COPD:
Spirometry
Clare Hawkins, MD, MS
Program Director, San Jacinto Methodist Hospital Family Medicine Residency,
Baytown, TX
Isaac M. Goldberg, MD
Faculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown,
TX
Educational Objectives
At the end of this presentation, the
learner should be able to …
• Utilize spirometry to diagnose and stage
COPD
• Overcome barriers to the use of office
spirometry
• Achieve confidence with spirometry
interpretation
Background
Objective measure of airway function for accurate
diagnosis of Chronic Obstructive Pulmonary
Disease (COPD)
 World Health Organization Global Obstructive Lung
Disease Consensus/ Evidence guideline (GOLD)
 American Thoracic Society (ATS)
 European Respiratory Society (ERS)
 National Committee for Quality Assurance (NCQA)
Background
Alternate ways to diagnose COPD
 Clinical Findings Late
- Increased AP diameter, tympanitic chest
- Signs of respiratory distress
 Peak flow reading not adequately sensitive or specific
 Radiographic findings occur late in disease
 CT scanning more accurate, but findings also occur
late in disease
Background
Who should receive spirometry?
 Early diagnosis relies on the recognition of the clinical
features
-
Persistent cough
Chronic sputum production
Breathlessness on exertion
Reduction in activity (often attributed to natural aging)
 About 20% of COPD patients identified in NHANES
study with obstruction never smoked
- Only 1/5 were explained by asthma
Background
Other testing considerations





Recurrent or chronic respiratory symptoms
Occupational exposure to respiratory irritants
Family history of respiratory diseases and symptoms
NCQA established use of spirometry as required
quality measure for accurate COPD diagnosis
Routine periodic use not recommended
Background
Screening



Not recommended in the absence of respiratory
symptoms (dyspnea, cough)
No threshold amount of smoking pack-years for
screening in the absence of respiratory symptoms
Not recommended by USPSTF or ACP 2011
Guideline
Background
 Family physicians able to do quality spirometry
 Quality of care increases with use of spirometry
- To prevent overdiagnosis of COPD, attention to quality
spirometry is important
 Suggestions to maintain quality of spirometry
-
Know technique
Have staff coach the patient
Do sufficient numbers of tests
Maintain and calibrate the equipment
Understand interpretative algorithms
Background
Why do office spirometry?
 Diagnostic accuracy. 30% of time diagnosis changes.
- Was not COPD; heart failure or asthma
- Was COPD rather than asthma
- If spirometry normal, then expensive meds discontinued
 Respect. Patients respect physicians who use
technology (Future of Family Medicine)
 Patient convenience. You can avoid an unnecessary
referral and additional visit
 Diagnostic power: You can connect diagnostic
information with rest of clinical encounter
 Financial benefit to practice.
Equipment
 Older volume/time loop
- Drum technique from John
Hutchinson 1844
 Newer flow/volume loop
using flow transducer
- Smaller Machines, Mobile
- Disposable Mouthpiece
 No other infection
transmission
precautions necessary
Equipment
 Numerous manufacturers produce quality instruments
 Reviews conducted by National Lung Health Education
Program (NLHEP) regarding appropriateness of
spirometers for office practice
- http://www.nlhep.org/spirometer-review-process.html
- Simplicity (fewer numbers)
- Reliability
Equipment
Calibration
 Daily calibration must be done with 3 L syringe
 Syringe must have accuracy of at least 15 ml
 Spirometer must have accuracy of ±105 mL or
0.105 L (calibration volume = 2.90 to 3.11)
 Calibration log/printouts must be kept
- Date and time of calibration
- Individual performing
- Comments
Technique
Forced expiratory maneuver



Coach patient to get a maximal effort
Six seconds of effort required though most of air pushed
out in the first second
Pace of expired air is most important variable; therefore
it should be released with explosive force
Technique
 Minimum 6 second exhalation with 2 second plateau
 Tracing should have no artifacts
 At least 3 acceptable maneuvers (<5 % variation)
- ATS criteria
 Empty bladder for females (concern if incontinence)
 Can be seated or standing
 Nose plug optional
Technique
None of the following should occur:





Unsatisfactory start, with excessive hesitation or false start
Air leak
Coughing during the first second
Early termination of forced expiration
Glottis closure
 Obstructed mouthpiece
- Tongue
- False teeth
- Chewing gum
Technique
Reliability
 Spirometry overdiagnoses COPD if insufficient effort
 Concerns that family physicians will not perform
quality testing and overdiagnose people with
obstructive lung disease
 Imperative that patients be coached on robust, forced
expiratory maneuver
Technique
Contraindications





Hemoptysis of unknown origin
Pneumothorax
Unstable cardiovascular status or recent MI or PE
Thoracic, abdominal, or cerebral aneurysms
Recent eye, thorax or abdomen surgery
Technique
Barriers






Inaccessibility of Equipment
Concern patient effort and cooperation are insufficient
Difficulty remembering interpretive algorithm
Frustration by ambiguous results
Difficulty working 30-minute spirometry into office flow
Central location for spirometry versus going room to
room
 Lack of staff training
 Poor integration with electronic health record
 Lack of adequate reimbursement
Measurements
Abbreviation
Characteristic measured
FEV1
Forced expired volume in 1 second
FVC
Forced vital capacity
FEV1 /FVC
Ratio
Ratio of the above
PEFR
Peak expiratory flow rate
FEF 25-75%
Forced expiratory flow between 25-75% of the vital
capacity
Measurements
Normal values
 Individual variation according to age, height, ethnicity
and gender
-
Height - Tall people have larger lungs
Age - Respiratory function declines with age
Sex - Lung volumes smaller in females
Race - Studies show Blacks and Asians have smaller lung
volumes (-12%)
- Posture - Little difference between sitting and standing;
reduced in supine position
Measurements
Bronchodilator reversibility testing
 Beta-agonist
- Short-acting – wait 20 minutes before retesting
- Long-acting – wait 2 hours before retesting
 Do not take bronchodilator the day of testing
- Measured reversibility will be limited if the patient is
bronchodilated for the pretest.
Measurements
Definition of reversibility
 Pre-Bronchodilator
- FEV1/FVC <70% of predicted
 Post-Bronchodilator
- Increase 12% AND at least 200 cc
Reversibility = Asthma!
Measurements
Pre-Bronchodilator
Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
2.66
1.32
50
1.26
47
-4
FEV1
2.02
0.54
26
0.50
25
-6
FEV1/FVC
76
41
-35
39
-37
-2
PEF
315
114
36
120
38
5
FEF 25
4.96
0.40
8
0.30
6
-28
FEF 50
2.85
0.20
7
0.20
7
-----
FEF 75
0.78
0.10
13
-----
-----
198
FEF 25-75
1.02
0.19
10
0.18
10
-6
Measurements
Severity of obstruction
FEV1
Mild
Moderate
% of predicted
>80
50 to 79
Severe
30 to
Very severe
<30
Severity of restriction
FVC
% of predicted
Mild
>65 to 80
Moderate
>50 to 65
Severe
<50
Case Study 1
A 53-year-old white male presents for annual
visit. Although he quit 10 years ago he is a
previous cigarette smoker with a 20 pack-year
history. During the past 12 months, he has had
3 episodes of bronchitis. His history of tobacco
use and recent episodes of acute bronchitis lead
you to perform spirometry.
Results
Pre-Bronchodilator
Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
4.65
4.65
100
4.95
106
6
FEV1
3.75
3.13
83
3.34
89
6
FEV1/FVC
80
67
-13
67
-13
0
PEF
511
462
90
522
102
12
FEF 25
7.86
5.7
73
6.00
76
5
FEF 50
4.46
2.3
52
2.10
47
-9
FEF 75
1.75
.5
29
0.60
35
18
FEF 25-75
3.76
1.77
47
1.78
47
0
Results
Pre-Bronchodilator Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
4.65
4.65
100
4.95
106
6
FEV1
3.75
3.13
83
3.34
89
6
80
67
-13
67
-13
0
FEV1/FVC
Is there obstruction?
FEV1/FVC = 67% of predicted; therefore, obstruction present
Is there restriction?
FVC = 100% of predicted; therefore, no restriction present
Results
Pre-Bronchodilator Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
4.65
4.65
100
4.95
106
6
FEV1
3.75
3.13
83
3.34
89
6
80
67
-13
67
-13
0
FEV1/FVC
What is the severity of obstruction?
FEV1 is 83% of predicted; therefore, the obstruction is mild
Is the obstruction reversible (is reversibility present)?
FEV1 increases from 83% to 89% (6% increase) and increases from 3,130
cc to 3,340 cc (increase of 210 cc)
Interpretation:
Mild Obstruction with minimal reversibility: Mild COPD
Common Obstructive
Pulmonary Disorders
Diffuse Airway Disease Upper-Airway Obstruction
Asthma
COPD
Bronchiectasis
Cystic fibrosis
Foreign body
Neoplasm
Tracheal stenosis
Tracheomalacia
Vocal cord paralysis
Diagnostic Flow Diagram for Obstruction
Is FEV1 / FVC Ratio Low? (<70%)
Yes
Obstructive Defect
Is FVC Low? (<80% pred)
Yes
No
Combined Obstruction &
Restriction /or Hyperinflation
Pure Obstruction
Improved FVC with
ß-agonist
Reversible Obstruction
with ß-agonist
No
Further Testing with
Full PFT’s
Yes
Yes
Suspect
Asthma
No
Suspect
COPD
Adapted from Lowry.
Case Study 2
A 33 year old female presents to the office
complaining of dyspnea and cough for the past 2
days. Her cough is productive of a white mucous.
Her past medical history is significant for asthma
since childhood, obesity, gastroesophageal reflux
disease (GERD), and an occasional migraine
headache. She is a nonsmoker and has no known
allergies.
Case Study 2 (cont)
Her current medications include the following:
 Albuterol 2 puffs po qid prn wheezing, cough,
or dyspnea
 Fluticasone 110 micrograms 2 puffs po bid
 Ranitidine 150 mg po bid
Her father recently died secondary to advanced
COPD.
Due to her symptoms, you order spirometry.
Results
Pre-Bronchodilator Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
3.78
1.92
51
2.7
71
34
FEV1
3.24
1.11
34
1.61
50
36
86
58
-28
60
-26
3
FEV1/ FVC
Obstruction?
FEV1/FVC = 60%; therefore, obstruction present
Restriction?
FVC = 51% of predicted; therefore, restriction present
Results
Pre-Bronchodilator Post-Bronchodilator
Predicted
Measured
%
Measured
%
% change
FVC
3.78
1.92
51
2.7
71
34
FEV1
3.24
1.11
34
1.61
50
36
86
58
-28
60
-26
3
FEV1/ FVC
What is the severity of obstruction?
60%; therefore, moderate obstruction
Is the obstruction reversible (is reversibility present)?
FEV1 increases from 34% to 50% (16% increase) and increases by 500 cc
What is the severity of restriction?
71% of predicted; therefore, mild restriction
Interpretation: Moderate obstruction with reversibility (Moderate obstruction)
Common Restrictive Pulmonary
Disorders
Parenchymal
Pleural
 Interstitial Lung Diseases

-
Fibrosis
Granulomatosis (TB)
Pneumoconiosis
Pneumonitis (lupus)
 Loss of Functioning Tissue
-
Atelectasis
Large Neoplasm
Resection

Effusion
Fibrosis
Chest Wall



Kyphoscoliosis
Neuromuscular Disease
Trauma
Extrathoracic


Obesity
Abdominal Trauma
Diagnostic Flow Diagram for Restriction
Is FEV1 / FVC Ratio Low? (<70%)
No
Is FVC Low?(<80% pred)
Yes
Restrictive Defect
Further Testing with
Full PFT’s; consider
referral if moderate to
severe
No
Normal Spirometry
Adapted from Lowry, 1998
Results
Lowry 1998
Results
“Full” Pulmonary Function Testing (PFT’s)
 Assessment of Oxygenation
- Transcutaneous oxygen saturation
- Arterial blood gasses
 Diffusion test to evaluate alveolar exchange (DLCO)
 Plethysmography
- To objectively assess lung volumes
- Delineate air-trapping versus restriction
 May also include Spirometry
Spirometry and Smoking Cessation
 Lung age calculation
- Use to motivate smoking cessation.
 Mixed results
- Normal results may give the impression that it’s
acceptable to continue smoking.
- Avoid fatalism with abnormal results.
 Research results recently favor use
- ACP and AHRQ advise only if symptomatic.
Spirometry and Smoking Cessation
Spirometry and Smoking Cessation
Coding and Reimbursement
Diagnosis
ICD-9 Code
Cough
786.2
Simple chronic bronchitis
491.0
Mucopurulent chronic bronchitis
491.2
Acute bronchitis
466.0
Chronic obstructive pulmonary disease
496.0
Shortness of breath
786.5
Restrictive lung disease
Asthma
515
493.91
Coding and Reimbursement
Procedure
CPT Code
Reimbursement*
Single spirometry
94010
$32.82
Pre-post spirometry
94060
$57.71
Pulmonary stress test simple
94620
$71.77
Medication administration
bronchodilator supply separate
94640
$13.34
Demonstration / instruction
94664
$14.79
Smoking Cessation <8x/ yr
99406
$12.98
Equipment
Office spirometer
*Reimbursement based upon Medicare payments 2009
Cost
$1,000 – 2,500
Estimated Return on Investment
Tests /week (#)
Reimbursement/year*
ROI $1,995 in weeks
4
$6,864
15
6
$10, 296
10
8
$13,728
7
10
$17,160
6
15
$25,740
4
20
$34,320
3
25
$42,900
2
*Based upon CPT code 94010
References
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•
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•
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AARC Clinical Practice Guideline. Delivery of aerosols to the upper airway.
Respir Care 1996;41(7):629-36
Belfer M. Office management of COPD in primary care: A 2009 clinical
update. Postgraduate Medicine 2009;121(4):82-90.
Blain EA, Craig TJ. The use of spirometry in a primary care setting. Int J
Gen Med. 2009; 2: 183–186.
Chavez,P.C. and Shokar,N.K. Diagnosis and management of chronic
obstructive pulmonary disease (COPD) in a primary care clinic. COPD
2009;6(6): 446-451.
Enright P. The use and abuse of office spirometry. Prim Care Respir J.
2008 Dec;17(4):238-42.
Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br
Med J. 1977;1(6077):1645-1648.
Ferguson GT et al. Office spirometry for lung health assessment in adults: A
consensus statement from the National Lung Health Education Program.
Respiratory Care 2000;45(5) 513-30
References (continued)
•
•
•
•
•
•
Grossman E, Sherman S. Telling smokers their "lung age" promoted
successful smoking cessation. Evid Based Med. 2008;13(4):104
Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values
from a sample of the general US population. Am J Respir Crit Care Med
1999;159:179–187
History Diagnosis Spirometer
http://www.umanitoba.ca/libraries/units/health/images/HistoryDiagnosisSpir
ometer.jpg
Jing JY. Should FEV1/FEV6 replace FEV1/FVC ratio to detect airway
obstruction? A metaanalysis. Chest. 2009 Apr;135(4):991-8.
Johannessen A, et al. Post-bronchodilator spirometry reference values in
adults and implications for disease management. Am J Respir Crit Care
Med 2006; 173(12):1316-25.
Kaminsky DA, Marcy TW, Bachand M, Irvin CG. Knowledge and use of
office spirometry for the detection of chronic obstructive pulmonary disease
by primary care physicians. Respir Care. 2005 Dec;50(12):1639-48.
•
•
•
•
•
•
Knudson RJ, Slatin RC, Lebowitz MD, Burrows B. The maximal expiratory
flow-volume curve. Normal standards, variability, and effects of age. Am
Rev Respir Dis 1976;113:587–600
Lin KW Screening Spirometry. American Family Physician 2009;80(8) :8612.
Lowry, Josiah A Guide to Spirometry for Primary Care Physicians 1998
Published by College of Family Physicians of Canada with Boehringer
Ingelheim
MacIntyre NR, Selecky PA. Is there a role for screening spirometry? Respir
Care. 2010;55(1):35-42 [Review].
National Committee on Quality Assurance. 2009 Healthcare Effectiveness
Data and Information Set (HEDIS) performance measures. 2010. Available
at www.ncqa.org/tabid/855/Default.aspx. Accessed August 2010.
Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of
telling patients their lung age: the Step2quit randomised controlled trial BMJ
2008;336:598-600.
References (continued)
•
•
•
•
•
•
Poels PJ, olde Hartman TC, Schermer TR. Qualitative studies to explore
barriers to spirometry use: a breath of fresh air? Respir Care. 2006
Jul;51(7):768.
Rennard S, Vestbo J. COPD: The Dangerous underestimate of 15%. Lancet
2006; 367, 1216-1219.
Spann SJ. Impact of spirometry on the management of chronic obstructive
airway disease. J Fam Pract. 1983 Feb;16(2):271-5.
Spirometer Review Process (SRP) – Revised.
http://www.nlhep.org/spirometer-review-process.html. Accessed, November
14th, 2010.
Wilt TJ, Niewoehner D, Kim C, et al. Use of spirometry for case finding,
diagnosis, and management of chronic obstructive pulmonary disease
(COPD). Evid Rep Technol Assess (Summ). 2005;(121):1-7 [Review].
Yawn BP et al. Spirometry can be done in family physicians' offices and
alters clinical decisions in management of asthma and COPD. Chest. 2007
Oct;132(4):1162-8. Epub 2007 Jun 5.