Spirometry in Primary Care Dr Max Matonhodze FRCP (London) M A Med Ed (Keele)
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Transcript of Spirometry in Primary Care Dr Max Matonhodze FRCP (London) M A Med Ed (Keele)
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Spirometry in Primary Care
Dr Max Matonhodze FRCP (London) M A Med Ed (Keele)
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Objectives
• Need for performing spirometry• Types of spirometers• Spirometric indices• Obstructive spirometry and severity scale• Practical tips• Quality control• Illustrative examples
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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.
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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
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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
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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.
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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
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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
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Volume Measuring Spirometer
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Flow Measuring Spirometer
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Desktop Electronic Spirometers
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Small Hand-held Spirometers
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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
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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
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Lung Volume Terminology
Totallung
capacity
Inspiratory reservevolume
Tidal volume
Expiratory reservevolume
Residual volume
Inspiratory capacity
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Spirogram Patterns
• Normal
• Obstructive
• Restrictive
• Mixed Obstructive and Restrictive
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Spirometry
Predicted Normal Values
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Predicted Normal Values
Affected by:
Age
Height
Sex
Ethnic Origin
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Criteria for Normal Post-bronchodilator Spirometry
• FEV1: % predicted > 80%
• FVC: % predicted > 80%
• FEV1/FVC: > 0.7 - 0.8, depending on age
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Normal Trace Showing FEV1 and FVC
5
4
3
2
1
Volu
me,
liters
1 2 3 4 5 6
Time, sec
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
FVC
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SPIROMETRY
OBSTRUCTIVE DISEASE
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Spirometry: Obstructive Disease
5
4
3
2
1
1 2 3 4 5 6
Time, seconds
Volu
me,
liters
Normal
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Obstructive
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Diseases Associated With Airflow Obstruction
• COPD• Asthma• Bronchiectasis• Cystic Fibrosis• Post-tuberculosis• Lung cancer (greater risk in COPD)• Obliterative Bronchiolitis
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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
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SPIROMETRY
RESTRICTIVE DISEASE
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Criteria: Restrictive Disease
• FEV1: normal or mildly reduced
• FVC: < 80% predicted
• FEV1/FVC: > 0.7
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Spirometry: Restrictive DiseaseVolu
me,
liters
Time, seconds
1 2 3 4 5 6
5
4
3
2
1
Restrictive
Normal
FEV1 = 1.9L
FVC = 2.0L
FEV1/FVC = 0.95
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Diseases Associated with a Restrictive Defect
Pulmonary• Fibrosing lung diseases• Pneumoconioses• Pulmonary edema• Parenchymal lung tumors• Lobectomy or
pneumonectomy
Extrapulmonary• Thoracic cage deformity• Obesity• Pregnancy• Neuromuscular disorders• Fibrothorax
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Mixed Obstructive/Restrictive
• FEV1: < 80% predicted
• FVC: < 80% predicted
• FEV1 /FVC: < 0.7
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SPIROMETRY
Flow Volume
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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
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Flow Volume Curve
Expiratory flow rateL/sec
FVC
Maximum expiratory flow (PEF)
Inspiratory flow rate
L/sec
RVTLC
Volume (L)
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Flow Volume Curve Patterns Obstructive and Restrictive
Obstructive Severe obstructive Restrictive
Volume (L)
E
xpir
ato
ry fl
ow
rate
Expir
ato
ry fl
ow
rate
Expir
ato
ry fl
ow
rate
Volume (L) Volume (L)
Steeple pattern, reduced peak flow, rapid fall
off
Normal shape, normal peak flow, reduced
volume
Reduced peak flow, scooped out mid-
curve
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Spirometry: Abnormal Patterns
Obstructive Restrictive Mixed
Time Time Time
V
olu
me
Volu
me
Volu
me
Slow rise, reduced volume expired;
prolonged time to full expiration
Fast rise to plateau at reduced
maximum volume
Slow rise to reduced maximum volume; measure
static lung volumes and full PFT’s to
confirm
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PRACTICAL SESSION
Performing Spirometry
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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
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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 minutesbefore performing spirometry
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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
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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
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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
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Reproducibility - Quality of Results
Volu
me,
lite
rs
Time, seconds
Three times FVC within 5% or 0.15 litre (150 ml)
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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
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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
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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
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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
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Troubleshooting
Examples - Unacceptable Traces
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Unacceptable Trace - Poor Effort
Volu
me,
lite
rs
Time, seconds
May be accompanied by a slow start
Inadequate sustaining of effort
Variable expiratory effort
Normal
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Unacceptable Trace – Stop Early
Volu
me,
lite
rs
Time, seconds
Normal
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Unacceptable Trace – Slow Start
Volu
me,
lite
rs
Time, seconds
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Unacceptable Trace - Coughing
Volu
me,
lite
rs
Time, seconds
Normal
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Unacceptable Trace – Extra Breath
Volu
me,
lite
rs
Time, seconds
Normal
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Spirometry
• Mrs PZ 47 yrs• FEV-1 = 0.8L (35% of pred)• FVC = 2.4L (85% of pred)• FEV-1/FVC Ratio = 30%
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Spirometry
• Answer:
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Spirometry
• Mr PY 83• FEV-1 =0.6L (28%pred)• FVC = 1.9 L (81% pred)• FEV-1/FVC ratio =31.5%
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Spirometry
• Answer:
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Spirometry
• Mr BY 63• FEV-1 = 1.6 L (63% pred• FVC = 2.1 L (67% pred)• FEV-1/FVC ratio = 76%
• Mr BY 63• FEV-1 = 1.6 L (63% pred• FVC = 2.1 L (67% pred)• FEV-1/FVC ratio = 76%
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Spirometry
• Answer-
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Spirometry
• Mrs TZ 56• FEV-1 =1.1L (41% pred)• FVC = 2.3 L (63%pred)• FEV-1/FVC ratio =48%
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Spirometry
• Answer?
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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;29:319-338www.thoracic.org/sections/publications/statements
• National Asthma Council: Spirometry Handbookwww.nationalasthma.org.au