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Competent performance of Spirometry1 Foundation Course In Spirometry 1-day Training Course Sandra Davies, Highly advanced Clinical Physiologist Cardiopulmonary.

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Presentation on theme: "Competent performance of Spirometry1 Foundation Course In Spirometry 1-day Training Course Sandra Davies, Highly advanced Clinical Physiologist Cardiopulmonary."— Presentation transcript:

1 Competent performance of Spirometry1 Foundation Course In Spirometry 1-day Training Course Sandra Davies, Highly advanced Clinical Physiologist Cardiopulmonary Unit, Prince Charles Hospital.

2 Competent performance of Spirometry2 Aimed At: New - to - practice Nurses. Any Healthcare practitioner.

3 Competent performance of Spirometry3 Course Objectives To understand what spirometry is. To learn how to maintain your spirometer.  Verification.  Cleaning. To perform spirometry accurately. To identify faults and errors.

4 Competent performance of Spirometry4 What Is Spirometry? Uses.

5 Competent performance of Spirometry5 What Is Spirometry? An objective measurement of lung function. Measures lung size (FVC). Measures airway calibre (FEV 1 ). Indicates airflow obstruction (FEV%).

6 Competent performance of Spirometry6 Spirometry As A Diagnostic Tool British Thoracic Society (BTS) guidelines suggest that the use of spirometry should be increased in primary care for:  Diagnosis  Improvement of medical management  Monitoring of progression Aims to provide a more efficient service

7 Competent performance of Spirometry7 What Does It Tell Us? The difference between : Normal lungs/airways. Airflow obstruction (e.g. Asthma, COPD). Restrictive disease (pulmonary fibrosis). Response to inhalers/treatment.

8 Competent performance of Spirometry8 Airflow Obstruction Any lung condition that causes narrowing of the airways:  Inflammation.  Mucus.  Foreign body.

9 Competent performance of Spirometry9 Restrictive Disease Reduced volume in the lungs due to inability of lungs to expand. Intrapulmonary diseases.  Pulmonary fibrosis.  Pulmonary oedema.  Collapse/consolidation of the lung. Extra-pulmonary conditions.  Large pleural effusion.  Rib cage deformity (scoliosis).  Respiratory muscle weakness.

10 Competent performance of Spirometry10 Combined Obstructive / Restrictive Airways are narrowed Small lung volumes

11 Competent performance of Spirometry11 Spirometry Definitions? Uses, terms and definitions.

12 Competent performance of Spirometry12 Common Terms FEV 1 FVC FEV 1 /FVC or FEV% or Ratio PEF VC

13 Competent performance of Spirometry13 Definitions - FEV 1 FEV 1 (litres) - Forced Expiratory Volume in one second.  Volume of air blown out in the first second of a forced blow out.  Reduced in both obstructive and restrictive disease.

14 Competent performance of Spirometry14 Definitions - FVC Forced Vital Capacity (litres).  Maximum volume blown out as hard as possible, following a full inspiration.  It is reduced in restrictive disease, and in obstructive disease if air trapping occurs.

15 Competent performance of Spirometry15 Basic Spirogram FVC FEV 1 1 second

16 Competent performance of Spirometry16 Definitions: FEV% Forced expiratory ratio (FEV%, FEV 1 %,FER)- L/min, L/sec.  Percentage of FVC blown out in the first second of a forced expiration.  FEV 1 /FVC x 100.  Normal in restrictive disease, reduced in obstructive disease.

17 Competent performance of Spirometry17 Peak Expiratory Flow (PEF). The maximum flow achievable from a forced expiration starting at a full inspiration with an open glottis. Achieved within first 100 milliseconds of blow. Measured in L/min but sometimes expressed as L/sec (SI units).

18 Competent performance of Spirometry18 Peak Expiratory Flow Not particularly informative on its own but serial monitoring can be useful. Must be performed on a device capable of measuring flow (L/min or L/sec). Measurement can either be integral to an FVC manoeuvre or separately on a Peak Flow Meter. Differentiation of volume measurements to obtain PEF accentuates noise.

19 Competent performance of Spirometry19 Definitions: VC Vital Capacity (litres). Slow Vital Capacity (SVC) or Relaxed Vital Capacity (RVC).  Maximal amount of air breathed out steadily from full inspiration to maximal expiration (not time dependent).  It should be >80% of predicted in ‘normals’, will be reduced in restrictive disease.

20 Competent performance of Spirometry20 Spirogram – Volume/time FEV 1 = 3.50L FVC = 5.20L FEV% =67%  (3.50/5.20) x 100 VC = 5.20L FEV 1 /VC% = 67%

21 Competent performance of Spirometry21 Flow Volume Curve/Loop Measurements are of flow. Volume is calculated (integration). Characteristic shapes with disease. FEV 1 FVC

22 Competent performance of Spirometry22 Performance of Spirometry Indications, before you test and how to make the measurement.

23 Competent performance of Spirometry23 Indications Detect the presence or absence of lung disease Quantify the extent of known disease Measure effects of occupational exposure Determine effects of therapy Assess risk for surgical procedures Evaluate disability or impairment

24 Competent performance of Spirometry24 When Not to Test. Patient coughing up blood of unknown origin. Recent collapsed lung. Recent heart attack or blood clot on the lung. Aneurysms (aortic or abdominal). Recent surgery (chest, abdomen, eye). Acute nausea or vomiting.

25 Competent performance of Spirometry25 Plus … Infectious patients e.g.  Open T.B.  MRSA (nose, throat etc).  D & V. Patients with current exacerbations. Semi conscious or confused patients. Very unwell patients.

26 Competent performance of Spirometry 26 General Pre-test Procedures On day of test patient asked to avoid:  Smoking prior to testing.  Alcohol consumption.  Eating a substantial meal.  Wearing clothing that restricts full chest expansion.  Short-acting bronchodilators for 4 hours.  Performing vigorous exercise.

27 Bronchodilators If possible please: do not take reliever inhalers (blue, green, red, or purple inhalers) for 4- 6hours prior to tests

28 Competent performance of Spirometry28 Before You Start… Is the subject fit to do the test?  Absolute contraindications.  Relative contraindications. Is the subject ABLE to do the test?  Poor understanding comprehension.  Poor motivation.  Language barriers etc.

29 Competent performance of Spirometry29 Height and Weight Essential for calculation of patients predicted ranges. Requires accurate measuring device. Indoor clothing, without shoes, feet together. Stand as tall as possible. Eyes looking straight ahead.

30 Competent performance of Spirometry30 Arm Span For patients with a deformity of the thoracic cage, such as kyphoscoliosis, the arm span can be used to estimate height. Two methods:  Fingertip to fingertip (arms fully outstretched, back against wall).  Fingertip to mid-sternum.  Correction factor should be applied: Height = arm span/(1.06. or 1.03). Specify on the report that arm span has been used !

31 Competent performance of Spirometry31 Recording Patient History Check all pre test procedures have been adhered to, note any deviations. Check for contraindications. Record full medication history. Bronchodilators.  device/ time of last use. Other drugs (may also affect the lungs).

32 Competent performance of Spirometry32 Smoking History Record full smoking history.  Increases airway resistance and therefore may affect FEV 1. Ex-smoker / current/ never. Number of years smoked. Maximum packs per day.  1 pack is 20 cigarettes. Calculate pack years:  No. packs/day x years smoking.

33 Competent performance of Spirometry33 Preparation for Testing Patient should be seated for 5-10minutes prior to testing. For safety reasons, patient should NOT stand during spirometry. Patient should sit upright in a chair with arms. Dentures should be left in, other than if very loose.

34 Competent performance of Spirometry34 Equipment Preparation Calibration or verification should be performed prior to every testing session:  Calibration syringe (1L or 3L).  Physiological check … blow in to the spirometer! Have all consumables ready:  One-way valve mouthpiece.  Tissues etc.

35 Competent performance of Spirometry35 Procedure Full explanation of test given to patient.  Implied consent. Relaxed Vital Capacity should be performed first.  Nose clips required. Minimum of 3 manoeuvres performed for each test set. Minimum of 30 seconds between attempts.  May be longer if patient is breathless.

36 Competent performance of Spirometry36 Procedure: VC Minimum of 3 patient efforts. Instruct patient to breathe in fully, place teeth and lips securely around the mouthpiece and blow out at a steady speed until completely empty. Encourage patient to keep breathing out for as long as possible. Observe trace and patient throughout the blow.

37 Competent performance of Spirometry37 Procedure: FEV 1 and FVC Minimum of 3 efforts performed. Maximum 8 efforts. Instruct patient to breathe in fully, place teeth and lips securely around the mouthpiece and blow out as fast and hard as possible until completely empty. Encourage patient to keep going for as long as possible. Observe trace and patient throughout the blow.

38 Competent performance of Spirometry38 Acceptability Criteria 2 VC’s within 100ml or 5%. 3 FEV 1 ’s within 100ml or 5%. 3 FVC’s within 100ml or 5%. The results reported should be the biggest values from technically acceptable manoeuvres, irrespective of the manoeuvre in which they occur.

39 Competent performance of Spirometry39 Patient Errors Subject issues:  Pain.  Incontinence  Understanding – demonstration needed.  Volition – flow loop will be submaximal, essential need for Practitioner encouragement Requirements:  Reproduce flow volume loop with effort.

40 Competent performance of Spirometry40 Patient Errors Sub maximal effort.  Usually due to: Poor understanding. Lack of motivation. Lack of co-ordination. Incomplete inspiration. Inadequate rest between attempts.

41 Competent performance of Spirometry41 Patient Errors Leaks.  Usually due to: ‘Puffing’ cheeks out. Lips not tightly round the mouthpiece. Loose fitting dentures. Teeth not over the mouthpiece. Tongue obstructing the mouthpiece. Facial palsy.

42 Competent performance of Spirometry42 Technical Errors Poor start. Early termination. Cough. Sub-maximal effort. Unable to obtain 3 technically acceptable efforts.

43 Competent performance of Spirometry43 Poor Start

44 Competent performance of Spirometry44 Early Termination

45 Competent performance of Spirometry45 Cough

46 Competent performance of Spirometry46 Sub-Maximal Effort

47 Good vs poor effort Competent performance of Spirometry47

48 Cough or Glottis closure Competent performance of Spirometry48

49 Insufficient inhalation Competent performance of Spirometry49

50 Competent performance of Spirometry50 Errors Most errors can be avoided by clear explanation and adequate coaching of the subject.

51 Competent performance of Spirometry51 1 2 3 Volume Time Effort Induced Bronchospasm

52 Competent performance of Spirometry52 Equipment Rotating vane, pneumotachographs and ultrasonic devices.

53 Competent performance of Spirometry53 Spirometers

54 Competent performance of Spirometry54 Rotating Vane Spirometer Also called “turbine” spirometers Swirl plate directs exhaled air onto the internal rotating vane The rotations are detected by a digital transducer which sends impulses to CPU Number of impulses per unit time is proportional to flow

55 Competent performance of Spirometry55 Rotating Vane Spirometer ADVANTAGES.  Cheap.  Simple to use.  Compact & portable.  Unaffected by changes in atmospheric conditions. DISADVANTAGES.  No graphical trace.  Unable to calibrate, only verify.  Cheaper models are not accurate particularly over low expiratory flows.

56 Competent performance of Spirometry56 Pneumotachograph FLOW =PRESSURE. RESISTANCE. RESISTANCE. The resistance is fixed, therefore the pressure difference is directly proportional to flow.

57 Competent performance of Spirometry57 Pneumotachograph Two types of resistive element:  Fleisch Type. A ‘bundle’ of capillary tubes.  Silverman or “Lilly” type. One or more screens.

58 Competent performance of Spirometry58 Pneumotachograph ADVANTAGES.  Portable.  Accurate.  Easily sterilised.  Easy to use.  Relatively cheap. DISADVANTAGES.  Require regular calibration.  Measurements are easily affected by condensation or particles on the element.  Needs a printer or PC to obtain trace.

59 Competent performance of Spirometry59 Ultrasonic Spirometers Transducers located on either side emit and receive sound in alternating directions. When gas flow is present, a pulse that travels against the flow is slowed and a pulse travelling with the flow is sped up. The transit time of the pulses is precisely measured and gas flow is then calculated.

60 Competent performance of Spirometry60 Ultrasonic Spirometer ADVANTAGES.  Portable.  Accurate.  Disposable transducer (infection control).  Easy to use.  Robust. DISADVANTAGES.  Needs a printer or PC to obtain trace.  Cannot be calibrated.  Consumables can be expensive.

61 Competent performance of Spirometry61 Cleaning Equipment Infection control, bacterial filters and cleaning spirometers.

62 Competent performance of Spirometry62 Infection Control Procedures to reduce cross-infection and contamination include:  Hand washing (!).  Use of disposable mouthpieces/nose clips.  Use of gloves when handling contaminated items.  Disinfection of tubing.  One way valves.  Use of filters.

63 Competent performance of Spirometry63 Bacterial Filters Provide a barrier between the patient and the equipment. Appropriate filter will depend on efficiency, cost and performance. Costs range from £0.45 to £2.50 each and are single patient use only.

64 Competent performance of Spirometry64 Infectious Patients Patients with active infection or TB should not normally be tested. Extra precautions should be taken for patients infected with Hepatitis B or HIV. Patients with acute exacerbation's should ideally be tested when resolved.

65 Competent performance of Spirometry65 Cleaning Cleaning of equipment involves the destruction of pathogens by either:  Physical means (heat, irradiation etc).  Chemical means. Decision depends on cost, effectiveness, ease of use and availability.

66 Competent performance of Spirometry66 Cleaning Procedures All parts touched by patient should be wiped between patients. Consumables must be disposed of between patients e.g mouthpieces. All parts in contact with mucous membranes should be washed in warm soapy water and rinsed. Tubing and other non disposables should be immersed in sterilising agents.

67 Competent performance of Spirometry67 Cleaning Spirometers According to manufacturer’s instructions. Frequency will depend on how frequently the device is used. Must consider:  How easy the spirometer is to dismantle.  How long the cleaning process will take.  What damage can be done by cleaning.

68 Competent performance of Spirometry68 Cleaning: Rotating Vane  Remove turbine transducer from housing.  Immerse in warm soapy water for routine cleaning.  Immerse in cold sterilising solution (Perasafe etc) for 10 minutes – NOT chlorine releasing!  Rinse in distilled water and air dry.  Reassemble.

69 Competent performance of Spirometry69 Cleaning: Pneumotach  Remove pneumotach.  Immerse in cold sterilising solution (Perasafe etc) for 10 minutes – NOT chlorine releasing!  Rinse well.  Shake excess water out of pneumotach.  Air drying can take in excess of 12hours.

70 Competent performance of Spirometry70 Cleaning – Ultrasonic devices Minimal cleaning required! Wipe down outer casing after each use. Dispose of spirette/breathing tubing after each patient.

71 Competent performance of Spirometry71 Reassembly Only reassemble equipment once it has dried completely. Ensure all parts are fitted correctly e.g the correct rotating vane in the correct housing. Calibrate/verify equipment before use.

72 Competent performance of Spirometry72 Checking your Equipment Calibration

73 Competent performance of Spirometry73 Calibration The act of checking or adjusting (by comparison with a standard) the accuracy of a measuring instrument. Ideally, a 3 litre syringe should be used.  3 litres + 3% or + 90mls. If adjustment is necessary, this is normally done by the software.

74 Competent performance of Spirometry74 When to Perform Calibration After cleaning and reassembling the equipment. At the start of each spirometry session. Whenever temperature fluctuates by >4 o C. After every ten patients in a busy clinic. If there are any doubts about sequential values in a stable subject.

75 Competent performance of Spirometry75 Results All calibration data must be recorded and stored. Calibration records should include:  Date/time.  Temperature.  Barometric pressure.  Syringe used.  Operator name.

76 Competent performance of Spirometry76 Causes of Calibration Failure Holes in the flow sensor or channels plugging with excess moisture (pneumotachographs). Technical problems with computer interface. Leaks in the tubing or connector. Inaccurate timing on the recorder. Inappropriate calibration software.

77 Competent performance of Spirometry77 Checking your Equipment Verification

78 Competent performance of Spirometry78 Verification Provides information about the actual measurement obtained by the spirometer versus the expected measurement. Many devices can not be internally adjusted and therefore have to be verified. Verification checks whether the spirometer reads with in acceptable limits – cannot adjust it if it does not.

79 Competent performance of Spirometry79 When to Perform Verification After cleaning and reassembling the equipment. At the start of each spirometry session. Whenever temperature fluctuates by >4 o C. After every ten patients in a busy clinic. If there are any doubts about sequential values in a stable subject.

80 Competent performance of Spirometry80 Results Volume measurements should be within  3% of the expected value. Equipment will print out whether it is reading within acceptable limits.

81 Competent performance of Spirometry81 Syringes Volume Syringe.  1 or 3 litre calibration syringes can be used. Flow Limited Syringe.  Useful when calibrating flow measuring devices.  Allow assessment of flow sensing spirometers using different speeds.

82 Competent performance of Spirometry82 Results All verification data must be recorded and stored. Verification records should include:  Date/time.  Temperature.  Barometric pressure.  Syringe used.  Operator name.

83 Competent performance of Spirometry83 Verification Checks If the calibration exceeds the +/- limit the spirometer should be thoroughly examined to locate the source of any discrepancy. Any serious problems must be reported to the manufacturer.

84 Competent performance of Spirometry84 Checking your Equipment Quality Control

85 Competent performance of Spirometry85 Quality Control A thorough QC programme should be employed alongside the calibration protocol to ensure accuracy and precision of all equipment. A QC programme should include:  Biological measurements.  Physical measurements.

86 Competent performance of Spirometry86 Biological QC This should be performed on a weekly basis. Biological QC involves healthy subjects performing spirometry on a regular basis to ensure that the equipment is reading accurately and precisely.

87 Competent performance of Spirometry87 Biological QC Ensure the subject is not suffering with any illness and/or respiratory disorder. The biological control should perform spirometry over a 2 week period. From this the subjects mean results can be calculated. These results should then be used for any subsequent QC measurements.

88 Competent performance of Spirometry88 Variability of QC Biological QC is affected by natural variability. It can be said that the measurements of a healthy subject will vary by 10% from day to day. Natural variability can be reduced to 5% by following some simple procedures:  Calibrate the equipment accurately before use.  Test the subject at the same time of day.  Use the same operator to test the subject.

89 Competent performance of Spirometry89 Understanding the Results Basic strategies

90 Competent performance of Spirometry90 Possible Causes Obstruction  COPD  Asthma  Emphysema  Bronchiectasis  Cystic Fibrosis  Tumour Etc! Restriction  Sarcoid  Fibrosis  Kyphosis  Heart failure  Tumour  Obesity Etc!

91 Competent performance of Spirometry91 Basic Understanding of Results FEV ratio reduced <70% indicates airflow obstruction. A reduced FEV 1 % predicted indicates how severe airway obstruction is. A reduced FVC% predicted indicates restriction.

92 FEV1 /FVC Ratio A normal subject should be able to blow out 70% of their lung volume in 1 second NICE Guidelines for COPD work on < 70%

93 Obstructive Lung Function FEV1reduced <80% predicted FVC normal/ or slightly reduced RVC normal Ratio < 70% PEF can be reduced or normal MEF reduced

94 Classification of COPD using FEV1 % Predicted FEV1 % Predicted 50- 80 % 30 – 49 % < 30% Classification Mild Moderate Severe Ref: NICE COPD Guidelines 2004

95 Restrictive Lung Function FEV1Reduced FVC Reduced RVC Reduced Ratio >70% PEF Normal/ reduced MEF Normal/reduced

96 Combined Lung Disease Both airways and lung size are affected Hence, both flow and volume are reduced

97 Mixed Lung Function FEV1 Reduced FVC Reduced RVC Reduced Ratio < 70% PEF Reduced/Normal MEF Reduced

98 Case Studies Patient 1 Rtd. painter and decorator, age 65y. Smoker since young adult. Recent cough and breathlessness, otherwise fit and well, No regular meds. Fhx asthma O/E lungs clear except for few fine crackles, no wheezing P.F. 350l/min no diurnal variation on daily P.F. monitoring

99 Case studies 1 Spirometry Fev1= 1.67 ( 57% predicted) Reduced. Fvc = 2.07 (55% predicted ) Reduced Fev1/Fvc ratio 81% normal

100 Case studies 1 Conclusion Fev1 and Fvc both well below 80%predicted, however the Fev1/Fvc ratio is above 70% suggesting ‘’Restrictive’’ rather than obstructive airway condition. Diagnosis Pulmonary Fibrosis

101 Case studies 2 Patient 2 Cook, age 55y Smoker 30/day since mid 20’s Smokers cough, increasing SOBOE.

102 Case studies 2 O/E Spirometry Fev1= 1.39 ( 56% predicted ) Reduced Fvc = 2.53 ( 86% predicted ) Normal Fev1/Fvc ratio = 55% Reduced Post bronchodilator Fev1= 1.51 (+120ml and 9%) Post steroid trial Fev1=1.38

103 Case studies 2 Conclusion Spirometry shows moderate airway obstruction not significantly reversed by bronchodilators or steroids. Diagnosis Moderate COPD

104 Case studies 3 Patient 3 Retired bricklayer 69y. Smoked 40/day since national service. Rtd from work on health grounds 15y ago Productive cough, frequent bouts of bronchitis, SOBOE O/E cyanosed

105 Case studies 3 Spirometry Fev1= 0.89 ( 28% predicted) Reduced Fvc = 2.74 (67% predicted ) Reduced Fev1/Fvc ratio = 32% Severe obstruction Post bronchodilator Fev1 = 1.04 ( +150ml and 17% ) Post steroid Fev1=0.91 ( +20ml and 2% )

106 Case studies 3 Conclusion Severe COPD with no significant reversibility,

107 Case studies 4 Patient 4 Sales manager 42y old Smoker 10/day since early 20’s. Always been ‘’ chesty’’ since childhood Bouts of cough and wheeze following Urti’s from which he is always slow to recover

108 Case studies 4 O/E spirometry Fev1 = 3.24 ( 76% predicted ) slightly reduced Fvc = 4.82 (91% predicted ) normal Fev1/Fvc ratio = 67% slightly reduced Post bronchodilator Fev1= 4.17 ( +930ml and 29%)

109 Case studies 4 Conclusion Mild obstructive defect highly responsive (significant reversibility criteria is FEV1 >400ml and 15% ) to bronchodilator. Diagnosis Asthma

110 Competent performance of Spirometry110 Portfolio ARTP/BTS Foundation Certificate in Spirometry

111 Competent performance of Spirometry111 Certificate Requirements Attend an ARTP approved one day foundation course or two day Introduction to Spirometry course. Complete a work based portfolio (takes approximately 6 months). Undertake the practical assessment.

112 Competent performance of Spirometry112 Portfolio Contents Page. CV. Background information. Procedure for performing tests. How your spirometer works.

113 Competent performance of Spirometry113 Evidence from Working Practice Verification.  20 days verification results/ printouts showing within range.  Action to be taken if out of range. Quality Control.  Physiological.  Test healthy subject for 10 days.  Calculate normal physiological range. Mean over 10 days -/+ 5%. Graph or tabulate results.

114 Competent performance of Spirometry114 Graphical QC Data

115 Competent performance of Spirometry115 Evidence from Working Practice Cleaning.  Procedure.  Policy for infectious patients.  Schedule. audit trail.

116 Competent performance of Spirometry116 Patient Tests 10 patient tests required. All efforts must be shown if kit does not do this, note every effort down.  Show all efforts- even those not acceptable.  Have to check testing to known acceptability criteria. Looking for accurate results within acceptability and reproducibility criteria.

117 Competent performance of Spirometry117 Problems Encountered Easiest section !!! Problems with patient tests.  i.e slow blow. For each problem include the trace and state how to overcame problem. 5 problems.  May be referenced from patient tests section if problem occurred.

118 Competent performance of Spirometry118 Questions

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