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

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Presentation on theme: "Spirometry Study Day 23 rd September 2010 Robert Daw Clinical Lead Nurse for COPD BACHS."— Presentation transcript:

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

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5 ….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

6 ….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

7 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

8 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

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

10 CT Scan ECG Echo Pulse Oximetry Sputum Culture Transfer factor for carbon monoxide (T L CO) Serial Domiciliary Peak Flows Alpha-1-antitrypsin

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

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15 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

16 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.

17 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.

18 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.

19 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.

20 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.

21 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

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24 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!!

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

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

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28 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

29 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

30 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

31 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

32 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

33 Could we have a volunteer please ?

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35 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

36 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

37 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

38 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

39 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

40 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

41 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

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44 BTS Guidelines Only Ethnic OriginCorrection Factor Caucasian100% Afro-CaribbeanReduce by 13% (87%) AsianReduce by 7% (93%)

45 SPIROMETRY IN PRACTICE A PRACTICAL GUIDE TO USING SPIROMETRY IN PRIMARY CARE 2 ND Edition BTS thoracic.org.uk/Portals/0/Clinical%20Information/COPD/COPD%20Consortium/spirometry_in_pract ice051.pdf GENERAL CONSIDERATIONS FOR LUNG FUNCTION TESTING ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING European Respiratory Journal STANDARDISATION OF SPIROMETRY ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING European Respiratory Journal 2005

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47 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?

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

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

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

51 Done in 70s 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

52 BTS Guidelines Only Ethnic OriginCorrection Factor Caucasian100% Afro-CaribbeanReduce by 13% (87%) AsianReduce by 7% (93%)

53 Done in 70s 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

54 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

55 Ceri 55 years old 155 cm tall FEV1 measured:1.64 l x 100 FEV1 predicted: 2.15 l FEV1 % predicted: 76%

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57 FEV1 > 80% predicted FVC > 80% predicted

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

59 COPD Asthma Bronchiectasis Tumour Foreign Body

60 Consider alternative diagnoses in: Older people without typical symptoms of COPD where the FEV 1 /FVC is <0.7 Younger people with symptoms of COPD where the FEV 1 /FVC ration is 0.7

61 FEV1 <80% predicted FVC < 80% predicted Ratio >70%

62 Kyphoscoliosis Muscular Dystrophy Problems Arthritis Pleural Problems Interstitial Lung Disease Obesity Drugs

63 FEV1 <80% predicted FVC <80% predicted Ratio <70%

64 Severe COPD Multiple Pathology e.g. Kyphscoliosis and COPD Tumour and COPD

65 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)

66 NICE Guideline (2004) ATS/ERS (2004) GOLD (2008)NICE Guideline (2010) Post- Bronchodilato r FEV 1 /FVC FEV1 % Predicted Severity of Airflow Obstruction Post - Bronchodilator <0.7 80%MildStage 1-MildStage 1-Mild* < %MildModerateStage 2- Moderate < %ModerateSevereStage 3-Severe <0.7< 30%SevereVery SevereStage 4-Very Severe** *Symptoms should be present to diagnose COPD with mild airflow obstruction **or FEV1 <50% with respiratory failure

67 MRC score BODE Modified BODE AOD

68 Grade Degree of breathlessness related to activities1 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

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71 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

72 Asthma Or COPD ?

73 ….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

74 ….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

75 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

76 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

77 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

78 COPDAsthma Smoker or ex-smoker Nearly allPossibly Symptoms under the age 35 RareOften Chronic Productive Cough CommonUncommon Breathlessness Present and progressive Variable Night time waking with breathlessness and or wheeze UncommonCommon Significant diurnal or day to day variability of symptoms UncommonCommon

79 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

80 COPDAsthma Smoker or ex-smoker Nearly allPossibly Symptoms under the age 35 RareOften Chronic Productive Cough CommonUncommon Breathlessness Present and progressive Variable Night time waking with breathlessness and or wheeze UncommonCommon Significant diurnal or day to day variability of symptoms UncommonCommon

81 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

82 Repeat Spirometry following one of the following (Post); 1. Salbutamol 100mcg MDI 4 puffs via spacer 2. Salbutamol 2.5mg nebuliser Repeat Spirometry after minutes

83 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

84 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%

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86 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

87 SPIROMETRY IN PRACTICE A PRACTICAL GUIDE TO USING SPIROMETRY IN PRIMARY CARE 2 ND Edition BTS thoracic.org.uk/Portals/0/Clinical%20Information/COPD/COPD%20Consortium/spirometry_in_pract ice051.pdf GENERAL CONSIDERATIONS FOR LUNG FUNCTION TESTING ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING European Respiratory Journal STANDARDISATION OF SPIROMETRY ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING European Respiratory Journal 2005

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89 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

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91 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 cant 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

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93 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

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95 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

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97 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

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99 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

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101 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

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103 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

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105 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

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107 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

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109 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

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