1. Spirometry Study Day 23rd September 2010 Robert Daw
Clinical Lead Nurse for COPD
BACHS

2. Anatomy and Physiology of COPD

4. COPD Definition
‘….airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.’ NICE 2004

5. Asthma Definition
‘….in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.’ BTS and SIGN 2003

6. Spirometry
Spirometry is a method of assessing lung function by measuring the volume of air the patient is able to expel out from the lungs after maximal inspiration

7. Spirometry is a reliable method of identifying
Obstructive illness i.e. chronic obstructive pulmonary disease
Reversible disease I.e. Asthma
Restrictive disease i.e. Pulmonary fibrosis
It can be used to grade the severity of COPD

8. Diagnosing COPD
At the time of their initial diagnostic evaluation in addition to spirometry all patients should have:
CXR
FBC
BMI

9. Additional Investigations
CT Scan
ECG
Echo
Pulse Oximetry
Sputum Culture
Transfer factor for carbon monoxide (TLCO)
Serial Domiciliary Peak Flows
Alpha-1-antitrypsin

10. Lung Volumes

11. Spirometry gives us 3 important measurements
FEV1 The volume of air that the patient is able to breathe out in the first second of forced expiration
FVC The total volume of air that the patient can exhale forcibly in one breathe
FEV1 / FVC The ratio is expressed as a percentage
ALSO
Peak Flow The volume of air that the patient is able to breathe out in the first 1000th of a second of forced expiration

12. Indices Measured

13. Spirometry - Maintenance of equipment

14. Spirometry Surveys Cooper B, 2005
Performing spirometry with no training were of poor standard when compared to labs
Machines not being compared cared for or calibrated
Minimum standards of acceptance
Poor Interpretation

15. Calibration or Verification?
This is to check that the spirometer is reading correctly using a known standard.
Calibration
Calibration is the process in which the signal from a spirometer is adjusted to produce a known output.

16. Why is calibration / verification important
If equipment is not properly calibrated it can lead to false results – i.e. the patient may appear better or worse than they really are.

17. How often should I calibrate?
This depends on the equipment. Most pneumotach based equipment needs calibrating every day. Some equipment can only be calibrated by a trained engineer. In this case it is necessary to perform regular quality control / verification.

18. Verification
Syringe
This can be performed using a 3 litre syringe or 1 litre syringe depending on spirometer model.
Results should be within 3% of calibration syringe
Biological Control
The person performing the quality control should have normal lung function.
Results should not vary by more than 10% from the last time.
Equipment should be calibrated if this is not the case.

19. Infection control
Spirometers are a potential source of cross infection for patients.
As a minimum one way cardboard mouthpieces should be used.
Ideally (especially in high TB areas) bacterial filters are the mouthpiece of choice.

20. Cleaning
Ease of cleaning the equipment should be considered when purchasing
Always use manufacturer guidelines.
FLOW HEADS SHOULD BE CLEANED USING MANUFACTUROURS GUIDELINES AFTER EVERY SESSION IF NOT USING BACTERIAL FILTERS

21. Any Questions?

22. Spirometry – Pre Test Procedures

23. Pre-test procedures The patient, ideally, should –
- Avoid alcohol for at least 4 hours
- Avoid eating a substantial meal
- Wear loose fitting clothing
If Reversibility is to be performed -
- Avoid taking short acting bronchodilators for at least 4 hours prior to testing
- Avoid smoking for 1 hour prior to testing
-Be Well!!

24. Contraindications Haemoptysis of unknown origin
Pneumothorax (Need confirmation of resolution)
Unstable cardiovascular status
Myocardial Infarction (Last 3 months)
Thoracic, abdominal or cerebral aneurysms

25. Contraindications Recent Eye surgery (3 months)
Recent thoracic or abdominal surgery (3 months)
Pregnancy (1st Trimester contraindicated but in 2nd and 3rd Trimester results may be effected by uterus size)

26. Spirometry Technique

27. Reinforce and Reassure
Prior to Spirometry
Gain verbal consent
Check for contraindications and that the patient has been properly prepared for the test
Gain an accurate height
Make note of Ethnic Origin and Age
The room should be a comfortable temperature
The patient should be sat in a hard backed chair with their feet able to touch the floor
The patient should sit upright with their legs uncrossed
A drink of water should be made available
The technique and purpose of spirometry should be explained in full prior to the test
Spirometry should be performed in the patients own time and they should not feel hurried
Reinforce and Reassure

28. Expiratory Relaxed Vital Capacity
Performed due to collapsing alveoli in some patients during Forced Vital Capacity technique
This technique would usually be performed before the Forced Vital Capacity readings
The reading is sometimes referred to as VC, EVC or RVC
Minimum of three readings taken
Two best results should be within 150mls of each other
Maximum of 4 tests

29. Expiratory Relaxed Vital Capacity
Take as large a breath of air in as possible
Pinch your nose or attach a nose clip to prevent air leakage
Put the filter into your mouth ensuring that there are no leaks at the sides of your mouth
Breathe out for as long as possible. This breath should be in your own time and should not be forced

30. Forced Vital Capacity (FVC)
A minimum of three readings should be taken
There should be less than 5% or 150mls variance between the best two results
The technique should be repeated until this is achieved or the patient is exhausted and can no longer perform the technique
Time should be given to the patient to recover between readings

31. Forced Vital Capacity (FVC)
Take as large a breath of air in as possible
Put the filter into your mouth ensuring there are no leaks at the side of your mouth
Pinch your nose or attach a nose clip to prevent air leakage
‘Blast’ as quickly as possible and for as long as possible

32. Could we have a volunteer please ?
Demonstration
Could we have a volunteer please ?

33. Technique Problems

34. The Normal Curve Volume Time
The vertical scale indicates total volume (l) the patient has blown out
The horizontal scale indicates the total time (s) the patient has been blowing out for
Note the initial part of the curve which is steep followed by a gradual flattening of the curve

35. The Normal Curve Flow Volume Loop
The vertical scale indicates litres of air breathed out per second (L/s) at that moment in time
The horizontal scale indicates total volume expired (L)
Note the sharp peak at the beginning of the curve followed by an initially sharp trough that gradually flattens out

36. Technique Problems Cough
This curve suggests the patient has coughed during a FVC reading
Note the peaks and troughs that occur throughout the curve
This will effect the FVC reading

37. Technique Problems Poor Effort
This curve suggests the patient has not blown as hard as they can during the FVC technique
Note the rounded top to the peak at the beginning of the curve
This will effect the FEV1 reading

38. Technique Problems Slow Start
This curve suggests the patient has started off blowing slowly during a FVC technique
Note the peak in L/s comes in the middle of the curve rather than at the beginning
This will effect the FEV1 reading

39. Technique Problems Inspiration
This curve indicates the patient has breathed in at the beginning of the technique
This usually occurs when the patient puts the filter in their mouth before they have finished breathing in
Note the negative L/s reading at the beginning of the curve
This could effect all readings

40. Technique Problems Inspiration
This curve suggests the patient has breathed in at the end of the FVC technique
This usually occurs when the patient attempts to take an extra breath in to prolong expiration
Note the negative L/s at the end of the curve
This could effect the FVC reading

41. Refreshments

42. Workshop

43. Correction Factors Ethnic Origin Correction Factor Caucasian 100%
BTS Guidelines Only
Ethnic Origin
Correction Factor
Caucasian
100%
Afro-Caribbean
Reduce by 13% (87%)
Asian
Reduce by 7% (93%)

44. References SPIROMETRY IN PRACTICE
A PRACTICAL GUIDE TO USING SPIROMETRY IN PRIMARY CARE 2ND Edition
BTS 2005
GENERAL CONSIDERATIONS FOR LUNG FUNCTION TESTING
ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING
European Respiratory Journal 2005
STANDARDISATION OF SPIROMETRY

45. Spirometry Interpretation

46. Accurate Interpretation
Use Best Test (Less than 5% Variance from next best)
Best Test – FVC, FEV1 or FVC & FEV1
If spirometer selects best test, CHECK
Minimum number of tests <3
Is Interpretation correct?

47. Accurate Interpretation
Curve shape – effort, cough, extra breath etc
Relaxed Expiratory Vital Capacity (EVC) recorded and used when better than FVC
Accurate height
Correction Factors

48. Recap
FEV1 The volume of air that the patient is able to breathe out in the first second of forced expiration
FVC The total volume of air that the patient can exhale forcibly in one breathe
FEV1 / FVC The ratio is expressed as a percentage
Peak Flow The volume of air that the patient is able to breathe out in the first 1000th of a second of forced expiration

49. ABREVIATIONS VITAL CAPACITY FORCED VITAL CAPACITY
VC, RVC, EVC
FORCED VITAL CAPACITY
Forced vital capacity describes the technique
FVC
RATIO
Ratio, FER, FEV1%, FEV1/VC, FEV1/FVC

50. Predicted Values Done in 70’s Need modernising
Use age, height and sex to make prediction of ability
Need to use correction factors for different ethnic origins
Accurate height essential
These can be reported as
Percentage of Predicted
Ranges
Standard Residuals

51. Correction Factors Ethnic Origin Correction Factor Caucasian 100%
BTS Guidelines Only
Ethnic Origin
Correction Factor
Caucasian
100%
Afro-Caribbean
Reduce by 13% (87%)
Asian
Reduce by 7% (93%)

52. Predicted Values Done in 70’s Need modernising
Use age, height and sex to make prediction of ability
Need to use correction factors for different ethnic origins
Accurate height essential
These can be reported as
Percentage of Predicted
Ranges
Standard Residuals

53. Percentage of Predicted
Most frequently referred to value within the community
Need to be aware that this gives an absolute value and clearly there is variability within normality
Measured x 100 = % Predicted
Predicted

54. % Predicted (Example) Ceri 55 years old 155 cm tall
FEV1 measured:1.64 l x 100
FEV1 predicted: l
FEV1 % predicted: 76%

55. Looking at the printout

56. Normal Results
FEV1 > 80% predicted
FVC > 80% predicted

57. Obstruction FEV1 < 80% predicted FVC > 80% predicted
Ratio <70%
Caution
If ratio is low but FEV1 and FVC are normal there is still obstruction present

58. Obstructive Disorders
COPD
Asthma
Bronchiectasis
Tumour
Foreign Body

59. NICE 2010 Consider alternative diagnoses in:
Older people without typical symptoms of COPD where the FEV1/FVC is <0.7
Younger people with symptoms of COPD where the FEV1/FVC ration is ≥ 0.7

60. Restriction FEV1 <80% predicted FVC < 80% predicted
Ratio >70%

61. Restrictive Disorders
Kyphoscoliosis
Muscular Dystrophy Problems
Arthritis
Pleural Problems
Interstitial Lung Disease
Obesity
Drugs

62. Combined
FEV1 <80% predicted
FVC <80% predicted
Ratio <70%

63. Combined Disorders Severe COPD Multiple Pathology e.g.
Kyphscoliosis and COPD
Tumour and COPD

64. Severity of Obstruction
Based on % Predicted of FEV1
Good predictor of Prognosis
Poor Predictor of Disability and Quality of Life
Categories;
BTS (1997)
GOLD (2001)
NICE (2004)
NICE (2010)

65. Severity of Obstruction
NICE Guideline (2004)
ATS/ERS (2004)
GOLD (2008)
NICE Guideline (2010)
Post-Bronchodilator FEV1/FVC
FEV1 % Predicted
Severity of Airflow Obstruction
Post -Bronchodilator
<0.7
≥ 80%
Mild
Stage 1-Mild
Stage 1-Mild*
50-79%
Moderate
Stage 2-Moderate
30-49%
Severe
Stage 3-Severe
< 30%
Very Severe
Stage 4-Very Severe**
*Symptoms should be present to diagnose COPD with mild airflow obstruction
**or FEV1 <50% with respiratory failure

66. Other Predictor of QOL and Prognosis
MRC score
BODE
Modified BODE
AOD

67. Degree of breathlessness related to activities
MRC Dyspnoea Scale
Grade
Degree of breathlessness related to activities 1
Not troubled by breathlessness except on strenuous exercise 2
Short of breath when hurrying or walking up a slight hill 3
Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4
Stops for breath after walking about 100m or after a few minutes on the level 5
Too breathless to leave the house, or breathless when dressing or undressing

68. Bode Index

69. Bode Index

70. Annual FEV1? Used to detect sudden deterioration in lung function
Should precipitate action if deterioration marked.
Normal deterioration in FEV1 thought to be 50ml/annum in none smoking individual

71. Asthma Or COPD ?

72. COPD Definition
‘….airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.’ NICE 2004

73. Asthma Definition
‘….in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.’ BTS and SIGN 2003

74. Post Bronchodilator Spirometry
QOF 12 (2009/10) states that a diagnosis of COPD should be confirmed by recording post bronchodilator spirometry
Bronchodilator should be taken 15 minutes prior to spirometry being performed i.e.
4 puffs Salbutamol 100 MDI with AeroChamber
Salbutamol 2.5mg nebuliser

75. Post Bronchodilator Spirometry
Why?
Post Bronchodilator recommended by GOLD and used in new trials e.g. UPLIFT
Removes conflict with many guidelines
Decrease work load in primary care
Failure to use post bronchodilator over estimates COPD by 25%
DOH 2009

76. Why Not Reversibility?
Repeated FEV1 measurements can show small spontaneous fluctuations
The results of a reversibility test performed on different occasions can be inconsistent and not reproducible
Over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml
The definition of the magnitude of a significant change is purely arbitrary
Response to long-term therapy is not predicted by acute reversibility testing. NICE 2010

77. Present and progressive
Diagnosing COPD
COPD
Asthma
Smoker or ex-smoker
Nearly all
Possibly
Symptoms under the age 35
Rare
Often
Chronic Productive Cough
Common
Uncommon
Breathlessness
Present and progressive
Variable
Night time waking with breathlessness and or wheeze
Significant diurnal or day to day variability of symptoms

78. 20 pack years is considered a significant factor for developing COPD
Smoking History
Cigarettes per Day x Years Smoked = 1 pack Year 20
e.g. 1 Pack Year = 20 cigarettes/day for 1 year or;
10 cigarettes/day for 2 years
40 cigarettes a day for 6 months
50g/2oz tobacco = 100 cigarettes
Cigars – Café Crème = 3 cigarettes
Hamlet = 5 cigarettes
Corona = 8+ cigarettes
20 pack years is considered a significant factor for developing COPD

79. Present and progressive
Diagnosing COPD
COPD
Asthma
Smoker or ex-smoker
Nearly all
Possibly
Symptoms under the age 35
Rare
Often
Chronic Productive Cough
Common
Uncommon
Breathlessness
Present and progressive
Variable
Night time waking with breathlessness and or wheeze
Significant diurnal or day to day variability of symptoms

80. Reversibility Useful if diagnosis is not clear Either;
Measure peak flows for 14 days morning and evening. Diurnal variation of greater than 20% indicates asthma
Record pre and post bronchodilator spirometry

81. Repeat Spirometry after 15-30 minutes
Reversibility
Repeat Spirometry following one of the following (Post);
Salbutamol 100mcg MDI 4 puffs via spacer
Salbutamol 2.5mg nebuliser
Repeat Spirometry after minutes

82. Reversibility
An FEV1 that increases by < 400mls is likely to have COPD
An FEV1 that increases by > 400mls is likely to have asthma
However if;
FEV1 < 80%
Ratio < 70%
Post > 400mls
Obstruction is not fully reversible

83. Reversibility (Example)
Billy
FEV l
FEV1 56% of predicted
Ratio 40%
Given Salbutamol 2.5mg nebuliser and spirometry repeated after 30 minutes
POST
FEV l
FEV1 91% of predicted
Ratio 71%

84. Case Studies

85. Case Study One Clive 47 years old
Smoked 30 cigarettes a day since he was 15 years old
Painter and decorator
Repeated chest infections every year
Finding it difficult to climb ladders and walk up steep hills
Chronic Productive Cough

86. References SPIROMETRY IN PRACTICE
A PRACTICAL GUIDE TO USING SPIROMETRY IN PRIMARY CARE 2ND Edition
BTS 2005
GENERAL CONSIDERATIONS FOR LUNG FUNCTION TESTING
ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING
European Respiratory Journal 2005
STANDARDISATION OF SPIROMETRY

88. Case Study Two Carol 69 years old
Has smoked 10 a day since the age of 21
Retired cleaner
Frequent chest infections
Frequent hospital admissions
Oxygen at home
House bound
10 metre exercise tolerance
None productive cough

90. Case Study Three Sarah 56 years old
Unemployed. Varied previous employment
3 recent admissions to hospital with breathlessness
Normally walks to shops with no problems
Breathing problems for the last 3 years
Smoked 20 a day since the age of 18
Currently sleeping on the sofa as can’t make it up stairs
Hospital measured spirometry on her last admission. Fev litres or 22% of predicted
Normally none productive cough currently coughing up green sputum

92. Case Study Four Sam 35 years old Teacher
20 pack year history of smoking
Breathless in the last 6 months
Breathless on exertion and has to stop if walking fast
None productive cough

94. Case Study Five Marjory
75 year old retired chef
Never smoked
4 hospital admissions in the last year with breathlessness
Home oxygen and nebulisers
Breathless since being a baby with repeated infections
Often walks to shops half a mile away, but when unwell unable to leave flat
No cough

96. Case Study Six Suzanne 50 years old 30 pack year history of smoking
Never worked
Recent frequent chest infections
Occasional productive cough
No exertional breathlessness
Only breathless with chest infections

98. Case Study Seven Colin 85 years old Retired office worker
80 pack year history of smoking but gave up 6 months ago
Regular rambler but finds himself increasingly breathless on hills
2 chest infections since giving up smoking
No cough unless he has a chest infection

100. Case Study Eight Paul 56 years old 25 pack year history of smoking
Works in dusty warehouses
Breathless for last 3 years
2 recent A&E admissions but discharged as panic attacks
Maximum inhaled bronchodilator therapy for COPD
Breathless around the house
Breathlessness starts when he is coughing but not sure of trigger for coughing
None productive cough
Lots of stress at home at present
During summer was playing 18 holes of golf

102. Case Study Nine Molly 75 years old
50 pack year history of smoking and still smokes 10 a day
Retired office worker
None productive cough
Walks everywhere and plays bowls when well
Breathless at rest and unable to leave the house when unwell
Frequent exacerbations though can never bring anything up
Audible wheeze at rest when unwell

104. Case Study Ten Bridget 77 years old
35 pack year history of smoking but ex smoker for 10 years
Retired shop worker
Breathless for the last 30 years since an acute episode of pulmonary Sarcoidosis (Inflammatory Lung Disease) which left lung scarring
Breathlessness has got progressively worse in the last 5 years
Long Term Oxygen and nebulisers
Breathless at rest even when well
Productive cough at all times

106. Case Study Eleven Eileen
72 years old
None smoker
Worked in wool mills as spinner for 5 years then a teacher
Breathless for last 15 years
Chronic Productive Cough
Frequent exacerbations
No hospital admissions
5 metre exercise tolerance
Long term Oxygen and nebulisers
Plays cards 7 times a week and goes to the gym on a Friday

108. Case Study Twelve Mohammed
62 years old
Breathless for last year
Breathless on exertion
Exercise tolerance 200 metres
None smoker
Works in a shop
No chest infections
None productive cough