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  1. 1. COPD: Spirometry Clare Hawkins, MD, MS Program Director, San Jacinto Methodist Hospital Family Medicine Residency, Baytown, TX Isaac M. Goldberg, MD Faculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown, TX
  2. 2. Educational Objectives At the end of this presentation, the learner should be able to … • Utilize spirometry to diagnose and stage COPD • Overcome barriers to the use of office spirometry • Achieve confidence with spirometry interpretation
  3. 3. Background Objective measure of airway function for accurate diagnosis of Chronic Obstructive Pulmonary Disease (COPD)  World Health Organization Global Obstructive Lung Disease Consensus/ Evidence guideline (GOLD)  American Thoracic Society (ATS)  European Respiratory Society (ERS)  National Committee for Quality Assurance (NCQA)
  4. 4. Background Alternate ways to diagnose COPD  Clinical Findings Late - Increased AP diameter, tympanitic chest - Signs of respiratory distress  Peak flow reading not adequately sensitive or specific  Radiographic findings occur late in disease  CT scanning more accurate, but findings also occur late in disease
  5. 5. Background Who should receive spirometry?  Early diagnosis relies on the recognition of the clinical features - Persistent cough - Chronic sputum production - Breathlessness on exertion - Reduction in activity (often attributed to natural aging)  About 20% of COPD patients identified in NHANES study with obstruction never smoked - Only 1/5 were explained by asthma
  6. 6. Background Other testing considerations  Recurrent or chronic respiratory symptoms  Occupational exposure to respiratory irritants  Family history of respiratory diseases and symptoms  NCQA established use of spirometry as required quality measure for accurate COPD diagnosis  Routine periodic use not recommended
  7. 7. Background Screening  Not recommended in the absence of respiratory symptoms (dyspnea, cough)  No threshold amount of smoking pack-years for screening in the absence of respiratory symptoms  Not recommended by USPSTF or ACP 2011 Guideline
  8. 8. Background  Family physicians able to do quality spirometry  Quality of care increases with use of spirometry - To prevent overdiagnosis of COPD, attention to quality spirometry is important  Suggestions to maintain quality of spirometry - Know technique - Have staff coach the patient - Do sufficient numbers of tests - Maintain and calibrate the equipment - Understand interpretative algorithms
  9. 9. Background Why do office spirometry?  Diagnostic accuracy. 30% of time diagnosis changes. - Was not COPD; heart failure or asthma - Was COPD rather than asthma - If spirometry normal, then expensive meds discontinued  Respect. Patients respect physicians who use technology (Future of Family Medicine)  Patient convenience. You can avoid an unnecessary referral and additional visit  Diagnostic power: You can connect diagnostic information with rest of clinical encounter  Financial benefit to practice.
  10. 10. Equipment  Older volume/time loop - Drum technique from John Hutchinson 1844  Newer flow/volume loop using flow transducer - Smaller Machines, Mobile - Disposable Mouthpiece  No other infection transmission precautions necessary
  11. 11. Equipment  Numerous manufacturers produce quality instruments  Reviews conducted by National Lung Health Education Program (NLHEP) regarding appropriateness of spirometers for office practice - http://www.nlhep.org/spirometer-review-process.html - Simplicity (fewer numbers) - Reliability
  12. 12. Equipment Calibration  Daily calibration must be done with 3 L syringe  Syringe must have accuracy of at least 15 ml  Spirometer must have accuracy of ±105 mL or 0.105 L (calibration volume = 2.90 to 3.11)  Calibration log/printouts must be kept - Date and time of calibration - Individual performing - Comments
  13. 13. Technique Forced expiratory maneuver  Coach patient to get a maximal effort  Six seconds of effort required though most of air pushed out in the first second  Pace of expired air is most important variable; therefore it should be released with explosive force
  14. 14. Technique  Minimum 6 second exhalation with 2 second plateau  Tracing should have no artifacts  At least 3 acceptable maneuvers (<5 % variation) - ATS criteria  Empty bladder for females (concern if incontinence)  Can be seated or standing  Nose plug optional
  15. 15. Technique None of the following should occur:  Unsatisfactory start, with excessive hesitation or false start  Air leak  Coughing during the first second  Early termination of forced expiration  Glottis closure  Obstructed mouthpiece - Tongue - False teeth - Chewing gum
  16. 16. Technique Reliability  Spirometry overdiagnoses COPD if insufficient effort  Concerns that family physicians will not perform quality testing and overdiagnose people with obstructive lung disease  Imperative that patients be coached on robust, forced expiratory maneuver
  17. 17. Technique Contraindications  Hemoptysis of unknown origin  Pneumothorax  Unstable cardiovascular status or recent MI or PE  Thoracic, abdominal, or cerebral aneurysms  Recent eye, thorax or abdomen surgery
  18. 18. Technique Barriers  Inaccessibility of Equipment  Concern patient effort and cooperation are insufficient  Difficulty remembering interpretive algorithm  Frustration by ambiguous results  Difficulty working 30-minute spirometry into office flow  Central location for spirometry versus going room to room  Lack of staff training  Poor integration with electronic health record  Lack of adequate reimbursement
  19. 19. Measurements Abbreviation Characteristic measured FEV1 Forced expired volume in 1 second FVC Forced vital capacity FEV1 /FVC Ratio Ratio of the above PEFR Peak expiratory flow rate FEF 25-75% Forced expiratory flow between 25-75% of the vital capacity
  20. 20. Measurements Normal values  Individual variation according to age, height, ethnicity and gender - Height - Tall people have larger lungs - Age - Respiratory function declines with age - Sex - Lung volumes smaller in females - Race - Studies show Blacks and Asians have smaller lung volumes (-12%) - Posture - Little difference between sitting and standing; reduced in supine position
  21. 21. Measurements Bronchodilator reversibility testing  Beta-agonist - Short-acting – wait 20 minutes before retesting - Long-acting – wait 2 hours before retesting  Do not take bronchodilator the day of testing - Measured reversibility will be limited if the patient is bronchodilated for the pretest.
  22. 22. Measurements Definition of reversibility  Pre-Bronchodilator - FEV1/FVC <70% of predicted  Post-Bronchodilator - Increase 12% AND at least 200 cc Reversibility = Asthma!
  23. 23. Measurements Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 2.66 1.32 50 1.26 47 -4 FEV1 2.02 0.54 26 0.50 25 -6 FEV1/FVC 76 41 -35 39 -37 -2 PEF 315 114 36 120 38 5 FEF 25 4.96 0.40 8 0.30 6 -28 FEF 50 2.85 0.20 7 0.20 7 ----- FEF 75 0.78 0.10 13 ----- ----- 198 FEF 25-75 1.02 0.19 10 0.18 10 -6
  24. 24. Measurements Severity of obstruction FEV1 % of predicted Mild >80 Moderate 50 to 79 Severe 30 to Very severe <30 Severity of restriction FVC % of predicted Mild >65 to 80 Moderate >50 to 65 Severe <50
  25. 25. Case Study 1 A 53-year-old white male presents for annual visit. Although he quit 10 years ago he is a previous cigarette smoker with a 20 pack-year history. During the past 12 months, he has had 3 episodes of bronchitis. His history of tobacco use and recent episodes of acute bronchitis lead you to perform spirometry.
  26. 26. Results Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 4.65 4.65 100 4.95 106 6 FEV1 3.75 3.13 83 3.34 89 6 FEV1/FVC 80 67 -13 67 -13 0 PEF 511 462 90 522 102 12 FEF 25 7.86 5.7 73 6.00 76 5 FEF 50 4.46 2.3 52 2.10 47 -9 FEF 75 1.75 .5 29 0.60 35 18 FEF 25-75 3.76 1.77 47 1.78 47 0
  27. 27. Results Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 4.65 4.65 100 4.95 106 6 FEV1 3.75 3.13 83 3.34 89 6 FEV1/FVC 80 67 -13 67 -13 0 Is there obstruction? FEV1/FVC = 67% of predicted; therefore, obstruction present Is there restriction? FVC = 100% of predicted; therefore, no restriction present
  28. 28. Results Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 4.65 4.65 100 4.95 106 6 FEV1 3.75 3.13 83 3.34 89 6 FEV1/FVC 80 67 -13 67 -13 0 What is the severity of obstruction? FEV1 is 83% of predicted; therefore, the obstruction is mild Is the obstruction reversible (is reversibility present)? FEV1 increases from 83% to 89% (6% increase) and increases from 3,130 cc to 3,340 cc (increase of 210 cc) Interpretation: Mild Obstruction with minimal reversibility: Mild COPD
  29. 29. Common Obstructive Pulmonary Disorders Diffuse Airway Disease Upper-Airway Obstruction Asthma COPD Bronchiectasis Cystic fibrosis Foreign body Neoplasm Tracheal stenosis Tracheomalacia Vocal cord paralysis
  30. 30. No Yes Obstructive Defect Is FVC Low? (<80% pred) Combined Obstruction & Restriction /or Hyperinflation Pure Obstruction Improved FVC with ß-agonist Reversible Obstruction with ß-agonist Further Testing with Full PFT’s Suspect Asthma Suspect COPD Is FEV1 / FVC Ratio Low? (<70%) Yes No Yes No Yes Diagnostic Flow Diagram for Obstruction Adapted from Lowry.
  31. 31. Case Study 2 A 33 year old female presents to the office complaining of dyspnea and cough for the past 2 days. Her cough is productive of a white mucous. Her past medical history is significant for asthma since childhood, obesity, gastroesophageal reflux disease (GERD), and an occasional migraine headache. She is a nonsmoker and has no known allergies.
  32. 32. Case Study 2 (cont) Her current medications include the following:  Albuterol 2 puffs po qid prn wheezing, cough, or dyspnea  Fluticasone 110 micrograms 2 puffs po bid  Ranitidine 150 mg po bid Her father recently died secondary to advanced COPD. Due to her symptoms, you order spirometry.
  33. 33. Results Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 3.78 1.92 51 2.7 71 34 FEV1 3.24 1.11 34 1.61 50 36 FEV1/ FVC 86 58 -28 60 -26 3 Obstruction? FEV1/FVC = 60%; therefore, obstruction present Restriction? FVC = 51% of predicted; therefore, restriction present
  34. 34. Results Pre-Bronchodilator Post-Bronchodilator Predicted Measured % Measured % % change FVC 3.78 1.92 51 2.7 71 34 FEV1 3.24 1.11 34 1.61 50 36 FEV1/ FVC 86 58 -28 60 -26 3 What is the severity of obstruction? 60%; therefore, moderate obstruction Is the obstruction reversible (is reversibility present)? FEV1 increases from 34% to 50% (16% increase) and increases by 500 cc What is the severity of restriction? 71% of predicted; therefore, mild restriction Interpretation: Moderate obstruction with reversibility (Moderate obstruction)
  35. 35. Common Restrictive Pulmonary Disorders Parenchymal  Interstitial Lung Diseases - Fibrosis - Granulomatosis (TB) - Pneumoconiosis - Pneumonitis (lupus)  Loss of Functioning Tissue - Atelectasis - Large Neoplasm - Resection Pleural  Effusion  Fibrosis Chest Wall  Kyphoscoliosis  Neuromuscular Disease  Trauma Extrathoracic  Obesity  Abdominal Trauma
  36. 36. No Yes Is FVC Low?(<80% pred) Restrictive Defect Normal Spirometry Further Testing with Full PFT’s; consider referral if moderate to severe Is FEV1 / FVC Ratio Low? (<70%) No Diagnostic Flow Diagram for Restriction Adapted from Lowry, 1998
  37. 37. Results Lowry 1998
  38. 38. Results “Full” Pulmonary Function Testing (PFT’s)  Assessment of Oxygenation - Transcutaneous oxygen saturation - Arterial blood gasses  Diffusion test to evaluate alveolar exchange (DLCO)  Plethysmography - To objectively assess lung volumes - Delineate air-trapping versus restriction  May also include Spirometry
  39. 39. Spirometry and Smoking Cessation  Lung age calculation - Use to motivate smoking cessation.  Mixed results - Normal results may give the impression that it’s acceptable to continue smoking. - Avoid fatalism with abnormal results.  Research results recently favor use - ACP and AHRQ advise only if symptomatic.
  40. 40. Spirometry and Smoking Cessation
  41. 41. Spirometry and Smoking Cessation
  42. 42. Coding and Reimbursement Diagnosis ICD-9 Code Cough 786.2 Simple chronic bronchitis 491.0 Mucopurulent chronic bronchitis 491.2 Acute bronchitis 466.0 Chronic obstructive pulmonary disease 496.0 Shortness of breath 786.5 Restrictive lung disease 515 Asthma 493.91
  43. 43. Coding and Reimbursement Procedure CPT Code Reimbursement* Single spirometry 94010 $32.82 Pre-post spirometry 94060 $57.71 Pulmonary stress test simple 94620 $71.77 Medication administration bronchodilator supply separate 94640 $13.34 Demonstration / instruction 94664 $14.79 Smoking Cessation <8x/ yr 99406 $12.98 Equipment Cost Office spirometer $1,000 – 2,500 *Reimbursement based upon Medicare payments 2009
  44. 44. Estimated Return on Investment Tests /week (#) Reimbursement/year* ROI $1,995 in weeks 4 $6,864 15 6 $10, 296 10 8 $13,728 7 10 $17,160 6 15 $25,740 4 20 $34,320 3 25 $42,900 2 *Based upon CPT code 94010
  45. 45. References • AARC Clinical Practice Guideline. Delivery of aerosols to the upper airway. Respir Care 1996;41(7):629-36 • Belfer M. Office management of COPD in primary care: A 2009 clinical update. Postgraduate Medicine 2009;121(4):82-90. • Blain EA, Craig TJ. The use of spirometry in a primary care setting. Int J Gen Med. 2009; 2: 183–186. • Chavez,P.C. and Shokar,N.K. Diagnosis and management of chronic obstructive pulmonary disease (COPD) in a primary care clinic. COPD 2009;6(6): 446-451. • Enright P. The use and abuse of office spirometry. Prim Care Respir J. 2008 Dec;17(4):238-42. • Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;1(6077):1645-1648. • Ferguson GT et al. Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program. Respiratory Care 2000;45(5) 513-30
  46. 46. References (continued) • Grossman E, Sherman S. Telling smokers their "lung age" promoted successful smoking cessation. Evid Based Med. 2008;13(4):104 • Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general US population. Am J Respir Crit Care Med 1999;159:179–187 • History Diagnosis Spirometer http://www.umanitoba.ca/libraries/units/health/images/HistoryDiagnosisSpir ometer.jpg • Jing JY. Should FEV1/FEV6 replace FEV1/FVC ratio to detect airway obstruction? A metaanalysis. Chest. 2009 Apr;135(4):991-8. • Johannessen A, et al. Post-bronchodilator spirometry reference values in adults and implications for disease management. Am J Respir Crit Care Med 2006; 173(12):1316-25. • Kaminsky DA, Marcy TW, Bachand M, Irvin CG. Knowledge and use of office spirometry for the detection of chronic obstructive pulmonary disease by primary care physicians. Respir Care. 2005 Dec;50(12):1639-48.
  47. 47. • Knudson RJ, Slatin RC, Lebowitz MD, Burrows B. The maximal expiratory flow-volume curve. Normal standards, variability, and effects of age. Am Rev Respir Dis 1976;113:587–600 • Lin KW Screening Spirometry. American Family Physician 2009;80(8) :861- 2. • Lowry, Josiah A Guide to Spirometry for Primary Care Physicians 1998 Published by College of Family Physicians of Canada with Boehringer Ingelheim • MacIntyre NR, Selecky PA. Is there a role for screening spirometry? Respir Care. 2010;55(1):35-42 [Review]. • National Committee on Quality Assurance. 2009 Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. 2010. Available at www.ncqa.org/tabid/855/Default.aspx. Accessed August 2010. • Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial BMJ 2008;336:598-600.
  48. 48. References (continued) • Poels PJ, olde Hartman TC, Schermer TR. Qualitative studies to explore barriers to spirometry use: a breath of fresh air? Respir Care. 2006 Jul;51(7):768. • Rennard S, Vestbo J. COPD: The Dangerous underestimate of 15%. Lancet 2006; 367, 1216-1219. • Spann SJ. Impact of spirometry on the management of chronic obstructive airway disease. J Fam Pract. 1983 Feb;16(2):271-5. • Spirometer Review Process (SRP) – Revised. http://www.nlhep.org/spirometer-review-process.html. Accessed, November 14th, 2010. • Wilt TJ, Niewoehner D, Kim C, et al. Use of spirometry for case finding, diagnosis, and management of chronic obstructive pulmonary disease (COPD). Evid Rep Technol Assess (Summ). 2005;(121):1-7 [Review]. • Yawn BP et al. Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD. Chest. 2007 Oct;132(4):1162-8. Epub 2007 Jun 5.

Notas do Editor

  • ANALOGY: Objective measurement of blood pressure, blood cholesterol, and echocardiogram used to evaluate heart disease
  • Therefore targeted evaluation programs should look beyond testing declared smokers with symptoms of COPD

    Chavez,P.C. and Shokar,N.K. Diagnosis and management of chronic obstructive pulmonary disease (COPD) in a primary care clinic. COPD 2009;6(6): 446-451.
    Belfer M. Office management of COPD in primary care: A 2009 clinical update. Postgraduate Medicine 2009;121(4):82-90.
    Spann SJ. Impact of spirometry on the management of chronic obstructive airway disease. J Fam Pract. 1983 Feb;16(2):271-5.

  • Yawn, 2007
    Enright, 2008

  • John Hutchinson, in 1844, wrote that measurements of the lungs were not only more sensitive but more importantly "it permitted doctors, whether able or inept, to make accurate judgements. No exquisite sensory training was required to obtain or understand the data.”


  • Spirometer Review Process (SRP) – Revised.
    Ferguson, 2000
  • Jing, 2009

  • A patient who does not make a maximal effort will have a spirometry curve and values which falsely look to represent obstruction.

    Patients are unable to consistently blow sub-maximally however, and therefore three FEV6 measurements within 5% of one another will be accurate
  • AARC Clinical Practice Guideline,1996
  • Blain, 2009
    Poels, 2006
    Kaminsky, 2005
  • Basic spirometry involves only the measurement of forced vital capacity (FVC) and the forced expired volume in the first second (FEV1). The ratio between the two is a self-controlled statistic which tells if obstruction is present. FVC and FEV1 can be measured against predicted values.

    PEFR is not reproducible enough measurement for accurate diagnosis, but may be used more for following progress with asthma.

    FEF 25-75% is a measurement of smaller airway function but this measurement is usually not clinically useful.
  • It is important to enter the accurate values for patient’s bio-demographic variables in order to have an accurate test, otherwise over or under-diagnosis can happen.
    When the values say >150% of predicted, one should re-enter the variables.
    There is debate over the different relationship between lung function and age before and after bronchodilation, so there is research to establish different “normal” values for post-bronchodilation spirometry.

    Johannessen, 2006
    Hankinson, 1999
    Knudson, 1976
  • GOLD guidelines no longer require “reversibility testing”, but consider it sufficient to have post-spirometry evidence of obstruction (FEV1/FVC< 70) (Some machines read this as FEV1% <70)
  • The most relevant numbers present in this table are in red. The “%” refers to the percent of the predicted value based upon the patient information entered.

    In this patient, the values actually become smaller post-spirometry and is likely secondary to fatigue. The results demonstrate no improvement rather than the minimum 12% change required to diagnose reversible bronchospasm.
  • This case study will assist in the interpretation of spirometry testing.
  • In the usual spirometry report, the number of values provided may cause confusion in interpretation. The following slide will present the values with the most clinical importance.
  • The three numbers highlighted in red provide the most clinical information:

    The FEV1/FVC ratio is 67% indicating obstruction.
    FVC is 100% indicating no restriction.
    The FEV1 is 83% of predicted with no significant reversibility.

    Interpretation: Mild Obstruction

    Ferguson, 2000
  • The further interpretation of the results indicate the mild obstruction present has minimal reversibility due to the finding that the FEV1 increases from 83% to 89% (6% increase) and increases from 3,130 cc to 3,340 cc (increase of 210 cc)

    Based upon the results of this spirometry test, the patient is motivated to make lifestyle changes. He is a woodworker and he wears a mask protection all the time now and has much improved ventilation in the workplace and avoids second-hand smoke and other irritants.

    Ferguson, 2000
  • This slide provides examples of common obstructive disorders. Asthma and COPD are by far the most common, but we should remember the others as well.
  • The results of this test provide the following information:

    Obstruction persists after bronchodilator treatment
    Restriction improves after “air trapping” relieved by bronchodilator
  • Upon further review, the following information is noted:

    Obstruction present and persists after bronchodilation so some component of “minimally reversible airways disease” is present.
    Restriction improves as the FVC changes from 51% to 71% with bronchodilator, indicating that the “air trapping” is relieved. (As an aside, if restriction is only mild, obesity may be the cause)
    The significant reversibility indicates that both asthma and COPD are present.
    After treatment with an inhaled corticosteroids and repeat spirometry in three months, all of the “air trapping” and even reversibility may be gone.
    As she is young in age, an underlying hereditary condition (i.e. alpha-1-antitrypsin deficiency) may be present

    Therefore, you diagnose asthma and COPD. You order alpha-1-antitrypsin testing and will repeat spirometry in 3 months.
  • The shapes of the curves in this graph can provide additional support in making the diagnosis of COPD. As noted by the red line, a curve which is scalloped out and leaning forward suggests obstruction.

    The shapes of the curves in this graph can give additional support in making the diagnosis of COPD diagnosis. As noted by the red line, a curve which is scalloped out and leaning away from the Y axis suggests obstruction. A curve that is straighter (green line) and leaning to the Y axis supports the diagnosis of restriction.

    Lowry, 1998
  • Office spirometry is sufficient for the confirmation and staging of COPD.

    Some patients have restrictive defects that can better be delineated through pulmonary function testing such as DLCO to evaluate the effectiveness of gas exchange or plethysmography to differentiate between small scarred lungs and large full lungs with air trapping.
  • Spirometry can be used with patients to assist with their smoking cessation efforts.

    In addition there are potential negative effects of communicating a normal spirometry to patients who are smoking. For this reason, and the fact that mild COPD only requires an as needed bronchodilator, AHRQ recommends not to “screen” asymptomatic smokers.

    Lin, 2005
    MacIntyre, 2010
  • Spirometry is necessary because we cannot assume that a person who smokes, or has smoked a great deal, has COPD.

    This curve demonstrates that when a person stops smoking, he resumes the milder slope of declining lung function.

    Also noted in the graph, only ~20% of 20 pack year smokers develop COPD. The 2009 Gold Guidelines noted that this data includes an average of many individuals. It is important not to inadvertently give the impressions that smoking is not harming them. Some patients have a very rapid decline.

    Spirometry should be repeated in a few years. The patient should be made aware that many other smoking related diseases such as lung cancer and heart disease exist.

    Fletcher, 1977
    Rennard, 2006
  • 43
  • Payment rules vary by state and by Medicare intermediary regarding medical necessity, frequency per year etc.

  • In general , spirometry is financially beneficial for most practices.