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Spirometry. “Spiro” – from the greek for breathing “Metry” – measurement “Spirometry” – The measurement of breathing. SPIROMETRY. SPIROMETRY.

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spirometry

Spirometry

“Spiro” – from the greek for breathing

“Metry” – measurement

“Spirometry” – The measurement of breathing

spirometry3
SPIROMETRY
  • Spirometry plays a key role in the diagnosis and assessment of Chronic Obstructive Pulmonary Disease and yet research shows that it is under-utilised
  • Importance highlighted with the new GMS contract
  • Reliable method of differentiating between obstructive and restrictive disorders
  • Can be used to detect the severity of disease
  • Can detect COPD before symptoms become apparent
when to perform spirometry
When to perform spirometry

Asthma

  • Interchangable with peak flow to demonstrate variability
  • May show changes suggestive of an alternative lung disease

COPD

  • At the time of diagnosis to conform obstruction
  • To reconsider the diagnosis, if the patient shows an exceptionally good response to treatment
  • Annually to monitor progression of disease

Screening?

  • All patients over 35, current or ex smokers, who have a chronic cough
  • Considered in patients with chronic bronchitis as a proportion of these will go on to develop airflow limitation

NICE (2004) – all health professionals managing patients with COPD should have access to spirometry and be competent in the interpretation of the results.

who can perform spirometry
Who can perform spirometry

Spirometry can be performed by any health care worker who is appropriately trained and who keeps his or her skills up to date

Spirometry services should be supported by quality control processes

reversibility testing
?Reversibility testing???

NICE 2004 R12

In most patients, routine spirometric reversibility testing is not necessary as a part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be misleading or unhelpful because

  • Repeated FEV1 measurements can show spontaneous fluctuations
  • Results on different occasions may be inconsistant and not reproducible
  • Unless change in FEV1 is >400mls a single test may be misleading
  • Definition of magnitude of significant change is purely arbitrary
  • Response to long term therapy not predicted by acute reversibility testing

History is Key in distinguishing asthma from COPD

patient preparation
Patient preparation

To withhold or not to withhold medication?

If you are doing reversibility testing:

  • No short acting bronchodilators for 4 hours
  • No long acting bronchodilators for 12 hours
  • No sustained release oral bronchodilators for 24 hours

For routine monitoring of COPD patients:

  • Take all medication as usual
terminology
Terminology

VC – Vital capacity, the total amount of air that acn be expelled from the lungs from full inspiration to full expiration

FVC – Forced vital capacity, should be the same volume as VC but is sometimes reduced due to air trapping in COPD

FEV1 – Forced expiratory volume in one second from full inspiration

FEV1/FVC or FEV1% or FEV1/FVC ratio –The percentage of the FVC that is produced in the first second

patient preparation14
Patient preparation

Before arrival

  • No large meal within 2 hours
  • No vigorous exercise within half an hour
  • Comfortable loose clothing
  • Empty bladder
  • ?false teeth
patient preparation15
Patient preparation

Who should not perform spirometry?

  • Recent eye surgery
  • Recent MI
  • Recent CVA or other cerebral event
  • Any recent surgery
  • Any others?
patient preparation16
Patient preparation
  • Record patients date of birth, height, ethnic origin
  • Note if the patient is currently unwell or has had a recent exacerbation
  • Ensure the patient is comfortable
  • Sit the patient in a chair with arms
  • Explain the purpose of the test
  • You may need to demonstrate the correct technique
  • Allow the patient practice attempts
patient preparation17
Patient preparation
  • Record patients date of birth, height, ethnic origin
  • Note if the patient is currently unwell or has had a recent exacerbation
  • Ensure the patient is comfortable
  • Sit the patient in a chair with arms
  • Explain the purpose of the test
  • You may need to demonstrate the correct technique
  • Allow the patient practice attempts
measuring vital capacity vc
Measuring vital capacity (VC)

The VC is a non forced measurement. It is often measured at the start of a session.

  • Patient breathes in as deeply as is comfortable
  • Seals lips around mouthpiece
  • Breathes out steadily at a comfortable pace
  • Continue until expiration complete
  • May need a nose clip
  • Repeat
measuring fev 1 and fvc
Measuring FEV1 and FVC
  • Ask the patient to take a deep breath in – full inspiration
  • Patient to blow out forcibly, as hard and fast as possible, until there is nothing left to dispell
    • Encourage patient to keep blowing
    • For some COPD patients this can take up to 15 seconds!
    • Spirometer may bleep to say manoeuvre complete
  • Repeat the procedure twice or until reproducible results
maintaining accuracy
Maintaining accuracy

The most common reason for inacurate results is patient technique

Common problems include:

  • Inadaquate or incomplete inhalation
  • Additional breath taken during manoeuvre
  • Lips not sealed around mouthpiece
  • A slow start to the forced exhalation
  • Some exhalation through the nose
  • Coughing
quality assurance
Quality assurance

Is the test valid?

Reproducibility:

  • Minimum of 2 relaxed vital capacities
  • Minimum of 3 forced vital capacities
  • Maximum of 8 forced blows in one session
  • Best 2 blows within 5% or 100ml of each other
interpreation of results
Interpreation of results
  • Take the best of the 3 consistent readings of FEV1 and of FVC
  • Find the predicted normals for your patient – Your machine may do this for you!
predicted normal values
Based on large population surveyse.g.ERS93, ECCS83

Predicted values are the mean values obtained from the survey

No surveys conducted in elderly populations

Predicted Normal values
normal ventilatory function
Normal ventilatory function
  • FVC 80 – 120% of predicted
  • FEV1 80 – 120% of predicted
  • FEV1/FVC ratio >70%
to calculate predicted
To calculate % predicted

Actual Measurement x100

Predicted Value

  • e.g. Actual FEV1 = 4.0 litres

Predicted FEV1 = 4.0 litres

4 x 100 = 100%

4

to calculate the ratio of fev1 to fvc fev1 fev1 fvc or fer
To calculate the ratio of FEV1 to FVC (FEV1%, FEV1/FVC or FER)

Actual FEV1 x100

Actual FVC

e.g. FEV1 = 3.0 litres

FVC = 4.0 litres

3 x100 =75%

4

results clasification
Results clasification
  • Normal
  • Obstructive
  • Restrictive
  • Combined
obstructive defects
Obstructive defects
  • COPD
  • Asthma
  • Bronchial carcinoma
  • Bronchiectasis
restrictive defects pulmonary causes
Fibrosing lung disease (CFA, UIP, EAA, rheumatiod)

Parenchymal tumours

Pneumoconiosis (coal workers, asbestosis, silicosis, siderosis)

Byssinosis

Pulmonary oedema

Restrictive defectsPulmonary causes
restrictive defects extra pulmonary causes
Restrictive defectsExtra-pulmonary causes
  • Thoracic cage deformity
  • Obesity
  • Cardiac fialure
  • Neuromuscular problems
  • Pneunonectomy/lobectomy
combined defects
Combined defects
  • Severe COPD
  • Advanced bronchiectasis
  • Cystic fibrosis
the history of inhalers
The history of Inhalers
  • 1956 :Riker laboratories (3M) developed the first meter dosed inhaler
  • 1969: Allen and Hanbury’s introduced inhaled salbutamol
  • 1972: introduction of first inhaled steroidClarke, 2003
aim of inhaled therapy

Aim of Inhaled therapy

Deliver high concentration of drugs directly to lungs & bronchioles while reducing systemic side effects

mdi s
MDI’s
  • Correct technique depends on knowledge & skills
  • Holder & canister act as a pump
  • Pt’s ability to use MDI has shown to decline over time
  • Good technique delivers 10-15% to small airways
  • Increase by 12% with a spacer
  • Togger,2001
meter dose inhaler mdi
Meter Dose Inhaler (MDI)
  • MDI is still the most common device used
  • Only 21% of people use inhalers correctly
medication available in the metered dose inhaler
Medication available in the metered dose inhaler
  • Terbutaline / Salbutamol
  • Ipratropium
  • Salmeterol
  • Budesonide / Beclometasone / Fluticasone / Ciclesonide
  • Seretide
spacers
Spacers
  • Several types available
  • Holding chamber & one way valve
  • Reduces need for hand breath co-ordination
  • Spacer should be compatible with MDI
  • BTS, 2003
recommendations about spacers
Recommendations about spacers

Cleaning:

Clean no more than monthly as more frequent cleaning affects performance (due to a build up of static)

Clean with water and washing up liquid and leave to air dry

Wipe mouthpiece clean of detergent before use

NOTE – Volumatic (large volume) spacer was discontinued in October 2005 and reintroduced in Feb 2006. (think patient choice/cost/ability to use)

the accuhaler
The Accuhaler

Medication available

  • Salbutamol
  • Salmeterol
  • Fluticasone
  • Seretide
    • 100/50
    • 250/50
    • 500/50
turbohaler
Turbohaler
  • Advantages less manual dexterity needed
  • No co-ordination required
  • Does not require spacer
  • Built in indicator to inform pt doses remaining
symbicort turbohaler
Symbicort Turbohaler

3 strengths

100/6, 200/6, 400/12

Other drugs available in the turbohaler

  • Terbutaline
  • Budesonide
  • Formoterol
how to use turbohaler
How to use Turbohaler®

4.Remove the inhaler from your mouth, before breathing out. Replace cover

3.Exhale, but not throughthe mouthpiece. Then inhale through the mouthpiece forcefully and deeply

2.Hold the inhaler upright and turn the grip as far as it will go in both directions (this needs to be carried out twice if using the TBH for the first time)

1.Unscrew and lift off the cover

how to use the handihaler
How to use the Handihaler
  • Open the dust cap and mouthpiece
  • Drop a Spiriva capsule into the centre chamber
  • Close the mouthpiece and press the green button to pierce the capsule
  • Breathe out completely away from the handihaler
  • Inhale through the mouthpiece and hold your breathe then inhale a second time.
what the guidelines say
What the guidelines say
  • In most cases bronchodilator therapy should be administered using a hand held inhaler device (including a spacer device if appropriate)
  • Find the most suitable device (remember that not all drugs come in all devices)
  • Patients must be trained in the use of the device and be able to demonstrate it’s use satisfactorily
  • Patients should be reassessed and re-taught correct technique regularly
  • The dose of medication should be titrated to clinical response

NICE Guidelines (Thorax 2004)