spirometry interpretation mcas miramar 4-7-10

8/7/2019 Spirometry Interpretation MCAS Miramar 4-7-10

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Using Office BasedSpirometry to Improve

Asthma Outcomes

Henry A. Wojtczak, [email protected]


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All Too Common!!


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Asthma Stakeholders

Patient with asthma

Parents, legal guardians, relatives, older siblings

Population Health and Disease Managers

Primary Care Team Provider ( MD, PA, NP)

Nurse Respiratory Therapist

Pharmacist

Case Manager

Social Worker

School / Preschool / Daycare staff Teacher / teachers aide Nurse

Coach

BUMED Asthma Action Team

Non profit Support Groups like Lung Association


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Background

Asthma is a significant and growing health

burden in the United States and around the

world High mortality and healthcare utilization

rates in the US clearly indicate that there are

a significant number of persons with poorly

controlled asthma


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US Burden of Asthma

Current asthma prevalence: 22 millionAmericans (6.5 million children)

Annual burden of illness:

497,000 hospitalizations annually

1.8 million ED visits annually

Approximately 3600 deaths per year in 2006

14 million lost school days in children and14.5 million lost workdays

$16.1 billion in health costs annually

American Lung Association Epidemiology & Statistics Unit Research Program Services. Trends inAsthma Morbidity and Mortality. July 2006. Available at: www.lungusa.org. Accessed June 25, 2007.


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Dr. Wojtczaks Office


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Goals of Asthma Therapy

Minimal or no chronic symptoms day or night

Minimal or no exacerbations

No limitations on activities; no missed school/work Maintain (near) normal pulmonary function

Minimal use of inhaled short-acting beta2-agonists

Minimal or no adverse effects from medications

Prevent progressive lost of lung function; prevent

reduced lung growth


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Foundation for Good Asthma

Outcomes

Cooperation: team-work and mutual respect

Treating the patient as partner Assuming and accepting responsibility

Shift of focus

Target: Improving Outcomes Ability and desire to follow-up


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Barriers to Quality Asthma Care

Health Care System Lack of health insurance, primary care, coordination of

care

High cost of medications and services Health care providers

Lack of recognition, severity and control

Suboptimal compliance with guidelines

Family Confusion about symptoms and therapies

Adherence

Reactive rather than proactive


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DOD-VA Asthma Severity Table


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DOD-VA Asthma Control Table


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The Spirometry Gap

The majority of asthma patients receivingcare at Navy MTFs have limited access to

timely spirometry Results in poor compliance with national

evidence-based asthma guidelines

7% of Navy asthma patients identified by populationhealth navigator have documented spirometry overthe last 2 years


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The Spirometry Gap

The Navy wide shortage of spirometry

resources likely results in delayed or

misdiagnosis of asthma, limited abilityfor the provider to assess asthma

control, and increased patient morbidity

A recent Navy wide survey revealed only31% of providers had on site access to

spirometry


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Background

The DOD-VA and NHLBI evidence based asthmaclinical practice guidelines recommend thatspirometry measurements(FEV1,FVC, FEV1/FVC)

before and after the patient inhales a short-actingbronchodilator should be undertaken for patients inwhom the diagnosis of asthma is being considered,including children 5 years of age (NHLBI 2007).

Patients perception of airflow obstruction is highlyvariable, and spirometry sometimes revealsobstruction much more severe than would have beenestimated from the history and physical examination.


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Another Problem Caused by Deforestation


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Spirometry Background

Objective assessments of pulmonary function arenecessary for the diagnosis of asthma because,medical history and physical examination are notreliable means of excluding other diagnoses or ofcharacterizing the status of lung impairment

Spirometry often do not correlate directly withsymptoms

One study reports that one-third of the childrenwho had moderate-to-severe asthma werereclassified to a more severe asthma categorywhen pulmonary function reports of FEV1 wereconsidered in addition to symptom frequency

Stout et al. 2006


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Background

Recent changes to assessing asthma severityand control require the primary careprovider to be able to easily measure an

asthma patients FEV1, FEV1/FVC, andchanges post bronchodilation

Inability to measure an asthma patientsspirometry, can result in either overestimation of asthma control, and /or underestimation of asthma severity.


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Flow Volume Loop


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IndicationsDiagnostic

Evaluate symptoms, signs, abnormal lab tests Symptoms: cough, wheeze, dyspnea, chest pain

Signs: overinflation, cyanosis, wheezing, chest deformity,crackles

Lab tests: hypoxemia, hypercapnia, CXR, polycythemia

Measure the effect of disease on pulmonary function

Assess preoperative risk

Assess prognosis Screen patients at risk for lung disease

Smokers

Occupational exposures

Routine physical examination


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Office Based Spirometry

Focus on test that can beperformed in office setting

Children > 5 years old

Reliable results dependon: Experienced tech

Devote time / effort toeach child

Appropriate environment

Measure Lung volumes

Flows and timed volumes

Reactivity


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Dynamic Lung Volumes

Valuable in spirometry for following theprogress of a patient with chronic lungdisease

Can be used to assess response to treatment Help assess preoperative risk

Do not provide the diagnosis, but can

demonstrate if lung function is consistent witha diagnosis (ie, obstructive vs. restrictivedisease)


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Dynamic Lung Volumes

Forced Vital Capacity (FVC): Volume expired

by a forced maximal expiration after maximal

inhalation, also known as FEV6.

Forced Exp. Volume in 1 second (FEV1):

Volume of air forcefully expired in the first 1

second from a position of maximal inspiration.

Forced Exp. Flow from 25-75% of Exhalation,

(FEF25-75): Average flow rate during the

middle 50% of the FVC maneuver.


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I Hope I Pass My Spirometry Test!!!


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Administering Spirometry in Children

Requires pt cooperation

(unlikely in children

less than 5-6 yrs).

Requires a technicianwho is sensitive to the

needs of children.

Practice makes perfect! Calm, success-oriented

environment.
http://record.wustl.edu/2002/05-10-02/asthma.html


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Administering Spirometry in Children

Ask child to take a full breath (to maximal

inflation), followed by a brief hold.

Next, perform a maximal forced exhalation

for at least 3 seconds.

Blow out all your birthday candles.


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Coaching During Testing

Perhaps the MOST importantaspect of testing.

Deep breath in, BLAST it out,keep blowing, blowing,

blowing, DEEP breath in, andthat's done!

Techs should become

competent by taking theBUMED spirometry trainingcourse, TAD training, civilianPFT labs, or manufacturer

inservice.


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Standards for TestingEnvironment

Torso and head erecteither sitting or standing

Nose clips

Pretest instructionperiod: Explain the test ( forceful

& long expiration)

Give demonstration

Chance to practice

Set a goal

Coach / Cheerleader


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Are We Going Too Fast?


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Standards for TestingReporting

Hard copy of results

All reports include DOB

DOT Height

Weight

Sex

Race Absolute values of all

measurements

Percent of predictedvalues ( Predicted Source)

Conditions of test


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Standards for TestingGuidelines for Interpretation

Older children and adolescents take the best

of 3 tests

Younger children may require more than 3

tests

The best test is the one with the greatest

sum of FEV1 and FVC


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Standards for TestingGuidelines for Interpretation

Comment on the quality

Use FVC, FEV1, and FEV1 / FVC % as primary guide

for interpretation

Interpret borderline values with caution

Primary indicator of obstruction is FEV1/ FVC % Classify degree of obstruction with % predicted FEV1

Determine response to bronchodilator Restriction can be suspected by spirometry but only

confirmed with TLC measurement

Data from Taussig LM, Chernick V, Wood R, et al: Standardization of lung function

testing in children. J Pediatr 97: 668-676, 1980


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Advantages of FEV1 Measurement

Most reproducible

Comparable between labs

Reflects changes in lung elastic recoil

Defines the bronchodilator response

Best measure of prognosis


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Spirometry Patterns


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Role of Spirometry In Asthma

Spirometric measures, before and after theadministration of a short acting B2-agonist

should be obtained on all capable ( usually> 5 years-old) patients in whom a diagnosisof asthma is under consideration

When physical exam findings are not

present, mild asthma may be detected byperforming spirometry, especially with pre-and post bronhodilator evaluation


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PFT Sheet


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Role of Spirometry In Asthma

Airflow obstruction can generally be determined by

using the forced expiratory volume in the first second

( FEV1) and the forced vital capacity ( FVC), and the

FEV1/FVC ratio

Peak flow should not be used to diagnose asthma

because it is less reliable due to poor reproducibility

and dependence on patient effort Remember there is no single test sufficient or

adequate to diagnose asthma


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Defining Airway Obstruction

Airway obstruction is defined as a FEV1/FVC of< .70 in adults and < .80 in children

Obstructive defects are characterized by a

disproportionate reduction in FEV1 with respect toFVC

An FEV1 < 80% of normal predicted is also suggestiveof airflow obstruction

Airways obstruction may also result in reduction ofother measures of airflow, such as mean mid-forcedexpiratory flow ( FEF 25-75)

An FEF25-75 which is < 50-60% of predicted normalvalue is indicative of small airways obstruction


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Reversible Airway Obstruction

Reversible airway obstruction is documented withimprovement in FEV1 of > 12% ( usually >200 ml inadults) or clinical improvement in symptoms

Airway obstruction is considered reversible whenFEV1 has increased > 12% after administration of a B2agonist

Failure to demonstrate a change after bronchodilatordoes not exclude a reversible component of obstruction

because airway inflammation may be present and notresponsive to B2 agonist


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Role of Spirometry for Monitoring

Asthma

Every patient capable of spirometry should

have testing performed at least every 1-2 years

All MTFs where asthma care is provided

should have access to timely spirometry

Spirometry also indicated in the following

situations:

After a change in control therapy to document

response

When symptom history suggests poor control


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Success

i i i


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Spirometry in Primary Care

Should play a central

role any time a

physician prescribes

potent bronchoactiveand anti-inflammatory

drugs

An objective measure

of airway obstruction,restriction

Petty, T.L. Benefits of and Barriers to the Widespread Use of Spirometry.

Current Opinions in Pulm Medicine, 2005, 11:115-120.


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Spirometry in Primary Care

Quality of studies in PC setting: 85 of 109(78%) tests administered met all criteria foracceptability and reproducibility (reviewedby peds pulm)

Good agreement between pediatriciansoffice testing and lab testing

Interpretation: Pediatrician was incorrect in

23 of 109 test (21%)

Zanconato, S. Office Spirometry in Primary Care Pediatrics: A Pilot Study.

Pediatrics, December 2005, 116; 792-797.


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Spirometry Take Home Points

Spirometric measurements are asfundamental to optimal asthma outcomes,as are measurements of pulse, blood

pressure, temperature, height, and weight togeneral wellness checks

Accurate spirometry requires propertraining for physicians, nurses, techs.

Portable spirometry equipment producesquality studies and allows for reliabletesting in the primary care setting.

R i t C t l


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Racing to Control

Asthma


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Ground Zerofor the Swine Flu!!!


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Spirometry:

Case Based Discussion

P l F ti T t


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Pulmonary Function Test

Interpretation

Assess quality and reproducibility

Pattern Recognition

Obstructive ventilatory defect Asthma, CF, COPD

Restrictive ventilatory defect Interstitial lung disease, chest wall deformities, neuromuscular

disease

Special cases - UAO

Bronchodilator response


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Reproducible Test

Am J Respir Crit Care Med. Vol 152:1107-1136, 1995


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Non-Reproducible Test

Am J Respir Crit Care Med. Vol 152:1107-1136, 1995.


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Robert Hyatt, et al. Interpretation of Pulmonary Function Tests:

A Practical Guide, 3rd Edition. 2009.

P tt f M j Ai


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Patterns of Major Airway

Obstruction

Robert Hyatt, et al. Interpretation of Pulmonary Function Tests:

A Practical Guide, 3rd

Edition. 2009.


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Measure My Lung

Function!!!!!


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Case 1

A 7-year old male presents to your clinic inNovember complaining of nightly cough for thepast 2 months

He denies symptoms of GE Reflux. He has visited the emergency room twice in the

past year where he received albuterol with goodsymptomatic relief

You obtain pre/post bronchodilator spirometry inyour office

Case # 1 Spirometry


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Case # 1 Spirometry


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Case # 1 Numbers


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Hang in There Almost

Finished!!!!!!

Case #2 Randy


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Case #2Randy History

6-year-old male with a history of asthma sinceinfancy

States that he never coughs or wheeze duringthe day, and maybe 1 night/month especially atnight

Currently on an ICS, Flovent 44 ug 2p BIDwith MPAC

Does not perceive his asthma as limiting hisactivity, but has difficulty keeping up with hisfriends due to wheezing

Parents believe that his asthma is wellcontrolled

Physical exam

Normal vital signs Chest: No wheezes but mildly prolonged

expiratory phase

Heart: Normal

Spirometry FEV1: 60% of predicted


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Racing to Control


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Racing to Control

Asthma


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The End!!!!!!


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Questions and

Comments !!!!

spirometry interpretation mcas miramar 4-7-10

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