1. Interpretation Normal Spirometry Obstructive pattern Restrictive pattern Mixed pattern Small airway obstruction Non-specific ventilatory pattern Probably normal pattern Upper airway obstruction pattern Neuromuscular diseases

5. Normal Spirogram All parameters are normal Normal shape in VT and FV loop

6. A. Normal: both the FVC and the FEV 1 /VC ratio are normal. “Knee ”

7. Obstructive pattern

9. The severity of the abnormality is graded: - % Pred FEV 1 > 100 = May be a physiological variant - % Pred FEV 1 70 Mild - % Pred FEV 1 60 Moderate severe -% Pred FEV 1 50 Moderately - % Pred FEV 1 35 Severe - % Pred FEV 1 < 35 Very severe

10. Severe obstructive pattern

14. Restrictive pattern

17. The severity of the abnormality might be graded as follows: - % Pred FVC 70 mild - % Pred FVC 60 Moderate -% Pred FVC 50 Moderately severe -% Pred FVC 34 Severe - % Pred FVC < 34 Very severe

18. Mixed pattern

19. Small airway obstruction

21. Early small airway obx FV curve :upward concavity FV curve :upward concavity FVC, FEV1, FEV1/FVC :NL FVC, FEV1, FEV1/FVC :NL  FEF 25-75 ???  FEF 25-75 ??? ATS states that FEF25-75% should not be used to diagnose small airway disease or to assess respiratory impairment

22. Probably normal

23. Isolated decrease in FEF25-75 Isolated decrease in FEV1/FVC

24. Probably normal spirogram Only  FEF 25-75 Only  FEF 25-75  No small airway disease (ATS) Only  FEV1/FVC Only  FEV1/FVC FEV1> 100% Probably Normal FEV1> 100% Probably Normal FVC>100% FVC>100%

25. Nonspecific ventilatory pattern Similar to restrictive pattern Normal TLC, RV & DLco Obesity Asthma COPD Normal variant

29. Upper airway obx

30. Upper airway obstruction pattern

34. Indications for referral FEV1/FVC less than %75 and FEV1 less than %80 FEV1/FVC more than %75 and FVC less than %80 Significant reduction across time Pulmonary symptoms or signs even with normal spirogram

35. Screening Spirometry General health Occupational health screening

36. Screening Spirometry in General Healthy Population Baseline spirogram in all at 20-25 Periodic spirogram depends on risk factors such as smoking each 1-5 yrs.

37. Occupational screening spirogram In certain occupational exposures Asbestos, silica, cadmium, cotton, coal, beryllium, wood dust,…. Usually each 1-2 yrs

38. Comparison of periodic spirogram Significant change in FEV1 or FVC  Cross-shift  Week-to-week  Year-to-year Definition

39. Considerations in periodic spirogram Using:  Similar reference values  Similar patient position  Similar time  Standard spirometer  Standard technique

40. Change in spirometric indices over time malefemalemalefemale 30 ml/yr 30 ml/yr 25 ml/yr FEV1 FEV1 FVC FVC NIOSH : (0.85.initial FEV1 or FVC) – (number of yr. 0.025) (value on time 1 – value on time 2 / value on time 1) × 100

41. In an ongoing annual surveillance of asbestos workers, a 24 year old woman is found to have an FVC of 3.59 liters. Her previous FVC was 4.17 liters. What is your interpretation ? Absolute change: 4.17-3.59 =.58 liters She showed a loss of.58 liters. Percent change: ((4.17-3.59)/4.17) x 100 = 13.9% She showed a loss of 13.9% in her FVC.

42. Further investigation recommended for follow-up results if : 1. Decline in FEV1 or FVC > 15% in longitudinal screening. If the period is > 5 years, adjust for the decline due to aging (25 ml/year) 2. FEV1, FVC or FEV1/FVC < LLN at any time 3. >10% decline between pre and post shift screening

43. Case 1 A 71 yrs male Height :175,weight :88 Height :175,weight :88 FVC:45% FVC:45% FEV1: 31% FEV1: 31% FEV1/ FVC :53% FEV1/ FVC :53% FEF25-75 :15% FEF25-75 :15% TLC :142% TLC :142% very severe obx very severe obx

44. Case 2 A 36 yrs female Height :162,weight :83 Height :162,weight :83 FVC:89% FVC:89% FEV1: 94% FEV1: 94% FEV1/ FVC :89% FEV1/ FVC :89% FEF25-75 :131% FEF25-75 :131% TLC :92% TLC :92% normal normal

45. Case 3 A 29 yrs female Height :165,weight :129 Height :165,weight :129 FVC:78% FVC:78% FEV1: 79% FEV1: 79% FEV1/ FVC :86% FEV1/ FVC :86% FEF25-75 :85% FEF25-75 :85% TLC :82% TLC :82% non specific ventilatory non specific ventilatory

46. Case 4 A 43 yrs female Height :61,weight :167 Height :61,weight :167 FVC:33% FVC:33% FEV1: 17% FEV1: 17% FEV1/ FVC :42% FEV1/ FVC :42% TLC :114% TLC :114% variable inthratoracic variable inthratoracic obx obx

47. Case 5 A 30 yrs male Height :186,weight :68 Height :186,weight :68 FVC:19% FVC:19% FEV1: 21% FEV1: 21% FEV1/ FVC :93% FEV1/ FVC :93% FEF25-75% :48% FEF25-75% :48% TLC :28% TLC :28% very severe restriction very severe restriction

48. Case 6 A 30 yrs male Height :175,weight :70 Height :175,weight :70 FVC: 88% FVC: 88% FEV1: 69% FEV1: 69% FEV1/ FVC :66% FEV1/ FVC :66% FEF25-75 :38% FEF25-75 :38% VEXT : 90 VEXT : 90 moderate obx moderate obx

49. Case 7 A 29 yrs male Height :179,weight :83 Height :179,weight :83 FVC: 95% FVC: 95% FEV1: 84% FEV1: 84% FEV1/ FVC :67% FEV1/ FVC :67% FEF25-75 :51% FEF25-75 :51% VEXT : 120 VEXT : 120 Mild obx

50. Case 8 A 26 yrs male Height :177,weight :67 Height :177,weight :67 FVC: 97% FVC: 97% FEV1: 77% FEV1: 77% FEV1/ FVC :66% FEV1/ FVC :66% FEF25-75 :48% FEF25-75 :48% VEXT : 60 VEXT : 60 mild obx mild obx

51. Post bronchodilator spirometry (reversibility testing) Short-acting inhaled drugs should not be used within 4h of testing Short-acting inhaled drugs should not be used within 4h of testing Long-acting should be stopped for 12h prior test Long-acting should be stopped for 12h prior test Smoking should be avoided for ≥ 1h Smoking should be avoided for ≥ 1h Salbutamol 400 µg (4 puffs) at 30 s intervals → ≥ 10 min and up to 15 min Salbutamol 400 µg (4 puffs) at 30 s intervals → ≥ 10 min and up to 15 min Ipratropium bromide 160 µg (4 puffs)→30 min Ipratropium bromide 160 µg (4 puffs)→30 min later

52. Positive reversibility testing Percent change from baseline & absolute change in FEV1 and/or FVC : >12% AND 200 CC Other criteria include: At least 20% increase in FEF25-75%

53. A 24 yrs male Height :170,weight :82 Height :170,weight :82 FVC:80% FVC:80% FEV1: 70% FEV1: 70% FEV1/ FVC :69% FEV1/ FVC :69% FEF25-75 :50% FEF25-75 :50%

54. pre post %change pre post %change FVC 4 4.26 +7 FVC 4 4.26 +7 FEV1 2.91 3.32 +14 FEV1 2.91 3.32 +14 FEV1/ FVC 72.8 77.9 +7 FEV1/ FVC 72.8 77.9 +7 FEF25-75 2.32 3.09 +31 FEF25-75 2.32 3.09 +31

55. Case A 70 yrs male, Height :172,weight :65 pre %pred post %chg pre %pred post %chg FVC 3.13 83 3.52 +12 FVC 3.13 83 3.52 +12 FEV1 2.02 70 2.49 +23 FEV1 2.02 70 2.49 +23 FEV1/ FVC 64.5 FEV1/ FVC 64.5

56. Case A 28 yrs male, Height :192,weight :92 pre %pred post %chg pre %pred post %chg FVC 5.68 95 5.81 +2 FEV1 4.02 81 4.28 +6 FEV1/ FVC 68.2

57. Thank you