1. Spirometry By: Dr Ziba Lookzadeh By: Dr Ziba Lookzadeh

2. Introduction A non-invasive method for evaluation of pulmonary function Simple, cost-effective, accessible Not for definite diagnosis of disease but help diagnosis along with history, physical examination and other paraclinical diagnostic method

4. Spirometry as a screening method Primary prevention  Pre-placement and fitness-for-duty examinations Physical demands of a job (heavy manual labor, fire fighting); Characteristics of respiratory use (prolonged use of negative- pressure mask under conditions of heavy physical exertion and/or heat stress - not required by OSHA); Research and monitoring of health status in groups of workers.

5. Spirometry as a screening method Secondary prevention  Medical surveillance programs – workers at risk of developing occupationally related respiratory disorders Baseline and periodic evaluations Mandated OSHA regulations (asbestos, cadmium, coke oven emissions or cotton dust) Local mandated medical surveillance program Component of workplace health promotion program

6. Spirometry as a screening method Tertiary prevention  Clinical evaluation of symptomatic individuals Restrictive Obstructive Combined ventilatory defects  Disability under Social Security Administration  Workers’ compensation setting

7. Contraindications of Spirometry Uncontrolled hypertension Suspected presence of active TB other communicable respiratory disease Thoracic or abdominal surgery within recent 3 wks MI or unstable angina within recent 6 wks Respiratory distress Active hemoptysis Recent eye/ear surgery or ear drum perforation Abdominal or thoracic aortic aneurysm

8. Confounding factors Common cold (3 days ego) Severe respiratory infection (3w) Smoking( 1hr) Heavy food (1hr) Bronchodilator use

9. Complications Chest pain Syncope, dizziness Increased ICP Paroxysmal coughing Nosocomial infection Bronchospasm

10. Lung volumes TV :The volume of air inhaled & exhaled at each breath during normal quiet breathing IRV: The maximum amount of air that can be inhaled after a normal inhalation ERV: The volume of air that can be forcefully expired following a normal quiet expiration RV: The volume of air remaining in the lungs after a forceful expiration

11. Lung capacities TLC: The total volume of the lungs VC: The maximum amount of air that can be exhaled after the fullest inspiration possible IC :The maximum of air that can be inhale after end tidal position FRC: The amount of air remaining in the lungs after a normal quiet expiration

13. Spirometry Parameters Forced Vital Capacity  FVC Forced Expiratory Volume in One Second  FEV1 Forced Expiratory Volume in One Second Expressed as a Percentage of the Forced Vital Capacity  FEV1/FVC % Mean Forced Expiratory Flow during the Middle Half of the Forced Vital Capacity  FEF 25-75%

14. FVC Definition:  Defined as the maximal amount of air that can be exhaled forcefully after a maximal inspiration or the most air a person can blow out after taking the deepest possible breath.

15. FVC - forced vital capacity defines maximum volume of exchangeable air in lung (vital capacity)  forced expiratory breathing maneuver  requires muscular effort and some patient training initial (healthy) FVC values approx 4 liters  slowly diminishes with normal aging significantly reduced FVC suggests damage to lung parenchyma  restrictive lung disease (fibrosis)  loss of functional alveolar tissue (atelectasis) intra-subject variability factors  age  sex  height  ethnicity

16. FEV1 Definition:  The volume of air exhaled during the first second of a forced expiratory maneuver.  normal FEV1 about 3 liters

17. FEV1/FVC% Definition:  The value expresses the volume of air the worker exhales in one second as a percent of the total volume of air that is exhaled.  Calculated by using largest valid FEV1 and largest FVC even if they are not from the same tracing. Find largest valid FEV1 Find largest valid FVC Divide FEV1 by FVC Multiply by 100 to obtain percentage.

18. FEF25-75% Definition:  The mean expiratory flow during the middle half of the FVC More sensitive than FEV1. Considerably more variability than FVC and FEV1. ATS recommends only be considered after determining presence and clinical severity of impairment and should not be used to diagnosis disease in individual patients

19. PEF - Peak Expiratory Flow rate measures airflow limitations in large (central) airways PEF measurements recommended for asthma management  spirometry is recommended to help make the diagnosis of asthma PEF not recommend to evaluate patients for COPD  cannot measure small airway airflow limitations advantages of PEF tests  measurements within a minute (three short breaths)  uses simple, safe, hand-held devices that typical, costs $20 disadvantages of PEF tests (compared to spirometry)  insensitive to obstruction of small airways (mild or early obstruction)  PEF is very dependent on patient effort (large intra-subject variability)  mechanical PEF meters are much less accurate than spirometers

20. mechanical

21. electronic

22. The Original Wright Peak Flow Meter - Standard and Low Range versions

23. The Mini Wright Peak Flow Meter - Standard and Low Range versions (from left to right: Wright scale, EU scale, ATS scale)

24. Other designs of peak flow meters are available

25. Most important parameters FEV1 FVC PEF FEF25-75% V-T Curve F-V loop

30. Spirometry Performance Steps Equipment performance criteria Equipment quality control ( calibration & leak ) Contraindications & interfering condition Age, height, race, gender Selection of appropriate reference value Patient maneuver Acceptability criteria Reproducibility criteria Selection of best curve and best result interpretation

33. Equipment quality control ( flow-type calibration) جهت انجام بررسي وضعيت کاليبراسيون از سرنگ 3 ليتري مخصوص استفاده مي شود. از منوي دستگاه “calibration check ”- option را انتخاب کنيد (جهت حذف فاکتور اصلاح BTPS). براي بررسي وضعيت کاليبراسيون اسپيرومترهاي flow- type بايد کاليبراسيون را باسه سرعت مختلف انجام داد. يکبار 3 ليتر را به مدت يک ثانيه (سریع) و بار دوم 3 ليتر را در مدت 2-3 ثانيه (سرعت متوسط) و بار آخر 3 ليتر را در مدت 6 ثانيه (سرعت آهسته) به دستگاه تزريق کنيد. در هر سه بار باید عدد ثبت شده FVC بين 2.91-3.09 ليتر باشد. در غير اينصورت کاليبراسيون دستگاه اشکال دارد. توجه: نکات مذکور اصول استاندارد نحوه کنترل کاليبراسيون و نشت مي باشد ولي در عين حال توصيه مي شود از کتابچه راهنماي دستگاه اسپيرومتر خريداري شده، در مورد نحوه کاليبراسيون و نشت، توصيه هاي کارخانه سازنده دستگاه رانيز مطالعه کرده و آن را نيز در نظر بگيريد.

34. Equipment validation Calibration: daily if for screening every 4hr

35. calibration

38. Subject’s position Subject’s position: 1. Sitting or standing? 2. Chair with arms & without wheels 3. Clothing 4. Chin & neck position 5. Nose clip 6. Denture

42. Good Start of Test Start of test must be quick and forceful No excessive hesitation Best evaluated using the Flow-Volume tracing No excessive back extrapolated volume

43. Good Start of Test

44. Back extrapolation volume ( BEV or vext )

46. No Coughing Especially during the first 1 second of the maneuver Best if no coughing present during maneuver, however:  Some patients cough near the end of each test, if present then document

47. No Coughing

49. No Variable Flow Flow rate should be maximal and consistent throughout testing Volume-Time and Flow-Volume tracings should be smooth

50. No Variable Flow

52. No Early Termination of Effort Best if maneuver lasts at least six (6) seconds Less than six seconds acceptable if a plateau of al least one (1) second is present If patient is unable to meet the above criteria, document in comment section

53. No Early Termination of Effort

57. Reproducibility:  Ok  Yes  Reproducible test

58. Reproducibility:  No  Non-reproducible

59. Reproducibility Spirometry induced bronchospasm  Each effort gets worse  Patient eventually reaches a plateau, however they may be too short of breath to continue.  Which effort to report?  Best effort unless pre and post bronchodilator study, then report the worst effort.

60. Spirometry Induced Bronchospasm

61. Selection of measures: 1. Report the largest FVC & FEV1, even if they are not from the same tracing. 2. Calculate FEV1/FVC by dividing the above parameters. 3. All flow rates from one acceptable tracing with largest sum of FEV1 + FVC.

62. Quality Control Technician needs to be aware of patient- related problems when performing FVC maneuvers  Submaximal effort  Leaks between lips and mouthpiece  Incomplete inspiration or expiration (prior to or during forced maneuvers)  Hesitation at start of the expiration

63. Technical errors in maneuvers Zero flow errors  ( baseline error) Leak Sensor problems Small inspiration Excessive hesitation (false start) Tongue in the mouthpiece Early termination Glottis closure Cough in first second Submaximal expiration ( weak push) Variable effort

68. Problematic examples compared with well-performed maneuvers.

69. Problematic examples compared with well-performed maneuvers.

72. Normal values Race, gender, height, age Knudson, NHANES III Caucasian for Iranian race