Asthma Spirometry Devices

1. AsthmaSpirometry & Devices BUMED Asthma Action Team

2. Objectives To understand the basic mechanics of respiration To have a basic understanding of how to properly administer spirometry to pediatric asthma patients. To understand the value of spirometry in the asthma clinic setting To provide patient education relating to testing and treatment

3. Dynamics of Breathing Inspiration: Negative intrathoracic pressure relative to atmosphere. Diaphragm and inspiratory muscles contract, lungs fill passively. Expiration: Passive process resulting from elastic recoil of expanded lung walls. During rapid breathing, internal intercostal and abdominal muscles contract to force air out of lungs. Expiratory effort becomes a function of muscular effort, elastic recoil of lungs and thorax, small and large airway function, and interdependence between small airways and surrounding alveoli.Expiratory effort becomes a function of muscular effort, elastic recoil of lungs and thorax, small and large airway function, and interdependence between small airways and surrounding alveoli.

4. Spirometry The measurement of the flow and volume of air entering and leaving the lungs.

5. Pulmonary Function Testing Dependent upon: Age Body Size (height and weight) Gender Pulmonary Health Altitude Irritants Effort dependant, (patient & tech) We use normal's based on age, weight, and height. Quality testing depends on the technicians skill and patient cooperation.We use normal's based on age, weight, and height. Quality testing depends on the technicians skill and patient cooperation.

6. Dynamic Lung Volumes Valuable in spirometry for following the progress of a patient with asthma Can be used to assess response to treatment (pre/post bronchodilator) Help assess lung health Does not provide the diagnosis, but can demonstrate if lung function is consistent with a diagnosis Used in conjunction with symptoms, history and physical exam.Used in conjunction with symptoms, history and physical exam.

7. Dynamic Lung Volumes Forced Vital Capacity (FVC): Volume expired by a forced maximal expiration after maximal inhalation, also known as FEV6. Forced Exp. Volume in 1 second (FEV1): Volume of air forcefully expired in the first 1 second from a position of maximal inspiration.

12. Administering PFTs in Children Requires pt cooperation (unlikely in children less than 5-6 yrs). Requires a technician who is sensitive to the needs of children. Practice makes perfect! Calm, success-oriented environment. Quality testing requires patient understanding and coperation.Quality testing requires patient understanding and coperation.

13. Administering PFTs in Children Ask child to take a full breath (to maximal inflation), followed by a brief hold. Next, perform a maximal forced exhalation for at least 3 seconds. �Blow out all your birthday candles�.� Cake and candles are part of a pediatric display to help perform PFT maneuvers.Cake and candles are part of a pediatric display to help perform PFT maneuvers.

14. Standards for the Testing Environment Torso and head should be erect in sitting or standing posture Nose clip should be used Special training is required for test administrators

15. Standards for the Testing Environment All reports should include date of birth, date of test, weight/height, sex, race, absolute values of all measurements with percent of predicted values and conditions of test VC should be reported as the largest value obtained from any of the respiratory maneuvers �Best of three� �Best� test is the one with the greatest sum of FEV1 and FVC

16. The key is patient cooperation! Testing must meet American Thoracic Society guidelines. (ATS)The key is patient cooperation! Testing must meet American Thoracic Society guidelines. (ATS)

17. Coaching during testing� Perhaps the MOST important aspect of testing. Deep breath in, BLAST it out, keep blowing, blowing, blowing, DEEP breath in, and that's done! Techs should become competent by TAD training, civilian PFT labs, extend out a Medivac to include time in the PFT lab of a major MTF, or manufacturer inservice.

22. Interpreting Results Spirometry allows comparison of patient�s lung function to reference values. Technicians should refrain from �diagnosing� any test directly to the patient. Should be interpreted by a pediatric asthma specialist until competencies are demonstrated for certification.

26. Interpreting Results Flow-volume loop: highest point of curve is the peak flow rate Volume expired versus time: helpful in determining FEV1

27. Interpreting Results Numerical data: Patient values compared to predicted values for dynamic lung volumes

28. Interpreting Results Assess quality of study! Appropriate curve shape without artifact. Sustained expiration for 3 seconds. At least 3 FVCs within 150cc�s of best effort (except in very young). Satisfactory effort as determined by tester. Response to bronchodilator >12% increase in FEV1

29. Pattern Recognition

30. Recognizing Artifact

31. Recognizing Artifact

33. Quality Assurance for Interpretations Studies should be entered into AHLTA Results should be made available to Dr. Wojtczak or Dr. Lee for review pending asthma treatment certification

34. Literature for testing� Outcomes Associated With Spirometry for Pediatric Asthma in a Managed Care Organization, Pediatrics 2006;118;151-156 Forced Expiratory Volume in 1 Second Percentage Improves the Classification of Severity Among Children With Asthma, Pediatrics 2006;118;347-355; Office Spirometry in Primary Care Pediatrics, Pediatrics 2005; 116;792-797 Guidelines for the Diagnosis and Management of Asthma, NIH, Nov 1997

35. Spirometry in Asthma Care Should be a tool for diagnosis and treatment. Can be used to help determine appropriate medications

36. Summary Spirometry is an important diagnostic tool which should be used in the primary care setting. Requires proper training for physicians, nurses, techs. Portable spirometry equipment produces quality studies and allows for testing in clinical setting.

37. Asthma Treatment Tools

38. Spirometers Ferraris KoKo Spirometer PC based, easy to use, ability to network, and a pediatric display. http://www.groupferraris.com/ferrarisrespiratory/usa/products/product_info.php?products_id=61&osCsid=7a923e38db968837f3692217ff7626f7 . About $2000.00http://www.groupferraris.com/ferrarisrespiratory/usa/products/product_info.php?products_id=61&osCsid=7a923e38db968837f3692217ff7626f7 . About $2000.00

39. Creative Biomedics DX-Portable Plus Self-contained portable unit, pediatric display http://www.creativebiomedics.com/Prod_DXPortablePlusDetails.asp. About $2100.00http://www.creativebiomedics.com/Prod_DXPortablePlusDetails.asp. About $2100.00

40. SDI Diagnostics, Spirolab II Small self-contained unit, no pediatric display, can�t network into AHLTA http://www.sdidiagnostics.com/spirolab2_highres.htm. About $1200.00http://www.sdidiagnostics.com/spirolab2_highres.htm. About $1200.00

41. Treatment Inhaler use Shake Medication Exhale Inhale medication slowly Hold your breath 10 seconds Slowly Exhale It is important that you inhale the medicine in slowly rather than try to �force� it down. You may even try to begin inhaling slightly before you expel the medicine. Spacers can make your inhalers more effective It is important that you inhale the medicine in slowly rather than try to �force� it down. You may even try to begin inhaling slightly before you expel the medicine. Spacers can make your inhalers more effective

42. Treatment . . . Is my Inhaler empty? Keep track of your puffs Controller inhalers have between 60-120 puffs Rescue inhalers have 200 puffs Replace when EMPTY Rinse mouth after using steroids! Manufacturers recommend that you keep track of your puffs in order to discern when they are empty. Preventive inhalers usually have 60 puffs and will last 1 month if used correctly. Diskus inhalers count the number of puffs for you. Rescue inhalers are difficult to count because they have so many puffs worth of medicine, about 200 puffs, and you do not use them regularly. Many manufacturers do not recommend getting your inhaler wet�the key is to dry the canister off if you use the float test. Most importantly, do not let yourself run out of medication.Manufacturers recommend that you keep track of your puffs in order to discern when they are empty. Preventive inhalers usually have 60 puffs and will last 1 month if used correctly. Diskus inhalers count the number of puffs for you. Rescue inhalers are difficult to count because they have so many puffs worth of medicine, about 200 puffs, and you do not use them regularly. Many manufacturers do not recommend getting your inhaler wet�the key is to dry the canister off if you use the float test. Most importantly, do not let yourself run out of medication.

43. Home Nebulizers Most MTF�s have units for home use. Open unit, attach nebulizer, add medication, turn on, and breath till meds are done. Recommended unit is the Devilbiss PulmoMate. Cost about $90.00.Recommended unit is the Devilbiss PulmoMate. Cost about $90.00.

44. Treatment . . . Valved Holding Chamber Insert the inhaler into the back piece of the chamber Shake, exhale, squirt, inhale slowly, hold 10 seconds and then exhale slowly Clean your spacer initially and weekly, warm soapy water, rinse well, air dry only. Some spacers �whistle� warning you that you are breathing in too quickly. Maintain good inhaler technique Some spacers �whistle� warning you that you are breathing in too quickly. Maintain good inhaler technique

45. Aerochamber with mask If using a mask, spend time getting the child used to it, seal it well over face, watch for flapper valve movement, administer meds, hold on face for 15 seconds.

46. Monitoring Asthma Peak flow meter A simple test that can be completed at home or school Follow package directions to determine �zones� Deep breath in, blast out Best of 3 efforts Record results For determining trends, patient specific Your doctor may prescribe a peak flow meter for you to use at home to give yourself an idea of how your lungs are doing on a daily basis. Your doctor may also recommend allergy testing to determine your allergiesFor determining trends, patient specific Your doctor may prescribe a peak flow meter for you to use at home to give yourself an idea of how your lungs are doing on a daily basis. Your doctor may also recommend allergy testing to determine your allergies