spirometry interpretation mcas miramar 4-7-10
TRANSCRIPT
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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 !!!!