Spirometry

Spirometry

Chris Loveridge gives practical advice on how to perform spirometry

Key learning points

  • Spirometry is recommended in both asthma and chronic obstructive pulmonary disease (COPD) guidelines
  • Variability in the performance and understanding of spirometry interpretation has resulted in an estimated 50% of people having an incorrect diagnosis1
  • Spirometry consists of two measurements, the relaxed vital capacity (VC) and the forced vital capacity (FVC)
  • There should be three attempts at all blows as a check of repeatability/reproducibility

Introduction

The use of spirometry as an objective measurement in the diagnosis of respiratory disease is widely acknowledged. It is recommended in both asthma and chronic obstructive pulmonary disease (COPD) guidelines, as well as those specific to spirometry.2-5

It is a relatively straightforward test to undertake and is essentially a practical skill. It has been available and performed in primary care for several years now, but with varying degrees of expertise and understanding.6

Recommendations in the recent publication ‘Improving the quality of diagnostic spirometry in adults: the National Register of certified professionals and operators’7 while not mandatory, aim to raise the standard of both performance and interpretation of spirometry. Collaboration with the Association for Respiratory Technology and Physiology (ARTP) will aim to standardise training and assessment, and a national scrutiny board will oversee this to ensure consistency.

The variability in performance and poor understanding of spirometry interpretation has resulted in an estimated 50% of people receiving an incorrect diagnosis.1Consequently, people are prevented from receiving appropriate treatment for their condition, or conversely receive medication they do not need.

Key areas: Preparing the equipment

The document ‘A guide to performing quality assured diagnostic spirometry’ outlines standards, and requirements for equipment and its maintenance.5

All equipment should be:

  • Calibrated annually
  • Verified with a 3 litre syringe before each session
  • Quality assured with a biological control undertaken on a person with normal lung function weekly or monthly depending on the number of tests undertaken
  • Cleaned between patients and sterilised once a week according to manufacturer’s instructions
  • Operated with a one-way single patient use mouthpiece

Preparing the patients

Patients should be well enough to undertake the test, and contraindications should be considered and recorded. These are defined as relative or absolute and are listed below.

Relative contraindications2,8

  • Exacerbation in last 4 to 6 weeks
  • Haemoptysis of unknown origin
  • Pneumothorax
  • Uncontrolled hypertension
  • Unstable cardiovascular status
  • Thoracic, abdominal or cerebral aneurysms
  • Recent eye surgery and detached retina
  • Nausea and vomiting
  • Recent thoracic or abdominal surgery
  • Pain

Patient comfort should also be considered and they should be asked in preparation for the test to avoid:

  • Eating a substantial meal within two hours of the test
  • Alcohol within four hours of the test
  • Smoking within 24 hours of the test
  • Vigorous exercise within 30 minutes of the test
  • Wearing restrictive clothing
  • Ladies in particular should also be offered the opportunity to empty their bladder

Performing the test

Spirometry consists of two measurements, the first is the relaxed vital capacity (VC), and the second is the forced vital capacity (FVC).

Relaxed vital capacity or VC

For this test, the patient must wear a nose clip or hold their nose. They are encouraged to take a maximum breath in, and then slowly and steadily exhale until all of the air is expelled and they cannot blow any more.

During the test, the mouthpiece should be completely within the mouth enclosed tightly by the teeth and not blocked by the tongue. Disposable, one-way filter mouthpieces should be used.

This should be repeated at least two more times and the values recorded manually to enable a check of repeatability/reproducibility. Guidelines state that three good blows should be performed, and the best two blows should be within 100 ml of each other.5

Forced vital capacity or FVC

The forced expiratory volume (FEV1) is taken from this test. FEV1 is the amount of air that is blown out in the first second of the FVC. A nose clip is not required for this test. Patients are encouraged to take a maximum breath in, and then exhale hard and fast until all of the air is expelled and they cannot blow any more.

As with the VC, the mouthpiece should be completely within the mouth enclosed tightly by the teeth and not blocked by the tongue. Disposable, one-way filter mouthpieces should be used.

This test should be repeated at least two more times and the values recorded manually to enable a check of repeatability/reproducibility. Guidelines state that three good blows should be performed and the best two blows should be within 100 ml of each other.5 This applies to both the FEV1 and the FVC values. For example:

  • FVC | 4.26 | 4.28 | 4.32
  • FEV1 | 3.99 | 3.97 | 3.99

The best two FVC values are highlighted and are within 40 ml of each other. All three are within 100 ml of each other. The best two FEV1 are the same, but are also only 20 ml different from the third blow. These results suggest this is a highly reproducible/repeatable test.

Finally, before the test can be interpreted, all readings and graphs need to be checked to see if they are also technically acceptable.

Some common technical errors in spirometry5

Graph showing the effects of an extra breath
Reprinted with permission from Education for Health
Graph showing effects of sub-maximal effort
Reprinted with permission from Education for Health
Graph showing the effects of coughing
Reprinted with permission from Education for Health
Graph showing the effects of a slow start
Reprinted with permission from Education for Health
graph showing the effects of an early stop
Reprinted with permission from Education for Health

Further information about accredited spirometry training can be found at www.educationforhealth.org/spirometry or www.artp.org.uk/en/spirometry/full-cert-spiro.cfm

 

This article was initiated and funded by Teva Respiratory. Teva have had no influence over content and the aforementioned trails. Topics and content have been selected and written by independent experts.


References
  1. Tinkelman DG, Price DB, et al. Journal of Asthma 2006;43(1):75-80.
  2. British Thoracic Society, Scottish Intercollegiate Guidelines Network. BTS/SIGN, 2016. Available at: www.brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/ (accessed 30 August 2017).
  3. Levy ML, Quanjer P, et al. Primary Care Respiratory Journal 2009;18(3):130-147.
  4. NICE. London, NICE, 2010. Available at: www.nice.org.uk/guidance/cg101 (accessed 30 August 2017).
  5. Primary Care Commissioning. PCC, 2013. Available at: www.pcc-cic.org.uk/sites/default/files/articles/attachments/spirometry_e-guide_1-5-13_0.pdf (accessed 30 August 2017).
  6. Strong M, Green A, et al. Primary Care Respiratory Journal 2014;23(1):67-73.
  7. Primary Care Commissioning. PCC, 2016. Available at: www.pcc-cic.org.uk/sites/default/files/articles/attachments/improving_the_quality_of_diagnostic_spirometry_in_adults_the_national_register_of_ certified_professionals_and_operators.pdf (accessed 30 August 2017).
  8. Cooper BG. Postgraduate Medicine Journal 2011;87(1032):724-733.

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