Presentation on theme: "COPD: Spirometry Clare Hawkins, MD, MS Program Director, San Jacinto Methodist Hospital Family Medicine Residency, Baytown, TX Isaac M. Goldberg, MD Faculty,"— Presentation transcript:
COPD: Spirometry Clare Hawkins, MD, MS Program Director, San Jacinto Methodist Hospital Family Medicine Residency, Baytown, TX Isaac M. Goldberg, MD Faculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown, TX
Educational Objectives At the end of this presentation, the learner should be able to … Utilize spirometry to diagnose and stage COPD Overcome barriers to the use of office spirometry Achieve confidence with spirometry interpretation
Background Objective measure of airway function for accurate diagnosis of Chronic Obstructive Pulmonary Disease (COPD) World Health Organization Global Obstructive Lung Disease Consensus/ Evidence guideline (GOLD) American Thoracic Society (ATS) European Respiratory Society (ERS) National Committee for Quality Assurance (NCQA)
Background Alternate ways to diagnose COPD Clinical Findings Late - Increased AP diameter, tympanitic chest - Signs of respiratory distress Peak flow reading not adequately sensitive or specific Radiographic findings occur late in disease CT scanning more accurate, but findings also occur late in disease
Background Who should receive spirometry? Early diagnosis relies on the recognition of the clinical features - Persistent cough - Chronic sputum production - Breathlessness on exertion - Reduction in activity (often attributed to natural aging) About 20% of COPD patients identified in NHANES study with obstruction never smoked - Only 1/5 were explained by asthma
Background Other testing considerations Recurrent or chronic respiratory symptoms Occupational exposure to respiratory irritants Family history of respiratory diseases and symptoms NCQA established use of spirometry as required quality measure for accurate COPD diagnosis Routine periodic use not recommended
Background Screening Not recommended in the absence of respiratory symptoms (dyspnea, cough) No threshold amount of smoking pack-years for screening in the absence of respiratory symptoms Not recommended by USPSTF or ACP 2011 Guideline
Background Family physicians able to do quality spirometry Quality of care increases with use of spirometry - To prevent overdiagnosis of COPD, attention to quality spirometry is important Suggestions to maintain quality of spirometry - Know technique - Have staff coach the patient - Do sufficient numbers of tests - Maintain and calibrate the equipment - Understand interpretative algorithms
Background Why do office spirometry? Diagnostic accuracy. 30% of time diagnosis changes. - Was not COPD; heart failure or asthma - Was COPD rather than asthma - If spirometry normal, then expensive meds discontinued Respect. Patients respect physicians who use technology (Future of Family Medicine) Patient convenience. You can avoid an unnecessary referral and additional visit Diagnostic power: You can connect diagnostic information with rest of clinical encounter Financial benefit to practice.
Equipment Older volume/time loop - Drum technique from John Hutchinson 1844 Newer flow/volume loop using flow transducer - Smaller Machines, Mobile - Disposable Mouthpiece No other infection transmission precautions necessary
Equipment Numerous manufacturers produce quality instruments Reviews conducted by National Lung Health Education Program (NLHEP) regarding appropriateness of spirometers for office practice - http://www.nlhep.org/spirometer-review-process.html http://www.nlhep.org/spirometer-review-process.html - Simplicity (fewer numbers) - Reliability
Equipment Calibration Daily calibration must be done with 3 L syringe Syringe must have accuracy of at least 15 ml Spirometer must have accuracy of ±105 mL or 0.105 L (calibration volume = 2.90 to 3.11) Calibration log/printouts must be kept - Date and time of calibration - Individual performing - Comments
Technique Forced expiratory maneuver Coach patient to get a maximal effort Six seconds of effort required though most of air pushed out in the first second Pace of expired air is most important variable; therefore it should be released with explosive force
Technique Minimum 6 second exhalation with 2 second plateau Tracing should have no artifacts At least 3 acceptable maneuvers (<5 % variation) - ATS criteria Empty bladder for females (concern if incontinence) Can be seated or standing Nose plug optional
Technique None of the following should occur: Unsatisfactory start, with excessive hesitation or false start Air leak Coughing during the first second Early termination of forced expiration Glottis closure Obstructed mouthpiece - Tongue - False teeth - Chewing gum
Technique Reliability Spirometry overdiagnoses COPD if insufficient effort Concerns that family physicians will not perform quality testing and overdiagnose people with obstructive lung disease Imperative that patients be coached on robust, forced expiratory maneuver
Technique Contraindications Hemoptysis of unknown origin Pneumothorax Unstable cardiovascular status or recent MI or PE Thoracic, abdominal, or cerebral aneurysms Recent eye, thorax or abdomen surgery
Technique Barriers Inaccessibility of Equipment Concern patient effort and cooperation are insufficient Difficulty remembering interpretive algorithm Frustration by ambiguous results Difficulty working 30-minute spirometry into office flow Central location for spirometry versus going room to room Lack of staff training Poor integration with electronic health record Lack of adequate reimbursement
Measurements AbbreviationCharacteristic measured FEV 1 Forced expired volume in 1 second FVCForced vital capacity FEV 1 /FVC Ratio Ratio of the above PEFRPeak expiratory flow rate FEF 25-75% Forced expiratory flow between 25-75% of the vital capacity
Measurements Normal values Individual variation according to age, height, ethnicity and gender - Height - Tall people have larger lungs - Age - Respiratory function declines with age - Sex - Lung volumes smaller in females - Race - Studies show Blacks and Asians have smaller lung volumes (-12%) - Posture - Little difference between sitting and standing; reduced in supine position
Measurements Bronchodilator reversibility testing Beta-agonist - Short-acting – wait 20 minutes before retesting - Long-acting – wait 2 hours before retesting Do not take bronchodilator the day of testing - Measured reversibility will be limited if the patient is bronchodilated for the pretest.
Measurements Definition of reversibility Pre-Bronchodilator -FEV 1 /FVC <70% of predicted Post-Bronchodilator -Increase 12% AND at least 200 cc Reversibility = Asthma!
Measurements Severity of obstruction FEV1% of predicted Mild>80 Moderate50 to 79 Severe30 to Very severe<30 Severity of restriction FVC% of predicted Mild>65 to 80 Moderate>50 to 65 Severe<50
Case Study 1 A 53-year-old white male presents for annual visit. Although he quit 10 years ago he is a previous cigarette smoker with a 20 pack-year history. During the past 12 months, he has had 3 episodes of bronchitis. His history of tobacco use and recent episodes of acute bronchitis lead you to perform spirometry.
Results Pre-BronchodilatorPost-Bronchodilator PredictedMeasured% % change FVC4.65 1004.951066 FEV13.753.13833.34896 FEV1/FVC8067-1367-130 Is there obstruction? FEV1/FVC = 67% of predicted; therefore, obstruction present Is there restriction? FVC = 100% of predicted; therefore, no restriction present
Results Pre-BronchodilatorPost-Bronchodilator PredictedMeasured% % change FVC4.65 1004.951066 FEV13.753.13833.34896 FEV1/FVC8067-1367-130 What is the severity of obstruction? FEV1 is 83% of predicted; therefore, the obstruction is mild Is the obstruction reversible (is reversibility present)? FEV1 increases from 83% to 89% (6% increase) and increases from 3,130 cc to 3,340 cc (increase of 210 cc) Interpretation: Mild Obstruction with minimal reversibility: Mild COPD
NoYes Obstructive Defect Is FVC Low? (<80% pred) Combined Obstruction & Restriction /or Hyperinflation Pure Obstruction Improved FVC with ß-agonist Reversible Obstruction with ß-agonist Further Testing with Full PFT’s Suspect Asthma Suspect COPD Is FEV 1 / FVC Ratio Low? (<70%) Yes NoYes NoYes Diagnostic Flow Diagram for Obstruction Adapted from Lowry.
Case Study 2 A 33 year old female presents to the office complaining of dyspnea and cough for the past 2 days. Her cough is productive of a white mucous. Her past medical history is significant for asthma since childhood, obesity, gastroesophageal reflux disease (GERD), and an occasional migraine headache. She is a nonsmoker and has no known allergies.
Case Study 2 (cont) Her current medications include the following: Albuterol 2 puffs po qid prn wheezing, cough, or dyspnea Fluticasone 110 micrograms 2 puffs po bid Ranitidine 150 mg po bid Her father recently died secondary to advanced COPD. Due to her symptoms, you order spirometry.
Results Pre-BronchodilatorPost-Bronchodilator PredictedMeasured% % change FVC3.781.92512.77134 FEV13.241.11341.615036 FEV1/ FVC8658-2860-263 What is the severity of obstruction? 60%; therefore, moderate obstruction Is the obstruction reversible (is reversibility present)? FEV1 increases from 34% to 50% (16% increase) and increases by 500 cc What is the severity of restriction? 71% of predicted; therefore, mild restriction Interpretation: Moderate obstruction with reversibility (Moderate obstruction)
NoYes Is FVC Low?(<80% pred) Restrictive DefectNormal Spirometry Further Testing with Full PFT’s; consider referral if moderate to severe Is FEV 1 / FVC Ratio Low? (<70%) No Diagnostic Flow Diagram for Restriction Adapted from Lowry, 1998
Results “Full” Pulmonary Function Testing (PFT’s) Assessment of Oxygenation - Transcutaneous oxygen saturation - Arterial blood gasses Diffusion test to evaluate alveolar exchange (DLCO) Plethysmography - To objectively assess lung volumes - Delineate air-trapping versus restriction May also include Spirometry
Spirometry and Smoking Cessation Lung age calculation - Use to motivate smoking cessation. Mixed results - Normal results may give the impression that it’s acceptable to continue smoking. - Avoid fatalism with abnormal results. Research results recently favor use - ACP and AHRQ advise only if symptomatic.
Coding and Reimbursement ProcedureCPT CodeReimbursement* Single spirometry94010$32.82 Pre-post spirometry94060$57.71 Pulmonary stress test simple94620$71.77 Medication administration bronchodilator supply separate 94640$13.34 Demonstration / instruction94664$14.79 Smoking Cessation <8x/ yr99406$12.98 EquipmentCost Office spirometer$1,000 – 2,500 *Reimbursement based upon Medicare payments 2009
Estimated Return on Investment Tests /week (#)Reimbursement/year*ROI $1,995 in weeks 4$6,86415 6$10, 29610 8$13,7287 10$17,1606 15$25,7404 20$34,3203 25$42,9002 *Based upon CPT code 94010
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