1. Greater Glasgow Outreach Spirometry Service: A model for closer collaboration between primary and secondary care and its impact on chronic lung disease management
Dr Roger Carter
Consultant Clinical Scientist
Lead for Respiratory and Sleep Physiology services GG&C NHS

2. indoor/outdoor pollution
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
dyspnea
indoor/outdoor pollution è
SPIROMETRY

3. Why Spirometry?
Undiagnosed airflow limitation (obstruction) is common in the general population.
It is associated with impaired health and functional status.
It is an independent predictor of morbidity and mortality.
The presence of any respiratory symptoms doubles the risk of airflow limitation.
Simple measurement of peak flow cannot substitute for spirometry, either for detecting airway obstruction or for determining its severity.

4. NICE COPD 2004: Severity of obstruction FEV1/FVC <70%
FEV1 <80% >=50% Predicted:
Mild airflow obstruction
FEV1 <49% >=30% Predicted:
Moderate airflow obstruction
FEV1 <30% Predicted:
Severe airflow obstruction

5. Spirometry in Primary Care
Unlike many medical tests during which the patients remain passive, spirometry testing requires co-operation and an almost athletic breathing manoeuvre.
With submaximal effort, the results are erroneous (false positive and false negative for disease or change in severity).
The misclassification rate is about 5% in most research and sub-speciality settings , but has been shown to be higher in primary care settings.
The most common cause of error is inadequate spirometry training and experience of the person performing the test

6. Outreach Spirometry Service:Introduction
In 1997, national guidelines (BTS) for the diagnosis and management of COPD placed emphasis on spirometry for the early and accurate diagnosis of this important disease.
Spirometers are becoming more widely used in general practice, however, training in the proper use of the spirometer and basic interpretation of the results is essential, as in untrained hands, a spirometer is likely to lead to confusion.
A novel initiative by Greater Glasgow Health Board, was used to address this problem by providing an outreach spirometry service using three trained clinical physiologists to provide spirometry (with Flow/Volume loop) and, if requested, assessment of bronchodilator response at primary and secondary care centres throughout the health board district.

9. Outreach Spirometry Flow Chart
Request Form
Received Administrative Centre
Faxed to appropriate testing centre
Glasgow Royal Victoria Infirmary Gartnavel Hospital
Appointment Booked
Tests Performed at designated sites
Results Returned to Administrative Centre for Interpretation
Results and interpretation returned to Primary Care

10. Sites Originally Identified
North East
Springburn Health Centre
Easterhouse Health Centre
Baillieston Health Centre
Shettleston Health Centre
Stobhill ACH
Glasgow Royal Infirmary (4 Sessions)
South
Castlemilk Health Centre
Clarkston Community Health Centre
Victoria ACH
Southern General Hospital
Govanhill Health Centre
Gorbals Health Centre
Rutherglen Primary Care Centre
Cambuslang Health Centre
North West
Clydebank Health Centre
Drumchapel Health Centre
Maryhill Health centre
Gartnavel General Hospital (1 sessions)
Western Infirmary (2 sessions)

12. Management of stable COPD
100 80 60 40 20
Healthy population
Smokers cough
Little or no dyspnoea
No abnormal signs
Exertional dyspnoea
Cough & sputum
Some abnormal signs
Dyspnoea on mild exertion
Hyperinflation & cyanosis
Wheeze & cough
Death
Worsening lung function
FEV1 as % predicted
Increasing investigation and treatment
Smoking cessation
Antibiotics for acute infections
Trial Symptomatic bronchodilator therapy
Trial Long acting Bronchodilators
Inhaled steroid if freq exacerbations
Influenza vaccination
Pulmonary rehabilitation
Assessment for LTOT
Symptoms

13. Outreach Spirometry Activity2003-2008 Total Patients Referred 36,325
Outreach Spirometry Activity Total Patients Referred , Total Patients Seen ,428

15. Does this service help in the diagnosis and management?
Retrospective analysis of 200 consecutive complete referral forms
Interpretation of completed Spirometry results
Management advice given based on clinical information and spirometry results against the GGHB COPD Primary Care Guideline

16. RESULTS

17. Breakdown of spirometry results on the diagnosis from
200 spirometry referrals 84 39 10 12 55
New
Diagnosis
Changed
COPD
Confirmed
Confirmation
Asthma
No diagnosis
made

19. Greater Glasgow Health Board COPD Outreach Spirometry: How does primary care view the service?

24. Conclusions
1) The spirometry service does help to confirm specific abnormalities but also shows the need for quality spirometry in aiding the correct diagnosis of COPD
2) Spirometry may also help to identify some patients with asthma but due to the nature of this disease, a single normal spirometry assessment can not exclude asthma.
3) In some patients with a significant smoking history asthma may be wrongly identified as COPD.
4) A number of patients with suspected asthma are not identified by routine screening and further assessment (Formal peak flow monitoring, assessment of bronchial reactivity) would be necessary to confirm the diagnosis if clinically appropriate.
5) A “radiological” diagnosis of COPD or clinical impression of COPD may not be reflected by the findings on spirometry.

25. Spirometry Outcomes 2008: Total Seen 4931
Number %
Asthma
Possible Asthma
Mild COPD
Moderate COPD
Severe COPD
Possible COPD
Early Airways Disease
Pulmonary rehabilitation
233
? Upper Airway Obstruction
Possible Restriction
Normal
Oxygen Assessment
Unable

26. MRC Score against %predicted FEV1 in 300 Consecutive Patients

27. MRC Score against %predicted FEV1 in patients with COPD (N= 96)

28. Conclusions
1) These findings suggest that this service provision, especially when coupled with management advice and further treatment options, is of significant benefit to primary care physicians and specialist practice nurses
2) The spirometric findings and consequent treatment advice given has helped to optimise the management of patients with obstructive disorders.
3) It is used as a gateway to further management options including medication advice, full pulmonary function testing, pulmonary rehabilitation and oxygen assessment.
4) It may also help to identify those patients with early changes associated with airways disease to allow reinforcement of smoking cessation advice and hence earlier intervention.