Spirometry Workshop
for Primary Care Nurse
Practitioners
Catherine “Casey” S.
Jones
PhD,
RN, AE-C, ANP-C
Certified Adult Nurse Practitioner
Texas Pulmonary & Critical Care
Consultants P.A.
and
Visiting Assistant Clinical Professor at
Texas Woman’s University - Dallas
Disclosures
No financial relationship with any
pharmaceutical manufacturer or medical device
Workshop Schedule
n
1:15 – 2:20 PM – Spirometry introduction
n
2:20 – 2:50 PM - Hands on spirometry & break
n
2:50 – 4:30 PM – Case Presentations
Objectives
n
1. Discuss the indications for performing
spirometry.
n
2. Describe the correct manner for preparing
both the spirometer and the patient for lung
function testing.
n
3. Carry out spirometry procedures on self and
other participants.
n
4. Assess the spirometry tracings with normal,
obstructive & restrictive patterns.
Spirometry
v
Gold standard for diagnosis of asthma &
COPD
v
Measure severity & progression of disease
v
Measure treatment response
v
Aid in diagnosis of restrictive &
obstructive diseases
v
Aid in smoking cessation with calculated
Hazards of Spirometry
v
Bronchospasm
v
Cough
v
Lightheadedness
v
Syncope
Patient Preparation
v
Comfortable, loose clothing
v
Avoid heavy meal within 2 hours
v
Avoid vigorous exercise within 30 minutes
v
Use bathroom prior to testing
v
No short-acting beta agonists for 4 hours
v
Patient sitting
Prepare the Spirometer
v
Calibration of the
spirometer
v
Disposable
Lung Volume Terminology
Tidal vol
Inspiratory
capacity
Inspiratory
reserve
vol
Expiratory
reserve vol
Vital
capacity
Residual vol
Spirometry Reference Values
n
NHANES III values for ages 8 - 80
n
Caucasians
n
African-Americans
n
Mexican-Americans
Predicted Values
n
Large population
studies
n
AGE
Predicted Values
n
GENDER
Predicted Values
n
HEIGHT
in inches
Predicted Values
n
RACE
Ethnic Corrections
n
Reductions:
n
African-Americans – 12 to 15 %
n
South Indians – 13 %
n
Japanese American – 11 %
n
Polynesians – 10 %
n
North Indians & Pakistanis – 10 %
n
Based on large
population
surveys
n
Predicted values
are the mean
values obtained
from the survey
Predicted Normal Lung Volumes
80% Mean 120%
Lung Volume Measurements
v
Forced Vital Capacity (FVC) – maximum
volume of air exhaled from the lungs after a
maximum inspiration.
v
Forced Expiratory Volume in One Second
(FEV
1
) – volume exhaled during the first
FEF 25-75%
n
Forced Expiratory Flow – the flow that occurs
between 25 to 75 % of the FVC
n
Also called MMEF = maximum mid-expiratory
flow
n
Represent airflow in medium or small airways
n
LEAST reliable & controversial
n
Normal = > 55 % predicted
Normal Lung Volume Values
v
FEV
1
/FVC: Ratio > 70 %
(> 80 % for children)
v
FVC: > 80 % predicted
v
FEV
1
: > 80 % predicted
Disease Patterns
Normal
Obstructed
Restricted
Combined
FEV
1
/
FVC
> 70 %
Down
Normal
Down
FVC
> 80 %
Pred
Normal
Down
Down
FEV
1
> 80 %
Pred
Obstructive Changes
v
Asthma
v
Chronic Obstructive Pulmonary Disease
v
Bronchiectasis
v
Cystic fibrosis
Restrictive Changes
n
Pulmonary
•
Idiopathic pulmonary fibrosis
•
Any interstitial lung disease (over 200
types currently listed)
•
Pneumonectomy/lobectomy
•
Pulmonary edema
•
Rheumatoid arthritis
•
Sarcoidosis *
•
Scleroderma
Restrictive Changes
n
Extra-pulmonary
•
Thoracic chest wall deformity
§
Pectus excavatum
§
Kyphoscoliosis
•
Congestive heart failure
•
Neuromuscular problems
•
Obesity
•
Pregnancy
•
Poor effort
Spirometry Tracings
v
Two basic types of display:
1)
Flow/volume loop
2)
Volume/time curve
• Expiration is the
area that can be
found above the
“waterline”
• This is the most
important part of
the flow volume
loop in lung
diseases
Flow/Volume Loop
Volume/Time Curve
Liters
*
FEV
1
Seconds
1
FVC
2
3
4
5
6
1
3
4
2
FVC
Volume-Time
Curve
Normal versus Obstructive & Restrictive
patterns:
flow-volume loop
Reversibility
n
Reversibility can be assessed with albuterol
and/ or ipratropium (Atrovent) via MDI
or nebulizer
n
Reversibility is defined by a change of at
least 12 % post bronchodilator AND an
increase of 200 mL
Examples of Poor Quality
Poor effort/Slow start
Extra breath
Cough
Slow start
Seven Step Spirometry Interpretation
n
Steps 1 and 2 – Quality Assurance
1. Is the test at least 6 seconds long?
2. Is the flow volume loop the correct shape?
n
Steps 3-5 – establish the numbers
3. Is the FEV
1
/FVC ratio more or less than 70%
4. Is the FVC more or less than 80% predicted
5. Is the FEV
1
more or less than 80% predicted
n
Step 6 – identify the pattern
Quality Assurance
n
Acceptability criteria (apply first)
n
Min. 3 acceptable tests, max. 8 attempts
n
Good start/rapid rise/no hesitation/no
false start
n
No cough, especially in 1
st
second
n
No early termination: 6 secs or obvious
plateau
Quality Assurance
n
Reproducibility
v
Best two FVC’s within 150 ml of each
other
v
Best two FEV
1
’s within 150 ml of
each other
n
Stop if repeated efforts trigger
bronchospasm
Performance of Spirometry
n
Instruct and demonstrate test to patient
v
nose clips
v
Inhale completely
v
Position mouthpiece
v
Exhale with maximal force
n
Position patient
Classification of Severity-COPD
A defining characteristic of COPD at all levels of severity is
an FEV
1
/FVC ratio of less than 70%.
Stage
GOLD (2014)
I – Mild COPD
With or without chronic symptoms
FEV
1> 80% predicted
II – Moderate COPD
With or without chronic symptoms
FEV
150 – 80% predicted
III – Severe COPD
With or without chronic symptoms
FEV
130 – 50% predicted
IV – Very severe COPD
FEV
1< 30% predicted
Components of Severity
Classification of Asthma Severity (≥12 years of age) Intermittent
Persistent Mild Moderate Severe Impairment Normal FEV1/FVC: 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70%
Symptoms ≤ 2 days/week >2 days/week but not
daily Daily Throughout the day
Nighttime awakenings ≤ 2x/month 3-4x/month >1x/week but not nightly Often 7x/week Short-acting beta2
-agonist use for symptom control (not
prevention of EIB)
≤ 2 days/week >2 days/week but not daily, and not more than 1x on any day
Daily Several times per day
Interference with
normal activity None Minor limitation Some limitation Extremely limited
Lung function
• Normal FEV1 between exacerbations • FEV1 > 80% predicted • FEV1/FVC normal • FEV1 >80% predicted • FEV1/FVC normal • FEV1 >60% but <80% predicted • FEV1/FVC reduced 5% • FEV1< 60% predicted • FEV1/FVC reduced >5% Risk Exacerbations
requiring oral systemic corticosteroids
0-1/year (see note) ≥ 2/year(see note)
Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Recommended Step for Initiating Treatment
Step 1 Step 2 Step 3 Step 4 or 5
and consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT
IN YOUTHS ≥ 12 YEARS OF AGE AND ADULTS
Assessing severity and initiating treatment for patients who are not currently taking long-term control medications
Key: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit
Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g. requiring urgent, unscheduled
care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥ 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTH ≥ 12 YEARS OF AGE AND
ADULTS
Components of Control
Classification of Asthma Control ( ≥ 12 years of age) Well Controlled Not Well
Controlled Very Poorly Controlled
Impairment
Symptoms ≤ 2 days/week >2 days/week Throughout the day
Nighttime awakenings ≤ 2x/month 1-3x/week ≥ 4x/week
Interference with normal activity None Some limitation Extremely limited Short-acting beta2-agonist use for
symptom control (not prevention of EIB)
≤ 2 days/week >2 days/week Several times per day
FEV1 or peak flow >80% predicted/
personal best
60-80% predicted/ personal best
<60% predicted/ personal best Validated Questionnaires ATAQ ACQ ACT 0 ≤ 0.75* ≥ 20 1-2 ≥ 1.5 16-19 3-4 N/A ≤ 15 Risk
Exacerbations requiring oral
systemic corticosteroids 0-1/year ≥ 2/year (see note) Progressive loss of lung function Evaluation requires long-term follow-up care. Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and
worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatment
• Maintain current step. • Regular follow ups every 1-6 months to maintain control. • Consider step down if well controlled for at least 3 months.
• Step up 1 step and • Reevaluate in 2-6 weeks. • For side effects, consider alternative treatment options.
• Consider short course of oral systemic corticosteroids, • Step up 1-2 steps, and • Reevaluate in 2 weeks. • For side effects, consider alternative treatment options.
*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit.
