1. Spirometry interpretation and COPD treatments
Hetal Dhruve
Chandra Sarkar

2. Aims Overview of spirometry and interpretion Treatment of COPD
COPD Care plans
Questions

3. Why spirometry?
Discrepancy in prevalence of COPD from rightcare/ population modelling suggest there are a number of undiagnosed cases in hackney.
Incorrect diagnosis
Useful tool in disease progression monitoring
Poor quality of spirometry –performance and interpretation Accreditation
This session does not qualify you to be on the register

4. Basis function of the lungs
Provide oxygen to the cells of the body
To remove carbon dioxide from the body
Few non-respiratory functions e.g. acid-base homeostasis, speech, some metabolism, filtering of toxic material, etc

5. Lung dysfunction
Obstructive and Restrictive patterns can arise from 1 of 5 abnormalities:
Respiratory disorders
Airway disease
Pleural cavity
Chest wall
Muscle disorders

6. Asthma and COPD
Asthma: a heterogenous disease, usually characterised by airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA 2016)
COPD: is a common preventable disease, characterised by persistent airway limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients (GOLD 2018).

7. Persistent and progressive
Asthma and COPD
Asthma
COPD
Smoker or ex-smoker
Nearly all
Possibly
Symptoms under age 35
Rare
Common
Chronic productive cough
Uncommon
Breathlessness
Persistent and progressive
Variable
Night-time waking with breathlessness and/or wheeze
Significant diurnal or day-to-day variability of symptoms

8. Diagnosis Measures flow (l/s) against volume (L)
Important part of a spirometry report
A quick way of distinguishing between normal, obstructive & restrictive
COPD – always obstructive
(unless v. severe COPD; mix of
Obstruction and restriction)

9. Spirometry results
FEV1: Forced expiratory volume in 1 second FVC: Forced vital capacity FEV1/FVC: <0.7 = obstruction Post bronchodilator spirometry: 12% change in FEV1; positive reversibility

10. FEV1/FVC lower limit of normal
Increase in disease – The new definition estimates COPD prevalence at 22% in those aged over 40 years in England and Wales compared with 13% using LLN criteria.
Evidence of misdiagnosis and missed diagnosis – Up to 13% of people thought to have COPD on GOLD criteria have been found to be misdiagnosed.
Harms from misdiagnosis and missed diagnosis – cardiovascular mortality is unexpectedly high among mildly breathless patients with GOLD-diagnosed COPD
GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Report
NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG
Eschenbache W in COPD Clinical Perspectives, Panos (Ed), Open access at
Cerveri I et al. Thorax. 2008;63:1040–5.

11. Pathophysiology 2 patterns of dysfunction Asthma; COPD Restrictive
Obstructive
Reduction in airflow/airflow limitation
Asthma; COPD
Restrictive
Reduction in lung size/increase in lung stiffness
Fibrosis; respiratory muscle disease; chest wall disorders

12. Belinda Breathless 46 F C/O breathlessness on exertion
Ex smoker: 1-2/day when at university
Weight – 66kg, BMI – 21
FH – sister has asthma
Triggers – walking upstairs or rushing for the bus

13. Slides from Imperial Health College NHS Trust

14. Test valid. Good effort.
Slides from Imperial Health College NHS Trust

15. FEV1/FVC ratio normal – no obstruction
Slides from Imperial Health College NHS Trust

16. FEV1, FVC & VC all within normal limits – no restriction
Slides from Imperial Health College NHS Trust

17. FV curve looks normal
Slides from Imperial Health College NHS Trust

18. Normal spirometry. No further action.
Slides from Imperial Health College NHS Trust

19. Patient 1: Belinda Breathless
46 F
C/O breathlessness on exertion
Ex smoker: 1-2/day when at university
Weight – 66kg, BMI – 21
FH – sister has asthma
Triggers – walking upstairs or rushing for the bus
CONCLUSION: normal lung function, no obstruction
? Likelihood of asthma
? Deconditioned/anaemia.

20. Patient 2: Coughing Carl
See trace 1
Age: 52 M
PC: Cough, worse at night
Ex smoker – 20/day
Conclusion: No obstruction, restriction may be due to weight (BM )
? Acid reflux
? CXR to rule out lung Ca/other co-morbidities.

21. Patient 3: Wheezy Wendy See trace 2 Asthma diagnosis since childhood
Diagnosed with COPD approx. 4 years ago
Ex Smoker
Diagnosis?

22. Patient 4: Phlegmy Phil See trace 3 73 M Weight: 73kg BMI 22.5
PC: Coughing, breathlessness (MRC – 4), CAT – 22,
Produces phlegm daily ++
Struggles to cough up
Ex smoker.

23. Patient 5: Tight Timothy
See trace 4.

25. Technique. Good peak. Expiration complete. Reproducible.

26. FEV1/FVC is reduced = obstruction

27. VC & FVC reduced – restrictive also? Further testing required

28. No significant change after salbutamol – no evidence of asthma

29. Severe obstructive defect
Severe obstructive defect. Reduced FVC & VC likely to be caused by such severe obstruction (early airway closure). No BD response – no evidence of asthma. Cannot rule out a combined restriction – refer for further testing.

30. Accreditation Performing spirometry Interpretation spirometry
?a Hub and spoke model to ensure consistent good quality spirometry

31. COPD treatment

32. Aims of treatment Reduce Symptoms: Relieve symptoms
Improve exercise tolerance
Improve health status
Reduce Risk:
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality.

33. Value Pyramid

34. ‘Breathing, Thinking, Functioning’ model

35. National Guidelines
NICE 2018 guidelines:
15/chapter/Recommendations#inhale d-combination-therapy
GOLD 2019 guidelines:
content/uploads/2018/11/GOLD v1.6-FINAL-08Nov2018-wms.pdf
Both consider phenotyping patients.

36. Treatments B2: Bind to beta adrenoreceptors, smooth muscle relaxation.
Bronchodilators:
Beta agonists/muscarinic antagonists
B2: Bind to beta adrenoreceptors, smooth muscle relaxation.
M3: block bronchocontrictor effects of acetylcholine; smooth muscle relaxation.
Anti-inflammatory:
Inhaled corticosteroids
Reduce inflammation in the airways .
POET-COPD trial – 7376 patients, 1 year RCT.

37. City and Hackney Guidelines

38. Why Self management plans?
Poor evidence – Cochrane
Continues to be recommended by NICE
Decreases hospital admissions
Increases quality of life
ACERs
Webinar link

39. NICE guidance Self-management
Develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), and:
include education on all relevant points from recommendation 
review the plan at future appointments. [2018]
Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. [2018]

40. Why Self management plans?
Poor evidence – Cochrane
Continues to be recommended by NICE
Decreases hospital admissions
Increases quality of life
ACERs
Webinar link

41. Self Management Plan – C&H

42. Thanks for listening
Any questions