Guidelines For Setting Up A Spirometry Service
Guidelines For Setting Up A Spirometry Service
Guidelines For Setting Up A Spirometry Service
spirometry
service
Flow
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Helping people to breathe easier
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Volume
Normal Spirometry
Introduction
Spirometry is the most basic objective measurement of lung function. The results
of well-performed spirometry give an indication of whether airflow and lung volume
are appropriate for a patient’s age, sex and height i.e. whether there is significant
airflow obstruction (e.g. asthma or emphysema) or a significant reduction in lung
volume (e.g. suggestive of a restrictive lung disease). Good quality spirometry
requires a trained and experienced operator.
If spirometry results are to be clinically useful then they are criticially dependent
on an accurately calibrated instrument capable of making the measurements
precisely, an operator trained to recognise correct measurement techniques and
a consistent and maximal effort by the patient.
Useful results depend on the elimination of variables other than those you are
interested in i.e. variable inflation (alters expiratory force) and variable effort.
Successful control of these other variables is gauged by reproducibility of the
results. Accordingly, a minimum of three manoeuvres must be completed and
the two best FEV1s and FVCs must be at least within 200ml of each other. The
first manoeuvre is often poor due to the learning required to do the test
successfully so four manoeuvres are commonly required. It is recommended
that no more than eight manoeuvres are performed at one session.
Lung volume and air flow depend on chest size. Therefore, reference values are
determined from the patient’s age, sex and height. It is essential that the reference
values used are appropriate to the patient being tested. Your nearest respiratory
laboratory can advise you on the choice of prediction equations. Although many
spirometers already contain this information the ‘pre-set’ reference values may
be inappropriate for our population in New Zealand.
Calibration and Quality Assurance
Calibration
Depending on the flow measuring technology, some spirometers require
calibration each session. This requires a calibrated syringe (ideally 3 litre) with a
leak free connection to the spirometer. The spirometer should be calibrated at
two or three flows (high, mid and low flow) and the proceedure should include
inspiratory and expiratory flows.
Validation
ALL spirometers require regular validation. There are two aspects to this process.
Your local respiratory laboratory will be able to assist you to set up this biological
control programme should help be needed. However, using yourself and staff as
controls is the approach most usually employed.
Environmental Conditions
Gas volumes depend on pressure and temperature. Variation in pressure is not
great and is rarely an issue. Air expands when heated, thus 2 litres of air in a
room at 21°C will become 2.2 litres when inhaled into the lung at 37°C. Unless
the spirometer has an internal temperature sensor, the operator must have access
to accurate temperature recordings in the room in which spirometry is performed
so the appropriate temperature correction of volume can be made. It is important
that the measuring head of the spirometer is at room temperature before testing
is commenced. A cold instrument from the car boot used in a warm room before
the temperature of the instrument has equilibrated will generate erroneous results.
Similarly a flow-head lying in the sun on a desk will be at a different temperature
from the room and will also generate erroneous results.
Preventers
Infection Control
Guidelines recommend that the staff member and the patient should wash their
hands prior to testing.
It has become common practice to use bacterial/viral barrier filters on the flow-
head of the spirometer. These filters lower the risk of cross infection between
patients. These filters must be chosen carefully to ensure they do not compromise
the measurements through imposing a resistance to airflow. ATS guidelines
provide specifications for air flow resistance in a spirometer, the addition of a
filter must not exceed this tolerance. An additional benefit of filter use is that the
patient perceives their use to be an assurance that they are being protected from
infection.
One brand of spirometer uses a disposable mouthpiece that isolates the exhaled
breath from the spirometer. In this case there is no need for a barrier filter.
If filters are not used it is usual practice to wash/disinfect the flow-head of the
spirometer between patients. You will need several flow-heads if you wish to
test more than one patient within the time it takes for the flow-head to dry
completely and be recalibrated.
There are other mouthpieces that contain a one-way valve preventing inspiration
through the mouthpiece. These may be adequate but they prevent the
measurement of inspiratory flow. Another consideration is that while the
instruction is to exhale into the spirometer some people have difficulty
comprehending the required manoeuvre and will attempt to inspire. Anecdotally,
there have been incidents of inhaling the valve. They may be cheap but are not
an ideal solution. In addition, these mouthpieces do not prevent exposure of the
flow-head to moisture.
The outside of the spirometer should be wiped down between patients. Depending
on the frequency of use it is recommended that the flow-head be cleaned
periodically. It is ESSENTIAL that after any cleaning the spirometer’s calibration
is verified following reassembly.
Training personnel
Quality spirometry requires comprehensive training. The Australian and New
Zealand Society of Respiratory Science in association with the Thoracic Society
of Australia and New Zealand have developed a guideline for spirometry training
courses preparatory to registering training courses available in Australia and
New Zealand. Formal spirometry training courses are available in Auckland and
Christchurch. Other centres in New Zealand will provide training, as the demand
requires.
It is well documented that skill updating is a critical part of any quality assurance
programme.
1. Examine reported data for accuracy and reproducibility and refer to additional
technical comments on test performance.
2. Determine if the FEV1/FVC ratio is normal or reduced (below the reference
range).
3. If the ratio is normal or high, examine the vital capacity, if FVC is low the
result suggests a restrictive pattern and referral for lung volume testing is
recommended. Otherwise you can be confident the result is within the
reference range.
4. If the FEV1 is low (below the reference range), obstructive lung disease is
present. The severity of obstruction is assessed using the % predicted
FEV1.
Figure 2. Restrictive pattern. FEV1/FVC ratio elevated. Reduced FVC at 66 per cent
reference value i.e. below the 95% C. I.
Age: 49 Height (cm): 167 Weight (kg): 146.5 BMI: 52.53 Gender: male
Ref Pre Pre Post Post CI LLN
Meas %Ref Meas % Chg
FEV1 (L) 3.24 2.27 70 1.00
FVC (L) 4.30 **2.85 **66 1.36
FEV1/FVC % 75 80
PEF (L/sec) 8.05 7.59 94 3.87
FEF25-75 (L/sec) 4.09 2.72 67 2.67
FET100% (sec) 14.86
FEV6 4.23 2.69 64 3.43
FEV1/FEV6 80 84 72
Reversibility testing
1. Confirm the patient has withheld medication appropriately prior to testing
reversibility eg. salbutamol for 6 hours, salmeterol for 24 hours.
2. Measure baseline spirometry in usual way
3. Administer bronchodilator medication (MDI and spacer or nebuliser).
4. Wait the required time for peak efficacy.
• 15-20 minutes for salbutamol.
• 25-30 minutes for ipratropium bromide or salbutamol with ipratropium
bromide.
5. Perform post-bronchodilator spirometry as for baseline test.
Interpretation of spirometry
Spirometers are able to produce a long list of indices in their reports. The
frequency of introducing a false negative result increases with the number of
indices reported. A simple regimen for interpreting data is to limit your inquiry
to three parameters viz. FEV1/FVC, FEV1 and FVC, plus careful inspection of the
accompanying flow-volume or volume-time curves. The following is a simple
guide to interpreting spirometry.
• Training in the use of the equipment after purchasing (this training does not
replace a spirometry training course).
• Reliable access to servicing from the manufacturer through their
representatives.
The spirometers listed overleaf satisfy most of these criteria. The list does not
cover all available instruments either because they are not recommended or
they are new to the market and we are unaware of them. The majority of
spirometers at the lower end of the market are intended for monitoring purposes
only and are not designed for diagnostic purposes. Monitoring spirometers are
useful for single patient use but have limitations for diagnostic use.
All the spirometers listed can be linked into a PC for data storage. The prices
quoted are for a single instrument. Bulk purchases will attract a discount.
Spirometer Manufacturer Price Distributor
SpiroPro SensorMedics/ $4,000.00 CARE Medical
(Printer not included) Jaegar + GST 0800 333 444
[email protected]
Flowscreen Jaegar $5,800.00
(Integrated ticket + GST
thermal printer)
Readings
Pocket Guide to Spirometry. David P Johns and Rob Pierce. McGraw-Hill Australia Pty Ltd.
ISBN 0 074 71331 0.
Medical Section of the American Lung Association. 1994. Standardization of spirometry: 1994
update. Am. J. Respir. Crit. Care Med. 152:1107-1136.
G.T. Ferguson, P.L. Enright, A.S. Buist, and M.W. Higgins. 2000. Office spirometry for lung
health assessment in adults: A consensus statement from the national lung health education
program. Chest 117:1146-1161.
Medical Section of the American Lung Association. 1991. Lung function testing: selection of
reference values and interpretative strategies. Am. Rev. Respir. Dis. 144:1202-1218.
Your Local Asthma Societies
Asthma Hawke’s Bay Rotorua Asthma Society
Ph: 06 835 0018 Ph: 07 347 1012
Asthma Society Northland South Canterbury Asthma Society
Ph: 09 438 5205 Ph: 03 686 2132
Canterbury Asthma Society Southland Asthma Society
Ph: 03 366 5235 Ph: 03 214 2356
Eastern Bay of Plenty Asthma and Taranaki Asthma Society
CORD Support Group Ph: 06 751 2501
Ph: 07 307 1447 Tauranga Asthma Society
Gisborne & East Coast Asthma Ph: 07 578 4602
Ph: 06 868 9970 Tu Kotahi Maori Asthma Society
Kapiti Asthma Society Ph: 04 939 4629
Ph: 04 902 6855 Waikato Asthma & Respiratory Society
Marlborough Asthma Society Ph: 07 839 6222
Ph: 03 572 8422 Wairarapa Asthma Society
Nelson Asthma Society Ph: 06 377 1175
Ph: 03 546 7675 Wanganui Asthma Society
North Otago Asthma Society Ph: 06 345 2703
Ph: 03 434 7111 Wellington Regional Asthma Society
Otago Asthma Society Ph: 04 237 4520
Ph: 03 471 6167