instructions if necessary –be an effective coach
– Repeat minimum of three times (check for reproducibility.)
(adapted from ATS, 1994)
CONDITIONS THAT COULD MARKEDLY INFLUENCE THE RESULT
OF MEASUREMENT

 strong, unpleasant pulmonary pain or stomach-ache

 strong, unpleasant pain in mouth or face
 stress incontinence
 dementia or mental disorder
 smoking 1 hour and less before the examination
 alcohol consumption 4 hours and less before the examination
 tiring activity (e.g. exhausting training) 30 minutes and less before the
examination
 satiety / consumption of bigger meal 2 hours and less before the examination
 firm, tight clothing, that can influence maximal breath
 tidiness of spirometric sensor - always keep the sensor and measuring mesh
clean and absolutely dry
 inserted silicone seal between spirometric sensor and pneumotachograph -
without its presence it is not possible to measure any curve or calibrate the
sensor!
 Flow-Volume Curves and Spirograms
• Two ways to record results of FVC maneuver:

– Flow-volume curve---flow meter measures flow

rate in L/s upon exhalation; flow plotted as
function of volume

– Classic spirogram---volume as a function of time

Normal Flow-Volume Curve and Spirogram
 Spirometry Interpretation: So what
constitutes normal?
• Normal values vary and depend on:
– Height
– Age
– Gender
– Ethnicity
 MAINTAINING ACCURACY

The most common reason for inconsistent readings is patient technique.

Errors may be detected by observing the patient throughout the
manoeuvre and by examining the resultant trace.
Common problems include:
• inadequate or incomplete inhalation
• lack of blast effort during exhalation
• additional breath taken during manoeuvre
• lips not tight around the mouthpiece
• a slow start to the forced exhalation
• exhalation stops before complete expiration
• some exhalation through the nose
• coughing.
Acceptable and Unacceptable
Spirograms (from ATS, 1994)
Measurements Obtained from the FVC Curve

• FEV1---the volume exhaled during the first second of the FVC

maneuver

• FEF 25-75%---the mean expiratory flow during the middle half

of the FVC maneuver; reflects flow through the small (<2 mm
in diameter) airways

• FEV1/FVC---the ratio of FEV1 to FVC X 100 (expressed as a

percent); an important value because a reduction of this ratio
from expected values is specific for obstructive rather than
restrictive diseases
Normal vs. Obstructive vs. Restrictive

(Hyatt,
2003)
 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
• Obstructive • Restrictive Disorders
Disorders – FVC ↓
– FVC nl or↓ – FEV1 ↓
– FEV1 ↓ – FEF 25-75% nl to ↓
– FEF25-75% ↓ – FEV1/FVC nl to ↑
– FEV1/FVC ↓ – TLC ↓
– TLC nl or ↑
 Spirometry Interpretation: What do the
numbers mean?
• FVC
• Interpretation of %
predicted:
– 80-120% Normal
– 70-79% Mild reduction
– 50%-69% Moderate reduction
– <50% Severe reduction
FEV1
Interpretation of % predicted:
– >75% Normal
– 60%-75% Mild obstruction
– 50-59% Moderate obstruction
– <49% Severe obstruction
• <25 y.o. add 5% and >60 y.o.
subtract 5
 Spirometry Interpretation: What do the
numbers mean?
• FEF 25-75% • FEV1/FVC
• Interpretation of % • Interpretation of
predicted: absolute value:
– >79% Normal – 80 or higher
– 60-79% Mild Normal
obstruction – 79 or lower
– 40-59% Moderate Abnormal
obstruction
– <40% Severe
obstruction
Flow-Volume Loops

(Rudolph and
Rudolph, 2003)
INTERPRETING THE RESULTS OF SPIROMETRY
 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
• Obstructive Disorders
– Characterized by a limitation
of expiratory airflow so that
airways cannot empty as
rapidly compared to normal
(such as through narrowed
airways from bronchospasm,
inflammation, etc.)
Examples:
– Asthma
– Emphysema
– Cystic Fibrosis
• Restrictive Disorders
– Characterized by reduced
lung volumes/decreased lung
compliance
Examples:
– Interstitial Fibrosis
– Scoliosis
– Obesity
– Lung Resection
– Neuromuscular diseases
– Cystic Fibrosis
 How is a flow-volume loop helpful?
• Helpful in evaluation of air flow limitation on inspiration and
expiration

• In addition to obstructive and restrictive patterns, flow-

volume loops can show provide information on upper airway
obstruction:
– Fixed obstruction: constant airflow limitation on inspiration and
expiration—such as in tumor, tracheal stenosis
– Variable extrathoracic obstruction: limitation of inspiratory flow,
flattened inspiratory loop—such as in vocal cord dysfunction
– Variable intrathoracic obstruction: flattening of expiratory limb; as in
malignancy or tracheomalacia
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