spirometry: a practical approach and some fun cases · 2018-11-26 · spirometry: a practical...
TRANSCRIPT
Spirometry: a practical approach and some fun cases
Ron Olivenstein, MD
Montreal Chest Institute
Montreal, Quebec
November 26, 2018.
Potential for Conflict of Interest
Advisory Boards: AstraZeneca, GlaxoSmithKline,
Merck, Novartis, Sanofi.
Speakers Fees: AstraZeneca, GlaxoSmithKline,
Merck, Novartis.
Research grants:, AstraZeneca, Boehringer
Ingelheim, Boston Scientific, Genentech,
GlaxoSmithKline, Medimmune, Merck, Novartis,
Sanofi.
Objectives
• Describe the benefits of spirometry in the diagnosis of obstructive lung diseases
• Learn to interpret spirometry results
3
Why spirometry ?
30% of doctor diagnosed
asthma is found to be mistaken
when not confirmed by
spirometry
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36.
Indications for Spirometry
• Detect the presence or absence of lung disease
• Quantify the severity of lung disease
• Assess the change in lung function over time or following administration of therapy
• Assess the potential effects of environmental or occupational exposure
• Assess impairment and/or disability
• Assess risk for surgical procedure
5
Who should be tested?
• All patients with suspected Asthma or COPD
• Smokers of > 20 pack years
– Screening vs. case finding
• Patients with significant occupational exposure to respiratory irritants
• Patients with family history of respiratory diseases
• Patients undergoing lung surgery
6
Spirometry Contraindications
• Contraindications (safety or reliability issues)
– Hemoptysis of unknown origin
– Pneumothorax
– Unstable cardiovascular status (eg. recent myocardial infarction or pulmonary embolus)
– Thoracic, abdominal, or cerebral aneurysms
– Recent eye, thorax or abdomen surgery
– Suspected TB or other contagious respiratory infection
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36. 7
Terms and Abbreviations
• FVC – is the volume of air that can be forcibly expelled from the lung from maximum inspiration to maximum expiration
• FEV1 – the volume of air that can be forcibly expelled from maximum inspiration in the first second
• FEV1 /FVC – Ratio
• PEFR – the maximum flow rate attained during an FVC maneuver
8
Lung Function Testing: Normal Effort
9
Spirometry Criteria:
• Minimum of 3 acceptable FVC maneuvers should be performed
– Discontinue testing after 8 attempts
– No cough, especially during the first second
• Good ‘start-of-test’ includes:
– No hesitation or false start
– Rapid start to rise time
• Minimum exhalation time of 6 seconds
AARC Clinical Practice Guideline. Respir Care 1996;41(7):629-36. 10
Examples of Anomalous Spirometric Measurements
Adapted from: GOLD. Spirometry for healthcare providers; Available at: http://www.goldcopd.com/OtherResourcesItem.asp?l1=2&l2=2&intId=1836
Used with permission from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung
Disease (GOLD) 2008. Available from: http://www.goldcopd.org
11
Predicted Normal Values
Reference value only, not absolute right or wrong!
12
3 steps to diagnose respiratory
disorders using spirometry
1. FEV1/FVC
If less than 70% implies OBSTRUCTION
If greater than 70%: normal or restriction
2. FEV1: degree of obstruction
3. FVC:
If less than 80% implies restriction
If greater than 80% implies normal.
Criteria to determine significant
reversibility after bronchodilators
Description VEMS
% reversibilité 12% et changement absolu du 200 mL
Q1
Relationship between significant reversibility after
bronchodilator administration and asthma
• Confirms asthma in the appropriate clinical setting especially if the
FEV1/FVC ratio is normalized post bronchodilator.
• < 70% pre b-d
•> 70% pre b-d
•But is also present in many patients with COPD. However in COPD by
definition the post b-d FEV1/FVC is always < 70%
•The greater the post b-d improvement, the more likely an asthmatic
component i.e > 400 ml improvement post b-d.
• The absence of reversibility does not exclude a diagnosis of asthma:
i.e. airways remodelling in severe asthma
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
16
Lung Function Testing : Obstruction
17
Ventilation (L/min)
0 20 40 60 80 0 20 40 60 80
140
120
100
80
60
40
20
0
140
120
100
80
60
40
20
0
Vo
lum
e (%
pre
d T
LC)
Normal(n=25)
COPD(n=105)
RV
IRVIC
ICVC
Dynamic Lung Hyperinflation
O'Donnell DE, et al.: Am J Respir Crit Care Med 2001; 164(5):770-7.
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
19
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Restriction
20
Lung Function Testing : Restriction
21
O’Donnell DE, et al. Can Respir J 2007;14(Suppl B):5B-32B
COPD: Classification By SpirometryBased on Postbronchodilator FEV1
Severity of Restriction: FVC
Mild 65% to 80% predictedModerate 50% to 65% predictedSevere <50% predicted
22
Bronchoprovocation testing
Case 1
61 female smoker 40 p-y
Morning cough and white sputum x 12 months without
dyspnea
Exam normal
Measured Predicted %Pred Post
B-D
FEV1 2.9 3.0 96 3.0
FVC 3.6 3.7 97 3.7
FEV1/
FVC%
80% 80% 100
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
25
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Restriction
26
Case 2
50 male smoker 40 p-y
Cough and wheezes and dyspnea on effort x 6
months
Exam – mild wheezes
Measured Predicted %Pred Post B-D
FEV1 3.2 4.0 80 3.25
FVC 4.8 5.0 90 4.85
FEV1/
FVC%
67 80 68
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
28
Measured Predicted %Pred Post B-D
FEV1 1.9 2.8 68 1.9
FVC 3.2 3.7 86 3.4
FEV1/
FVC%
59 75 55
Case 3
66 female smoker 40 p-y
Morning cough x 5 yrs, wheezes, dyspnea
Exam –diffuse wheezes
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
30
Case 4
70 male COPD; 2 exacerbations past year requiring use
of oral steroids.
Spiriva, Serevent, Ventolin Stable
Measured Predicted %Pred Post B-D
FEV1 0.9 3.0 30 1.0
FVC 2.5 4.0 63 2.5
FEV1/
FVC%
36 75 40
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
32
Ventilation (L/min)
0 20 40 60 80 0 20 40 60 80
140
120
100
80
60
40
20
0
140
120
100
80
60
40
20
0
Vo
lum
e (%
pre
d T
LC)
Normal(n=25)
COPD(n=105)
RV
IRVIC
ICVC
Dynamic Lung Hyperinflation
O'Donnell DE, et al.: Am J Respir Crit Care Med 2001; 164(5):770-7.
EPREUVE DE FONCTIONS PULMONAIRES / PULMONARY FUNCTIONS
Division Respiratoire / Respiratory Division
PT : --------- SEX : F AGE : 71
PHYSICIAN : H. KREISMAN HT : 156.0 cm
TECH : P. KUPFER WT : 76.0 kg
Prebronchodilator Postbronchodilator
Spirometry Actual %Pred Predicted Actual %Pred %Chg
VEMS (L) 1.31 67 1.96 1.66 85 26%
CVF (L) 1.97 74 2.53 2.31 92 23%
VEMS/CVF (%) 67 89 79 72 90 2
CPT (L) 3.64 85 4.29
CRF (L) 1.80 81 2.21
VR (L) 1.54 90 1.71
Pre-Drug* Avgs
Diffusion Actual %Pred Predicted
Dsb ml/min/mmHg 22.5 133 16.9
NOTES: 2 puffs VENTOLIN, NON-SMOKER, C/) SOB & SOBOE X 3 months
Patient was on METOPROLOL for high BP, MVV = 56% PRED
0
2
4
6
8
10
-10
-2
-4
-6
-8
Flow (L/S)
Vol (L)
Pre
Post
1 2 3 4 5 6 7
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Obstruction
38
EPREUVE DE FONCTIONS PULMONAIRES / PULMONARY FUNCTIONS
Division Respiratoire / Respiratory Division
PT : --------- SEX : F AGE : 32
PHYSICIAN : COPELAND HT : 162.0 cm
TECH : MATTOSCIO WT : 66.0 kg
Pre-Drug* Post-Drug* Ventolin 200mcg
Spirometry Actual %Pred Predicted Actual %Pred %Chg
FEV1 (L) 3.52 119 2.96 3.49 118 0
FVC (L) 4.16 120 3.46 4.07 118 -2
FEV1 / FVC (%) 84 99 86 86 100 1
TLC (L) 5.32 105 5.05
FRC (L) 2.92 107 2.72
RV (L) 1.39 88 1.57
Pre-Drug* Std
Diffusion Actual %Pred Predicted
Dsb ml/min/mmHg 25.56 116 22.09
NOTES: EX-SMOKER 0.4 PPD 15 YRS or 6 PACK/YRS; C/O SOBOE, WHEEZING,
COUGH, CHEST TIGHTNESS X 6 MONTHS; MVV = 115% PRED;
0
2
4
6
8
10
-10
-2
-4
-6
-8
Flow (L/S)
Vol (L)
Pre
Post
1 2 3 4 5 6 7
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Restriction
41
CONCENTRATION MG/ML FEV1(L) %CHG
0.06
0.125 2.28 1
0.25
0.50 2.21 4
1.0
2.0 1.71 26
200 MCG VENTOLIN 2.50
EPREUVE DE FONCTIONS PULMONAIRES / PULMONARY FUNCTIONS
Division Respiratoire / Respiratory Division
PT : --------- SEX : F AGE : 52
PHYSICIAN : BARON HT : 154.0 cm
TECH : KLEBANSKYJ WT : 62.0 kg
Pre-Drug* Post-Drug* Ventolin 200mcg
Spirometry Actual %Pred Predicted Actual %Pred %Chg
FEV1 (L) 1.77 77 2.31 1.71 74 -3
FVC (L) 1.86 67 2.77 1.82 66 -2
FEV1 / FVC (%) 95 115 83 94 113 -1
TLC (L) 2.57 60 4.26
FRC (L) 1.44 61 2.37
RV (L) 0.81 54 1.50
Pre-Drug* Avg
Diffusion Actual %Pred Predicted
Dsb ml/min/mmHg 8.63 46 18.85
NOTES: C/O SOBOE X 6 MONTHS; MVV = 135% PRED; PT HAD DIFFICULTY
PERFORMING FVL & SVC
Lowry JB, A Primary Care Physician primer on Spirometry
Diagnostic Flow Diagram For
Restriction
44
0
2
4
6
8
10
-10
-2
-4
-6
-8
Flow (L/S)
Vol (L)
Pre
Post
1 2 3 4 5 6 7
Other spirometric diagnoses
40 y.o. male
Obese
SOB
Daytime Sleepiness
Lack of concentration
Snores
0
2
4
6
8
10
-10
-2
-4
-6
-8
Flow (L/S)
Vol (L)
Pre
Post
1 2 3 4 5 6 7
All that wheezes is not asthma
52 year old female
Intubation 2 weeks for respiratory failure
Increasing SOB and wheezes 2 months post
discharge from ICU
“Blue” and “orange” pumps don t help
0
2
4
6
8
10
-10
-2
-4
-6
-8
Flow (L/S)
Vol (L)
Pre
Post
1 2 3 4 5 6 7
Tracheal Stenosis
Conclusions
Spirometry is a necessary tool for diagnosis and
evaluation of many respiratory diseases including
common diseases such as asthma and COPD.
Spirometry does require some issues of quality
control.
Categorization of obstructive vs restrictive
disorders is fairly easy and can be performed
looking at 3 parameters: FEV1/FVC, FEV1,
FVC.