Spirometry for Primary Care Physician Office

Spirometry for the Primary Care Physicians Office

Randy ClareRespiratory Diagnostics

2016

Spirometry

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• Spirometry (spy-ROM-uh-tree) is a common office test used to assess how well your lungs work by measuring how much air you inhale, how much you exhale and how quickly you exhale. Spirometry is used to diagnose asthma, chronic obstructive pulmonary disease (COPD) and other conditions that affect breathing.

http://www.mayoclinic.org/tests-procedures/spirometry/basics/definition/prc-20012673


Asthma


• Asthma (AZ-ma) is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning.

• Asthma affects people of all ages, but it most often starts during childhood. In the United States, more than 25 million people are known to have asthma. About 7 million of these people are children – NIH/NHLBI

http://www.nhlbi.nih.gov/health/health-topics/topics/copd

http://www.nhlbi.nih.gov/health/health-topics/topics/cough



COPD

• COPD, or chronic obstructive pulmonary (PULL-mun-ary) disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

• COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

• Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants—such as air pollution, chemical fumes, or dust—also may contribute to COPD. – NIH/NHLBIhttp://www.nhlbi.nih.gov/health/health-topics/topics/copd

http://www.nhlbi.nih.gov/health/health-topics/topics/cough/



Spirometry for Diagnosis of COPDSpirometry measurements used for diagnosis of COPD include: • FVC (forced vital capacity): maximum volume of air that can be exhaled during a forced maneuver. • FEV1 (forced expired volume in one second): volume expired in the first second of maximal expiration after a maximal inspiration. This is a measure of how quickly the lungs can be emptied. • FEV1/FVC: FEV1 expressed as a percentage of the FVC, gives a clinically useful index of airflow limitation. The ratio FEV1/FVC is between 70% and 80% in normal adults; a value less than 70% indicates airflow limitation and the possibility of COPD. FEV1 is influenced by the age, sex, height, and ethnicity, and is best considered as a percentage of the predicted normal value.


4 Stages of COPD and Spirometric Classifications

• Stage I: Mild COPD • Mild airflow limitation (FEV1/FVC < 70%; FEV1 > 80% predicted) and sometimes, but not always, chronic cough and sputum production. At this stage, the individual may not be aware that his or her lung function is abnormal.


• Stage II: Moderate COPD

• Worsening airflow limitation (FEV1/FVC < 70%; 50% < FEV1 < 80% predicted), with shortness of breath typically developing during exertion. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease.



• Stage III: Severe COPD • Further worsening of airflow limitation (FEV1/FVC < 70%; 30% < FEV1 < 50% predicted), greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients’ quality of life.



• Stage IV: Very Severe COPD

• Severe airflow limitation (FEV1/FVC < 70%; FEV1 < 30% predicted) or FEV1 < 50% predicted plus chronic respiratory failure. Patients may have Very Severe (Stage IV) COPD even if the FEV1 is > 30% predicted, whenever this complication is present. At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening.



How to perform a Spirometry Test

Pregame

• Calibration Of Spirometry equipment• Collect biometric information• Ready a supply of filters• Describe the test to the patient• Demonstrate the Spirometry maneuver


Daily Calibration of Spirometer

• The importance of properly calibrated spirometers has been repeatedly Stressed by the American Thoracic Society (ATS)

• Calibration checks of the flow sensor are needed to verify spirometer accuracy each day it is in use. A 3.0 L calibration syringe should be used for this verification


Calibration Step By Step• Select a calibration check@ from the menu of the spirometer (so that

the software does not apply a BTPS correction factor to the results). • First fill the syringe with air completely, then attach it firmly to the flow

sensor, and empty it smoothly and completely. • End the maneuver carefully until a soft click is heard, meaning that the

syringe was emptied completely. • Do not bang the syringe while emptying it, to avoid damage• Refill with air, and then empty the syringe three times, each time at a

different speed: First, empty it in less than one second (fast), next in 2 or 3 seconds (medium), and the third time take about six seconds (slow).

• Count a-one-one-thousand, two-one-thousand@ etc, while emptying the syringe, to gauge the speed of emptying.

• The resulting FVC for all 3 of these maneuvers should be between 2.91 and 3.09 liters. Record all three results on the daily worksheet or quality log.

http://www.cdc.gov/niosh/docs/2004-154c/pdfs/2004-154c-ch3.pdf

Centers for Disease Control. (n.d.). NIOSH Spirometry Training Guide. Retrieved from http://www.cdc.gov/niosh/docs/2004-154c/pdfs/2004-154c-ch3.pdf



Care and Feeding of a Cal Syringe• Store the calibration syringe near the spirometer so that

the two devices remain at the same temperature. • Store the syringe with the plunger pushed all the way in. • Take care not to drop the syringe. • Don’t loosen the metal rings on the shafts, since this will

disrupt the factory calibration. Periodically check the syringe for leaks by filling with air, holding your palm against the outlet snout, and trying to empty the syringe. If any air is expelled with the outlet plugged, the syringe has a leak and must be repaired.

• A dropped or damaged syringe should be considered out of calibration until it is checked by the factory


Biometric Calculations

• Measure Height Accurately. Predicted FVC and FEV1 values are greatly influenced by height.

• Standing height should be measured to the nearest half inch (or centimeter) in stocking feet prior to administering the first spirometry test.

• If the patient has obvious spinal deformities, measure the arm span from fingertip to fingertip with arms outstretched against a wall.

• Arm span should then be entered into the spirometer in place of standing height.


Avoid Cross-Contamination

• There have been no documented cases of a patient contracting a respiratory infection from a spirometer contaminated by a previously tested patient.

• minimize the risk of cross-contamination, always replace the single use disposable mouthpiece between patients.

• Routine hand-washing, proper cleaning of permanent flow sensors, and instructing patients not to inhale from the spirometer are equally important precautions.


Explain the Procedure

• Explain to the patient that the purpose of spirometry is to determine how hard and fast air can be exhaled.

• It should be “like blowing out candles on a birthday cake.”

• The patient should inhale as deeply as possible

• When the lungs are completely full, quickly seal the lips around the mouthpiece and exhale as hard and fast as possible.

• Testing should be done in the sitting position. If the patient sniffs air through the nose at the end of the test, use nose clips.

• Even better, just use nose clips


Demonstrate the Maneuver

• Demonstrate the FVC spirometry maneuver with a separate mouthpiece or flow sensor.

• To emphasize that you are taking a very deep breath, throw back your shoulders, widen your eyes, and stand on your toes.

• Next, stick out your tongue, place the mouthpiece on top of your tongue, and seal your lips around it.

• Finally, dramatically BLAST out as hard and as fast as possible for at least 6 seconds.

• Your vigorous demonstration will prevent time and effort from being wasted on unacceptable maneuvers.

Conduct a Spirometry Test


Coach The Patient

• Ensure that the spirometer is ready to record the FVC maneuver.

• Coach the patient to take as deep a breath as possible. Watch to ensure that the patient inhales deeply.

• Encourage the patient to keep the chin up.

• Once he or she has sealed the lips around the mouthpiece, shout loudly, “BLAST out the air!”

• Tell the patient more quietly to, “Keep going, keep going, blow out a little more air.”

• Some spirometers will help you by indicating with a graph or tone that the patient is continuing to exhale air toward the end of the maneuver.


Recognize Poorly Performed Breathing Maneuvers• . As soon as a poorly performed

maneuver is detected (poor inhalation or weak exhalation), tell the patient to stop.

• Instruct the patient how to perform the test better. Demonstrate the correct maneuver again.

• Prepare the spirometer to record another maneuver. Tell the patient to repeat the maneuver.

• The goal is to obtain three acceptable FVC maneuvers with the best two matching closely.

• If the goal is not reached after eight attempts, end the test session and suggest that spirometry be rescheduled for another day.

Primary Care Physician SpirometerDevices


Vyntus SPIRO

• Use your Vyntus SPIRO for all of the essential spirometry testing:

• Flow/Volume-loop (FVC)• Slow Vital Capacity (SVC)• Maximum Voluntary

Ventilation (MVV)• Pre and Post medication

testing or therapy control• Bronchial Challenge

testing program

MicroLab spirometer

• MicroLab spirometer is highly portable, allowing it to be used in physicians' offices or for bedside testing.

• Free downloadable bronchial provocation PC software available with full ATS/ERS protocols for challenge testing, using the MicroLab spirometer.

• Full flow volume and volume time curves for on-screen inspection of maneuvers and internationally recognized, on-screen test quality prompts.

• Built-in high resolution printer with option to direct print to external printers using USB connection.



MicroLoop Spirometer

• Free downloadable bronchial provocation PC software available with full ATS/ERS protocols for challenge testing, using the MicroLoop spirometer.

• Fully configurable, allowing up to 41 indices to be selected including, a choice of predicted values and languages.

• Full flow volume and volume time curves for on-screen inspection of maneuvers and internationally recognized, on-screen test quality prompts.


Micro 1

• Measures FEV1, FVC, FEV6, PEF, FEV1/FVC, FEV1/FEV6, F25-75.

• Choice of 4 indices can be displayed.• ATS/ERS 2005 Quality prompts for

each maneuver.• NLHEP configuration mode.• Current maneuver and Best

maneuvers available for viewing.• Quick examination option for quick

patient testing.• Predicted values displayed as either

% predicted or z score.• Post bronchodilator option with %

change displayed.• Remembers the last patient tested

to allow testing to continue.• Calibration check to verify device.


References

• For more information◦ www.mdspiro.comReferencesAmerican Thoracic Society. (1993). Guidelines for the evaluation of impairment/disability in patients with asthma. Am Rev Respir Dis. 147:1056-1061.American Thoracic Society. (1991). Lung function testing: selection of reference values and interpretive strategies. Am Rev Respir Dis. 144:1202-1218. American Thoracic Society. (1995). Standardization of spirometry: 1994 update. Am J Respir Crit Care Med. 152:1107-1136.Centers for Disease Control. (n.d.). NIOSH Spirometry Training Guide. Retrieved from http://www.cdc.gov/niosh/docs/2004-154c/pdfs/2004-154c-ch3.pdfOaklahoma Department of Human Services. (n.d.) Stages of COPD and Spirometric Classifications. Retrieved from http://advantage.ok.gov/CHCC/Publications/Spirometric%20Classifications%20of%20COPD.pdf

http://www.mdspiro.com/




http://advantage.ok.gov/CHCC/Publications/Spirometric%20Classifications%20of%20COPD.pdf




ReferencesReferencesNational Heart, Lung and Blood Institute. (2013). What is COPD? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/copd

Mayo Clinic. (2014). Tests and Procedures-Spirometry- Definition. Retrieved From http://www.mayoclinic.org/tests-procedures/spirometry/basics/definition/prc-20012673






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Spirometry for Primary Care Physician Office

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