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Spirometry Interpretation

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Spirometry Interpretation

  1. 1. Spirometry Interpretation
  2. 2. Data generated  Volume time curve (spirogram)  FEV1, FVC, Ratio  Flow volume loop  Peak flow  FVC  FEF 25-75% MEF 75, 50, and 25  Inspiratory flow data
  3. 3. Normal Values  FVC  80 – 120% of predicted is a normal value  70 – 80% demonstrates mild reduction/restriction  50 – 70% demonstrates moderate reduction <50% demonstrates severe reduction
  4. 4. Normal Values  FEV1  80 – 120% of predicted is a normal value  70 – 80% demonstrates mild reduction/restriction  50 – 70% demonstrates moderate reduction <50% demonstrates severe reduction
  5. 5. Normal Values  FEF25-75 reflects small airway function ● >80% is normal ● 60 – 80% reflects mild obstruction in the small airways ● 40 – 60% reflects moderate obstruction ● <40% reflects severe obstruction
  6. 6. Criteria for Normal Post-bronchodilator Spirometry  FEV1: % predicted > 80%  FVC: % predicted > 80%  FEV1/FVC: > 0.7 - 0.8, depending on age
  7. 7. Obstructive Pattern o Decreased FEV1/FVC - <70% predicted o Decreased FEV1 < 80% predicted o FVC can be normal or reduced – usually to a lesser degree than FEV1 o FEV1 used to grade the severity
  8. 8. Restrictive Pattern  FEV1: Normal or mildly reduced  FVC: < 80% predicted  FEV1/FVC: Normal or increased > 0.7
  9. 9. Mixed Obstructive/Restrictive  FEV1: < 80% predicted  FVC: < 80% predicted  FEV1 /FVC: < 0.7
  10. 10. 12
  11. 11. Notes ➔ Spirometry which is not performed correctly may produce misleading results. ➔ The FEV1, FVC and FEV1/FVC ratio are all necessary to interpret spirometry. ➔ An obstructive defect causes a reduction in FEV1 and a reduced FEV1/FVC ratio. ➔ Restrictive defects cause a reduction in FVC with a normal or high FEV1/FVC ratio.
  12. 12. Notes ➔ 12% and 200 mL or more improvement in either FEV1 or FVC after bronchodilator indicates significant reversibility. ➔ The FEV1/FVC ratio should not be used to assess reversibility. ➔ Correct interpretation of spirometry requires that it be performed correctly (ATS/ERS criteria for acceptable and repeatable Spirometry).
  13. 13. To obtain an accurate recording the subject should be told to: • Sit up straight • Get a good seal around the mouthpiece of the spirometer • Rapidly inhale maximally (‘breathe in all the way’) • Without delay, blow out as hard and as fast as possible (‘blast out’) • Continue to exhale (‘keep going … keep going’) until the patient can blow no more.
  14. 14. Expiration should continue for at least 6 seconds (3 seconds in children under 10 years old) and up to 15 seconds if necessary (some patients will find this exhausting and prolonged manoeuvres should be used with caution) Manoeuvres are repeated until at least three technically acceptable manoeuvres (NO coughs, air leaks, false starts) are completed.
  15. 15. If required, more tests should be done to try to meet repeatability criteria (no more than 8 attempts in total). Poor measurement technique can produce results which mimic disease patterns. Common errors occur when the patient fails to inhale fully before the test, stops blowing too early (apparent restrictive defect), or doesn’t blow out hard enough (apparent obstructive defect).
  16. 16. TECHNIQUE OF SPIROMETRY The patient must be clinically stable, should sit straight, with head erect, nose clip in place, and holding the mouthpiece tightly between the lips. Initially, he or she should breathe in and out at the tidal volume ( V T : normal quiet breathing) to record the tidal flow–volume loop. Then, when the patient is ready, the technician instructs him/her to inhale maximally to TLC , and then exhale as fast and as completely as possible to record the FVC .
  17. 17. TECHNIQUE OF SPIROMETRY The point at which no more air can be exhaled is the RV . The patient is then instructed to inhale fully to TLC again in order to record the IVC . This test is then repeated to ensure reproducibility in order to meet quality control criteria (American Thoracic Society or ATS criteria) .
  18. 18. Flow/Volume loop 12 8 4 0 -4 -8 Flow (L/s) PEF Man 176 cm 76 kg Volume (L)
  19. 19. ATS/ERS criteria for acceptable and repeatable Spirometry ACCEPTABILITY CRITERIA 1.Free from artefacts (such as cough or glottis closure early in expiration) 2.Free from leaks 3.Good starts — extrapolation back from the peak flow (which is the steepest part of the spirogram curve) produces a theoretical start time from which the measurements should be timed. This ‘new time zero’ should occur within 5% of the FVC or within 150 mL
  20. 20. ATS/ERS criteria for acceptable and repeatable Spirometry Acceptability Criteria Acceptable exhalation — Adults: at least 6 seconds of exhalation and a plateau in the volume curve (plateau = no detectable change in volume over 1 second) — Children aged under 10: at least 3 seconds of exhalation and a plateau in the volume curve
  21. 21. Acceptability The ATS mandates three acceptable maneuvers. The number of trials that can be performed on an individual should not exceed 8. An acceptable trial should have a good start, a good end, and absence of artifacts. 1. Good start of the test: • If the study needs back extrapolation, the extrapolation volume should not exceed 5% of FVC or 150 ml, whichever is larger.
  22. 22. Note : Back extrapolation applies to the VT curve and means that if the start of the test is not optimal, correction can be made by shifting the time axis forward, provided that the extrapolation volume is within either one of the limits mentioned earlier. To simplify this, consider that a patient’s FVC is 2 L and the study requires a back extrapolation correction, and 5% of the FVC (2 L) is 100 ml. Because 150 ml is larger than 5% of the patient’s FVC (100 ml), 150 ml should be used as the upper limit of extrapolated volume. Then, if the measured extrapolated volume is greater than 150 ml, the result cannot be accepted.
  23. 23. Extrapolation volume of 150 ml or 5% of FVC (whichever is larger)
  24. 24. Note : A good start of the study can be identified qualitatively on the FV curve as a rapid rise of flow to PEF from the baseline (0 point), with the PEF being sharp and rounded. The FEV 1 can be over- or underestimated with submaximal effort, which may mimic lung disorders such as those due to airway obstruction or lung restriction;
  25. 25. 2. Smooth flow–volume (FV) curve, free of artifacts : These artifacts will show in both volume–time (VT) and FV curves but will be more pronounced in the FV curve. These artifacts include the following: (a) Cough during the 1st second of exhalation may significantly affect FEV 1 . The FV curve is sensitive in detecting this artifact; Coughing after the 1st second is less likely to make a significant difference in the FVC and so it is accepted provided that it does not distort the shape of the FV curve (judged by the technician).
  26. 26. (a) Cough during the 1st second of exhalation may significantly affect FEV 1 . Cough in the 1st second. It is much clearer in the FV curve than in the VT curve as indicated by the arrows
  27. 27. (b) Variable effort
  28. 28. (c) Glottis closure; (d) Early termination of effort. (e) Obstructed mouthpiece, by applying the tongue through the mouthpiece or biting it with the teeth. (f) Air leak : • The air leak source could be due to loose tube connections or, more commonly, because the patient weakly applies lips around the mouthpiece. Air leak can be detected from the FV loop
  29. 29. 3. Good end of the test (demonstrated in the VT curve): (a) Plateau of VT curve of at least 1 s, i.e.volume is not changing much with time indicating that the patient is approaching the residual volume (RV). OR (b) Reasonable duration of effort (FET) : • Six seconds is the minimum accepted duration (3 s for children) . • Ten seconds is the optimal. .
  30. 30. • FET of >15 s is unlikely to change the clinical decision and may result in the patient’s exhaustion. Patients with obstructive disorders can exhale for more than 40 s before reaching their RV, i.e., before reaching a plateau in the VT Curve Normal individuals, however, can empty their lung (i.e., reach a plateau) within 4 s
  31. 31. (c) The patient cannot or should not continue to exhale. Note : A good end of the study can be shown in the FV curve as an upward concavity at the end of the curve. A downward concavity, however, indicates that the patient either stopped exhaling (prematurely) or started inhaling before reaching the RV . This poor technique may result in underestimation of the FVC.
  32. 32. Poor end in comparison to good end (small upward concavity) of FV curve. A poor end (downward concavity) indicates premature termination of exhalation (before 0 flow)
  33. 33. ATS/ERS criteria for acceptable and repeatable Spirometry REPEATABILITY CRITERIA • Three acceptable manoeuvres (meeting above criteria) • The two largest FVC measurements within 150mL of each other • The two largest FEV1 measurements within 150mL of each other When both acceptability and repeatability criteria are met, the test can be concluded. Up to 8 manoeuvres should be performed until the criteria are met or the patient is unable to continue. As a minimum, the three satisfactory (or best) manoeuvres should be saved.
  34. 34. Reproducibility After obtaining three acceptable maneuvers, the following reproducibility criteria should be applied: – The two largest values of FVC must be within 150 ml of each other. – The two largest values of FEV 1 must be within 150 ml of each other. If the studies are not reproducible, then the studies should be repeated until the ATS criteria are met or a total of eight trials are completed or the patient either cannot or should not continue testing.
  35. 35. • The final values should be chosen based on the following : – FEV1 and FVC should be reported as the highest values from any acceptable/reproducible trial (not necessarily from the same trial). – The other flow parameters should be taken from the best test curve (which is the curve with the highest sum of FVC + FEV1). – If reproducibility cannot be achieved after eight trials, the best test curve (the highest acceptable trial) should be reported. The technician should comment on this deviation from protocol so that the interpreting physician understands that the results may not be accurate. .
  36. 36. Acceptable and reproducible trials
  37. 37. Acceptable trials are not necessarily reproducible,because the patient may not produce maximum effort in all trials
  38. 38. Keep in mind that the lack of any of these features may indicate a lung disorder rather than a poor study
  39. 39. Spirometry interpretation  Obstructive v. Restrictive  Mid flow obstruction  Shape of the FV loop Obstruction v. restriction  Fixed large airway obstruction  Variable airway obstruction 1. Extrathoracic 2. Intrathoracic
  40. 40. Key Notes 1. be conservative in suggesting a specific diagnosis based only on pulmonary function abnormalities. 2. Interpret borderline normal values with caution. 3. First step = to evaluate and comment on the quality of the tests.
  41. 41. Good Measurements are Essential! Acceptable Loop Unacceptable Loop
  42. 42. Spirometry Quality
  43. 43. 48
  44. 44. Quality Check Patient should exhale suddenly and forced. Patient should exhale suddenly and forced Patient should cough before starting the measurement Patient should inhale longer and to the maximum Patient should exhale as long as possible; minimal 6 s www.spiro-webCard.de
  45. 45. 50
  46. 46. 51
  47. 47. 52
  48. 48. 53
  49. 49. 54
  50. 50. 55
  51. 51. 57
  52. 52.  The standard normal values roughly range from 80 to 120% of the predicted values that are derived from Caucasian studies.  When you interpret a PFT, you should always look at the patient’s results as percentage of the predicted values for that particular patient (written in the report as % pred.).  If the patient is normal, then his/her values should roughly lie within 80–120% of predicted values.*
  53. 53. 59 Obstructive Lung dis. RLD Interinsic RLD Extrinsic FEV1 FVC FEV1/FVC RV TLC RV/TLC VC FRC
  54. 54. ● Only need to look at 5 numbers ● Look at the post bronchodilator values too! FEV1 % Predicted FVC % Predicted FER (FEV1 / FVC ratio)
  55. 55. Features of obstructive disorders  Diagnostic features: ↓ FEV 1 /FVC ratio  Other features:  ↓ FEV 1  ↓ FVC (can be normal)  ↓ FEFs and MMEF (FEF 25 , FEF 50, FEF 75 , FEF 25–75 )  ↓ PEF  ↓ FET  Significant bronchodilator response  Scooped (concave) descending limb of FV curve
  56. 56. Obstructive Disorders  The two major obstructive disorders are bronchial asthma and COPD .  The key to the diagnosis of these disorders is the drop in FEV 1 /FVC ratio.   FEV 1 may be reduced too and is used to define the severity of obstruction  FVC may be reduced in obstructive disorders but usually not to the same degree as FEV 1 .
  57. 57. Obstructive Disorders  The flow–volume curve can be used alone to confidently make the diagnosis of obstructive disorders, as it has a distinct shape in such disordersThese features include the following: – The height of the curve (PEF) is much less than predicted. – The descending limb is concave (scooped), with the outward concavity being more pronounced with more severe obstruction. – The slope of the descending limb that represents MMEF and FEFs is reduced due to airflow limitation at low lung volumes.
  58. 58. Obstructive Disorders There are five features that make the diagnosis of a significant airway obstruction definite, based on The FV curve alone. 1 – Decreased PEF when compared to the predicted curve. 2 – Scooping of the curve after PEF, indicating airflow limitation. 3 – The 1st second mark is almost in the middle of the curve indicating that the FEV 1 and FEV 1 /FVC ratio are significantly decreased.
  59. 59. Obstructive Disorders 4 – FVC is decreased when compared to the predicted curve. 5 – The inspiratory component of the curve is normal, excluding a central airway obstruction. ( b ) There is a clear response to bronchodilators indicating reversibility and supporting the diagnosis of an obstructive disorder, most likely bronchial asthma
  60. 60.  Lack of bronchodilator response does not exclude bronchial asthma as responsiveness can vary over time.  Similarly many patients with COPD can show reversibility.  Reversibility in the correct clinical context (i.e. young nonsmoker) supports the diagnosis of asthma.
  61. 61. • Special Conditions – In mild (or early) airway obstruction, the classic reduction in FEV1 and FEV1/FVC ratio may not be seen. – The morphology of the FV curve can give a clue, as the distal upward concavity may show to be more pronounced and prolonged – Another clue is the prolonged FET evident in the VT curve
  62. 62. Mild airway obstruction, with prolonged duration of exhalation (20 s)
  63. 63. • Special Conditions – In emphysema and because of loss of supportive tissues, the airways tend to collapse significantly at low lung volumes, giving a characteristic “dog-leg” appearance in FV curve
  64. 64. Features of restrictive disorders  Most important features: ↓ FVC and normal or ↑ FEV 1 /FVC ratio  Other features:  ↓ FEV 1 (proportional to FVC), but it can be normal  ↓ MMEF  PEF: normal, increased, or decreased  Steep descending limb of FV curve
  65. 65. Restrictive Disorders  In restrictive disorders, such as pulmonary fibrosis, the key to the diagnosis is the drop in FVC, as the volume of the air spaces is significantly lower than normal.   The lung elasticity increases and the lungs retract.  The FEV 1 /FVC ratio has to be preserved or increased.
  66. 66.  To make a confident diagnosis of a restrictive disorder, the TLC should be measured and should be low.  So, based on spirometry alone, the earlier features are reported as suggestive (not diagnostic) of a restrictive disorder.  Remember that normal FVC or VC excludes lung restriction.
  67. 67. FV curve features of different forms of restriction: ( a ) ILD with witch’s hat appearance; ( b ) chest wall restriction (excluding NMD);
  68. 68. FV curve features of different forms of restriction: ( c ) NMD (or poor effort study) producing a convex curve
  69. 69. This is a widely used grading system but different organizations use different systems of grading.
  70. 70. GRADING OF SEVERITY  Different variables and values were used to grade severity of different pulmonary disorders  Recently, FEV 1 has been selected to grade severity of any spirometric abnormality (obstructive, restrictive, or mixed)  The traditional way of grading severity of obstructive and restrictive disorders involve the following:
  71. 71. GRADING OF SEVERITY  The traditional way of grading severity of obstructive and restrictive disorders involve the following: – In obstructive disorders, the FEV1/FVC ratio should be <0.7, and – The value of FEV1 is used to determine severity
  72. 72. GRADING OF SEVERITY – In restrictive disorders, however, FEV1/FVC ratio is normal and the TLC is less than 80% predicted. – The ATS suggested using the TLC to grade the severity of restrictive disorders, which cannot be measured in simple spirometry. – Where only spirometry is available, FVC may be used to make that grading. – The TLC, however, should be known before confidently diagnosing a restrictive disorder
  73. 73. Nomogram algorithm for separating obstructive from restrictive defects Nomogram algorithm for separating obstructive from restrictive defects
  74. 74. Spirometry interpretation Inhaled B2 reverse 11/13/14 FEV1/FVC Obstruction Mixed* * FVCต้อง ตำ่ำ FVC Normal Mixed Restriction* FEF25-75% Small airway disease Normal spirometry Reversible airway obstruction Irreversible airway obstruction Low Low Low Normal Yes No Normal or Increase * Definite Dx ดู TLC
  75. 75. 85
  76. 76. 86
  77. 77. Diagnostic Flow Diagram for Restriction Is FEV1 / FVC Ratio Low? (<70%) Is FVC Low?(<80% pred) Yes No Restrictive Defect Normal Spirometry Further Testing with Full PFT’s; consider referral if moderate to severe No Adapted from Lowry, 1998
  78. 78. Diagnostic Flow Diagram for Obstruction Obstructive Defect Is FVC Low? (<80% pred) Combined Obstruction & Restriction /or Hyperinflation No Yes 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 Yes No Yes No Adapted from Lowry.
  79. 79. Nomogram algorithm for separating obstructive from restrictive defects Nomogram algorithm for separating obstructive from restrictive defects
  80. 80. 90 American family physican 2004
  81. 81. 92
  82. 82.  Know the 3 aspects of lung function test: 1) spirometry 2) volumes 3) diffusion
  83. 83. Normal values Spirometry:  FEV1 and FVC >80% predicted.  FEV1/FVC >80% predicted. Volumes: 80-120%. Diffusion: 75-125%.
  84. 84.  Low FVC suggest possible restriction but need to look at TLC to confirm (TLC <80%)  High FRC and TLC (>120% predicted) suggest hyperinflation.  High RV/TLC suggest gas trapping.
  85. 85. Case (1)  FEV1/FVC: 48%  FVC: 3.24L (86%)  FEV1: 1.55L (48%)  FEF25-75%: 0.64L (28%)
  86. 86. Case (1)  FEV1/FVC: 48% Severely ↓  FVC: 3.24L (86%) Normal  FEV1: 1.55L (48%) Severely ↓  FEF25-75%: 0.64L (28%) Severely ↓  Interpretation: Moderate obstruction
  87. 87. Case (2)  FEV1/FVC: 59%  FVC: 2.27L (71%)  FEV1: 1.34L (49%)  FEF25-75%: 0.95L (22%)
  88. 88. Case (2)  FEV1/FVC: 59% Moderately ↓  FVC: 2.27L (71%) Mildly ↓  FEV1: 1.34L (49%) Severely ↓  FEF25-75%: 0.95L (22%) Severely ↓  Interpretation: Moderate obstructive impairment, FVC mildly reduced, can not rule out restrictive impairment
  89. 89. Case (3)  FEV1/FVC: 86%  FVC: 2.49 L (61%)  FEV1: 1.96 L (64%)  FEF25-75%: 2.83 L (98%)  FRC: 1.94 L (59%)  TLC: 4.03 L (70%)  RV: 1.38 L (65%)  DLCO: 55% Interpretation: Moderate Restrictive pattern with moderately reduced DLCO
  90. 90. Case (4)  FEV1/FVC: 56%  FVC: 2.54 (68%)  FEV1: 1.41 (49%)  DLCO: 68%
  91. 91. Case (4)  FEV1/FVC: 56% Moderately ↓  FVC: 2.54 (68%) Mildly ↓  FEV1: 1.41 (49%) Severely ↓  DLCO: 68% Mildly ↓  Interpretation: Severe obstruction, maybe restrictive, reduced DLCO
  92. 92. Male 57 years, 182 cm, 78 kg Pred. best % (B/P) FVC 4.86 4.92 101 FEV1 3.68 3.74 102 FEV1/FVC% 77 76 99 FEF25/75 3.44 3.10 88 Normal
  93. 93. Male 18 years, 168 cm, 61 kg Pred. best % (B/P) FVC 3.71 3.51 95.1 FEV1 3.12 2.35 75.3 FEV1/FVC% 83,8 62.2 74.4 FEF25/75 4.31 1.8 41 Mild obstruction with small airway affection
  94. 94. Male 54 years, 178 cm, 92 kg Pred. best % (B/P) FVC 4.60 3.25 78 FEV1 3.55 0.76 22 FEV1/FVC% 77 22 29 FEF25/75 3.51 0.22 6.1 Severe obstruction with small airway affection
  95. 95. Male 59 years, 170 cm, 82 kg Pred. best % (B/P) FVC 4.10 1.45 33 FEV1 3.25 3.10 96 FEV1/FVC% 83 Severe restriction
  96. 96. A 71 yrs male Height :175 ,weight :88 FVC:45% FEV1: 31% FEV1/ FVC :53% FEF25-75 :15% TLC :142% Very Severe obstruction
  97. 97. Meas Ref Pred% FVC 2.2 2.58 85 FEV1 1.79 1.85 97 FEV1/FVC 81 72 FEF 25-75 1.82 2.23 82 PEF 5.67 5.2 109 Normal
  98. 98. A 75 year old female has a history of dyspnea and palpitations Meas Ref Pred% FVC 2.62 2.82 93 FEV1 1.45 1.98 72 FEV1/FVC 55 69 FEF25-75 0.43 2.20 20 PEF 4.50 5.48 82 Interpretation: mild obstruction
  99. 99. Interpretation: moderate obstruction
  100. 100. Actual Predicted % Predicted FVC 4.0 4.5 88 FEV1 3.4 4.2 89 FEV1/FVC 85 82 112 FEF25-75 Normal
  101. 101. Actual Predicted % Predicted FVC 2.0 4.0 50 FEV1 1.8 3.7 47 FEV1/FVC 90 82 112 FEF25-75 Restrictive Pattern
  102. 102. Actual Predicted % Predicted FVC 4.0 4.5 88 FEV1 2.4 4.2 58 FEV1/FVC 60 82 76 FEF25-7 2.2 4.4 50 Obstructive Pattern
  103. 103. A 36 yrs female Height :162 ,weight :83 FVC:89% FEV1: 94% FEV1/ FVC :89% FEF25-75 :131% TLC :92% Normal
  104. 104. A 30 yrs male Height :186,weight :68 FVC:19% FEV1: 21% FEV1/ FVC :93% FEF25-75% :48% TLC :28% Very Severe restriction
  105. 105. A 26 yrs male Height :177 ,weight :67 FVC: 97% FEV1: 77% FEV1/ FVC :66% FEF25-75 :48% Mild obstruction
  106. 106. A 30 yrs male Height :175 ,weight :70 FVC: 88% FEV1: 69% FEV1/ FVC :66% FEF25-75 :38% VEXT : 90 Moderate obstruction
  107. 107. 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.
  108. 108. 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/FV 80 67 -13 67 -13 0 C 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
  109. 109. 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
  110. 110. Results Pre-Bronchodilator Post-Bronchodilator Predicte d 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
  111. 111. 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.
  112. 112. Case Study 2 (cont) Her current medications include the following: 1. Albuterol 2 puffs po qid prn wheezing, cough, or dyspnea 2. Fluticasone 110 micrograms 2 puffs po bid 3. Ranitidine 150 mg po bid Her father recently died secondary to advanced COPD. Due to her symptoms, you order spirometry.
  113. 113. Results Pre-Bronchodilator Post-Bronchodilator Predicte d 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
  114. 114. Results Pre-Bronchodilator Post-Bronchodilator Predicte d 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 •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? 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) Interpretation: obstruction with reversibility (Moderate obstruction)

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