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Spirometry

Content

•• Indication Indication

•• Indications in Indications in

occupational medicineoccupational medicine

•• Contraindications Contraindications

•• Lung volumes & Lung Lung volumes & Lung

capacitiescapacities

•• Spirometric values Spirometric values

•• Hygiene &Hygiene & infection infection •• Contraindications Contraindications

•• Confounding factorsConfounding factors

•• ComplicationsComplications

•• Type of spirometer Type of spirometer

•• Hygiene &Hygiene & infection infection

controlcontrol

•• Spirometry stepsSpirometry steps

•• Reference valuesReference values

•• InterpretationInterpretation

Pulmonary function testsPulmonary function tests

•• SpirometrySpirometry

• Post bronchodilator spirometry

• Bronchial challenge test• Bronchial challenge test

• Diffusing capacity of lung (DLCO)

• Arterial blood gas (ABG)

• Static lung volumes (TLC, RV )

• Resistance & compliance of lung

Definition of spirometryDefinition of spirometry

A physiological test for measuring volumes A physiological test for measuring volumes

inhaled or exhaled by an individual as a inhaled or exhaled by an individual as a inhaled or exhaled by an individual as a inhaled or exhaled by an individual as a

function of timefunction of time

IndicationIndication

•• Not a screening test for general Not a screening test for general

populationpopulation

•• Diagnostic Diagnostic •• Diagnostic Diagnostic

•• MonitoringMonitoring

•• Impairment evaluationImpairment evaluation

Indication (diagnostic)Indication (diagnostic)

•• Evaluation of symptoms and signsEvaluation of symptoms and signs

•• Measuring the effect of dis. on pulmonary Measuring the effect of dis. on pulmonary

functionfunctionfunctionfunction

•• Screening individuals at risk for pulmonary dis.Screening individuals at risk for pulmonary dis.

•• Assess preoperative riskAssess preoperative risk

Indication (monitoring)Indication (monitoring)

•• Assess therapeutic interventionAssess therapeutic intervention

•• Monitor people exposed to injurious agentsMonitor people exposed to injurious agents

Indications in occupational medicineIndications in occupational medicine

•• Primary preventionPrimary prevention (Pre(Pre--employment)employment)

• physical demands of a job require a certain level of cardiopulmonary fitness, eg, heavy manual labor or firefightingof cardiopulmonary fitness, eg, heavy manual labor or firefighting

• Respirator use can impose a significant burden on the cardiopulmonary systems, eg, use of a self-contained breathing apparatus, or prolonged use of certain negative-pressure masks under conditions of heavy physical exertion and/or heat stress

•• Secondary preventionSecondary preventionMedical surveillance programs & periodic evaluationMedical surveillance programs & periodic evaluation

OSHA :OSHA :

asbestos, cadmium, coke oven emissions, or cotton dustasbestos, cadmium, coke oven emissions, or cotton dust

respiratorrespirator--wearers exposed to benzene, formaldehyde wearers exposed to benzene, formaldehyde methylene chloridemethylene chloride

SilicosisSilicosis

Spirometry detect large changes over a short time or Spirometry detect large changes over a short time or smaller changes cumulated over a longer observation smaller changes cumulated over a longer observation period, it is not sensitive to small, shortperiod, it is not sensitive to small, short--term changesterm changes

•• Tertiary preventionTertiary prevention•• FollowFollow--up spirometryup spirometry

•• Workers’ compensation settingWorkers’ compensation setting

ContraindicationsContraindications

•• Active Active hemoptysishemoptysis

•• PneumothoraxPneumothorax

•• Unstable Cardiovascular status (Unstable Cardiovascular status (6 6 w)w)

•• Cerebral/Thoracic/Abdominal aneurysmCerebral/Thoracic/Abdominal aneurysm•• Cerebral/Thoracic/Abdominal aneurysmCerebral/Thoracic/Abdominal aneurysm

•• Recent eye surgeryRecent eye surgery

•• Acute disorder that may interfere with Acute disorder that may interfere with performance (performance (e.ge.g, vomiting) , vomiting)

•• Thoracic or abdominal surgery( Thoracic or abdominal surgery( 3 3 w)w)

•• Recent CVA or pulmonary emboliRecent CVA or pulmonary emboli

•• Respiratory distress Respiratory distress

Confounding factorsConfounding factors

•• Common cold (Common cold (3 3 days ego)days ego)

•• Severe respiratory infection (Severe respiratory infection (33w)w)

•• Smoking( Smoking( 11hr)hr)•• Smoking( Smoking( 11hr)hr)

•• Heavy food (Heavy food (11hr)hr)

•• Bronchodilator useBronchodilator use

ComplicationsComplications

•• Chest painChest pain

•• Syncope, dizzinessSyncope, dizziness

•• Increased ICPIncreased ICP•• Increased ICPIncreased ICP

•• Paroxysmal coughingParoxysmal coughing

•• Nosocomial infectionNosocomial infection

•• BronchospasmBronchospasm

Type of spirometerType of spirometer

•• Volumetric spirometerVolumetric spirometer

•• FlowFlow--type spirometertype spirometer

Spirometry standardsSpirometry standards

•• ATSATS (American Thoracic Society)(American Thoracic Society)

•• ERSERS (European Respiratory Society)(European Respiratory Society)

Lung volumesLung volumes

•• TV :TV :The volume of air inhaled & exhaled at each

breath during normal quiet breathing

• IRV: IRV: The maximum amount of air that can be

inhaled after a normal inhalationinhaled after a normal inhalation

•• ERV: ERV: The volume of air that can be forcefully

expired following a normal quiet expiration

•• RV: RV: The volume of air remaining in the lungs

after a forceful expiration

Lung capacitiesLung capacities

•• TLC: TLC: The total volume of the lungs The total volume of the lungs

•• VC:VC:The maximum amount of air that can The maximum amount of air that can

be exhaled after the fullest inspiration be exhaled after the fullest inspiration be exhaled after the fullest inspiration be exhaled after the fullest inspiration

possiblepossible

•• IC :IC :The maximum of air that can be inhale The maximum of air that can be inhale

after end tidal positionafter end tidal position

•• FRC: FRC: The amount of air remaining in the The amount of air remaining in the

lungs after a normal quiet expiration lungs after a normal quiet expiration

Lung volumesLung volumes

ICIC

VCVC

TLCTLC

RVRV

ERVERV

ICIC

RVRV

TLCTLC

Spirometric valuesSpirometric values

•• FVC FVC (forced vital capacity)(forced vital capacity)

•• FEVFEV1 1 (forced expiratory volume in (forced expiratory volume in 1 1 s)s)

•• FEVFEV11/FVC/FVC

•• FEVFEV (forced expiratory volume in t s)(forced expiratory volume in t s)•• FEVFEVt t (forced expiratory volume in t s)(forced expiratory volume in t s)

•• FEFFEF2525--75 75 (maximum midexpiratory flow)(maximum midexpiratory flow)

•• PEF PEF (peak expiratory flow)(peak expiratory flow)

•• VT curveVT curve

•• FV curveFV curve

Normal values depends on:Normal values depends on:

•• AgeAge

•• HeightHeight

��KyphoscoliosisKyphoscoliosis→ → arm span (H=arm span/arm span (H=arm span/11..0606))

•• GenderGender

•• RaceRace

��CaucasianCaucasian

Hygiene & infection controlHygiene & infection control

•• Hand washingHand washing

•• GlovesGloves

•• Disposable mouth piece & nose clipDisposable mouth piece & nose clip•• Disposable mouth piece & nose clipDisposable mouth piece & nose clip

•• Disinfection or sterilization of reusable Disinfection or sterilization of reusable

mouth piecemouth piece

•• Extra precautions for patient with known Extra precautions for patient with known

transmissible infectiontransmissible infection

Spirometry stepsSpirometry steps

Equipment performance criteria

Equipment validation

Quality control

Subject maneuvers

Measurements procedures

Acceptability

Repeatability

interpretation

Equipment validationEquipment validation

•• Calibration:Calibration: dailydaily if for screening every if for screening every 44hrhr

calibratiocalibratio

nn

Subject maneuversSubject maneuvers

�� FVC maneuverFVC maneuver

•• Closed circuit Closed circuit

•• Open circuit Open circuit

•• WellWell--fittingfitting

• Sitting or standing

• Nose clip• Nose clip

•• ProcedureProcedure

1. Inhale

2. Exhale

maneuver evaluation

•• Start of test criteriaStart of test criteria

-- Extrapolation volumeExtrapolation volume (EV < (EV < 55% of FVC% of FVCoror 150 150 ml)ml)

--TimeTime--toto--PEF < PEF < 00..120 120 ss

•• End of test criteriaEnd of test criteria-- the subject cannot or should not continuethe subject cannot or should not continue

-- exhalation at least exhalation at least 66ss (in children <(in children <10 10 yrs: at least yrs: at least 33s)s)

-- volumevolume--time curve show no change in volume (<time curve show no change in volume (<00..025 025 lit) lit)

for at least for at least 11ss

�� In obstruction or older subjects more than In obstruction or older subjects more than 66s exhalation s exhalation

(till (till 1515s)s)

b

a

c

AcceptabilityAcceptability

�� Start of test criteriaStart of test criteria

�� End of test criteriaEnd of test criteria

�� Cough especially during first secondCough especially during first second

�� ValsalvaValsalva maneuver (glottis closure) maneuver (glottis closure)

�� Leak from the mouthLeak from the mouth

�� Obstruction of the mouthpieceObstruction of the mouthpiece

�� Extra breath during the maneuverExtra breath during the maneuver

Acceptable spirogramAcceptable spirogramAcceptable spirogramAcceptable spirogramAcceptable spirogramAcceptable spirogramAcceptable spirogramAcceptable spirogram

“rainbow”

G

ReproducibilityReproducibility

•• At least three acceptable maneuversAt least three acceptable maneuvers

Maximum difference between the largest and next Maximum difference between the largest and next Maximum difference between the largest and next Maximum difference between the largest and next

largest FVC largest FVC andand FEVFEV11 = = 150150ml ml oror 55% %

(If FVC <(If FVC <11lit, this value is lit, this value is 100100ml)ml)

ReproducibilityReproducibilityReproducibilityReproducibilityReproducibilityReproducibilityReproducibilityReproducibility

Flow chart of criteriaFlow chart of criteria

Perform FVC

Acceptability criteria

3 acceptable maneuvers

Repeatability criteria

Largest FVC and largest FEV1

Maneuver with largest FVC + FEV1 for other indices

Reference valuesReference values

•• Knudson (male/ female)Knudson (male/ female)

•• NHANES III (race difference)NHANES III (race difference)

•• ACOEM recommends that the NHANES III ACOEM recommends that the NHANES III •• ACOEM recommends that the NHANES III ACOEM recommends that the NHANES III

equations be considered for general use in the equations be considered for general use in the

occupational setting occupational setting

•• ERSERS

•• ATSATS

Predicted value & lower limit of normal Predicted value & lower limit of normal

(LLN)(LLN)

•• LLN LLN : fifth percentile, the point below : fifth percentile, the point below

which which 55% of normal subjects fall. % of normal subjects fall. which which 55% of normal subjects fall. % of normal subjects fall.

•• LLNLLN calculated in this way affect by age calculated in this way affect by age

sex , height & racesex , height & race

LLNLLN

• FEV1 and FVC = 80%

• FEV1/FVC = 70-75%

• FEF25-75 = 50-60%• FEF25-75 = 50-60%

InterpretationInterpretation

A. Normal:A. Normal: both the FVC and the both the FVC and the

FEVFEV11/VC ratio are normal./VC ratio are normal.

“Knee”“Knee”

• B.Obstructive : FEV1/FVC , FEV1

TLC & RV or NL

The severity of the abnormality is graded:The severity of the abnormality is graded:

-- % Pred FEV% Pred FEV11 > > 100100 = =May be a physiological May be a physiological variantvariant

-- % Pred FEV% Pred FEV < < 80 80 and > and > 7070 = =MildMild-- % Pred FEV% Pred FEV11 < < 80 80 and > and > 7070 = =MildMild

-- % Pred FEV% Pred FEV11 < < 70 70 and > and > 6060 = =ModerateModerate

-- % Pred FEV% Pred FEV11 < < 60 60 and > and > 5050 = =Moderately Moderately severesevere

-- % Pred FEV% Pred FEV11 < < 50 50 and > and > 35 35 SevereSevere

-- % Pred FEV% Pred FEV11 < < 3434 = = Very severeVery severe

C. Restrictive: C. Restrictive: FEVFEV11/FVC or NL /FVC or NL

FVC & FEVFVC & FEV1 1 , TLC & RV , TLC & RV

The severity of the abnormality might be The severity of the abnormality might be graded as follows:graded as follows:

-- % Pred FVC < LLN and > % Pred FVC < LLN and > 70 70 = mild= mild-- % Pred FVC < LLN and > % Pred FVC < LLN and > 70 70 = mild= mild

-- % Pred FVC < % Pred FVC < 70 70 and > and > 6060 = =ModerateModerate

-- % Pred FVC < % Pred FVC < 60 60 and > and > 5050 = =

Moderately severeModerately severe

-- % Pred FVC < % Pred FVC < 50 50 and > and > 3434 = = SevereSevere

-- % Pred FVC < % Pred FVC < 34 34 == Very severeVery severe

D.Mixed pattern:D.Mixed pattern:

FEVFEV11,, FVC, FEVFVC, FEV11/FVC< LLN/FVC< LLN

VCVC VCVCVCVC

RVRV

ObstructiveObstructive

VCVC

RVRV

NormalNormal

VCVC

RVRV

RestrictiveRestrictive

Upper airway obxUpper airway obx

Early small airway obxEarly small airway obx

FV curve :upward concavityFV curve :upward concavity

FVC, FEVFVC, FEV11, FEV, FEV11/FVC :NL/FVC :NLFVC, FEVFVC, FEV11, FEV, FEV11/FVC :NL/FVC :NL

•• �� FEF FEF 2525--75 75 ??????

• ATS states that FEF25-75% should not be

used to diagnose small airway disease or to

assess respiratory impairment

Probably normal spirogramProbably normal spirogram

•• Only Only �� FEF FEF 2525--7575

•• No small airway disease (ATS)No small airway disease (ATS)

•• If FEVIf FEV11/FVC is borderline → airway obx/FVC is borderline → airway obx•• If FEVIf FEV11/FVC is borderline → airway obx/FVC is borderline → airway obx

•• Only Only �� FEVFEV11/FVC /FVC

FEVFEV11> > 100100% Normal% Normal

FVC>FVC>100100%%

NonNon--specific ventilatory patternspecific ventilatory pattern

•• FEVFEV11/FVC → NL/FVC → NL

•• FEVFEV1 1 < LLN< LLN

•• FVC< LLNFVC< LLN•• FVC< LLNFVC< LLN

•• TLC , RV , DLCO → NLTLC , RV , DLCO → NL

•• ObesityObesity

•• Normal variantNormal variant

•• Occult asthmaOccult asthma

•• Early stage of parenchymal diseaseEarly stage of parenchymal disease

•• Spirogram with restrictive patternSpirogram with restrictive pattern

•• Spirogram with mixed patternSpirogram with mixed pattern•• Spirogram with mixed patternSpirogram with mixed pattern

•• Spirogram with obstructive patternSpirogram with obstructive pattern

Case Case 11

A A 71 71 yrs maleyrs male

HeightHeight ::175 175 ,,weightweight ::8888

FVC:FVC:4545%%

FEVFEV11: : 3131%%

FEVFEV11/ FVC :/ FVC :5353%%

FEFFEF2525--75 75 ::1515%%

Case Case 22

A A 36 36 yrs femaleyrs female


FVC:FVC:8989%%

FEVFEV11: : 9494%%


FEFFEF2525--75 75 ::131131%%

TLC :TLC :9292%%

Case Case 33



FVC:FVC:7878%%

FEVFEV11: : 7979%%FEVFEV11: : 7979%%


FEFFEF2525--75 75 ::8585%%

TLC :TLC :8282%%

Case Case 44


HeightHeight ::167167,,weightweight ::6161

FVC:FVC:3333%%FVC:FVC:3333%%

FEVFEV11: : 1717%%


TLC :TLC :114114%%

RV/TLC :RV/TLC :103103%%

Case Case 55


HeightHeight ::186186,,weightweight ::6868

FVC:FVC:1919%%FVC:FVC:1919%%

FEVFEV11: : 2121%%


FEFFEF2525--7575% :% :4848%%

TLC :TLC :2828%%

Case Case 66



FVC: FVC: 8888%%FVC: FVC: 8888%%

FEVFEV11: : 6969%%


FEFFEF2525--75 75 ::3838%%

VEXT : VEXT : 9090

Case Case 77



FVC: FVC: 104104%%FVC: FVC: 104104%%

FEVFEV11: : 8484%%


FEFFEF2525--75 75 ::5151%%

VEXT : VEXT : 120120

Case Case 88



FVC: FVC: 9797%%FVC: FVC: 9797%%

FEVFEV11: : 7777%%


FEFFEF2525--75 75 ::4848%%

VEXT : VEXT : 6060

Post bronchodilator spirometry

(reversibility testing)

•• ShortShort--acting inhaled drugs should not be used acting inhaled drugs should not be used

within within 44hh of testingof testing

•• LongLong--acting should be stopped for acting should be stopped for 1212hh prior testprior test

•• Smoking should be avoided for Smoking should be avoided for ≥ ≥ 11hh•• Smoking should be avoided for Smoking should be avoided for ≥ ≥ 11hh

•• Salbutamol Salbutamol 400 400 µgµg ((4 4 puffs) at puffs) at 3030s intervalss intervals→ ≥ → ≥

10 10 min and up to min and up to 15 15 minmin

•• Ipratropium bromide Ipratropium bromide 160 160 µgµg ((4 4 puffs)→puffs)→30 30 minmin

later

Positive reversibility testing

• Percent change from baseline & absolute

change in FEV1 and/or FVC :

>12% AND 200 CC>12% AND 200 CC



FVC:FVC:8080%%

FEVFEV11: : 7070%%


FEFFEF2525--75 75 ::5050%%

pre post %changepre post %change

FVC FVC 4 44 4..26 26 ++77

FEVFEV1 21 2..91 391 3..32 32 ++14 14

FEVFEV11/ FVC / FVC 7272..8 778 77..9 9 ++7 7

FEFFEF2525--75 275 2..32 332 3..09 09 ++31 31

Case Case 77



pre %pred post %chgpre %pred post %chg

FVC FVC 33..13 83 313 83 3..52 52 ++1212FVC FVC 33..13 83 313 83 3..52 52 ++1212

FEVFEV1 21 2..02 70 202 70 2..49 49 ++23 23

FEVFEV11/ FVC / FVC 6464..55

Case Case 2626



pre %pred post %chgpre %pred post %chg

FVC FVC 55..68 95 568 95 5..81 81 ++22

FEVFEV1 41 4..02 81 402 81 4..28 28 ++6 6

FEVFEV11/ FVC / FVC 6868..22

Change in spirometric indices over Change in spirometric indices over

timetime

•• In occupational setting, changes over time In occupational setting, changes over time

in pulmonary function should be examined in pulmonary function should be examined

for two reasons: for two reasons:

((11) to evaluate a worker's response to ) to evaluate a worker's response to

treatment in the clinical settingtreatment in the clinical setting

((22) to screen healthy workers for excessive ) to screen healthy workers for excessive

loss of function overloss of function over time.time.

Change in spirometric indices over Change in spirometric indices over

timetime

NIOSHNIOSH :(:(00..85 85 .baseline value) .baseline value) –– (expected decline over time)(expected decline over time)

malemale femalefemale malemale femalefemale

30 30 ml/yrml/yr 25 25 ml/yrml/yr 25 25 ml/yrml/yr 25 25 ml/yrml/yr

FEVFEV11 FVCFVC

Significant change in periodic spirometrySignificant change in periodic spirometry

(ATS)(ATS)

•• �� > > 1515% of FEV% of FEV1 1 or FVC over one yearor FVC over one year

•• �� > > 55% of FEV% of FEV1 1 or FVC over oneor FVC over one

working shift (working shift (8 8 amam-- 4 4 pm)pm)

•• �� > > 2525--3030% of PEF over one working shift % of PEF over one working shift

Bronchial provocation testBronchial provocation test

•• SpecificSpecific: emergency hospital available: emergency hospital available

•• NonspecificNonspecific : out patient : out patient •• NonspecificNonspecific : out patient : out patient

•• PurposePurpose : detection hyper reactive airways: detection hyper reactive airways

Methacholine challenge test Methacholine challenge test

(MCT)(MCT)

•• Most agent for BCT: Most agent for BCT: methacholinemethacholine

•• Immediate responseImmediate response

•• More useful in excluding a More useful in excluding a dxdx of asthmaof asthma•• More useful in excluding a More useful in excluding a dxdx of asthmaof asthma

•• Excellent sensitivityExcellent sensitivity

•• MCT is also positive in:MCT is also positive in:•• Allergic rhinitisAllergic rhinitis

•• Sarcoidosis (Sarcoidosis (5050%)%)•• Sarcoidosis (Sarcoidosis (5050%)%)

•• COPDCOPD

•• CF CF

Data presentationData presentation

•• PCPC2020

pprovocative rovocative cconcentration causing a oncentration causing a 2020% % pprovocative rovocative cconcentration causing a oncentration causing a 2020% %

fall in FEVfall in FEV1 1

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