GOLD Spirometry 2010 CorxFeb11(22)
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Transcript of GOLD Spirometry 2010 CorxFeb11(22)
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Spirometry in Primary Care
Global Initiative for Chronic ObstructiveLung Disease (GOLD) 2010
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Spirometry - Introduction
Spirometry is the gold standard for COPDdiagnosis
Underuse leads to inaccurate COPD diagnosis
Widespread uptake has been limited by:
Concerns over technical performance ofoperators
Difficulty with interpretation of results
Lack of approved local training courses
Lack of evidence showing clear benefit when
spirometry is incorporated into management
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What is Spirometry?
Spirometryis a method of
assessing lung function bymeasuring the total volume ofair the patient can expel from
the lungs after a maximalinhalation.
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Why Perform Spirometry?
Measure airflow obstruction to help make adefinitive diagnosis of COPD
Confirm presenceof airway obstruction
Assess severity of airflow obstruction in COPD Detect airflow obstruction in smokers who may
have few or no symptoms
Monitor disease progression in COPD Assess one aspect of response to therapy
Assessprognosis (FEV1) in COPD
Perform pre-operative assessment
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SpirometryAdditional Uses
Make a diagnosis and assess severity in arange of other respiratory conditions
Distinguish between obstruction and
restrictionas causes of breathlessness
Screen workforces in occupationalenvironments
Assess fitness to dive
Performpre-employment screening in certainprofessions
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Types of Spirometers
Bellows spirometers:
Measure volume; mainly in lungfunction units
Electronic desk top spirometers:
Measure flow and volume with real
time display Small hand-held spirometers:
Inexpensive and quick to use but no
print out
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Flow Measuring Spirometer
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Desktop Electronic Spirometers
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Standard Spirometric Indicies
FEV1- Forced expiratory volume in one second:
The volume of air expired in the first second ofthe blow
FVC- Forced vital capacity:
The total volume of air that can be forciblyexhaled in one breath
FEV1/FVC ratio:
The fraction of air exhaled in the first secondrelative to the total volume exhaled
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Additional Spirometric Indicies
VC - Vital capacity:A volume of a full breath exhaled in the patientsown time and not forced. Often slightly greaterthan the FVC, particularly in COPD
FEV6Forced expired volume in six seconds:Often approximates the FVC. Easier to performin older and COPD patients but role in COPD
diagnosis remains under investigation
MEFR Mid-expiratory flow rates:Derived from the mid portion of the flow volume
curve but is not useful for COPD diagnosis
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Criteria for NormalPost-bronchodilator Spirometry
FEV1: % predicted > 80%
FVC: % predicted > 80%
FEV1/FVC: > 0.7 - 0.8, dependingon age
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SPIROMETRY
OBSTRUCTIVE
DISEASE
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Spirometric Diagnosis of COPD
COPD is confirmed by postbronchodilator FEV1/FVC < 0.7
Post-bronchodilator FEV1/FVC
measured 15 minutes after 400gsalbutamol or equivalent
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Bronchodilator Reversibility Testing
Provides the best achievable FEV1(and FVC)
Helps to differentiate COPD fromasthma
Must be interpreted with clinicalhistory - neither asthma nor COPDare diagnosed on spirometry alone
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Figure 5.1-6.
BronchodilatorReversibilityTesting in COPD
GOLDReport (2009)
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Figure 5.1-6. BronchodilatorReversibility Testing in COPD
Preparation
Tests should be performed when patients areclinically stable and free from respiratory infection
Patients should not have taken:
inhaled short-acting bronchodilators in theprevious six hours
long-acting bronchodilator in the previous 12hours
sustained-release theophylline in the previous
24 hours
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Figure 5.1-6. BronchodilatorReversibility Testing in COPD
Spirometry (continued)
Possible dosage protocols: 400 g 2-agonist, or 80-160 g anticholinergic, or the two combined
FEV1 should be measured again:15 minutes after a short-acting bronchodilator45 minutes after the combination
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Figure 5.1-6. BronchodilatorReversibility Testing in COPD
Results
An increase in FEV1that is bothgreaterthan 200 ml and 12% above the pre-
bronchodilator FEV1(baseline value) isconsidered significant
It is usually helpful to report the absolutechange (in ml) as well as the % changefrom baseline to set the improvement in a
clinical context
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Criteria: Restrictive Disease
FEV1: normal or mildly reduced
FVC: < 80% predicted
FEV1/FVC: > 0.7
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Volume,
liters
Time, seconds
FEV1= 1.9L
FVC = 2.0L
FEV1/FVC = 0.95
1 2 3 4 5 6
5
4
3
2
1
Spirometry: Restrictive Disease
Normal
Restrictive
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Mixed Obstructive/Restrictive
FEV1: < 80% predicted
FVC:< 80% predicted
FEV1/FVC: < 0.7
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SPIROMETRY
Flow Volume
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Flow Volume Curve
Standard on most desk-top spirometers
Adds more information than volume
time curve Less understood but not too difficult to
interpret
Better at demonstrating mildairflowobstruction
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Flow Volume Curve
Expiratoryflow rateL/sec
Volume (L)
FVC
Maximumexpiratory flow(PEF)
Inspiratoryflow rate
L/sec
RVTLC
Flow Volume Curve Patterns
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Flow Volume Curve PatternsObstructive and Restrictive
Obstructive Severe obstructive Restrictive
Volume (L)
Ex
piratoryflowr
ate
E
xpiratoryflow
rate
E
xpiratoryflow
rate
Volume (L) Volume (L)
Steeple pattern,reduced peak flow,
rapid fall off
Normal shape,normal peak flow,
reduced volume
Reduced peak flow,scooped out mid-
curve
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PRACTICAL SESSION
Performing Spirometry
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Spirometry Training
Training is essential for operators to learn correctperformance and interpretation of results
Training for competent performance of spirometry
requires a minimum of 3 hours Acquiring good spirometry performance and
interpretation skills requires practice, evaluation,and review
Spirometry performance (who, when and where)should be adapted to local needs and resources
Training for spirometry should be evaluated
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Performing Spirometry - Preparation
1. Explain the purpose of the test anddemonstrate the procedure
2. Record the patients age, height and
gender and enter on the spirometer
3. Note when bronchodilator was last used
4. Have the patient sitting comfortably
5. Loosen any tight clothing
6. Empty the bladder beforehand if needed
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f
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Watchthe patient during the blow toassure the lips are sealed around themouthpiece
Check to determine if an adequatetrace has been achieved
Repeat the procedure at least twicemore until ideally 3 readings within 100ml or 5% of each other are obtained
Performing Spirometry
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Three times FVC within 5% or 0.15 litre (150 ml)
Reproducibility - Quality of Results
Vo
lume,
liters
Time, seconds
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Spirometry - Possible Side Effects
Feeling light-headed
Headache
Getting red in the face Fainting: reduced venous return or
vasovagal attack (reflex)
Transient urinary incontinence
Spirometry should be avoided after
recent heart attack or stroke
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Spirometry - Quality Control
Most common cause of inconsistentreadings is poor patient technique
Sub-optimal inspiration
Sub-maximal expiratory effortDelay in forced expiration
Shortened expiratory time
Air leak around the mouthpiece
Subjects must be observed and encouragedthroughout the procedure
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SpirometryCommon Problems
Inadequate or incomplete blow
Lack of blast effort during exhalation
Slow start to maximal effort
Lips not sealed around mouthpiece Coughing during the blow
Extra breath during the blow
Glottic closure or obstruction of mouthpiece
by tongue or teeth
Poor postureleaning forwards
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Equipment Maintenance
Most spirometers need regular calibration tocheck accuracy
Calibration is normally performed with a 3 litre
syringe Some electronic spirometers do not require
daily/weekly calibration
Good equipment cleanliness and anti-infectioncontrol are important; check instruction manual
Spirometers should be regularly serviced; check
manufacturers recommendations
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Troubleshooting
Examples - Unacceptable Traces
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bl S l
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Vo
lume,
liters
Time, seconds
Unacceptable TraceStop Early
Normal
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U bl T C hi
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Vo
lume
,liters
Time, seconds
Unacceptable Trace - Coughing
Normal
U t bl T E t B th
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Vo
lume,l
iters
Time, seconds
Unacceptable TraceExtra Breath
Normal
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Some Spirometry Resources
Global Initiative for Chronic Obstructive LungDisease (GOLD) - www.goldcopd.org
Spirometry in Practice - www.brit-thoracic.org.uk
ATS-ERS Taskforce: Standardization ofSpirometry. ERJ2005;29:319-338www.thoracic.org/sections/publications/statements
National Asthma Council: Spirometry Handbookwww.nationalasthma.org.au
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