Spirometry - FMF

Spirometry
Learning objectives
• Review what spirometry can do for you
• Review who you should be sending for spirometry
• Discuss how spirometry can help differentiate asthma vs
COPD
• Discuss how spirometry can guide your therapy
• Review the limitations of spirometry
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DISCLOSURE
Why Spirometry?
Dr. Alan G. Kaplan
Chair, Family Physician Airways Group of Canada
Perceive no conflict of interest with giving this
presentation presentation, but present the following companies
that I have worked with or consulted for:
Astra Zeneca, Bayer, Boehringer Ingeleheim,
Graceway, GSK, JOI, Merck Frosst, Novartis,
Nycomed, Pfizer, Purdue, and Talecris.
In addition, I am on Health Canada committee for
Section of Allergy and Respiratory Therapeutics
and
Public Health Agency of Canada Section of
Respiratory Surveillance
Risk Monitor Tools
Hypertension Blood pressure BP Cuff
Diabetes Blood sugar Glucometer
IIschemic h i Heart H t Bl Blood d lipid li id levels l l Bl Blood d test t t
Disease
(HDL/LDL Ratio)
Lung Disease Lung Function Spirometry
COPD Diagnosis: Spirometry Indications for Spirometry
• Detect the presence or absence of lung disease
• Quantify the severity of lung disease
• Assess the change in lung function over time or following
administration of therapy
• Assess the potential effects of environmental or
occupational exposure
• Assess impairment and/or disability
• Assess risk for surgical procedure
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36.
10/16/2011
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Benefits of Spirometry
• Confirms the diagnosis of Asthma or COPD
• Assesses the severity of the illness
• Assesses the response to therapy
• Provides education and opportunity to teach delivery
devices
• Opens a dialogue for a conversation on Smoking Cessation
• Allows assessment of lung Restriction
Assessment of COPD:
Canada Lung Health Test
1. Do you cough regularly?
2. Do you cough up phlegm regularly?
33. Do even simple chores make you short of breath?
4. Do you wheeze when you exert yourself, or at night?
5. Do you get frequent colds that persist longer than
those of other people you know?
If the patient is a smoker or ex-smoker and = 40 yrs old
and answers yes to any of the listed questions,
referrals should be made for further assessment,
including spirometry.
2008 Canadian Thoracic Society recommendations for COPD. Can Respir J 2008;15 Suppl A: 1A-8A
Terms and Abbreviations
• FVC –is the volume of air
that can be forcibly expelled
from the lung from
maximum inspiration to
maximum expiration
c)
• FEV1 –the volume of air
that can be forcibly expelled
from maximum inspiration
in the first second
• FEV1 /FVC –Ratio
• PEFR – the maximum flow
rate attained during an FVC
maneuver
Flow (L/sec
5
4
3
2
1
0
PEFR
FEV1
FVC
0 1 2 3 4
Volume (L)
7
11
Who should be tested?
• All patients with suspected Asthma or COPD
• Smokers of > 20 pack years
– Screening vs. case finding
• Patients with significant occupational exposure to
respiratory irritants
• Patients with family history of respiratory diseases
• Patients undergoing lung surgery
Access to Spirometric Testing
• Portable spirometers – office use
• Pulmonary function laboratory – Respirologist’s office
• Other medical laboratories (must assure quality control)
• Need results immediately available to the clinician in order
to make treatment decisions
Lung Function Testing : Normal Effort
Flow (L/s)
6
5 5
4
3
2
1
Flow-Volume Curve Volume-Time Curve
Peak Expiratory Flow
0
0 1 2 3 4 5 6 7 8
Volume (L)
Normal curve
FEV1/ FVC >0.70
Forced Vital Capacity
Volume (L)
6
4
3
2
1
Normal
Forced Expired Volume in 1 second
(FEV 1)
0
0 1 2 3 4 5 6 7 8
Time (sec)
10/16/2011
Forced Vital Capacity (FVC)
FEV 1/ FVC >0.70
8
10
12
2

Lung Function Testing : Obstruction
Flow (L/s)
6
Flow-Volume Curve Volume-Time Curve
5 5
4
3
2
1
Peak Expiratory Flow
Obstruction
• FEV1/FVC < 0.70
• Low expiratory flows
• Low vital capacity (if severe)
0
0 1 2 3 4 5 6 7 8
Volume (L)
Normal curve
FEV1/ FVC >0.70
Forced Vital Capacity
Volume (L)
6
4
3
2
1
Normal
Mild obstruction
0
0 1 2 3 4 5 6 7 8
Time (sec)
FVC
FEV1 FVC
Severe obstruction
FEV1/ FVC = 0.44
FEV1 Normal, Obstruction & Restriction
Flow (L/sec)
12
10
8
6
4
2
Normal
Obstruction
Restriction
0
0 1 2 3 4 5 6
Volume (L)
Spirometry Criteria:
Obstruction
– reduction in flow relative
to volume (FEV1/FVC)
• expiratory time
prolonged
• airway i narrowing i f for
many reasons
– bronchial smooth
muscle, inflammation of
mucosa, mucus plugging
Restriction
–reduction in volume
• Bellows action of chest
– kyphoscoliosis, gross
obesity
• Lung parenchyma
– fibrosis
• Minimum of 3 acceptable FVC maneuvers should be
performed
– Discontinue testing after 8 attempts
– N No cough, h especially i ll dduring i th the fi first t second d
• Good ‘start-of-test’ includes:
– Extrapolated volume of ≤ 5% of the FVC or 150 mL, whichever is
greater
– No hesitation or false start
– Rapid start to rise time
• Minimum exhalation time of 6 seconds
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36. 17
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15
Lung Function Testing : Restriction
Flow (L/s)
6
Flow-Volume Curve Volume-Time Curve
5 5
4
3
2
1
Peak Expiratory Flow
Restriction
• FEV1/FVC>0.80
• High expiratory flows
• Low vital capacity
0
0 1 2 3 4 5 6 7 8
Volume (L)
Normal curve
FEV1/ FVC >0.70
Forced Vital Capacity
Performing Spirometry
Volume (L)
6
4
3
2
1
Normal
Forced Expired Volume in 1 second
(FEV1) FEV1 Restriction
0
0 1 2 3 4 5 6 7 8
Time (sec)
10/16/2011
Forced Vital Capacity (FVC)
FEV 1/ FVC >0.70
FVC
FEV1/FVC=1.00 • Ensure the patient is seated, has both feet flat on the
ground (not crossed), nose clips on nose and lips sealed
around mouthpiece
• EExplain l i the h procedure d to the h patient i
• Demonstrate the procedure to the patient
• Observe the patient’s inhalation and exhalation
• Coach: Maximum inspiration, with a good start, smooth
continuous exhalation, with maximum effort
What is not acceptable?
• Unsatisfactory start with excessive hesitation
• Coughing during the first second of maneuver
• Early termination – minimum 6 second exhalation time
• Glottis closure
• Leak
• Obstructed mouthpiece – tongue, false teeth, chewing gum
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Predicted Normal Values
Age FEV1, FVC and PEF increases, while FEV1/FVC %
decreases with age until about 20 years old in females and
25 years in males
Gender For a given height and age, males have a larger FEV1, FVC
and PEF but a slightly lower FEV1/FVC %
Height All indices other than FEV1/FVC % increase with standing
height (never rely on stated height – shoes off, arm span)
Race 10-15% adjustment for Asians and African Americans
Reference value only, not absolute right or wrong!
Diagnostic Flow Diagram For
Restriction
Is FEV 1 / FVC Ratio Low? (

Assessing Disability in COPD
Spirometry Contraindications
• Contraindications (safety or reliability issues)
– Hemoptysis of unknown origin
– Pneumothorax
– UUnstable t bl cardiovascular di l status t t ( (eg. recent t myocardial di l iinfarction f ti or
pulmonary embolus)
– Thoracic, abdominal, or cerebral aneurysms
– Recent eye, thorax or abdomen surgery
– Suspected TB or other contagious respiratory infection
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36. 27
Julie’s History
Previous Previous visits for acute
bronchitis
treated with antibiotics
four episodes episodes in last two years
Half Half a pack/day for 20 years
Grew Grew up in family of smokers
Survival in COPD – Relationship to Lung Function and Disability
Julie, 58 years old
Presentation
Worsening Worsening x 3 months
Complains Complains of SOB when walking
up stairs
Wheezing Wh Wheezing i at night i h and d productive d i
cough
10/16/2011
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Volume
(L)
4
3
2
1
0
Flow
(L/sec)
12
10
VOLUME/TIME CURVE
FEV
1
FVC
0 1 2 3 4 5 6 7 8
8
6
4
2
0
Time (seconds)
OBSTRUCTION
PEFR
FEV 1
0 1 2 3 4 5 6
Volume
(L)
NORMAL, ORMAL, OBSTRUCTION
BSTRUCTION AND ND
RESTRICTION
ESTRICTION COMPARED
OMPARED
Flow
(L/sec)
12
10
8
6
4
2
0
Normal
Obstruction
Restriction
0 1 2 3 4 5 6
Volume
(L)
NORMAL EXPIRATORY FLOW
VOLUME CURVE
12
10
8
4
2
0
PEFR
Flow 6
(L/sec) FEV1 Flow
(L/sec)
0 1 2 3 4 5 6
Volume (L)
12
10
8
6
4
2
0
RESTRICTION
ESTRICTION
PEFR
FEV 1
0 1 2 3 4 5 6
Volume
(L)
NORMAL ORMAL WITH ITH WEAK EAK EFFORT FFORT
Flow
(L/sec)
12
10
8
6
4
2
0
FEV 1
PEFR
FEV 1
0 1 2 3 4 5 6
Volume (L)
10/16/2011
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Flow (LL/sec)
12
8
4
Julie’s Spirometry Results
0
0 2 4
Volume (L)
Key Points for Julie
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Age: 58
Height: 160 cm
Sex: Female
Ethnicity: Caucasian
Smoking Smoking cessation can prevent further
long long-term term lung damage or slow the rate of
decline of lung function
If If one bronchodilator b h dil f fails, il ensure patient i i is
compliant and able to use prescribed delivery
system properly
Use Use stepwise approach to treatment plan
Canadian Respiratory Review Panel, 1998.
Pre-bronchodilator
Post-bronchodilator
Terms and Abbreviations
FVC - forced vital capacity
FEV FEV1 1second
FEV 1 /FVC
/FVC Ratio
- forced expired volume in
PEFR -peak peak expiratory flow
FEF 25 25-75% 75% -forced forced expiratory flow between
25 25-75% 75% of the vital capacity
Julie’s Spirometry Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured
%
Predicted Measured
10/16/2011
%
Change
FVC 4.37 L 4.65 L 106% 4.65 L 0%
FEV1 3.78 L 2.79 L 74% 2.94 L 7%
FEV 1/ FVC (%) 86% 60% 63%
Decline of FEV FEV1 with Age and
Smoking History
100
75
50
25
Symptoms
Smoked regularly and
susceptible to smoke
Disability
Death
0
25 50 75
Age (years)
Never smoked or not
susceptible to
smoke
Stopped at 45
Stopped at 65
Fletcher C. BMJ 1977;1:1645-1648.
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Smokers with airway obstruction
are more likely to quit
Smoking quit ratess
at 12 months (%)
50%
40%
30%
20%
10%
0%
Usual smoking quit rate with physician advice = 4 – 6%
p = 00.0003 0003 p = 00.003 003 p = 00.005 005 p = 0229 0.229
16.3%
18.5%
16.1%
14.6%
Any airway
obstruction
Severe
Obstruction
Moderate
obstruction
Bednarek M et al. Thorax 2006;61:869
2006;61:869-73. 73.
Treat the COPD
12.0%
Mild obstruction No obstruction
Smoking cessation
Vaccinations
Post BD ratio 79%
Moderate COPD
LABD either LAAC or LABA
ICS in combination to prevent exacerbations
More coming later
Julie’s Spirometry Results/2
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured
%
Predicted Measured
%
Change
FVC 4.37 L 4.65 L 106% 4.65 L 0%
FEV1 3.78 L 2.79 L 74% 3.50 L 21%
FEV 1/ FVC (%) 86% 60% 73%
What’s in a Cigarette?
♦Tobacco smoke: ≥ 4000 chemicals 1 , ≥ 50
carcinogenic 2
Chemicals in
Tobacco Smoke 1 Also Found In…
Acetone
Butane
Arsenic
Cadmium
Carbon monoxide
Toluene
Paint stripper
Lighter fluid
Ant poison
Car batteries
Car exhaust fumes
Industrial solvent
Nicotine is responsible for the addiction, but other chemicals
are also involved. 2
Smoking cigarettes with lower tar and nicotine provides no health
benefit. 2
1. World Health Organization. Tobacco: deadly in any form or disguise, 2006.
2. Health Canada. What’s in Cigarette smoke?, August 2005.
Julie’s Spirometry Results
Pre-Bronchodilator Post-Bronchodilator
Predicted Measured
%
Predicted Measured
10/16/2011
%
Change
FVC 4.37 L 4.65 L 106% 4.65 L 0%
FEV1 3.78 L 2.79 L 74% 2.94 L 7%
FEV 1/ FVC (%) 86% 60% 63%
How long after B2 to wait for repeat FEV!?
So what if…..
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Asthma: Diagnostic Algorithm
Symptoms consistent with asthma
Spirometry before and after bronchodilator
(if unavailable: peak flow monitoring, trial of therapy)
SSpirometry i t results lt normall
• Consider an alternative diagnosis and/or
• Peak flow monitoring and/or
• Bronchoprovocation challenge testing
• Introduction of treatment (appropriate only
for those with high likelihood of asthma;
diagnostic confirmation should occur at
some later date)
Kaplan A et al. CMAJ 2009;181:e210-20
Spirometry results consistent with asthma
• Administer short-acting β-agonist as needed
to relieve symptoms
• Commence anti-inflammatory therapy (usually
low-dose inhaled corticosteroids)
• Look for triggers by history and occupational
exposure, and consider allergy testing (allergen
specific skin or blood tests)
• Consider comorbidities (e.g.: rhinitis, GERD)
Arrange follow-up to reassess diagnosis, control, and treatment
GERD: gastroesophageal reflux disease
Do you want to learn more about
Spirometry?
FPAGC has a Mainpro C workshop on
spirometry interpretation that can be brought to
your community
www.fpagc.com
www www.fpagc.com fpagc com
SpiroTrec is a program that teaches your staff
how to appropriately DO spirometry
www.resptrec.org/spirotrec.php
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Pulmonary function testing = /
Spirometry
Also includes:
Measurement of Oxygen
Measurement of gas exchange
Diffusion capacity
Measurement of lung volumes
This is NOT needed for the diagnosis of
COPD, so do not order it!!
I look forward to being
able to assist you in your
respiratory needs!
www www.fpagc.com fpagc com
for4kids@gmail.com
10/16/2011
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