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COPD:Spirometry

Clare Hawkins, MD, MSProgram Director, San Jacinto Methodist Hospital Family Medicine Residency,Baytown, TX

Isaac M. Goldberg, MDFaculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown,TX



Educational Objectives

At the end of this presentation, thelearner should be able to …

• Utilize spirometry to diagnose and stageCOPD

• Overcome barriers to the use of officespirometry

• Achieve confidence with spirometryinterpretation



Background

Objective measure of airway function for accuratediagnosis of Chronic Obstructive PulmonaryDisease (COPD)

World Health Organization Global Obstructive LungDisease Consensus/ Evidence guideline (GOLD)

American Thoracic Society (ATS)

European Respiratory Society (ERS)

National Committee for Quality Assurance (NCQA)



Background

Alternate ways to diagnose COPD

Clinical Findings Late- Increased AP diameter, tympanitic chest

-

Signs of respiratory distress Peak flow reading not adequately sensitive or specific

Radiographic findings occur late in disease

CT scanning more accurate, but findings also occur

late in disease



Background

Who should receive spirometry? Early diagnosis relies on the recognition of the clinical

features- Persistent cough

-Chronic sputum production

- Breathlessness on exertion

- Reduction in activity (often attributed to natural aging)

About 20% of COPD patients identified in NHANESstudy with obstruction never smoked

- Only 1/5 were explained by asthma



Background

Other testing considerations Recurrent or chronic respiratory symptoms Occupational exposure to respiratory irritants

Family history of respiratory diseases and symptoms NCQA established use of spirometry as required

quality measure for accurate COPD diagnosis Routine periodic use not recommended



Background

Screening Not recommended in the absence of respiratory

symptoms (dyspnea, cough)

No threshold amount of smoking pack-years forscreening in the absence of respiratory symptoms Not recommended by USPSTF or ACP 2011

Guideline



Background

Family physicians able to do quality spirometry

Quality of care increases with use of spirometry- To prevent overdiagnosis of COPD, attention to quality

spirometry is important

Suggestions to maintain quality of spirometry- Know technique

- Have staff coach the patient

- Do sufficient numbers of tests

-Maintain and calibrate the equipment

- Understand interpretative algorithms



Background

Why do office spirometry? Diagnostic accuracy. 30% of time diagnosis changes.

- Was not COPD; heart failure or asthma

- Was COPD rather than asthma

- If spirometry normal, then expensive meds discontinued

Respect. Patients respect physicians who usetechnology (Future of Family Medicine)

Patient convenience. You can avoid an unnecessaryreferral and additional visit

Diagnostic power: You can connect diagnosticinformation with rest of clinical encounter

Financial benefit to practice.



Equipment

Older volume/time loop- Drum technique from John

Hutchinson 1844

Newer flow/volume loopusing flow transducer- Smaller Machines, Mobile

- Disposable Mouthpiece

No other infection

transmissionprecautions necessary



Equipment

Numerous manufacturers produce quality instruments

Reviews conducted by National Lung Health EducationProgram (NLHEP) regarding appropriateness ofspirometers for office practice- http://www.nlhep.org/spirometer-review-process.html

- Simplicity (fewer numbers)

- Reliability

http://www.nlhep.org/spirometer-review-process.html








Equipment

Calibration

Daily calibration must be done with 3 L syringe

Syringe must have accuracy of at least 15 ml

Spirometer must have accuracy of ±105 mL or0.105 L (calibration volume = 2.90 to 3.11)

Calibration log/printouts must be kept

- Date and time of calibration

-Individual performing

- Comments



Technique

Forced expiratory maneuver

Coach patient to get a maximal effort

Six seconds of effort required though most of air pushed

out in the first second Pace of expired air is most important variable; therefore

it should be released with explosive force



Technique

Minimum 6 second exhalation with 2 second plateau

Tracing should have no artifacts

At least 3 acceptable maneuvers (<5 % variation)

- ATS criteria

Empty bladder for females (concern if incontinence)

Can be seated or standing

Nose plug optional



Technique

None of the following should occur: Unsatisfactory start, with excessive hesitation or false start

Air leak

Coughing during the first second Early termination of forced expiration

Glottis closure

Obstructed mouthpiece -

Tongue- False teeth

- Chewing gum



Technique

Reliability

Spirometry overdiagnoses COPD if insufficient effort

Concerns that family physicians will not perform

quality testing and overdiagnose people withobstructive lung disease

Imperative that patients be coached on robust, forcedexpiratory maneuver



Technique

Contraindications

Hemoptysis of unknown origin

Pneumothorax

Unstable cardiovascular status or recent MI or PE Thoracic, abdominal, or cerebral aneurysms

Recent eye, thorax or abdomen surgery



Technique

Barriers Inaccessibility of Equipment Concern patient effort and cooperation are insufficient Difficulty remembering interpretive algorithm

Frustration by ambiguous results Difficulty working 30-minute spirometry into office flow Central location for spirometry versus going room to

room Lack of staff training Poor integration with electronic health record Lack of adequate reimbursement



Measurements

Abbreviation Characteristic measured

FEV1 Forced expired volume in 1 second

FVC Forced vital capacity

FEV1 /FVC

Ratio

Ratio of the above

PEFR Peak expiratory flow rate

FEF 25-75% Forced expiratory flow between 25-75% of the vital

capacity



Measurements

Normal values Individual variation according to age, height, ethnicity

and gender

-Height - Tall people have larger lungs

- Age - Respiratory function declines with age

- Sex - Lung volumes smaller in females

- Race - Studies show Blacks and Asians have smaller lung

volumes (-12%)- Posture - Little difference between sitting and standing;

reduced in supine position



Measurements

Bronchodilator reversibility testing

Beta-agonist

- Short-acting – wait 20 minutes before retesting

-Long-acting – wait 2 hours before retesting

Do not take bronchodilator the day of testing

- Measured reversibility will be limited if the patient isbronchodilated for the pretest.



Measurements

Definition of reversibility

Pre-Bronchodilator

- FEV1/FVC <70% of predicted

Post-Bronchodilator- Increase 12% AND at least 200 cc

Reversibility = Asthma!





Measurements

Pre-Bronchodilator Post-Bronchodilator

Predicted Measured % Measured % % change

FVC 2.66 1.32 50 1.26 47 -4

FEV1 2.02 0.54 26 0.50 25 -6

FEV1/FVC 76 41 -35 39 -37 -2

PEF 315 114 36 120 38 5

FEF 25 4.96 0.40 8 0.30 6 -28

FEF 50 2.85 0.20 7 0.20 7 -----

FEF 75 0.78 0.10 13 ----- ----- 198FEF 25-75 1.02 0.19 10 0.18 10 -6



MeasurementsSeverity of obstruction

FEV1 % of predicted

Mild >80

Moderate 50 to 79

Severe 30 to

Very severe <30

Severity of restriction

FVC % of predicted

Mild >65 to 80Moderate >50 to 65

Severe <50



Case Study 1

A 53-year-old white male presents for annualvisit. Although he quit 10 years ago he is aprevious cigarette smoker with a 20 pack-year

history. During the past 12 months, he has had3 episodes of bronchitis. His history of tobaccouse and recent episodes of acute bronchitis leadyou to perform spirometry.



Results

Pre-Bronchodilator Post-BronchodilatorPredicted Measured % Measured % % change

FVC 4.65 4.65 100 4.95 106 6

FEV1 3.75 3.13 83 3.34 89 6

FEV1/FVC 80 67 -13 67 -13 0

PEF 511 462 90 522 102 12

FEF 25 7.86 5.7 73 6.00 76 5

FEF 50 4.46 2.3 52 2.10 47 -9

FEF 75 1.75 .5 29 0.60 35 18

FEF 25-75 3.76 1.77 47 1.78 47 0



Results


FVC 4.65 4.65 100 4.95 106 6

FEV1 3.75 3.13 83 3.34 89 6

FEV1/FVC 80 67 -13 67 -13 0

Is there obstruction?

FEV1/FVC = 67% of predicted; therefore, obstruction present

Is there restriction?FVC = 100% of predicted; therefore, no restriction present



Results


FVC 4.65 4.65 100 4.95 106 6

FEV1 3.75 3.13 83 3.34 89 6

FEV1/FVC 80 67 -13 67 -13 0

What is the severity of obstruction?

FEV1 is 83% of predicted; therefore, the obstruction is mild

Is the obstruction reversible (is reversibility present)?

FEV1 increases from 83% to 89% (6% increase) and increases from 3,130

cc to 3,340 cc (increase of 210 cc)

Interpretation: Mild Obstruction with minimal reversibility: Mild COPD



Common ObstructivePulmonary Disorders

Diffuse Airway Disease Upper-Airway Obstruction

Asthma

COPDBronchiectasis

Cystic fibrosis

Foreign body

NeoplasmTracheal stenosis

Tracheomalacia

Vocal cord paralysis



No Yes

Obstructive Defect

Is FVC Low? (<80% pred)

Combined Obstruction &Restriction /or HyperinflationPure Obstruction

Improved FVC withß-agonist

Reversible Obstructionwith ß-agonist

Further Testing withFull PFT’s

SuspectAsthma

SuspectCOPD

Is FEV1 / FVC Ratio Low? (<70%)

Yes

No Yes

No Yes

Diagnostic Flow Diagram for Obstruction

Adapted from Lowry.







Results

Pre-Bronchodilator Post-Bronchodilator

Predicted Measured % Measured % % change

FVC 3.78 1.92 51 2.7 71 34

FEV1 3.24 1.11 34 1.61 50 36

FEV1/ FVC 86 58 -28 60 -26 3

Obstruction?

FEV1/FVC = 60%; therefore, obstruction present

Restriction?

FVC = 51% of predicted; therefore, restriction present



Results


FVC 3.78 1.92 51 2.7 71 34

FEV1 3.24 1.11 34 1.61 50 36

FEV1/ FVC 86 58 -28 60 -26 3

What is the severity of obstruction?60%; therefore, moderate obstruction

Is the obstruction reversible (is reversibility present)?

FEV1 increases from 34% to 50% (16% increase) and increases by 500 ccWhat is the severity of restriction?

71% of predicted; therefore, mild restriction

Interpretation: Moderate obstruction with reversibility (Moderate obstruction)



Common Restrictive PulmonaryDisorders

Parenchymal Interstitial Lung Diseases

- Fibrosis

- Granulomatosis (TB)

- Pneumoconiosis

- Pneumonitis (lupus)

Loss of Functioning Tissue

- Atelectasis

- Large Neoplasm

- Resection

Pleural Effusion

Fibrosis

Chest Wall

Kyphoscoliosis

Neuromuscular Disease

Trauma

Extrathoracic

Obesity

Abdominal Trauma



No Yes

Is FVC Low?(<80% pred)

Restrictive Defect Normal Spirometry

Further Testing with

Full PFT’s; consider

referral if moderate to

severe

Is FEV1 / FVC Ratio Low? (<70%)

No

Diagnostic Flow Diagram for Restriction

Adapted from Lowry, 1998



Results

Lowry 1998



Results

“Full” Pulmonary Function Testing (PFT’s) Assessment of Oxygenation

- Transcutaneous oxygen saturation

- Arterial blood gasses

Diffusion test to evaluate alveolar exchange (DLCO) Plethysmography

- To objectively assess lung volumes

- Delineate air-trapping versus restriction

May also include Spirometry







Spirometry and Smoking Cessation





Coding and Reimbursement

Procedure CPT Code Reimbursement*

Single spirometry 94010 $32.82

Pre-post spirometry 94060 $57.71

Pulmonary stress test simple 94620 $71.77

Medication administrationbronchodilator supply separate

94640 $13.34

Demonstration / instruction 94664 $14.79

Smoking Cessation <8x/ yr 99406 $12.98

Equipment Cost

Office spirometer $1,000 – 2,500

*Reimbursement based upon Medicare payments 2009



Estimated Return on Investment

Tests /week (#) Reimbursement/year* ROI $1,995 in weeks

4 $6,864 15

6 $10, 296 10

8 $13,728 710 $17,160 6

15 $25,740 4

20 $34,320 3

25 $42,900 2

*Based upon CPT code 94010



References

• AARC Clinical Practice Guideline. Delivery of aerosols to the upper airway.Respir Care 1996;41(7):629-36

• Belfer M. Office management of COPD in primary care: A 2009 clinicalupdate. Postgraduate Medicine 2009;121(4):82-90.

• Blain EA, Craig TJ. The use of spirometry in a primary care setting. Int JGen Med. 2009; 2: 183 –186.

• Chavez,P.C. and Shokar,N.K. Diagnosis and management of chronicobstructive pulmonary disease (COPD) in a primary care clinic. COPD 2009;6(6): 446-451.

• Enright P. The use and abuse of office spirometry. Prim Care Respir J.2008 Dec;17(4):238-42.

• Fletcher C, Peto R. The natural history of chronic airflow obstruction. BrMed J. 1977;1(6077):1645-1648.

• Ferguson GT et al. Office spirometry for lung health assessment in adults: Aconsensus statement from the National Lung Health Education Program.Respiratory Care 2000;45(5) 513-30



References (continued)

• Grossman E, Sherman S. Telling smokers their "lung age" promotedsuccessful smoking cessation. Evid Based Med. 2008;13(4):104

• Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference valuesfrom a sample of the general US population. Am J Respir Crit Care Med1999;159:179 –187

• History Diagnosis Spirometerhttp://www.umanitoba.ca/libraries/units/health/images/HistoryDiagnosisSpir ometer.jpg

• Jing JY. Should FEV1/FEV6 replace FEV1/FVC ratio to detect airwayobstruction? A metaanalysis. Chest. 2009 Apr;135(4):991-8.

• Johannessen A, et al. Post-bronchodilator spirometry reference values inadults and implications for disease management. Am J Respir Crit CareMed 2006; 173(12):1316-25.

• Kaminsky DA, Marcy TW, Bachand M, Irvin CG. Knowledge and use ofoffice spirometry for the detection of chronic obstructive pulmonary diseaseby primary care physicians. Respir Care. 2005 Dec;50(12):1639-48.



• Knudson RJ, Slatin RC, Lebowitz MD, Burrows B. The maximal expiratoryflow-volume curve. Normal standards, variability, and effects of age. AmRev Respir Dis 1976;113:587 –600

• Lin KW Screening Spirometry. American Family Physician 2009;80(8) :861-2.

• Lowry, Josiah A Guide to Spirometry for Primary Care Physicians 1998Published by College of Family Physicians of Canada with BoehringerIngelheim

• MacIntyre NR, Selecky PA. Is there a role for screening spirometry? RespirCare. 2010;55(1):35-42 [Review].

• National Committee on Quality Assurance. 2009 Healthcare EffectivenessData and Information Set (HEDIS) performance measures. 2010. Availableat www.ncqa.org/tabid/855/Default.aspx. Accessed August 2010.

• Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate oftelling patients their lung age: the Step2quit randomised controlled trial BMJ2008;336:598-600.

http://www.ncqa.org/tabid/855/Default.aspx.%20Accessed%20August%202010

http://www.ncqa.org/tabid/855/Default.aspx.%20Accessed%20August%202010



References (continued)

• Poels PJ, olde Hartman TC, Schermer TR. Qualitative studies to explorebarriers to spirometry use: a breath of fresh air? Respir Care. 2006Jul;51(7):768.

• Rennard S, Vestbo J. COPD: The Dangerous underestimate of 15%. Lancet2006; 367, 1216-1219.

• Spann SJ. Impact of spirometry on the management of chronic obstructiveairway disease. J Fam Pract. 1983 Feb;16(2):271-5.

• Spirometer Review Process (SRP) – Revised.http://www.nlhep.org/spirometer-review-process.html. Accessed, November14th, 2010.

• Wilt TJ, Niewoehner D, Kim C, et al. Use of spirometry for case finding,diagnosis, and management of chronic obstructive pulmonary disease(COPD). Evid Rep Technol Assess (Summ). 2005;(121):1-7 [Review].

• Yawn BP et al. Spirometry can be done in family physicians' offices andalters clinical decisions in management of asthma and COPD. Chest. 2007Oct;132(4):1162-8. Epub 2007 Jun 5.

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