2. 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
3. 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
4. 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)
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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.
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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
21. 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
22. 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.
23. Measurements
Definition of reversibility
Pre-Bronchodilator
- FEV1/FVC <70% of predicted
Post-Bronchodilator
- Increase 12% AND at least 200 cc
Reversibility = Asthma!
26. 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
27. 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.
29. 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
30. 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
32. 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.
33. 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.
34. 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.
36. 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)
38. 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
40. 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
41. 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.
45. 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
46. 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
47. 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
48. 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.
49. • 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.
50. 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.”
http://www.umanitoba.ca/libraries/units/health/resources/historyclinicalskills.html
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.