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Interpreting Spirometry: Patient or Data ?

Interpreting Spirometry: Patient or Data ?. David Robiony-Rogers CRFS Service Leader Respiratory Medicine Capital & Coast District Health Board. The colours of disease. The colours of respiratory disease. For the movie conscious. For the spacer conscious. Medication type colour coding.

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Interpreting Spirometry: Patient or Data ?

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  1. Interpreting Spirometry:Patient or Data? David Robiony-Rogers CRFS Service Leader Respiratory Medicine Capital & Coast District Health Board

  2. The colours of disease

  3. The colours of respiratory disease

  4. For the movie conscious...

  5. For the spacer conscious...

  6. Medication type colour coding...

  7. Spirometry Spirometry is the timed measurement of dynamic lung volumes during forced expiration and inspiration, and is used to quantify how effectively and how quickly the lungs can be emptied.

  8. Spirometry: Graphic Displays Flow volume loop Volume time curve

  9. Spirometry Test

  10. Spirometry Interpretation • Acceptability • minimum of 3 acceptable manoeuvres • good start and satisfactory effort • no artefacts induced by coughing or glottic closure in 1st second, or equipment problems • minimum of 6 seconds exhalation and/or plateau in the volume time curve • Maximal inspiration prior to blow

  11. Artefacts No artefact Cough within 1st second of forced exhalation Incomplete exhalation/early termination (glottic closure) Slow start/submaximal forced effort at start of blow Hesitant start

  12. SpirogramsNormal and problematic

  13. Flow Volume LoopsNormal and problematic

  14. Reproducibility • Reproducibility • two largest FVC within 0.150 L (150ml) of each other • two largest FEV1 within 0.150 L (150ml) of each other • must meet criteria for acceptability If the reproducibility criteria is not met after a total of 8 tests, stop testing.

  15. Disease Patterns • Obstructive pattern A disproportionate reduction of maximal airflow from the lung in relation to the maximal volume • Restrictive pattern Characterised by a normal FEV1/VC ratio and reduction in FVC below the 5th percentile of the predicted • Mixed pattern Characterised by the coexistence of obstruction and restriction, and is defined physiologically when both FEV1/FVC and FVC are below 5th percentiles of the predicted value

  16. Spirometric overlap between Asthma and COPD • COPD has been described as a disease characterized by fixed airflow obstruction because in many patients FEV1 values improve little after bronchodilator challenge. • Current guidelines on diagnosis and management describe COPD as a condition that is partially reversible because some patients exhibit substantial improvements in FEV1 (despite an FEV1-FVC ratio that remains below 0.70) that compares in magnitude to what is observed in some asthma patients. • Tashkin et al (2008) have shown that about 54% of a large COPD cohort (N = 5756) exhibited an improvement in FEV1 values > 12% and 200 mL, while about 65% of patients had FEV1 increases > 15%. • This substantial overlap in FEV1 reversibility between asthma and COPD underscores an important limitation of using this measurement to distinguish between asthma and COPD. • Can Fam Physician. Oct 2011; 57(10): 1148–1152.

  17. The overlap of Asthma and COPD

  18. Disease Patterns The presence and site of disease have various effects on the volume-time and maximal expiratory flow volume curve Vitalograph Ltd 1986 &2000

  19. Normal Ventilatory Function The pattern of the lung and spirogram show a pattern of normality Vitalograph Ltd 1986 &2000

  20. Age: 22, Gender: Female; Height: 166 cm, Weight: 69.3 kg; BMI: 25.15

  21. Age: 23; Gender: Male; Height: 175 cm; Weight: 67.6 kg; BMI: 22.07

  22. Reversible Obstruction The lungs and spirogram show a pattern of airway obstruction (black), with the spirogram showing a marked improvement after the administration of a bronchodilator (red) Vitalograph Ltd 1986 &2000

  23. Age: 75; Gender: Male; Height: 175 cm; Weight: 97.2 kg; BMI: 31.74

  24. Age: 29; Gender: Female; Height: 162 cm; Weight: 98.6 kg; BMI: 37.57

  25. Irreversible Obstruction The lungs and spirogram show a pattern of airflow obstruction, with the spirogram showing little or no improvement after the administration of a bronchodilator Vitalograph Ltd 1986 &2000

  26. Age: 74; Gender: Female; Height: 161 cm; Weight: 70.9 kg; BMI: 27.35

  27. Restrictive Defect The lung and spirogram show a pattern of volume restriction Vitalograph Ltd 1986 &2000

  28. Age: 74; Gender: Male; Height: 160 cm; Weight: 82.3 kg; BMI: 32.15

  29. Combined Pattern The lungs and spirogram show a pattern of combined airflow obstruction and volume restriction Vitalograph Ltd 1986 &2000

  30. Age: 69; Gender: Male; Height: 171 cm; Weight: 50.9 kg; BMI: 17.41

  31. Age: 35; Gender: Male; Height: 168 cm; Weight: 90.6 kg; BMI: 32.10

  32. Response to ß2-agonist • ß2-agonist bronchodilator • Dose: 4 puffs of ß2-agonist delivered through a spacer device • Wait 15-20 minutes before repeating spirometry • Significant response defined as >12% and more than 200mL increase in either the FEV1 or FVC.

  33. Spirometry: Pre & Post ß2-agonist

  34. Severity classification Severity of any spirometric abnormality based on the forced expiratory volume in one second (FEV1) ATS/ERS Task Force: Standardisation of lung function testing. Interpretative strategies for lung function tests. EurRespir J 2005; 26: 948

  35. Interpretation algorithm No Yes Yes No National Asthma Council Australia: www.nationalasthma.org.au

  36. Spirometry interpretation algorithm: Primary Care Respiratory Alliance of Canada Pre ß2-agonist FEV1/FVC ratio Reduced < LLN Normal > LLN ß2-agonist ß2-agonist Reduced < LLN Normal (not COPD) FVC ≥ 80% predicted FEV1 and FVC  FEV1, 12% and 200mL  FEV1, 12% and 200mL  FEV1, 12% and 200mL Restrictive disorder Asthma vs COPD (history) Consistent with asthma Consistent with asthma Refer to specialist Modified from Primary Health Care Alliance of Canada spirometry interpretation algorithm 2011

  37. Visual Interpretation

  38. Age: 58; Gender: Female; Height: 156 cm; Weight: 61.1 kg; BMI: 25.11

  39. Age: 68; Gender: Female; Height: 170 cm; Weight: 70.0 kg; BMI: 24.22

  40. Age: 35; Gender: Male; Height: 168 cm; Weight: 90.6 kg; BMI: 32.10

  41. Age: 50; Gender: Female; Height: 164 cm; Weight: 109.2 kg; BMI: 40.60

  42. Age: 64; Gender: Male; Height: 162 cm; Weight: 60.5 kg; BMI: 23.05

  43. Age: 70; Gender: Female; Height: 153 cm; Weight: 127.9 kg; BMI: 54.64

  44. Age: 70; Gender: Female; Height: 144 cm; Weight: 81.8 kg; BMI: 39.45

  45. Age: 52; Gender: Female; Height: 161 cm; Weight: 50.8 kg; BMI: 19.60

  46. Age: 39; Gender: Female; Height: 157 cm; Weight: 100.1 kg; BMI: 40.61

  47. Age: 67; Gender: Female; Height: 157 cm; Weight: 67.7 kg; BMI: 27.47

  48. Spirometry Education Pulmonary Function Tests (PFT): Lesson 2 - Spirometry Published on Feb 3, 2014 A discussion of FEV1, FVC, FEV1/FVC ratio, and the flow volume loop, including how these are used in the diagnosis of various lung diseases, with a particular focus on the distinction between obstructive and restrictive lung disease. A summary of flow volume loop patterns in upper airway obstruction is covered as well. https://www.youtube.com/watch?v=yNDKD_xI684

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