NOSE CLIP IN SPIROMETRY TO USE OR NOT TO USE?

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www.wjpr.net Vol 4, Issue 06, 2015.

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NOSE CLIP IN SPIROMETRY-TO USE OR NOT TO USE?

Senthil Kumar K1, Viswanatha Rao B2 and Prema Sembulingam*3 1

Assistant Professor, Department of Physiology, Madha Medical College & Research

Institute, Kundrathur Main Road, Thandalam, Kovur, Chennai - 600 122. Tamil Nadu, India

2

Professor and Head of the Department of Physiology, Madha Medical College & Research

Institute, Kundrathur Main Road, Thandalam, Kovur, Chennai - 600 122. Tamil Nadu, India

3

Professor of Physiology and Head of R & D, Madha Medical College & Research Institute,

Kundrathur Main Road, Thandalam, Kovur, Chennai - 600 122. Tamil Nadu, India

ABSTRACT

Spirometry is an easy, reliable and reproducible test in diagnosis and

prognosis of respiratory diseases. While recording spirogram in

spirometer, nose clip is applied invariably to close the nose. But

whether it is necessary to apply the nose clip or not is debatable.

Literature says that it can be used but not necessary. Some

experimental evidences show that using nose clip has no significant

impact on the recorded values of spirogram. These non-committal

controversies intrigued us to venture into the present study. 54 normal

young and healthy subjects of both genders were recruited from Madha

Medical College & Research Institute, Chennai. After training them to

perform the maneuver, spirogrm was recorded first with nose clip on

and then nose clip off in the same individual with sufficient time

interval between the two procedures. Forced vital capacity (FVC),

forced expiratory volume in first second (FEV1) and peak expiratory

flow rate (PEFR) were selected for analysis. The results showed that

there was no significant difference in the values of the variables between the two methods of

recording making us to conclude that wearing nose clip is not necessary while recording,

spirogram.

KEY WORDS: Nose clip, Pulmonary function test, Spirogram, Spirometer, Spirometry.

Volume 4, Issue 6, 1306-1312. Research Article ISSN 2277– 7105

Article Received on 29 March 2015,

Revised on 20 April 2015, Accepted on 11 May 2015

*Correspondence for

Author

Dr. Prema Sembulingam

Professor of Physiology

and Head of R & D,

Madha Medical College &

Research Institute,

Kundrathur Main Road,

Thandalam, Kovur,

Chennai - 600 122. Tamil

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1307 1. INTRODUCTION

Spirogram is the recording of lung volumes in spirometer and is universally accepted as a

good diagnostic tool for identifying lung dysfunction and the whole process is named as

spirometry.[1, 2, 3] It is also used as a prognostic tool in evaluating efficacy of a medication and

the progression of the lung disease.[4] The credit of this recording goes to the fact that it is a

reliable, reproducible and simple bed-side procedure without incurring much expenditure.

The vital lung parameters like forced vital capacity (FVC), functional residual capacity

(FRC), maximum voluntary ventilation (MVV), peak expiatory flow rate (PEFR) etc., can be

recorded in spirometer.[5, 6, 7, 8] It also helps in differentiating obstructive or restrictive pattern

of lung diseases.[4]

Usually, recording of spirogram is done in sitting position and the subject is asked to breath

through the mouth piece which is kept in the mouth of the subject and sealed tightly by the

lips around it.[9] The mouth piece is continued with the instrument through a rubber tube. Up

to this, there is no second opinion or controversy regarding the setting-up of recording.

Now, coming to the point of closing the nose manually or with a nose clip while recording

spirogram, lot of controversy exist in the literature. According to some, nose clip was not

necessary but recommended.[10] Some others stated that nose clip should be used to avoid the

technical error of breathing through the nose while recording.[11] There were some

non-committal statements like “soft nose clips may be used to prevent air escaping through the

nose[12] and „although not strictly necessary, it is recommended to put a nose clip on the

patient's nose during the test”.[13]

Verelli et al found in their cross-over design study that use

of nose clip did not affect the values of spirogram significantly.[14] Chavasse et al were of the

opinion that wearing nose clip did not have any clear advantage while recording spirogram

and they recommended the use of nose clip only for research protocol and not for routine

clinical usage.[15] Miller et al recommended the nose clip while recording lung volumes and

the reason given was to prevent the subjects breathing through the nose.[5] These

controversial and non-committal statements intrigued the authors to venture into the present

study.

2. MATERIALS AND METHODS

The study was an experimental study with cross-over design where each subject served as

his/her own reference. The Institutional Ethical Committee approved the study and the

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role in the study. The subjects were 54 healthy young adults of both the genders (41 males

and 13 females) in the age group 18-25years belonging to the Madha Medical College and

Research Institute, Chennai. The subjects with pulmonary diseases, cardiovascular problems,

neurological disorders, endocrine disorders or any other clinical condition were excluded

from the study. Even the smokers, alcoholics, athletes and regular exercising persons were

also excluded from the study.

2.1. Procedure

The subjects were instructed to report in the Research laboratory of Physiology Department

between 9-11 AM. They were advised not to have any caffeinated drinks for 24 hours prior

to the procedure. They were seated in a well ventilated and aerated room on a stool with an

erect back. Stools were preferred to avoid the back-leaning. A computerized spirometer

(Medikro windows) was used for the recording. Before commencing the procedure, basic

demographic data with age, height, weight, family history, personal history and medical

history were collected. BMI was calculated from the height and weight. Brief explanation

was given about the spirometer and the method of blowing into the instrument was

demonstrated. Then, the subject was connected to the instrument through the mouth piece and

each one was made to practice the maneuver till they got it rightly.

2.2. With nose clip

The nose clip was applied and the subject was asked to breathe normally through the mouth

piece for few seconds. Then, they were instructed to take deep inspiration through the mouth

piece and at the end of inspiration, they were prompted to blow into the mouth piece as

forcefully and as fast as they could.[14] The procedure was repeated three times with adequate

time intervals of about 5 min to recover from the previous effort of forceful breathing and

best of three readings was taken for analysis.

2.3. Without nose clip

The nose clip was removed and the subject was rested for 20 minutes. Then the procedure

was repeated and the spirogram was recorded. The variables chosen for this study were FVC,

forced expiratory volume in first second (FEV1) and PEFR.

The data were analyzed in SPSS 21 version by using Student t test. Significance was fixed at

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1309 3. RESULTS

3.1. Table 1 shows the demographic particulars of the subjects. All of them were within the

normal range of BMI as per WHO criteria (18.50 - 24.99).[16]

Table 1. Demographic variables of the participants

Variable Values (mean ± SD)

Age (Years) 20.02 ± 3.34

Height (cm) 166.78 ± 9.34

Weight (kg) 55.78 ± 11.60

BMI 19.92 ± 3.44

3.2. Table 2 show the volumes of the FVC, FEV1 and PEFR recorded with and without the

nose clip in the same subject. There was no significant change in the recorded values between

the two proceedings.

Table 2. Values of some spirogram variables recorded with and without nose clip

Variable Procedure Volume (L)

mean ± SEM

Significance p <

FVC With nose clip 3.43 ± 0.11 0.127

Without nose clip 3.53 ± 0.11

FEV1 With nose clip 3.04 ± 0.10 0.211

PEFR With nose clip 6.06 ± 0.23 0.100

3.3. Table 3 depicts the impact of not wearing the nose clip while recording the spirogram.

59.26% (32/54) of the subjects showed slight increase in FVC and FEV1 though the increase

was non-significant. However, the number of subjects with increased PEFR was less (23/54,

42.59%) compared to the number of subjects with decreased PEFR (31/54, 57.41%).

DISCUSSION

Recording of lung volumes by spirometer is in practice in all graded hospitals and among

private practitioners. The method of recording is also almost the same - mostly in sitting or

occasionally in standing posture. But the irk is „to use or not to use‟ nose clip while

recording. From the personal subjective feelings of the participants in this study (not in

record), they expressed their feeling of comfort without the nose clip. This type of discomfort

with nose clip on had been already reported. Blowing through the mouth piece itself is

strenuous performance; application of nose-clip may add more burden on the performance,

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nose clip the values were slightly more than with the nose clip. Non-significance may be

attributed to the less number of subjects.

Table 3. Impact of not wearing the nose clip on some spirogram values Variable Mean difference

± SEM

Increase Decrease

No % No %

FVC -0.10 ± 0.07 32 59.26 22 40.74

FEV1 -0.05 ± 0.04 31 57.41 23 42.59

PEFR 0.23 ± 0.14 23 42.59 31 57.41

However, just because the subject is feeling discomfort by wearing nose clip, we cannot

withdraw the nose clip as the values of spirogram are important for diagnosis and prognosis

of the respiratory diseases than the personal feeling of the subject. And, we could not get a

reliable answer for this query from the literature because of the controversies. So we made a

preliminary attempt to see the validity of using the nose clip in spirometry. In our study, we

found that using or not using nose clip did not have any significant impact on the selected

spirogram values. Admittedly, 54 participants is less to authenticate the fact. But it is a

preliminary attempt and we want to put it in record. We are in process of expanding it with

more number of participants and we want to expand it with various group of subjects - both

normal ones and patients.

Our results coincide with some of the earlier reports like “a nose clip is not mandatory for

forced expiratory maneuvers because the variation among the values of spirogram with and

without nose-clip were minimal and statistically not significant [17], “nose-clip did not have

any impact on spirogram values”[18], and “with or without nose clip did not affect the recorded

lung volumes.[14]

CONCLUSION

As per our evaluation, wearing nose clip while recording spirogram need not be mandatory

because it does not alter the values significantly. Some of the weak points in our study are i.

being a cross-over design study, the number of the participants is less to authenticate the fact;

ii. we do not know whether the recorded spirogram values are consistent if repeated over time

with or without nose clip. iii. We did not assess whether these results are first

time-performance effect or experience-time-performance effect. Thus, there are “miles to go” before

coming to a definite conclusion.

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