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Ms Priya PattniClinical Physiologist
WDHB
Hamilton
8:30 - 9:25 WS #96: Lung Function Testing in Your Practice
9:35 - 10:30 WS #108: Lung Function Testing in Your Practice
(Repeated)
Lung Function in Your Practice
By Priya Pattni
Clinical Physiologist CRFS
Key points covered
• Spirometry in your practice, testing and interpretation
• Very brief discussion on how Spirometry should be performed
• Some case examples demonstrating different abnormality types
• When clinical question not answered by Spirometry, what other options in lung function
Spirometry Why?
• Employment Screening• Pre-employment medical• Monitoring• Weaning steroid meds• SOBOE• Query chronic cough• Abnormal CXR (hyper-inflated lung)• Diagnostics • Heart vs Lungs• Hyperventilation or genuine airflow limitation• Obstruction, restriction or both
Spirometry why not?
• Recent eye, thoracic or abdominal surgery• Recent MI (4weeks)• AAA • Hernia• Acute illness • Dementia• Untreated PE• Nausea • Dementia• Recent chest, neck or back injury
Spirometry – Patient prep
• Reason of testing – indication
• Brief explanation on how testing is required to be done, it is not a relaxed test.
• Medication list, if already taken any inhalers
• Check for any contra-indications, i.e. Brief medical history
Spirometry Testing 1
• Simple brief instructions, followed by prompts during testing in a timely manner.
• Deep breath in and blast out with no pause or hesitation, hard and fast
• Continuous encouragement to keep exhaling is very important
• Then take hard fast deep breath in before coming off the mouthpiece
Spirometry Testing
• Take a deep breath in..
• Without any pause blast out…
• And keep breathing out….
• Keep going until six seconds reached or patient unable to breath out any further.
• Encourage patient right through the trial…then take a deep breath in and catch your breath.
Phases of Spirometry
Acceptability 1
Slow start?
Acceptability 2
Acceptability 3
Acceptability 4
• Short blow with normal ratio and restrictive indication
Acceptability 5
Acceptability 6
• Same patient with much long breath out
Acceptability 7
Acceptability 8
Acceptability 9
Acceptability 10
Repeatability
Lung volumes
Airway network
Volume-Time Graph
Components of FV-Loop
• FV-Loop labelled with components
Components of FV-Loop
• FEV1: Forced expiratory volume in first second, is the volume of air exhaled forcefully in first second after maximal inhalation
• FVC: Forced Vital capacity, is the total volume of air exhaled forcefully until no more air can be expired
• FEV1/FVC%: AKA (FER) that is forced expiratory ratio. The FEV1 is presented as a percentage of FVC
• MMEF or FEF25-75%- Maximum Mid Expiratory Flow, decreased in obstructive lung disorders with a concaving pattern of the loop
Interpretation
Case 1
• Increasing SOBOE
• Hx working in building industry
• Occupational exposure, inhaler given with not much relief
• Spirometry ordered.
• Bloods and CXR pending
Case 1
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Case 1
Case 1 cont..
Large airflow obstruction -Fixed
• Flattened expiratory and inspiratory components of loop
Case 2
• Increased SOBOE
• Hx of subglottic stenosis with polyps
• Increased symptoms over the last month
• Abs did not help
• ? Benefit from inhalers
• Ex 30pys
Case 2
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Case 2
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Case 2
Grading scale
Case 2
Case 3
• Patient increased SOB
• ? PAH
• possible MCTD?
• PFTs ordered
• Bloods pending
• Significant smoking Hx
• Nil inhalers
Case 3
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Case 3
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Case 3
Grading scale
Case 3
Extra-thoracic Obstruction
• Example VCD
Intra-thoracic Obstruction
Variable airflow Obstruction
Variable airflow Obstruction
Interpretation Guide
C. Look at the FVC C. Look at the FVC
Variable airflow Obstruction
Grading scale
Variable airflow Obstruction
Variable airflow Obstruction
Variable airflow Obstruction
Variable airflow Obstruction
Reversibility
Reversibility
Reversibility
Reversibility
Probable Restriction
Probable Restriction?
Erect/Supine
Erect/Supine
Spirometry normal but patient still symptomatic
• Dlco – Gas transfer using CO gas and He or CH4 gas for single breath volumes
• Body plethysmography – Static lung volumes
• Bronchial challenge tests – Can be direct or indirect agents egdirect Methacholine and Indirect Saline or Mannitol
• Erect Supine spirometry
• FeNO – Exhaled nitric oxide
Messages from Respiratory Consultants 1
• Dr Ron Hayudini (Waikato Hospital)
“Look Before you Leap….Always establish that the results are reliable before using them”
“Pre/post should be done even if pre is normal. For COPD dx you need post spirometry any way.”
Any comments on inhalers for COPD and asthma patients
“COPD – 1st line is LAMA, and in Asthma first line is ICS”
Messages from Respiratory Consultants 2
• Dr Paul Tan (Whangarei Hospital)
“Firstly, ensure spirometry done is technically adequate.”
“ Secondly, if pre is abnormal do a post. Should do post if pre is normal, depending on what is the clinical question. Always use results in clinical context, know what the question is know what you are looking for. ”
Messages from Respiratory Consultants 3
• Dr Christine Bradley (Whangarei Hospital)
• “Do bronchodilator spirometry even if baseline is normal, post BD done to excluded the reversibility component , as sometimes there can be significant reversibility.”
Messages from Respiratory Consultants 4
• Dr Janice Wong (Waikato hospital) “A negative response to pre/post bronchodilator spirometry does not exclude Asthma, especially when the patients are exacerbated or wheezy”
Summary
• Detect
• Diagnose
• Follow up
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