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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
FEV
1
Forced expired volume in 1 second
FVC Forced vital capacity
FEV
1
/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
- FEV
1
/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 % of predicted
Mild >80
Moderate 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
FEV1/FVC 80 67 -13 67 -13 0
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
FEV1/FVC 80 67 -13 67 -13 0
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
No Yes
Obstructive Defect
Is FVC Low? (<80% pred)
Combined Obstruction &
Restriction /or Hyperinflation
Pure Obstruction
Improved FVC with
-agonist
Reversible Obstruction
with -agonist
Further Testing with
Full PFTs
Suspect
Asthma
Suspect
COPD
Is FEV
1
/ FVC Ratio Low? (<70%)
Yes
No Yes
No Yes
Diagnostic Flow Diagram for Obstruction
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
FEV1/ FVC 86 58 -28 60 -26 3
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
FEV1/ FVC 86 58 -28 60 -26 3
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
Interstitial Lung Diseases
- Fibrosis
- Granulomatosis (TB)
- Pneumoconiosis
- Pneumonitis (lupus)
Loss of Functioning Tissue
- Atelectasis
- Large Neoplasm
- Resection
Pleural
Effusion
Fibrosis
Chest Wall
Kyphoscoliosis
Neuromuscular Disease
Trauma
Extrathoracic
Obesity
Abdominal Trauma
No Yes
Is FVC Low?(<80% pred)
Restrictive Defect Normal Spirometry
Further Testing with
Full PFTs; consider
referral if moderate to
severe
Is FEV
1
/ FVC Ratio Low? (<70%)
No
Diagnostic Flow Diagram for Restriction
Adapted from Lowry, 1998
Results
Lowry 1998
Results
Full Pulmonary Function Testing (PFTs)
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 its
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 515
Asthma 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 Cost
Office spirometer $1,000 2,500
*Reimbursement based upon Medicare payments 2009
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
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