Spirometry

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Spirometry

• Spiro from the greek for
  breathing
• Metry measurement
• Spirometry The measurement of breathing

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SPIROMETRY
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SPIROMETRY

• Spirometry plays a key role in the diagnosis and
  assessment of Chronic Obstructive Pulmonary
  Disease and yet research shows that it is
  under-utilised
• Importance highlighted with the new GMS contract
• Reliable method of differentiating between
  obstructive and restrictive disorders
• Can be used to detect the severity of disease
• Can detect COPD before symptoms become apparent

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When to perform spirometry

• Asthma
• Interchangable with peak flow to demonstrate
  variability
• May show changes suggestive of an alternative
  lung disease
• COPD
• At the time of diagnosis to conform obstruction
• To reconsider the diagnosis, if the patient shows
  an exceptionally good response to treatment
• Annually to monitor progression of disease
• Screening?
• All patients over 35, current or ex smokers, who
  have a chronic cough
• Considered in patients with chronic bronchitis as
  a proportion of these will go on to develop
  airflow limitation
• NICE (2004) all health professionals managing
  patients with COPD should have access to
  spirometry and be competent in the interpretation
  of the results.

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Who can perform spirometry

• Spirometry can be performed by any health care
  worker who is appropriately trained and who keeps
  his or her skills up to date
• Spirometry services should be supported by
  quality control processes

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?Reversibility testing???

• NICE 2004 R12
• In most patients, routine spirometric
  reversibility testing is not necessary as a part
  of the diagnostic process or to plan initial
  therapy with bronchodilators or corticosteroids.
  It may be misleading or unhelpful because
• Repeated FEV1 measurements can show spontaneous
  fluctuations
• Results on different occasions may be
  inconsistant and not reproducible
• Unless change in FEV1 is gt400mls a single test
  may be misleading
• Definition of magnitude of significant change is
  purely arbitrary
• Response to long term therapy not predicted by
  acute reversibility testing
• History is Key in distinguishing asthma from COPD

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Patient preparation

• To withhold or not to withhold medication?
• If you are doing reversibility testing
• No short acting bronchodilators for 4 hours
• No long acting bronchodilators for 12 hours
• No sustained release oral bronchodilators for 24
  hours
• For routine monitoring of COPD patients
• Take all medication as usual

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Terminology

• VC Vital capacity, the total amount of air that
  acn be expelled from the lungs from full
  inspiration to full expiration
• FVC Forced vital capacity, should be the same
  volume as VC but is sometimes reduced due to air
  trapping in COPD
• FEV1 Forced expiratory volume in one second
  from full inspiration
• FEV1/FVC or FEV1 or FEV1/FVC ratio The
  percentage of the FVC that is produced in the
  first second

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Patient preparation

• Before arrival
• No large meal within 2 hours
• No vigorous exercise within half an hour
• Comfortable loose clothing
• Empty bladder
• ?false teeth

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Patient preparation

• Who should not perform spirometry?
• Recent eye surgery
• Recent MI
• Recent CVA or other cerebral event
• Any recent surgery
• Any others?

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Patient preparation

• Record patients date of birth, height, ethnic
  origin
• Note if the patient is currently unwell or has
  had a recent exacerbation
• Ensure the patient is comfortable
• Sit the patient in a chair with arms
• Explain the purpose of the test
• You may need to demonstrate the correct technique
• Allow the patient practice attempts

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Patient preparation

• Record patients date of birth, height, ethnic
  origin
• Note if the patient is currently unwell or has
  had a recent exacerbation
• Ensure the patient is comfortable
• Sit the patient in a chair with arms
• Explain the purpose of the test
• You may need to demonstrate the correct technique
• Allow the patient practice attempts

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Measuring vital capacity (VC)

• The VC is a non forced measurement. It is often
  measured at the start of a session.
• Patient breathes in as deeply as is comfortable
• Seals lips around mouthpiece
• Breathes out steadily at a comfortable pace
• Continue until expiration complete
• May need a nose clip
• Repeat

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Measuring FEV1 and FVC

• Ask the patient to take a deep breath in full
  inspiration
• Patient to blow out forcibly, as hard and fast as
  possible, until there is nothing left to dispell
• Encourage patient to keep blowing
• For some COPD patients this can take up to 15
  seconds!
• Spirometer may bleep to say manoeuvre complete
• Repeat the procedure twice or until reproducible
  results

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Maintaining accuracy

• The most common reason for inacurate results is
  patient technique
• Common problems include
• Inadaquate or incomplete inhalation
• Additional breath taken during manoeuvre
• Lips not sealed around mouthpiece
• A slow start to the forced exhalation
• Some exhalation through the nose
• Coughing

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Quality assurance

• Is the test valid?
• Reproducibility
• Minimum of 2 relaxed vital capacities
• Minimum of 3 forced vital capacities
• Maximum of 8 forced blows in one session
• Best 2 blows within 5 or 100ml of each other

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Interpreation of results

• Take the best of the 3 consistent readings of
  FEV1 and of FVC
• Find the predicted normals for your patient
  Your machine may do this for you!

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Predicted Normals

• Depends on
• Age
• Sex
• Height
• Race

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Predicted Normal values

• Based on large population surveyse.g.ERS93,
  ECCS83
• Predicted values are the mean values obtained
  from the survey
• No surveys conducted in elderly populations

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Normal ventilatory function

• FVC 80 120 of predicted
• FEV1 80 120 of predicted
• FEV1/FVC ratio gt70

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To calculate predicted

• Actual Measurement x100
• Predicted Value
• e.g. Actual FEV1 4.0 litres
• Predicted FEV1 4.0 litres
• 4 x 100 100
• 4

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To calculate the ratio of FEV1 to FVC (FEV1,
FEV1/FVC or FER)

• Actual FEV1 x100
• Actual FVC
• e.g. FEV1 3.0 litres
• FVC 4.0 litres
• 3 x100 75
• 4

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Results clasification

• Normal
• Obstructive
• Restrictive
• Combined

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Interpreting Spirometry
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Obstructive defects

• COPD
• Asthma
• Bronchial carcinoma
• Bronchiectasis

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Restrictive defectsPulmonary causes

• Fibrosing lung disease (CFA, UIP, EAA,
  rheumatiod)
• Parenchymal tumours
• Pneumoconiosis (coal workers, asbestosis,
  silicosis, siderosis)

• Byssinosis
• Pulmonary oedema

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Restrictive defectsExtra-pulmonary causes

• Thoracic cage deformity
• Obesity
• Cardiac fialure
• Neuromuscular problems
• Pneunonectomy/lobectomy

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Combined defects

• Severe COPD
• Advanced bronchiectasis
• Cystic fibrosis

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The history of Inhalers

• 1956 Riker laboratories (3M) developed the first
  meter dosed inhaler
• 1969 Allen and Hanburys introduced inhaled
  salbutamol
• 1972 introduction of first inhaled
  steroidClarke, 2003

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Aim of Inhaled therapy

• Deliver high concentration of drugs directly to
  lungs bronchioles while reducing systemic side
  effects

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MDIs

• Correct technique depends on knowledge skills
• Holder canister act as a pump
• Pts ability to use MDI has shown to decline over
  time
• Good technique delivers 10-15 to small airways
• Increase by 12 with a spacer
• Togger,2001

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Meter Dose Inhaler (MDI)

• MDI is still the most common device used
• Only 21 of people use inhalers correctly

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Meter dose Inhaler (MDI)
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Medication available in the metered dose inhaler

• Terbutaline / Salbutamol
• Ipratropium
• Salmeterol
• Budesonide / Beclometasone / Fluticasone /
  Ciclesonide
• Seretide

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Spacers

• Several types available
• Holding chamber one way valve
• Reduces need for hand breath co-ordination
• Spacer should be compatible with MDI
• BTS, 2003

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Recommendations about spacers

• Cleaning
• Clean no more than monthly as more frequent
  cleaning affects performance (due to a build up
  of static)
• Clean with water and washing up liquid and leave
  to air dry
• Wipe mouthpiece clean of detergent before use
• NOTE Volumatic (large volume) spacer was
  discontinued in October 2005 and reintroduced in
  Feb 2006. (think patient choice/cost/ability to
  use)

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The Accuhaler?

• Medication available
• Salbutamol
• Salmeterol
• Fluticasone
• Seretide
• 100/50
• 250/50
• 500/50

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Turbohaler

• Advantages less manual dexterity needed
• No co-ordination required
• Does not require spacer
• Built in indicator to inform pt doses remaining

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Turbohaler
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Symbicort Turbohaler?

• 3 strengths
• 100/6, 200/6, 400/12
• Other drugs available in the turbohaler
• Terbutaline
• Budesonide
• Formoterol

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How to use Turbohaler
4. Remove the inhaler from your mouth, before
breathing out. Replace cover
3. Exhale, but not throughthe mouthpiece. Then
inhale through the mouthpiece forcefully and
deeply
2. Hold the inhaler upright and turn the grip as
far as it will go in both directions (this needs
to be carried out twice if using the TBH for the
first time)
1. Unscrew and lift off the cover
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Handihaler (tiotropium/spiriva)
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How to use the Handihaler

• Open the dust cap and mouthpiece
• Drop a Spiriva capsule into the centre chamber
• Close the mouthpiece and press the green button
  to pierce the capsule
• Breathe out completely away from the handihaler
• Inhale through the mouthpiece and hold your
  breathe then inhale a second time.

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Which Device?
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What the guidelines say

• In most cases bronchodilator therapy should be
  administered using a hand held inhaler device
  (including a spacer device if appropriate)
• Find the most suitable device (remember that not
  all drugs come in all devices)
• Patients must be trained in the use of the device
  and be able to demonstrate its use
  satisfactorily
• Patients should be reassessed and re-taught
  correct technique regularly
• The dose of medication should be titrated to
  clinical response
• NICE Guidelines (Thorax 2004)

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Any questions

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