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Interpreting Spirometry: Patient or Data? David Robiony-Rogers CRFS Service Leader Respiratory Medicine Capital & Coast District Health Board.

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Presentation on theme: "Interpreting Spirometry: Patient or Data? David Robiony-Rogers CRFS Service Leader Respiratory Medicine Capital & Coast District Health Board."— Presentation transcript:

1 Interpreting Spirometry: Patient or Data? David Robiony-Rogers CRFS Service Leader Respiratory Medicine Capital & Coast District Health Board

2

3 The colours of disease

4 The colours of respiratory disease

5 For the movie conscious...

6 For the spacer conscious...

7 Medication type colour coding...

8 Spirometry Spirometry is the timed measurement of dynamic lung volumes during forced expiration and inspiration, and is used to quantify how effectively and how quickly the lungs can be emptied.

9 Spirometry: Graphic Displays Volume time curveFlow volume loop

10 Spirometry Test

11 Spirometry Interpretation Acceptability *minimum of 3 acceptable manoeuvres *good start and satisfactory effort *no artefacts induced by coughing or glottic closure in 1st second, or equipment problems *minimum of 6 seconds exhalation and/or plateau in the volume time curve *Maximal inspiration prior to blow

12 Artefacts a)No artefact b)Cough within 1 st second of forced exhalation c)Incomplete exhalation/early termination (glottic closure) d)Slow start/submaximal forced effort at start of blow e)Hesitant start

13 Spirograms Normal and problematic

14 Flow Volume Loops Normal and problematic

15 Reproducibility *two largest FVC within L (150ml) of each other *two largest FEV1 within L (150ml) of each other *must meet criteria for acceptability If the reproducibility criteria is not met after a total of 8 tests, stop testing.

16 Disease Patterns  Obstructive pattern A disproportionate reduction of maximal airflow from the lung in relation to the maximal volume  Restrictive pattern Characterised by a normal FEV 1 /VC ratio and reduction in FVC below the 5th percentile of the predicted  Mixed pattern Characterised by the coexistence of obstruction and restriction, and is defined physiologically when both FEV 1 /FVC and FVC are below 5th percentiles of the predicted value

17 Spirometric overlap between Asthma and COPD *COPD has been described as a disease characterized by fixed airflow obstruction because in many patients FEV1 values improve little after bronchodilator challenge. *Current guidelines on diagnosis and management describe COPD as a condition that is partially reversible because some patients exhibit substantial improvements in FEV1 (despite an FEV1-FVC ratio that remains below 0.70) that compares in magnitude to what is observed in some asthma patients. *Tashkin et al (2008) have shown that about 54% of a large COPD cohort (N = 5756) exhibited an improvement in FEV1 values > 12% and 200 mL, while about 65% of patients had FEV1 increases > 15%. *This substantial overlap in FEV1 reversibility between asthma and COPD underscores an important limitation of using this measurement to distinguish between asthma and COPD. Can Fam Physician. Oct 2011; 57(10): 1148–1152.

18 The overlap of Asthma and COPD

19 Disease Patterns The presence and site of disease have various effects on the volume- time and maximal expiratory flow volume curve Vitalograph Ltd 1986 &2000

20 Normal Ventilatory Function The pattern of the lung and spirogram show a pattern of normality Vitalograph Ltd 1986 &2000

21 Age: 22, Gender: Female; Height: 166 cm, Weight: 69.3 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.7 FEV1, L – 4.0 FEV1/FVC, % – 95.9

22 Age: 23; Gender: Male; Height: 175 cm; Weight: 67.6 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 6.3 FEV1, L – 5.2 FEV1/FVC, % – 93.0

23 Reversible Obstruction The lungs and spirogram show a pattern of airway obstruction (black), with the spirogram showing a marked improvement after the administration of a bronchodilator (red) Vitalograph Ltd 1986 &2000

24 Age: 75; Gender: Male; Height: 175 cm; Weight: 97.2 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 5.0 FEV1, L – 3.7 FEV1/FVC, % – 82.5

25 Age: 29; Gender: Female; Height: 162 cm; Weight: 98.6 kg; BMI: Spirometry measurePre bronchodilator best Post bronchodilator best % improvementReferenceRef ± CI FVC, L – 4.4 FEV1, L – 3.8 FEV1/FVC, % – 94.4

26 Irreversible Obstruction The lungs and spirogram show a pattern of airflow obstruction, with the spirogram showing little or no improvement after the administration of a bronchodilator Vitalograph Ltd 1986 &2000

27 Age: 74; Gender: Female; Height: 161 cm; Weight: 70.9 kg; BMI: Spirometry measurePre bronchodilator best Post bronchodilator best % improvementReferenceRef ± CI FVC, L – 3.5 FEV1, L – 2.7 FEV1/FVC, % – 84.9 FEV 6, L – 3.3

28 Restrictive Defect The lung and spirogram show a pattern of volume restriction Vitalograph Ltd 1986 &2000

29 Age: 74; Gender: Male; Height: 160 cm; Weight: 82.3 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 3.9 FEV1, L – 2.9 FEV1/FVC, % – 82.5

30 Combined Pattern The lungs and spirogram show a pattern of combined airflow obstruction and volume restriction Vitalograph Ltd 1986 &2000

31 Spirometry measureBestReferenceRef ± CI FVC, L – 4.9 FEV1, L – 3.7 FEV1/FVC, % – 83.5 Age: 69; Gender: Male; Height: 171 cm; Weight: 50.9 kg; BMI: 17.41

32 Age: 35; Gender: Male; Height: 168 cm; Weight: 90.6 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 5.6 FEV1, L – 4.6 FEV1/FVC, % – 90.5

33 Response to ß2-agonist ß2-agonist bronchodilator *Dose: 4 puffs of ß2-agonist delivered through a spacer device *Wait minutes before repeating spirometry *Significant response defined as >12% and more than 200mL increase in either the FEV1 or FVC.

34 Spirometry: Pre & Post ß2-agonist

35 Severity classification Degree of severityFEV1 % predicted Mild>70 Moderate60-69 Moderately severe50-59 Severe35-49 Very severe<35 Severity of any spirometric abnormality based on the forced expiratory volume in one second (FEV1) ATS/ERS Task Force: Standardisation of lung function testing. Interpretative strategies for lung function tests. Eur Respir J 2005; 26: 948

36 Interpretation algorithm National Asthma Council Australia: Yes No

37 Spirometry interpretation algorithm: Primary Care Respiratory Alliance of Canada Asthma vs COPD (history)Consistent with asthma Refer to specialist  FEV1, 12% and 200mL Restrictive disorder Reduced < LLNNormal (not COPD) FVC ≥ 80% predicted  FEV1 and  FVC ß2-agonist Reduced < LLNNormal > LLN Pre ß2-agonist FEV1/FVC ratio Modified from Primary Health Care Alliance of Canada spirometry interpretation algorithm 2011

38 Visual Interpretation

39 Age: 58; Gender: Female; Height: 156 cm; Weight: 61.1 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 2.7 FEV1, L – 2.1 FEV1/FVC, % – 82.5

40 Age: 68; Gender: Female; Height: 170 cm; Weight: 70.0 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.2 FEV1, L – 3.3 FEV1/FVC, % – 86.2

41 Age: 35; Gender: Male; Height: 168 cm; Weight: 90.6 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 5.6 FEV1, L – 4.6 FEV1/FVC, % – 90.5

42 Age: 50; Gender: Female; Height: 164 cm; Weight: kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.3 FEV1, L – 3.5 FEV1/FVC, % – 90.0

43 Age: 64; Gender: Male; Height: 162 cm; Weight: 60.5 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.4 FEV1, L – 3.4 FEV1/FVC, % – 84.5

44 Age: 70; Gender: Female; Height: 153 cm; Weight: kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 3.2 FEV1, L – 2.4 FEV1/FVC, % – 85.7

45 Age: 70; Gender: Female; Height: 144 cm; Weight: 81.8 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 2.7 FEV1, L – 2.1 FEV1/FVC, % – 85.7

46 Age: 52; Gender: Female; Height: 161 cm; Weight: 50.8 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.1 FEV1, L – 3.3 FEV1/FVC, % – 89.6

47 Age: 39; Gender: Female; Height: 157 cm; Weight: kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 4.1 FEV1, L – 3.4 FEV1/FVC, % – 92.3

48 Age: 67; Gender: Female; Height: 157 cm; Weight: 67.7 kg; BMI: Spirometry measureBestReferenceRef ± CI FVC, L – 3.5 FEV1, L – 2.7 FEV1/FVC, % – 86.4

49 https://www.youtube.com/watch?v=yNDKD_xI684 Spirometry Education Pulmonary Function Tests (PFT): Lesson 2 - Spirometry Published on Feb 3, 2014 A discussion of FEV1, FVC, FEV1/FVC ratio, and the flow volume loop, including how these are used in the diagnosis of various lung diseases, with a particular focus on the distinction between obstructive and restrictive lung disease. A summary of flow volume loop patterns in upper airway obstruction is covered as well.

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