To Perform Optimal Spirometric Measurement

1. To Perform Optimal Spirometric Measurement Ass.Prof.Dr.Gaye Ulubay Baskent University School of Medicine Dept. of Pulmonary Diseases

2. Overview • Definition • History of spirometry • Why needed standardisation? • Equipment • Acceptability • Repeatability • Test selection

3. Description • Pulmonary function testings (PFTs) are maneuvers to measure airflow and lung volumes using standardized equipments

4. History of Spirometry • 1846 Hutchinson water spirometer • 1933 Hermannsen MVV • 1948 Normal predicted values of MVV determined • 1947 Tiffeneau and Pinelli FVC • 1955 Leuallen and Fowler FEF 25-75%

5. 1979 Standardization of PFTs by ATS • 1987 Spirometry standards revised • 1991Reference values & interpretation • 1993 ERS standards • 1994 BTS standards • 1994 ATS standards revised • 2005ATS/ERS Task Force:General Laboratory, spirometry,diffusion capacity, lung volumes and interpretation

6. Why do we need to standards? • to reduce the noise on the signal • to ensure data are universally comparable • The standards • should not limited obtaining data on an individual • should not over ride common sense

7. European Respiratory Journal 2005; 26: 153-161

8. European Respiratory Journal 2005; 26: 319-338

9. Standardization • Availability of equipment • Calibration control • Measurement • Acceptability • Repeatability • Reference values • Interpretation

10. Contraindications • Patients should not be tested within 1 month of a myocardial infarction

11. Conditions which test could be suboptimal • Abdominal or chest pain of any causes • Oral or facial pain exacerbated by a mouthpiece • Stress incontinence • Dementia or confusial state

12. Laboratory • Ambient temperature, pressure and time of day must be recorded • Test should not performbelow 17 Cº • Same equipment for repeat testing • Same technician, same time of day • Technicians should be trained once for each 3-5 years

13. Equipments • The spirometer must be capable of measuring volume for 15s • Measuring volumes of  8L with an accuracy of at least 3 % or  0.050 L • Total resistance to airflow at 14L/s must be <1.5cmH2O/L/s

14. Cihazın kontrolü

15. Syringe should be stored and used in a same ambient conditions with the spirometer • Syringe should be checked for leak monthly

17. Ambient temperature should be 17-40 oC during calibration and tests • Air leaks should be checked every day • Leaks should be checked by applying a constant pressure of 3cmH2O

18. Predicted values • Weight • Age (year) • Height • Gender • Subjects with a deformity of thoracic cage Height = arm span distance/1.06

19. Patient preperation

20. Should not smoke within at least 1h of testing Should not consume alcohol within 4 h of testing Should not performe vigorous exercise within 30 min of testing Should not wear strict clothes Should not eat a large meal within 2 hours of testing Bronchodilator medications? Before test

21. During test • Sitting or standing position • Upright sitting • Nose clip • Army chair • Wheelchair? • Obesity? • False teeth?

22. During test • Should be rest 5-10 min. • Should be relaxed • Should be informed on tests

23. Recommended order of tests • Dynamic studies: spirometry, flow volume loop, PEF • Static lung volumes • Diffusing capacity • Bronchodilator test

24. In spirometry; • First step is maximum inspiration • Second step is maksimum forced expiration

25. Acceptability criteriasATS/ERS Task Force 2005 No artefacts on spirogram: • Should not cough • Should not close glottis within 1s of exhalation • Should not terminate test early • Should not perform variable effort • Should not leak from mouthpiece • Should not close of openness by mouthpiece

26. BACK EXTRAPOLATION 4 ZERO TIME (EV) MAXIMAL INSPIRATORY LEVEL 3 EXTRAPOLATED VOLUME 2 VOLUME, L 1 0 1 2 3 4 TIME, s Start of test must be rapid Extrapolation volume • Ekstrapolation volume must be < 5% of FVC or 0.150 L • A pause of < 1s at TLC after inspirium

27. End of test criteria Exhalation: • Exhalation time must be  6s and/or a plateau must be seen in volume time curve • The patient cannot continue further exhalation • No change in volume for  1 s at the end of exhalation • Time could be prolonged in patients with obstruction or older subjects

28. Quality control of test • Volume –time display • Flow- volume display

31. Acceptable Spirogram Volume-Time Flow-Volume

32. Cough in 1second Volume-Time Flow-Volume

33. Glottic closure Volume-Time Flow-Volume

34. Variable effort Early termination Volume-Time Flow-Volume

35. Air leak Volume-Time Flow-Volume

36. Spirometry Acceptability CriteriasATS/ERS Task Force 2005 Three acceptable spirograms • The largest values of FVC must be < 0.150 L of each other • The largest values of FEV1 must be < 0.150 L • For those with an FVC of ≤ 1 L both these values are 0.100L If both of these criteria do not meet Continue testing until • Both criteria are met with acceptable spirograms • A total 8 tests have been performed • The patient cannot continue

37. Test selection • Three tests with acceptable start of test and free from artefact are selected and saved • The largest FVC and the largest FEV1 should be recorded and FEV1 /FVC should be calculated

38. Test appropriate for the repeatability criterias Volume-Time Flow-Volume

39. Test not appropriate for the repeatability criterias Tekrarlanabilirlik Kriterine Uygun Olmayan Test TEKRARLANABİLİRLİK Volume-Time Flow-Volume

40. FVC Maneuver No Met within acceptability criteria? Yes No 3 acceptability manoeuvers? Yes No Met between repeatibilty criteria? Yes Determine the largest FVC and largest FEV1 Select maneouvre with largest FVC+ FEV1 Interpret Standardisation

41. Equipment performance criteria Equipment validation Quality control Perform maneuver Measurement procedures Acceptability Repeatability Reference value/ interpretation Clinical assessment Feedback to technician Quality assessment