1. to the Spirometry Course
Welcome
to the Spirometry Course
Developed by:
Felip Burgos: Hospital Clínic of Barcelona
Jordi Giner: Hospital de la Santa Creu i Sant Pau of Barcelona
SIBELMED

2. Let's Begin

3. Spirometry History
Let's Begin

4. Let's Begin History of Spirometry Etymologically, spirometry means
the measurement of breath or breathing.
The term is attributed to Lavoisier (1862),
who discovered oxygen and gave it its name.

6. First Attempt to Measure Lung Capacity
Galen (AD  )
Doctor and Greek philosopher
In his experiment, he asked a child to breath into a bladder, observing that the volume entering the bladder did not vary with each breath. (he did not record any measurements).

7. He made more than 4000 spirometers
The First Spirometer
John Hutchinson ( ) Inventor of the spirometer.
He made more than 4000 spirometers
Born in Newcastle
He studied medicine at the University of London and surgery at Southampton.
He worked for 2 years at London Brompton Hospital, where he developed his spirometry working theories and principles (1846).
As we know it today, spirometry was developed by him when designing the spirometer model.

8. Lineal relation between VC and height
John Hutchinson ( ) vc
Lineal relation between VC and height
He observed that the volume of air that could be exhaled from the lungs when completely inflated (Vital Capacity or VC) was a good indicator of an individual's longevity.
When this measure was compromised, premature death was expected. (PROGNOSIS VALUE).

9. Other Early Spirometers
Spirometer made in 1850 (Pixxi Family, Paris 1850) and by Dr. S.W. Mitchell (1859).
Portable Spirometers
(Circa 1900).
Water Spirometer (Godart, 1960)

10. First Spirometry Performed at Hospital de la Santa Creu i Sant Pau.
(Barcelona 1958)
Unknown Author / Fons Escuela Claret

11. Ventilation Diagram VC vt I RV TLC E RV FRC RV VC: Vital Capacity8 VC
TLC
I RV 6 4 vt 2
FRC
E RV RV
VC: Vital Capacity
Vt: Tidal Volume
RV: Residual Volume
ERV: Expiratory Reserve Volume
TLC: Total Lung Capacity
FRC: Functional Residual Capacity
IRV: Inspiratory Reserve Volume

12. What is Spirometry?
Spirometry is a test which is essential to study lung function. It measures the volume of air moved during a maximum and forced exhale.
It is useful for studying respiratory problems (asthma, COPD, etc.) and to evaluate possible occupational pulmonary disorders.

13. Spirometry VEMS = FEV1 FVC8 6 4 2
VEMS = FEV1
FVC
In the
1st second
VEMS: Volume Expiratoire Maximum Seconde (Maximum Expiratory Volume in one Second)
FEV1: Forced Expiratory Volume in the first Second

14. COPD
Chronic Obstructive Pulmonary Disease is characterized by a chronic and irreversible obstruction of the airflow caused, mainly, by an inflammatory reaction to tobacco smoke. (GOLD; GESEPOC)
ASTHMA
Chronic respiratory disease characterized by the inflammation of the airways, hyperresponsive to a wide variety of stimuli and reversible bronchial obstruction. (GINA; GEMA)
Volume (L)
Flow (L/s)

15. According to their properties Characteristics (pneumotachometers)
Types of Spirometer
According to their properties
Water / Dry
Closed / Open
Volumetric / Pneumotachometer
According to their use
Pulmonary function laboratories
Patient screening
The most used are Pneumotachometers (Open)
Types of Pneumotachometer:
Lilly
Fleisch
Turbine
Ultrasonic
Venturi
Other: Hot wire, Pitot, etc....
Characteristics (pneumotachometers)
They are the open type
They are flow sensors
Flow-time relation
Calculate volumes by microprocessor
Different types of curves:
Volume/Time
Flow/Volume
Tachometer: From the Greek τάχος, tachos, ‘velocity’ and μέτρον, metron, ‘measure’
(In some bibliographies the pneumotachometer is referred to as pneumotachograph)

16. Spirometer Requirements
Measure a minimum volume of 8 liters and a flow of 0 to 14 l/s
Measure a volume with a minimum precision of ± 3% or ± 50ml (whichever is better)
Signal accumulation during 30"
Resistance to a 14 l/s flow less than 1.5 cmH2O
Assessment of the start of the maneuver by retrograde extrapolation
Simultaneous graph-plotting

17. Moves the paper and marker The bell moves when exhaling
Water Bell Spirometer
Water Spirometer
Moves the paper and marker
The bell moves when exhaling
Results are plotted

18. Moves the paper and marker When exhaling the bellows inflate
Bellows Spirometer
Closed and Dry Type
Moves the paper and marker
The results appear
Registers the forced expiration.
The most used spirometer until the pneumotachometer.
When exhaling the bellows inflate

19. Piston Spirometer Closed and Dry Type
Moves the paper, and plots results
When exhaling, the piston and marker move
Sealed cylinder prevents air escaping.

20. LILLY Pneumotachometer (operating principle)
Measurement based on the difference in air-flow pressure before and after passing through a known RESISTANCE (screen (A)), which is directly proportional to the airflow that passes through a PRESSURE SENSOR. Once the flow is obtained, the microprocessor calculates the volumes by mathematically integrating the flow with the time function.
Pneumotachometer diagram
LILLY P1 P2 B A
Disposable Lilly Pneumotachometer
Avoids cross contamination
A: Resistance
B: Pressure sensor or differential transducer
The differential transducer measures the pressure before the resistance (P1) and after the resistance (P2) to calculate the flow; using integration of the flow the volume is obtained.

21. FLEISCH Pneumotachometer (operating principle)
Measurement based on the difference in airflow pressure before and after passing through a known RESISTANCE (capillaries arranged in parallel(A)), which, is directly proportional to the flow of that passes through a PRESSURE SENSOR. Once the flow is obtained, the microprocessor calculates the volumes by mathematically integrating the flow with the time function. P1 P2 B A
Pneumotachometer diagram
FLEISCH
A: Resistance
B: Pressure sensor or differential transducer
The differential transducer measures the pressure before the resistance (P1) and after the resistance (P2) to calculate the flow; using integration of the flow the volume is obtained.

22. TURBINE (operating principle)
The TURBINE spirometer acquires physical signals and processes the information that the signal provides in relation to the pulmonary function. During the process, physical energy is converted into electrical energy. The units that produce this change are called transducers.
TRANSMITTER
RECEIVER
ROTATION
The transduction function is performed in two stages:
The volume to be measured passes through the turbine and causes the rotor to turn proportionally.
The turn is detected by a break in an infrared light beam, whose sensor converts the light received into a digital electrical signal.

23. Ultrasonic (operating principles)
To calculate the flow, these transducers use the ultrasonic wave property: when they form a certain angle with respect to the flow direction, ultrasonic waves that travel in the same direction as the flow take less time to arrive to the receiver than those traveling in the opposite direction. A B C

24. Spirometry Graphs

25. Spirometry
Volume (L)
Flow (L/s)
Time (s)
Volume (L)

26. Contribution of both graphs
Check for correct end
Check the quality of the maneuver
Flow (L/s)
Volume (L)
Ensure that the start was sudden and without hesitation
Ensure that the start was sudden and without hesitation
Time (s)
Volume (L)

27. Functional Alterations:
Obstruction
No Obstruction

28. Lung of a healthy person Lung of the same person with COPD
Lungs
Lung of a healthy person
Lung of the same person with COPD
Bronchus
Normal airway
Airway in
asthma
Airway in COPD
Relaxed smooth muscle
Muscle smooth still relaxed
Inflamed wall
Inflamed and swollen wall
Air trapped in the alveolus
Contracted smooth muscle

29. Spirometry
“Normal”
Airway
Volume (L)
Flow (L/s)
Time (s)
Volume (L)

30. Spirometry
Obstructed
Airway
Volume (L)
Flow (L/s)
Time (s)
Volume (L)

31. NON-Obstructive Airway
Spirometry
NON-Obstructive Airway
Volume (L)
Flow (L/s)
Time (s)
Volume (L)

32. Spirometry
Mixed
Airway
Volume (L)
Flow (L/s)
Time (s)
Volume (L)

33. Spirometry parameters

34. Spirometric Parameters
FVC : Forced Vital Capacity (FVC)
Volume of air expelled during a forced expiration maneuver (L).
FEV1:
Forced Expiratory Volume in the first second.
FEV1/FVC :
Expresses the volume of air expelled in the first second with respect to the maximum that can be expelled during the forced expiration maneuver.
FEV6:
Forced Expiratory Volume in the sixth second (L).
Forced Spirometry
Time (s)
Volume (L)
FEV6
FVC
FEV1

35. Spirometric Parameters
PEF (Peak Flow)
Maximum expiratory flow or peak flow.
Maximum flow achieved during the forced expiration maneuver.
It is generated before having expelled 15% of the FVC and must be maintained for a minimum of 10 ms (milliseconds)
Expressed in L/sec.
Effort-dependent parameter.
Forced Spirometry
Volume (L)
Flow (L/s)
PEF

36. Spirometric Parameters
FEF 50 %
Maximum flow when the 50% of the FVC has been exhaled.
FEF %
Maximum flow between 25% and 75% of the FVC (mid-expiratory flows).
Mid-expiratory flows may early detect obstruction (in the small tract), but they are highly variable.
Forced Spirometry
Volume (L)
Flow (L/s)
FEF
FEF 25
FEF 50
FEF 75

37. Inflamed and swollen wall
Spirometry
Obstructed
Airway
Time (s)
Volume (L)
FVC ≈ FEV6
Inflamed and swollen wall
FEV6
6 sec
FVC
1 sec
FEV1
FEV1

38. FVC ≈ FEV6
6 sec
In patients with an obstruction in the airflow, the expiratory maneuver can be tedious and prolonged, have insufficient relevance and wide variability; therefore, specific authors and consensus suggest that, in these cases, the value of FEV6 (forced expiratory volume in the sixth second) is comparable to the FVC. Likewise, the ratio FEV1/FVC would be replaced by FEV1/FEV6.

39. Which parameters should we focus on?
On the screen we can see selected some of the 'most significant' parameters. The other parameters, although important, have less relevance.

40. “Normal” Spirometry FEV1 3.9 (L) FVC 5.0 (L) FEV1/ FVC 78% FVC FVC
> 80% reference value
Volume (L)
Flow (L/s)
Between 70% and 80%
Curve
Flow / Volume
Curve
Volume / Time
Time (s)
Volume (L)
FVC
PEF
FVC
FEV1

41. “Obstructive” Spirometry
FEV (L)
FVC 4.0 (L)
FEV1/ FVC 38%
Volume (L)
Flow (L/s)
Less than 70%
Curve
Flow / Volume
Curve
Volume / Time
Time (s)
Volume (L)
FVC
PEF
FVC
FEV1

42. Progression of the Obstruction
Spirometry
Progression of the Obstruction
COPD
Chronic Obstructive Pulmonary Disease is characterized by a chronic and irreversible obstruction of the airflow caused, mainly, by an inflammatory reaction to tobacco smoke (GOLD, GESEPOC).
COPD
Flow (L/s)
Volume (L)

43. “NON-Obstructive” Spirometry
FEV (L)
FVC 1.9 (L)
FEV1/ FVC 95%
Volume (L)
Flow (L/s)
Greater than 80%
Curve
Flow / Volume
Curve
Volume / Time
Time (s)
Volume (L)
PEF
FVC
FVC
FEV1

44. Instructions and Limitations

45. Instructions
Evaluation of the respiratory capacity whenever there are respiratory symptoms.
Assessment of the respiratory impact of illnesses relating to other organs or systems (heart, kidney, liver or neuromuscular disease, etc.).
Respiratory functional disorder screening in relation to possible health-risk diseases (tobacco, work related factors, allergic processes, etc.).
Evaluation of the risks derived from surgical procedures.
Evaluation of the presence of respiratory disorders on request from professional incapacity or other types of legal evaluations.
Assessment of the therapeutic response in view of different pharmaceuticals or clinical pharmacological trials
Epidemiological studies.

46. Limitations Contraindications
Oral injuries.
Facial hemiparesis.
Nausea when introducing the mouthpiece or pneumotachometer.
In poorly-treated tracheotomies or with excessive secretions.
Contraindications
Mentally or physically impossibility to correctly perform a forced maneuver.
Chest pain, pneumothorax, hemoptysis.
Unstable angor.
Retinal detachment.
Litigant patient behavior.

47. (Also denoted THEORETICAL)
Reference Values
(Also denoted THEORETICAL)

48. Reference Values (theoretical)
Objective:
Compare the measured values with the corresponding values of Sex, Age, Size, Weight and Ethnicity.
Material (reference equations):
FVC:
M T P E
F T P E
ANTHROPOMETRY
Method:
The observed / reference values expressed as a %.

49. Reference Values (theoretical)
Recommended spirometric reference values in our environment

50. Parameter Measuring Method

51. Expressing results Dispersion around the prediction equation
The results are expressed as a % with respect to the reference value
% Vref = Vobs/Vref x 100
(The percentage of the reference value is equal to the observed value divided by the reference value multiplied by 100)
Dispersion around the prediction equation
The 95% confidence interval or 95 percentile are the same; they calculate the lower limit of the normal distribution (LIN) using the formula: LIN = VR - SEE x 1.645
99.7%
95.4%
68.3%
µ-3ơ µ-2ơ µ-ơ µ µ+ơ µ+2ơ µ+3ơ

52. Performing Spirometry

53. for Performing Spirometry
Decalogue
for Performing Spirometry 1
TRAINING
the expert that will perform the spirometry and having notions of respiratory pathologies. 2
QUALITY CONTROL
Daily verification, with a known pattern, the correct operation of the spirometer, since this proves that it is functioning within the established limits.
The daily verification and/or calibration (with a syringe of at least three liters) ensures verifiable quality control and confirms professional good practice.

54. Quality control (calibration)
Objective:
To establish a relationship between the pattern unit (syringe) and the degrees of measurement.
Material:
Syringe
(At least three liters).
Weather station (Quality spirometers already have one incorporated; otherwise, use conventional wall or desktop stations).

55. Quality control (calibration)
Method:
Daily calibration.
High, moderate and low flow *.
To verify the correct operation of a spirometer, carry out a single maneuver at moderate flow: from 2 to 5 l/s.
However, ideal verification/calibration to ensure good practice should carry out high, moderate and low flows.
* Flow Level
Low: From 0.4 to 1.2 l/s
Moderate: From to 5 l/s
High: From to 12 l/s

56. Performing Verification/Calibration
Quality control
Performing Verification/Calibration
Another method of representing the calibration depending on the make and model of the equipment.
ESP %
F l o w M l / s
I NSP %

57. Pharmaceuticals to stop taking and duration
INFORM
The patient of the procedure to follow, the reasons behind it and how to avoid problems, as well as of the importance of their cooperation. 3
Pharmaceuticals to stop taking and duration
Hours
Agonist ß2 short-acting 6
Agonist ß2 long-acting 12
Anticholinergics short-acting
Anticholinergics long-acting 24
Sustained release theophylline
AVOID
Before taking the test:
Prior administration of bronchodilators. If they have been administered, this should be recorded.
Smoking.
Vigorous exercise.
Excessive eating and/or drinking.
Tight clothing. 4

58. How to calculate the breadth5
FIND OUT
The size and weight of the patient with their shoes off and wearing light clothing, as well as their age and sex, in order to calculate the reference values.
For patients with acute chest deformity, measure their breadth instead of their size (arms extended in a cross); this should be registered in the report.
Breadth
How to calculate the breadth
Size = Breadth/ 1.06 7
SEAT
The patient in a comfortable chair with vertical back support and do not incline them forwards.
Seat the patient with their head up and legs uncrossed.
Keep the nostrils occluded using nose clips.
Place the mouthpiece into the transducer, bacterial filter or disposable transducer (only use certified products).
If the test is carried out with the patient lying flat, this must be noted.

59. 6 EXPLAIN Inhale as much as possible
In a clear and simple way how to perform the spirometry maximum and forced maneuvers.
Inhale as much as possible
Place the mouthpiece into your mouth
Blow:
STRONGLY
CONTINUALLY
WITHOUT STOPPING UNTIL I SAY SO:
it may seem that there is no more air to come out, but there is, I control it through the screen

60. more Encourage Very good Blow
When performing spirometry, it is essential to encourage the patient so that the maneuver will be valid; they need to cooperate in order to achieve a sudden, maximum and prolonged effort.
(6 seconds).
Time (s)
Volume (L)
Curve
Volume / Time
Modern spirometers incorporate incentives which are very useful in meeting this objective.

61. 8 PERFORM A slow, maximum inhalation, pause < 1 sec.
Maximum expiration, quick and forced with a sudden start.
Perform a minimum of 3 and a maximum of 8 maneuvers, ensuring that 2 of them are error-free and that the FVC and the FEV1 differences are less than 5% or 150ml (100 if the FVC is less than 1 liter).
The duration time for each maneuver should not be less than 6 seconds (3 seconds for children).
Check the lines. 8

62. Characteristics of the Maneuver Line
The maneuver line is characterized by the absence of bumps and dips.
Concaved curve
Without bumps
Without dips
A concave curve should be drawn. 62

63. Repeat Criteria
Three (3) acceptable maneuvers, in a maximum of eight (8) that comply with these criteria:
The difference between the best two, for the FVC and the FEV1, should be less than 5% or 150ml (100 ml if the FVC < 1 liter).
More than eight maneuvers tire the patient and will make it difficult to obtain better values.
Less than three maneuver may cause errors due to lack of patient training.

64. Retrograde Extrapolation
Retrograde extrapolation is the method recommended to find the zero time point (start of the maneuver).
The volume-time spirometry maneuver extends the time and volume base lines (blown-up diagram) and the cutoff point is the extrapolated zero time point.
Note:
The extrapolated volume should be equal to or less than 150ml or 5% of the FVC (the better of the two criteria).
Modern spirometers automatically calculate it and, should the value be exceeded, give a maneuver error message.
0 time point
Volume (L)
Extrapolated volume
Time (s)

65. Initial Criteria
The start of the maneuver should be quick, sudden and without hesitation.
Correct Start
Volume (L)
Time (s)

66. Initial Criteria Maneuver with a poor start.
Maneuver with a correct start.

67. Finalization Criteria
Maneuver time longer than 6 sec.
No changes for 1 sec; volume less than 25ml.
On the red background the image shows a curve that ended suddenly; on the green background the maneuver was finished correctly.
Incorrect curve, finished quickly.
Maneuver with a good finish.

68. 9
SELECT
The best FVC and FEV1 values even if they come from different maneuvers; but they meet the previous criteria.
The rest of the parameters are taken from the maneuver with the greater sum of FVC and FEV1 .

69. Which Parameters Should be Reported?
Choose the best FVC and FEV1 values, even if they come from different maneuvers.
Ideally, choose parameters from error-free maneuvers (no warnings), although in many cases this is difficult.
Once the maneuvers have been performed, report the best FVC and the best FEV1 , even though they may come from different maneuvers.
The rest of the parameters are taken from the maneuver with the greater sum of the FVC and the FEV1 . In the majority of modern equipment these criteria are automatically applied.
Once the maneuvers have been performed, report the best FVC and the best FEV1 , even though they may come from different maneuvers. The rest of the parameters are taken from the maneuver with the greater sum of the FVC and the FEV1 . Most equipment applies these criteria automatically. Ideally choose parameters from error-free maneuvers although, as will be seen later, this is difficult in many cases.

70. NLHEP Proposal on Quality Grades
(National Lung Health Education Program)
Grade
Description A
Three acceptable maneuvers (error-free) with a difference between the best two FVC and FEV1 of less than 150 ml B
Three acceptable maneuvers (error-free) with a difference between the best two FVC and FEV1 of between 151 ml and 200 ml C
Two or three acceptable maneuvers (error-free) with a difference between the best two FVC and FEV1 of between 201 ml and 250 ml D
Two or three acceptable maneuvers (error-free) with a difference between the best two FVC and FEV1 greater than 250 ml E
An acceptable maneuver (error-free) F
No acceptable maneuver (error-free)
NLHEP Proposal (Office Spirometry for Lung Health Assessment in Adults: A Consensus Statement From the National Lung Health Education Program ; CHEST: 2000; 117: )

71. Bronchodilation test 15 min PRE POST
Inhale bronchodilator
Relaxed smooth muscle
Bronchodilated airway
Contracted smooth muscle
Inflamed and swollen wall
Air trapped in the alveolus
Airway in asthma
15 min
4 inhalations (with camera)
PARAMETER
PRE
REF
(%)
POST
FVC
3.21
3.89 85
3.56 7
FEV1
2.32
3.14 74
2.65 13
FEV1/FVC
69.91
79.38 88
74.37 6
PRE POST
The test is considered positive if it produces an increase equal to or greater than:
FVC: 12% or FEV1: 12%
and additionally, a minimum of 200 ml

72. CLEANING
Given that the transducer is directly exposed to the patient, it must be kept in perfect physical and hygienic conditions.
Clean and disinfect it as per the manufacturer's instructions If this is not possible use soap and water and, wherever possible, sterilize periodically the pieces exposed to the patient.
For potentially contagious patients (HIV+, hepatitis C, pulmonary tuberculosis, etc.), use single-use pneumotachometers or carry out the test at the end of the day using antibacterial filters. Then, proceed to clean it thoroughly. 10

73. Thank You
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