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Interpreting Spirometry Results
Spirometry requires considerable patient effort and cooperation. Therefore, results must
be assessed for validity before they can be interpreted. Inadequate patient effort can lead to
misdiagnosis and inappropriate treatment.
To determine the validity of spirometric results, at least three acceptable spirograms
must be obtained. In each test, patients should exhale for at least six seconds and stop when there
is no volume change for one second. The test session is finished when the difference between the
two largest FVC measurements and between the two largest FEV1 measurements is within 0.2 L.
If both criteria are not met after three maneuvers, the test should not be interpreted. Repeat
testing should continue until the criteria are met or until eight tests have been performed. The
lines of the flow-volume curve are free of glitches and irregularities. The volume-time curve
extends longer than six seconds, and there are no signs of early termination or cutoff.
If the test is valid, the second step is to determine whether an obstructive or
restrictive ventilatory pattern is present.
Restrictive ventilatory pattern can be:
Parenchymal
• Sarcoidosis
• Pneumoconiosis
•Pulmonary fibrosis
• Interstitial lung disease
Extraparenchymal
• Neuromuscular diseases
• Affections of thoracic cage: kyphosis, scoliosis, obesity
The characteristic element is reduction of lung volumes, especially TLC and VC.
In parenchymal restrictive ventilatory disease RV is generally low and expiratory flows
are maintained (FEV1 is normal). Curve flow/volume shows imbalance between flows and lungvolumes – the curve is relatively high, but narrow.
In extraparenchymal restrictive ventilatory disease, dysfunction can be predominantly
during inspiration or combined (inspiration and expiration).
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The inspiratory restrictive dysfunction can be due to weak inspiratory muscles, rigid
thoracic cage and the lung, which is normal, is under insufficient force. In consequence TLC is
low, RV is not usually affected and expiratory flow is conserved.
In combined restrictive dysfunction the ability to expire to RV is limited (RV is high).
FEV1/FVC is variable, depending on respiratory muscles strength. If this strength is significantly
low, the ratio will be low, in the absence of obstruction. If muscles strength is conserved, but
thoracic cage is rigid, the ratio will be normal or high.
A reduced FEV1 and absolute FEV1/FVC ratio indicates an obstructive ventilatory
pattern. A Tiffeneau index (FEV1/FVC x 100) of less than 70% is very suggestive for
obstructive lung disease. VC is often low in obstructive disease, because of important increase of
RV, but with insignificant change of TLC.
When the FVC and FEV1 are decreased, the distinction between an obstructive and
restrictive ventilatory pattern depends on the absolute FEV1/FVC ratio. If the absolute
FEV1/FVC ratio is normal or increased, a restrictive ventilatory impairment may be present.
However, to make a definitive diagnosis of restrictive lung disease, the patient should be referred
to a pulmonary laboratory for static lung volumes. If the TLC is less than 80 percent, the pattern
is restrictive, and diseases such as pleural effusion, pneumonia, pulmonary fibrosis, and
congestive heart failure should be considered.
Bronchodilator challenge testing is recommended to detect patients with reversible
airway obstruction (e.g., asthma). A bronchodilator is given, and spirometry is repeated after
several minutes. The test is positive if the FEV1 increases by at least 12 percent and the FVC
increases by at least 200 mL. The patient should not use any bronchodilator for at least 48 hours
before the test. A negative bronchodilator response does not completely exclude the diagnosis of
asthma.
The mid-expiratory flow rate (FEF 25–75%) is the average forced expiratory flow rate
over the middle 50 percent of the FVC. It can help in the diagnosis of an obstructive ventilatory
pattern. Because it is dependent on FVC, the FEF 25–75% is highly variable. In the correct
clinical situation, a reduction in FEF25–75% of less than 60 percent of that predicted and an
FEV1/FVC ratio in the low to normal range may confirm airway obstruction.
The maximal voluntary ventilation (MVV) maneuver is another test that can be used to
confirm obstructive and restrictive conditions. The patient is instructed to breathe as hard and fast
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as possible for 12 seconds. The result is extrapolated to 60 seconds and reported in liters per
minute. MVV generally is approximately equal to the FEV1. A low MVV can occur in
obstructive disease but is more common in restrictive conditions. If the MVV is low but FEV1
and FVC are normal, poor patient effort, a neuromuscular disorder, or major airway lesion must
be considered.
Once the ventilatory pattern is identified, the severity of the disease must be determined.
The obstructive syndrome is considered to be:
• Mild – if FEV1/FVC ratio = 60-75%
• Moderate – if FEV1/FVC ratio = 40-60%
• Severe – if FEV1/FVC ratio < 40%
The final step in interpreting spirometry is to determine if additional testing is needed to
further define the abnormality detected by spirometry. Measurement of static lung volumes,
including FRC, is required to make a definitive diagnosis of restrictive lung disease.
Table 1. Ventilatory dysfunction
Ventilatory dysfunction
TLC RV VC FEV1/ FVC
Obstructive N / ↑ ↑ ↓ ↓
Restrictive
Parenchymal ↓ ↓ ↓ N / ↑
Extraparenchymal affection of
inhaling
↓ N / ↓ ↓ N
Extraparenchymal affection of
inhaling + exhaling
↓ ↑ ↓ Variable
Mixed ventilatory dysfunction
• Low VC
• Low FEV1/FVC
• Very low FEV1
Diagnostic is not certain without the evidence of restrictive component (low TLC)
• E.g. lung tuberculosis + chronic bronchitis
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Fig.1 Flow-volume in obstructive lung disease is concave, FEF25-75 too low, FVC normal
Fig.2 Volume-time curve in obstructive lung disease: FEV1 low, FET ( Forced Expiratory Time)
higher due to the lower flow but equal volume.
Fig.3 Variable Extrathoracic Obstruction. Typically the expiratory part of the F/V-loop is
normal: the obstruction is pushed outwards by the force of the expiration. During inspiration the
obstruction is sucked into the trachea with partial obstruction and flattening of the inspiratory
part of the flow-volume loop. This is seen in cases of vocal cord paralysis, extrathoracic goiter and laryngeal tumors.
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Fig.4 Variable Intrathoracic Obstruction. A tumor located near the intrathoracic part of thetrachea is sucked outwards during inspiration with a normal morphology of the inspiratory part
of F/V-loop. During expiration the tumor is pushed into the trachea with partial obstruction andflattening of the expiratory part of the F/V loop.
Fig.5 Flow-volume in restrictive lung disease - shape normal, FVC low. Total lung volume is
low, which results in a low FVC. PEF can be normal or low. FEV1 is equally lowered than FVC,so the Tiffeneau index will be normal or even raised.
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Fig. 6 Volume-time curve in restrictive lung disease - FEV1 too low, FET normal
Fig. 7 Fixed Large Airway Obstruction. This can be both intrathoracic as extrathoracic. The
flow-volume loop is typically flattened during inspiration and expiration. Examples are tracheal
stenosis caused by intubation and a circular tracheal tumor.
Fig.8 Mixed Lung Disease Often patients will show signs of both obstructive and restrictive lungdisease. The flow-volume loop will have characteristics of both syndromes - FVC, FEV1 and
FEF25-75 too low.
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Diagnostic algorithm
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Investigation of asthma
Allergens
Extrinsic allergens include:
• pollen
• animal dander
• house dust or mold
• kapok or feather pillows
• food additives containing sulfites
• other sensitizing substances.
Intrinsic allergens include:
• irritants
• emotional stress
• fatigue
• endocrine changes
• temperature variations
• humidity variations
• exposure to noxious fumes
•
anxiety• coughing or laughing
• genetic factors
Laboratory Studies
• Laboratory assessments and studies are not routinely indicated for asthma, but they may
be used to exclude other diagnoses.
• Blood eosinophilia greater than 4% or 300-400/µL supports the diagnosis of asthma, but
an absence of this finding is not exclusionary. Eosinophil counts greater than 8% may be
observed in patients with concomitant atopic dermatitis. This finding should prompt an
evaluation for allergic bronchopulmonary aspergillosis or eosinophilic pneumonia.
• Total serum immunoglobulin E levels greater than 100 IU are frequently observed in
patients experiencing allergic reactions, but this finding is not specific for asthma and
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may be observed in patients with other conditions (eg, allergic bronchopulmonary
aspergillosis). A normal total serum immunoglobulin E level does not exclude the
diagnosis of asthma.
• In assessing asthma control, the British Thoracic Society recommends using sputum
eosinophilia determinations to guide therapy. An improvement in asthma control, a
decrease in hospitalizations, and a decrease in exacerbations were noted in those patients
in whom sputum-guided therapy was used. A controlled prospective study has shown that
adjusting inhaled corticosteroid (ICS) treatment to control sputum eosinophilia - as
opposed to controlling symptoms, short-acting beta-agonist (SABA) use, nocturnal
awakenings, and pulmonary function - significantly reduced both the rate of asthma
exacerbations and the cumulative dose of inhaled corticosteroids.
Imaging Studies
• In most patients with asthma, chest radiography findings are normal or may indicate
hyperinflation. Findings may help rule out other pulmonary diseases such as allergic
bronchopulmonary aspergillosis or sarcoidosis, which can manifest with symptoms of
reactive airway disease. Chest radiography should be considered in all patients being
evaluated for asthma to exclude other diagnoses.
• Sinus CT scanning may be useful to help exclude acute or chronic sinusitis as a
contributing factor. In patients with chronic sinus symptoms, CT scanning of the sinuses
can also help rule out chronic sinus disease.
Other Tests
• Allergy skin testing is a useful adjunct in individuals with atopy. Results help guide
indoor allergen mitigation or help diagnose allergic rhinitis symptoms. The allergens that
most commonly cause asthma are aeroallergens such as house dust mites, animal danders,
pollens, and mold spores.
• Two methods are available to test for allergic sensitivity to specific allergens in the
environment: allergy skin tests and blood radioallergosorbent tests (RAST).
• In patients with asthma and symptoms of gastroesophageal reflux disease (GERD), 24-
hour pH monitoring can help determine if GERD is a contributing factor.
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Procedures
• Pulmonary function testing (spirometry)
o Spirometry assessments should be obtained as the primary test to establish the
asthma diagnosis. Spirometry should be performed prior to initiating treatment in
order to establish the presence and determine the severity of baseline airway
obstruction. Optimally, the initial spirometry should also include measurements
before and after inhalation of a short-acting bronchodilator in all patients in whom
the diagnosis of asthma is considered. Spirometry measures the forced vital
capacity (FVC), the maximal amount of air expired from the point of maximal
inhalation, and the FEV1. A reduced ratio of FEV1 to FVC, when compared with
predicted values, demonstrates the presence of airway obstruction. Reversibility is
demonstrated by an increase of 12% and 200 mL after the administration of a
short-acting bronchodilator.
o The assessment and diagnosis of asthma cannot be based on spirometry findings
alone because many other diseases are associated with obstructive spirometry
indices.
o As a preliminary assessment for exercise-induced asthma (EIA), or exercise-
induced bronchospasm (EIB), perform spirometry in all patients with exercisesymptoms to determine if any baseline abnormalities (ie, the presence of
obstructive or restrictive indices) are present.
• Methacholine- or histamine- challenge testing
o Bronchoprovocation testing with either methacholine or histamine is useful when
spirometry findings are normal or near normal, especially in patients with
intermittent or exercise-induced asthma symptoms. Bronchoprovocation testing
helps determine if airway hyperreactivity is present, and a negative test result
usually excludes the diagnosis of asthma.
o Trained individuals should perform this asthma testing in an appropriate facility
and in accordance with the guidelines. Methacholine is administered in
incremental doses up to a maximum dose of 16 mg/mL, and a 20% decrease in
FEV1, up to the 4 mg/mL level, is considered a positive test result for the presence
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of bronchial hyperresponsiveness. The presence of airflow obstruction with an
FEV1 less than 65-70% at baseline is generally an indication to avoid performing
the test.
• Exercise testing
o Exercise spirometry is the standard method for assessing patients with exercise-
induced bronchospasm. Testing involves 6-10 minutes of strenuous exertion at 85-
90% of predicted maximal heart rate and measurement of postexercise spirometry
for 15-30 minutes. The defined cutoff for a positive test result is a 15% decrease
in FEV1 after exercise.
o Exercise testing may be accomplished in 3 different ways, using cycle ergometry,
a standard treadmill test, or free running exercise. This method of testing is
limited because laboratory conditions may not subject the patient to the usual
conditions that trigger exercise-induced bronchospasm symptoms, and results
have a lower sensitivity for asthma compared with other methods.
• Eucapnic hyperventilation
o Eucapnic hyperventilation with either cold or dry air is an alternate method of
bronchoprovocation testing.
o It has been used to evaluate patients for exercise-induced asthma and has been
shown to produce results similar to those of methacholine-challenge asthmatesting.
• Peak-flow monitoring
o Peak-flow monitoring is designed for ongoing monitoring of patients with asthma
because the test is simple to perform and the results are a quantitative and
reproducible measure of airflow obstruction.
o It can be used for short-term monitoring, exacerbation management, and daily
long-term monitoring. Peak-flow monitoring should not be used as a substitute for
spirometry to establish the initial diagnosis of asthma.
o Results can be used to determine the severity of an exacerbation and to help guide
therapeutic decisions as part of an asthma action plan.
• Guidelines for the use of peak-flow meters for asthma
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o Advise the patient to use the peak-flow meter upon awakening in the morning
before using a bronchodilator.
o Instruct the patient on how to establish a personal best peak expiratory flow (PEF)
rate.
o Inform the patient that a peak flow of less than 80% of the patient's personal best
indicates a need for additional medication and a peak flow below 50% indicates
severe exacerbation.
o Advise the patient to use the same peak-flow meter over time.
• Exhaled nitric oxide
o Exhaled nitric oxide analysis has been shown to predict airway inflammation and
asthma control; however, it is technically more complex and not routinely used in
the monitoring of patients with asthma.
o A prospective, controlled study has shown that when inhaled corticosteroid
asthma treatment was adjusted to control the fraction of exhaled nitric oxide, as
opposed to controlling the standard indices of asthma, the cumulative dose of ICS
was reduced, with no worsening of the frequency of asthma exacerbations.
Medical Care
The latest version of the goals for successful assessment and management of asthma outlined in
the 2008 US National Heart, Lung, and Blood Institute publication "Global Strategy for AsthmaManagement and Prevention" include the following :
• Achieve and maintain control of asthma symptoms
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal as possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality
Overall management of asthma should incorporate the following 4 treatment components:
• Objective measures of lung function
• Environmental control measures and avoidance of risk factors
• Comprehensive pharmacologic therapy
• Patient education
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