1. Deep breath and blow - the HCA role in respiratory care
Hilary Andrews
Nurse Advisor
Woodlands Health Centre
Paddock Wood, Kent
What a title!
Who am I
Stress – not a full blown training session on practical use of spirometer.
Training and Assessment of Competence elsewhere after this session

2. Respiratory Care Lung Function Tests Health Promotion Peak Flow (PEFR)
Asthma
Spirometry
COPD – Monitoring, QOF
Reversibility testing – to exclude asthma
Opportunistic – Over 35yrs, asthmatic coughing smokers
Health Promotion
What do I mean by Respiratory Care?
Why might someone need Respiratory Care?
Patient scenarios
Explain that in some practices HCAs help out in asthma or COPD clinics
At other practices patients are booked in to see the HCA for spirometry alone and then return to see Dr or Practice nurse with results
Opportunistic Spirometry

3. The Respiratory System
Nasal Cavity
Pharynx
Larynx
Trachea
Right Bronchus
Left Bronchus
Right Lung
Left Lung
Heart Position

4. Asthma
Tightening of muscles surrounding bronchiole causes Bronchospasm
Allergens cause inflammation which further narrows airway
Secretions
Explain the terms:-
Inflammation
Bronchospasm – Intermittant Get them to breath through straws but explain ‘straw-wider-straw-wider’
Allergic triggers
Diurnal variation
Asthma Attack

5. COPD Chronic Obstructive Airways Disease
Umbrella term for Emphysema and Chronic Bronchitis
Walls of alveoli break down with loss of surface area
COPD is an umbrella term used for Chronic Bronchitis and Emphysema
Major cause – Smoking
LETTER NEXT

6. Other respiratory terms
Pack Years
An estimation of the amount someone has smoked
Dyspnoea
Difficulty Breathing
Orthopnoea
Breathlessness relieved by sitting upright
LTOT
Long Term Oxygen Therapy
Expectorating
Coughing up sputum
Haemoptysis
Coughing up blood
Exacerbation
Increase in severity of a disease
Cyanosis
Blueness of skin
Transcutaneous Oxygen Saturation
Concentration of oxygen in the blood measured through the skin
FEV1
Forced Expiratory Volume in 1 second (often expressed as % predicted)
FVC
Forced Vital Capacity (often expressed as % predicted)
Preventers
Medication given to prevent inflammation of airways eg steroids
Relievers
Medication given to relieve obstructed airways eg bronchodilators – salbutamol
CXR
Chest X-ray

7. PEFR Peak Flow demonstrates maximum flow rate of lungs
What device is used?
Peak Flow Meter
Technique?
‘Fast Blast’ not ‘Slow Blow’
Limitations
Insufficient effort
Poor seal
Not horizontal
When can it be performed?
Anytime, at home, in surgery, after exercise etc
PEFR Diary
Demonstrates – The key diagnostic tool for asthma
Technique –
Explanation
Demonstration
New Mouth Piece
Horizontal
Check zero
Tight Seal
‘Fast Blast’ not ‘slow blow’
Record highest reading
Reasons for inaccuracy:- Insufficient effort
Tight seal not maintained
Peak Flow meter Not held horizontally

8. Peak Flow Diary

9. Spirometry Spirometry demonstrates airflow obstruction Devices
New Diagnosis COPD
Monitoring COPD
Devices
Contraindications
Technique & Accuracy
Spirometry assess lung function by measuring the volume of air that the patient is able to expel from the lungs after a maximal inspiration.
It is the most effective way of determining the severity of COPD.
Useful for early detection of COPD (Onset of symptoms slow and insidious - many smokers initially put symptoms of COPD down to the smoking)
Preparing the Patient

10. Spirometers

11. Contraindications to Spirometry
Pneumothorax or within 2 weeks of resolution
Following recent MI
Unstable angina
Haemoptysis
Following recent eye surgery
Following recent abdominal or thoracic surgery
Following recent CVA
Previous vasovagal episodes
Cervical Disc problems
Ruptured tympanic membrane in last 6 months

12. Other points to consider prior to Spirometry
Chest infection in last four weeks
Alcohol in last four hours
Vigorous exercise in last 30 minutes
Is clothing restrictive?
Large meal eaten in previous 2 hours?

13. Technique and Accuracy
Calibration of spirometer
New mouthpiece
Checklist
Prepare the patient
Standing preferably
Breathe in as deeply as possible
Blow breath out forcibly, as hard and fast as possible
Keep blowing!
Repeat at least twice
Check for consistency in trace
Store or print results
Checklist useful for contraindications and also What information is needed to make calculations
– sex, age, height, ethnic origin, recent exacerbation, use of inhalers
Demonstrate
Do a couple of practice goes (limit total goes to 8 though)
Pinch nose or where nose clip
Blowing breath out can take up to 15 seconds (especially in severe COPD)
Repeat until best two readings are within 100mls or 5% of each other
You may be asked to measure Vital Capacity (VC) – Full inspiration followed by slow full expiration – maybe for patients unable to perform FEV1 or FVC

14. Normal Spirometry Trace

15. Identifying abnormal spirometry traces
Slow start to forced expiration
Coughing during exhalation
Other inaccuracies include:-
Inadequate inhalation
Lack of force
Lips not tight around mouthpiece
Breathing out through nose
Extra breath taken during test
Early stoppage of test

16. Health Promotion 900,000 people diagnosed with COPD in UK
450,000 estimated as being undiagnosed
Cost of COPD to NHS
£982,000,000 estimated cost/year (2004)

17. Health Promotion Therefore:- Smoking
Offer help to stop smoking at every opportunity
Smoking cessation allows the rate of decline in lung function to return to that of non-smoker
Recognition of other problems that may be affecting the patients quality of life
Get straws out again and give out sweets. Get them to try to eat sweet while breathing through straw (holding nose preferably so they cant cheat)

18. For more information
‘Spirometry in practice - A practical guide to using spirometry in primary care’
The BTS COPD Consortium