Presentation on Hands on Session :ICT supporting

Integrated Healthcare Services--------- Kutub Ashraf

Biotechnology DepartmentUniversity of Chittagong, Bangladesh

Overview :• Integrated care• Spirometry• Common errors and Quality assurance of Spirometry• Case study and Data interpretation• Concluding Remarks

What is Integrated Health care ?

• WHO gives the following definition

“ Integrated care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion “So……

Simple Schematic outline of integrated care :

Spirometry Spirometry is a test that can help diagnose various lung conditions, most commonly chronic obstructive pulmonary disease (COPD).

It is also used to monitor the severity of some other lung conditions, and their response to treatment.

Spirometry Quality Assurance: Common Errors and Their Impact on Test Results

• Quality assurance includes examination of test values and evaluation of both the volume-time and flow-volume curves for evidence of technical errors.

• Technically poor spirometry may have little value and may even

provide misleading information.

• When erroneous curves are detected, additional maneuvers are often needed

A Spirometer produces 2 types of curves from which common parameters are measured:FEV1 – Forced expiratory volume in one second –This is the amount of air you can blow out within one second.

• FVC – Foced vital capacity – The total amount of air you can blow out in one breath.

• FEV1 / FVC – The ratio of FEV1 over FVC

• PEF – Peak expiratory flow – The highest speed at which you blow out the air.

The volume time curve ( left) shows the time course of exhalation from baseline• Rising Sharply• Then gradually slows until 1 second FVC

plateau drawn

Examples of Poorly performed tests are :• Error 1: Expiration too slow• Error #2: Excessive Extrapolated Volume• Error #3: Sub-maximal Blast , leak• Error #4: Cough in First Second• Error #5: Early Termination• Error #6: Variable Effort• Error #7: Cessation of Airflow – Glottis Closure or Breath Holding

Error 4 : Cough in First SecondFEV1 (L) FEV1 % Pred

Good Effort 4.12 88Error 3.96 84

• Problem: Coughing in the first second may affect the FEV1 measurement, while coughing after the first second will not affect the FVC measurement• Identification: Although this example has one cough, often there are multiple coughs in a single maneuver. Cough is more difficult to see on the volume-time curve.

• Test Result Implications: However, a cough is difficult to define and its appearance on the display is very instrument-dependent. • Significant coughing may cause a falsely reduced FVC. In any case, because the

FEV1/FVC ratio may be inaccurate, the maneuver is unacceptable.

• Solution: Coughing is difficult to manage. Offering a drink of water before the maneuver may help.• Spirometer Error Message: Some spirometers label this error with “Cough

Case Study :MANEUVER 1.

Questions ?• What error do I observe?• How would it affect the accuracy of the measurement? so……..

Parameter Maneuver 1 (L)

Maneuver 2 (L)

Maneuver 3 (L)

Predicted (L)

Percentage of Predicted

FVC 3.4 3.4

3.4 2.99 113%

FEV1 2.5 2.5 2.5 2.13 117% FEV1/FVC 0.735 0.735 0.735

Observation : No Obstruction detection• Normal cases : FEV1/FVC: >0.70 “Normal”• OBSTRUCTION <<<<<<< FEV1/FVC <0.70 In our cases, The spirometry correspond to a normal flow since the FEV1/FVC ratio is > 0.7. We can also observe that the predicted percentage are above 100% meaning that the patient has a better flow compared to the average flow measured from the corresponding population of the patient (gender, ethnicity, etc)

Severity classification (GOLD)

Vestbo J, Hurd SS, Agusti AG, et al. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, GOLD Executive Summary. American journal of respiratory and critical care medicine 2012

Hence……..• In case 2 our ratio was less than o.70 so we can observe a Partially

Obstructed Mouthpiece error .• The speed of exhaled air is reduced if the mouthpiece is partially

blocked by the subject’s tongue, teeth, loose dentures, or strong biting that deforms the shape of the mouthpiece

Obstructive Lung DiseaseA patient with obstructive lung disease typically has a concave F/V loop.

In patients with obstructive lung disease, the small airways are partially obstructed by a pathological condition. The most common

forms are asthma and COPD.

The air in the large airways usually can be expired without problems, so PEF may be normal.

When all the air is expired from the large airways, air from the smaller airways will be expired. With obstructive lung disease, these airways are partially blocked, so the air will come out slower

Solution and Future ??• Clinical Decision Support Systems--- As it reduces clinical error and serve as clinical assistant--- Cost Reduction without compromising care

• Decision support service for automatic quality control of spirometry

• Non-specialized professionals in primary care and in pharmacy offices.

• Web-based application • Remote assistance • In pharmacies (CASE FINDING out of Primary Care)