Spirometry Workshop for Primary Care Nurse Practitioners Catherine Casey S. Jones PhD, RN, AE-C, ANP-C Certified Adult Nurse Practitioner Texas Pulmonary & Critical Care Consultants P.A. and Visiting Assistant Clinical Professor at Texas Woman s University - Dallas Disclosures No financial relationship with any pharmaceutical manufacturer or medical device company 1
Workshop Schedule n 1:15 2:20 PM Spirometry introduction n 2:20 2:50 PM - Hands on spirometry & break n 2:50 4:30 PM Case Presentations Objectives n 1. Discuss the indications for performing spirometry. n 2. Describe the correct manner for preparing both the spirometer and the patient for lung function testing. n 3. Carry out spirometry procedures on self and other participants. n 4. Assess the spirometry tracings with normal, obstructive & restrictive patterns. Spirometry v Gold standard for diagnosis of asthma & COPD v Measure severity & progression of disease v Measure treatment response v Aid in diagnosis of restrictive & obstructive diseases v Aid in smoking cessation with calculated lung age current recommendations - 2
Hazards of Spirometry v Bronchospasm v Cough v Lightheadedness v Syncope Patient Preparation v Comfortable, loose clothing v Avoid heavy meal within 2 hours v Avoid vigorous exercise within 30 minutes v Use bathroom prior to testing v No short-acting beta agonists for 4 hours v Patient sitting Prepare the Spirometer v Calibration of the spirometer v Disposable mouthpieces 3
Lung Volume Terminology Tidal vol Inspiratory capacity Inspiratory reserve vol Vital capacity Expiratory reserve vol Residual vol Spirometry Reference Values n NHANES III values for ages 8-80 n Caucasians n African-Americans n Mexican-Americans Predicted Values n Large population studies n AGE 4
Predicted Values n GENDER Predicted Values n HEIGHT in inches Predicted Values n RACE 5
Ethnic Corrections n Reductions: n African-Americans 12 to 15 % n South Indians 13 % n Japanese American 11 % n Polynesians 10 % n North Indians & Pakistanis 10 % Predicted Normal Lung Volumes 80% Mean 120% n Based on large population surveys n Predicted values are the mean values obtained from the survey Lung Volume Measurements v Forced Vital Capacity (FVC) maximum volume of air exhaled from the lungs after a maximum inspiration. v Forced Expiratory Volume in One Second (FEV 1 ) volume exhaled during the first second this should be > 80 % of FVC 6
FEF 25-75% n Forced Expiratory Flow the flow that occurs between 25 to 75 % of the FVC n Also called MMEF = maximum mid-expiratory flow n Represent airflow in medium or small airways n LEAST reliable & controversial n Normal = > 55 % predicted Normal Lung Volume Values v FEV 1 /FVC: Ratio > 70 % (> 80 % for children) v FVC: > 80 % predicted v FEV 1 : > 80 % predicted Disease Patterns Normal Obstructed Restricted Combined FEV 1 / FVC > 70 % Down Normal Down FVC > 80 % Pred FEV 1 > 80 % Pred Normal Down Down Down Down Down 7
Obstructive Changes v Asthma v Chronic Obstructive Pulmonary Disease v Bronchiectasis v Cystic fibrosis Restrictive Changes n Pulmonary Idiopathic pulmonary fibrosis Any interstitial lung disease (over 200 types currently listed) Pneumonectomy/lobectomy Pulmonary edema Rheumatoid arthritis Sarcoidosis * Scleroderma Restrictive Changes n Extra-pulmonary Thoracic chest wall deformity Pectus excavatum Kyphoscoliosis Congestive heart failure Neuromuscular problems Obesity Pregnancy Poor effort 8
Spirometry Tracings v Two basic types of display: 1) Flow/volume loop 2) Volume/time curve Flow/Volume Loop Expiration is the area that can be found above the waterline This is the most important part of the flow volume loop in lung diseases Volume/Time Curve Liters FEV 1 * 4 3 2 FVC FVC 1 1 2 3 4 5 6 Seconds 9
Volume-Time Curve Normal versus Obstructive & Restrictive patterns: flow-volume loop Vocal Cord Dysfunction 10
Reversibility n Reversibility can be assessed with albuterol and/ or ipratropium (Atrovent) via MDI or nebulizer n Reversibility is defined by a change of at least 12 % post bronchodilator AND an increase of 200 ml Examples of Poor Quality Poor effort/slow start Extra breath Cough Slow start n n n n Seven Step Spirometry Interpretation Steps 1 and 2 Quality Assurance 1. Is the test at least 6 seconds long? 2. Is the flow volume loop the correct shape? Steps 3-5 establish the numbers 3. Is the FEV 1 /FVC ratio more or less than 70% 4. Is the FVC more or less than 80% predicted 5. Is the FEV 1 more or less than 80% predicted Step 6 identify the pattern Step 7 classify severity 11
Quality Assurance n Acceptability criteria (apply first) n Min. 3 acceptable tests, max. 8 attempts n Good start/rapid rise/no hesitation/no false start n No cough, especially in 1 st second n No early termination: 6 secs or obvious plateau Quality Assurance n Reproducibility v Best two FVC s within 150 ml of each other v Best two FEV 1 s within 150 ml of each other n Stop if repeated efforts trigger bronchospasm Performance of Spirometry n Instruct and demonstrate test to patient v nose clips v Inhale completely v Position mouthpiece v Exhale with maximal force n Position patient n Coach! 12
Classification of Severity-COPD Stage GOLD (2014) I Mild COPD With or without chronic symptoms II Moderate COPD With or without chronic symptoms III Severe COPD With or without chronic symptoms IV Very severe COPD FEV 1 > 80% predicted FEV 1 50 80% predicted FEV 1 30 50% predicted FEV 1 < 30% predicted A defining characteristic of COPD at all levels of severity is an FEV 1 /FVC ratio of less than 70%. Components of Severity Impairment CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS 12 YEARS OF AGE AND ADULTS Assessing severity and initiating treatment for patients who are not currently taking long-term control medications Intermittent Classification of Asthma Severity ( 12 years of age) Symptoms 2 days/week >2 days/week but not daily Persistent Mild Moderate Severe Daily Throughout the day Normal FEV 1/FVC: 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70% Nighttime awakenings 2x/month 3-4x/month >1x/week but not nightly Short-acting beta 2-2 days/week >2 days/week but not Daily agonist use for daily, and not more symptom control (not than 1x on any day prevention of EIB) Often 7x/week Several times per day Interference with normal activity None Minor limitation Some limitation Extremely limited Lung function Normal FEV 1 between exacerbations FEV 1 > 80% predicted FEV 1/FVC normal FEV 1 >80% predicted FEV 1/FVC normal FEV 1 >60% but <80% predicted FEV 1/FVC reduced 5% FEV 1< 60% predicted FEV 1/FVC reduced >5% Risk Exacerbations requiring oral systemic corticosteroids 0-1/year (see note) 2/year(see note) Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category Relative annual risk of exacerbations may be related to FEV 1 Recommended Step for Initiating Treatment Step 1 Step 2 Step 3 Step 4 or 5 and consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly Key: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g. requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTH 12 YEARS OF AGE AND ADULTS Components of Control Classification of Asthma Control ( 12 years of age) Well Controlled Not Well Very Poorly Controlled Controlled Symptoms 2 days/week >2 days/week Throughout the day Nighttime awakenings 2x/month 1-3x/week 4x/week Interference with normal activity None Some limitation Extremely limited Impairment Short-acting beta 2-agonist use for symptom control (not prevention of EIB) FEV 1 or peak flow 2 days/week >2 days/week Several times per day >80% predicted/ 60-80% predicted/ <60% predicted/ personal best personal best personal best Validated Questionnaires ATAQ ACQ ACT 0 0.75* 20 1-2 1.5 16-19 3-4 N/A 15 Risk Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects 0-1/year 2/year (see note) Consider severity and interval since last exacerbation Evaluation requires long-term follow-up care. Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended Action for Treatment Maintain current step. Regular follow ups every 1-6 months to maintain control. Consider step down if well controlled for at least 3 months. Step up 1 step and Reevaluate in 2-6 weeks. For side effects, consider alternative treatment options. Consider short course of oral systemic corticosteroids, Step up 1-2 steps, and Reevaluate in 2 weeks. For side effects, consider alternative treatment options. *ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma. Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit. Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g. requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. 13
Review of Basics n Insure that demographic data is correct n Remember that weight is not a measured value pick your battles. n Measure lung age only with smokers and prior smokers it is the most inaccurate measurement Modalities of Pulmonary Function Testing 1. Spirometry 2. Pre and post bronchodilator 3. Lung volumes complete testing 4. Diffusing lung capacity using carbon monoxide CPT codes n 94010 - Simple spirometry, including graphic record, total & timed VC, expiratory flow rates. No bronchodilator. Includes 94375. n 94060 - Spirometry as with 94010 but with pre/ post bronchodilation. Reimbursement rates vary across the country ~ $ 35.00. 14
Practice Time! References " Global Initiative on Chronic Obstructive Lung Disease (GOLD) http://www.goldcopd.com " National Asthma Education and Prevention Program (NAEPP) National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/guidelines asthma/asthgdln.pdf References " Barreiro, T. & Perillo, I. (2004). An approach to interpreting spirometry. American Family Physician, 69(5) 1107-1115. " Cherniack, R. (1992). Pulmonary Function Testing (2 nd ed.). Philadelphia: W.B. Saunders. n Feyrouz A., Mehra, R. & Mazzone, P.J. (2003). Interpreting pulmonary function tests: Recognize the pattern, and the diagnosis will follow. Cleveland Clinic Journal of Medicine, 70(10) 866-881. 15
References " Hancox, B. & Whyte, K. (2006). Pocket Guide to Lung Function Tests (2 nd ed.). New York: McGraw-Hill s. " Hankinson, J.L., Odencrantz, J.R. & Fedan, K.B. (1999). Spirometric reference values from a sample of the general U.S. population. American Journal of Respiratory & Critical Care Medicine, 159, 179-187. " Lange, N.E., Mulholland, M. & Kreider, M.E. (2009). Spirometry: Don t blow it! Chest, 136, 608-614. References n Wallace, L.D. & Troy, K.E. (2006). Office-based spirometry for early detection of obstructive lung disease. Journal of the American Academy of Nurse Practitioners, 18, 414-421. Thank you! caseyjonesnp@gmail.com 16