Using Office Based

Spirometry to Improve
Asthma Outcomes

Henry A. Wojtczak, M.D.

Henry.Wojtczak@med.navy.mil
All Too Common!!
 Asthma Stakeholders
• Patient with asthma
• Parents, legal guardians, relatives, older siblings
• Population Health and Disease Managers
• Primary Care Team
– Provider ( MD, PA, NP)
– Nurse
– Respiratory Therapist
– Pharmacist
– Case Manager
– Social Worker
• School / Preschool / Daycare staff
– Teacher / teacher’s aide
– Nurse
– Coach
• BUMED Asthma Action Team
• Non profit Support Groups like Lung Association
 Background
• Asthma is a significant and growing health
burden in the United States and around the
world
• High mortality and healthcare utilization
rates in the US clearly indicate that there are
a significant number of persons with poorly
controlled asthma
 US Burden of Asthma
• Current asthma prevalence: 22 million
Americans (6.5 million children)
• Annual burden of illness:
– 497,000 hospitalizations annually
– 1.8 million ED visits annually
– Approximately 3600 deaths per year in 2006
– 14 million lost school days in children and
14.5 million lost workdays
– $16.1 billion in health costs annually
American Lung Association Epidemiology & Statistics Unit Research Program Services. Trends in
Asthma Morbidity and Mortality. July 2006. Available at: www.lungusa.org. Accessed June 25, 2007.
Dr. Wojtczak’s Office
 Goals of Asthma Therapy
• Minimal or no chronic symptoms day or night
• Minimal or no exacerbations
• No limitations on activities; no missed school/work
• Maintain (near) normal pulmonary function
• Minimal use of inhaled short-acting beta2-agonists
• Minimal or no adverse effects from medications
• Prevent progressive lost of lung function; prevent
reduced lung growth
 Foundation for Good Asthma
Outcomes

• Cooperation: team-work and mutual respect

• Treating the patient as partner
• Assuming and accepting responsibility
• Shift of focus
• Target: Improving Outcomes
• Ability and desire to follow-up
Barriers to Quality Asthma Care
• Health Care System
– Lack of health insurance, primary care, coordination of
care
– High cost of medications and services
• Health care providers
– Lack of recognition, severity and control
– Suboptimal compliance with guidelines
• Family
– Confusion about symptoms and therapies
– Adherence
– Reactive rather than proactive
DOD-VA Asthma Severity Table
DOD-VA Asthma Control Table
 The Spirometry Gap

• The majority of asthma patients receiving

care at Navy MTFs have limited access to
timely spirometry
• Results in poor compliance with national
evidence-based asthma guidelines
– 7% of Navy asthma patients identified by population
health navigator have documented spirometry over
the last 2 years
 The Spirometry Gap

• The Navy wide shortage of spirometry

resources likely results in delayed or
misdiagnosis of asthma, limited ability
for the provider to assess asthma
control, and increased patient morbidity
– A recent Navy wide survey revealed only
31% of providers had on site access to
spirometry
 Background
• The DOD-VA and NHLBI evidence based asthma
clinical practice guidelines recommend that
spirometry measurements(FEV1,FVC, FEV1/FVC)
before and after the patient inhales a short-acting
bronchodilator should be undertaken for patients in
whom the diagnosis of asthma is being considered,
including children ≥5 years of age (NHLBI 2007).

• Patients’ perception of airflow obstruction is highly

variable, and spirometry sometimes reveals
obstruction much more severe than would have been
estimated from the history and physical examination.
Another Problem Caused by Deforestation
 Spirometry Background
• Objective assessments of pulmonary function are
necessary for the diagnosis of asthma because,
medical history and physical examination are not
reliable means of excluding other diagnoses or of
characterizing the status of lung impairment
• Spirometry often do not correlate directly with
symptoms
• One study reports that one-third of the children
who had moderate-to-severe asthma were
reclassified to a more severe asthma category
when pulmonary function reports of FEV1 were
considered in addition to symptom frequency
Stout et al. 2006
 Background

• Recent changes to assessing asthma severity

and control require the primary care
provider to be able to easily measure an
asthma patient’s FEV1, FEV1/FVC, and
changes post bronchodilation

• Inability to measure an asthma patient’s

spirometry, can result in either over
estimation of asthma control, and /or under
estimation of asthma severity.
Flow Volume Loop
 Indications
Diagnostic
• Evaluate symptoms, signs, abnormal lab tests
– Symptoms: cough, wheeze, dyspnea, chest pain
– Signs: overinflation, cyanosis, wheezing, chest deformity,
crackles
– Lab tests: hypoxemia, hypercapnia, CXR, polycythemia
• Measure the effect of disease on pulmonary function
• Assess preoperative risk
• Assess prognosis
• Screen patients at risk for lung disease
– Smokers
– Occupational exposures
– Routine physical examination
 Office Based Spirometry
• Focus on test that can be
performed in office setting
• Children > 5 years old
• Reliable results depend
on:
– Experienced tech
– Devote time / effort to
each child
– Appropriate environment
• Measure
– Lung volumes
– Flows and timed volumes
– Reactivity
 Dynamic Lung Volumes

• Valuable in spirometry for following the

progress of a patient with chronic lung
disease
• Can be used to assess response to treatment
• Help assess preoperative risk
• Do not provide the diagnosis, but can
demonstrate if lung function is consistent with
a diagnosis (ie, obstructive vs. restrictive
disease)
 Dynamic Lung Volumes

• Forced Vital Capacity (FVC): Volume expired

by a forced maximal expiration after maximal
inhalation, also known as FEV6.
• Forced Exp. Volume in 1 second (FEV1):
Volume of air forcefully expired in the first 1
second from a position of maximal inspiration.
• Forced Exp. Flow from 25-75% of Exhalation,
(FEF25-75): Average flow rate during the
middle 50% of the FVC maneuver.
I Hope I Pass My Spirometry Test!!!
Administering Spirometry in Children

• Requires pt cooperation
(unlikely in children
less than 5-6 yrs).
• Requires a technician
who is sensitive to the
needs of children.
• Practice makes perfect!
• Calm, success-oriented
environment.
Administering Spirometry in Children

• Ask child to take a full breath (to maximal

inflation), followed by a brief hold.
• Next, perform a maximal forced exhalation
for at least 3 seconds.
• “Blow out all your birthday candles….”
 Coaching During Testing
• Perhaps the MOST important
aspect of testing.
• Deep breath in, BLAST it out,
keep blowing, blowing,
blowing, DEEP breath in, and
that's done!
• Techs should become
competent by taking the
BUMED spirometry training
course, TAD training, civilian
PFT labs, or manufacturer
inservice.
 Standards for Testing
Environment
• Torso and head erect
either sitting or standing
• Nose clips
• Pretest instruction
period:
– Explain the test ( forceful
& long expiration)
– Give demonstration
– Chance to practice
– Set a goal
• Coach / Cheerleader
Are We Going Too Fast?
 Standards for Testing
Reporting
• Hard copy of results
• All reports include
– DOB
– DOT
– Height
– Weight
– Sex
– Race
– Absolute values of all
measurements
– Percent of predicted
values ( Predicted Source)
– Conditions of test
 Standards for Testing
Guidelines for Interpretation

• Older children and adolescents take the best

of 3 tests
• Younger children may require more than 3
tests
• The “best” test is the one with the greatest
sum of FEV1 and FVC
 Standards for Testing
Guidelines for Interpretation

• Comment on the quality

• Use FVC, FEV1, and FEV1 / FVC % as primary guide
for interpretation
• Interpret borderline values with caution
• Primary indicator of obstruction is FEV1/ FVC %
– Classify degree of obstruction with % predicted FEV1
– Determine response to bronchodilator
• Restriction can be suspected by spirometry but only
confirmed with TLC measurement
Data from Taussig LM, Chernick V, Wood R, et al: Standardization of lung function
testing in children. J Pediatr 97: 668-676, 1980
Advantages of FEV1 Measurement

• Most reproducible
• Comparable between labs
• Reflects changes in lung elastic recoil
• Defines the bronchodilator response
• Best measure of prognosis
Spirometry Patterns
 Role of Spirometry In Asthma
• Spirometric measures, before and after the
administration of a short acting B2-agonist
should be obtained on all capable ( usually
> 5 years-old) patients in whom a diagnosis
of asthma is under consideration
• When physical exam findings are not
present, mild asthma may be detected by
performing spirometry, especially with pre-
and post bronhodilator evaluation
PFT Sheet
 Role of Spirometry In Asthma

• Airflow obstruction can generally be determined by

using the forced expiratory volume in the first second
( FEV1) and the forced vital capacity ( FVC), and the
FEV1/FVC ratio
• Peak flow should not be used to diagnose asthma
because it is less reliable due to poor reproducibility
and dependence on patient effort
• Remember there is no single test sufficient or
adequate to diagnose asthma
 Defining Airway Obstruction

• Airway obstruction is defined as a FEV1/FVC of

< .70 in adults and < .80 in children
• Obstructive defects are characterized by a
disproportionate reduction in FEV1 with respect to
FVC
• An FEV1 < 80% of normal predicted is also suggestive
of airflow obstruction
• Airways obstruction may also result in reduction of
other measures of airflow, such as mean mid-forced
expiratory flow ( FEF 25-75)
• An FEF25-75 which is < 50-60% of predicted normal
value is indicative of small airways obstruction
 Reversible Airway Obstruction
• Reversible airway obstruction is documented with
improvement in FEV1 of > 12% ( usually >200 ml in
adults) or clinical improvement in symptoms
• Airway obstruction is considered reversible when
FEV1 has increased > 12% after administration of a B2
agonist
• Failure to demonstrate a change after bronchodilator
does not exclude a reversible component of obstruction
because airway inflammation may be present and not
responsive to B2 agonist
 Role of Spirometry for Monitoring
Asthma
• Every patient capable of spirometry should
have testing performed at least every 1-2 years
• All MTFs where asthma care is provided
should have access to timely spirometry
• Spirometry also indicated in the following
situations:
– After a change in control therapy to document
response
– When symptom history suggests poor control
Success
 Spirometry in Primary Care

• “Should play a central

role any time a
physician prescribes
potent bronchoactive
and anti-inflammatory
drugs…”
• An objective measure
of airway obstruction,
restriction

Petty, T.L. “Benefits of and Barriers to the Widespread Use of Spirometry”.

Current Opinions in Pulm Medicine, 2005, 11:115-120.
 Spirometry in Primary Care
• Quality of studies in PC setting: 85 of 109
(78%) tests administered met all criteria for
acceptability and reproducibility (reviewed
by peds pulm)
• Good agreement between pediatricians
office testing and lab testing
• Interpretation: Pediatrician was incorrect in
23 of 109 test (21%)

Zanconato, S. “Office Spirometry in Primary Care Pediatrics: A Pilot Study”.

Pediatrics, December 2005, 116; 792-797.
 Spirometry Take Home Points
• Spirometric measurements are as
fundamental to optimal asthma outcomes,
as are measurements of pulse, blood
pressure, temperature, height, and weight to
general wellness checks
• Accurate spirometry requires proper
training for physicians, nurses, techs.
• Portable spirometry equipment produces
quality studies and allows for reliable
testing in the primary care setting.
Racing to Control
Asthma
 Ground Zero
for the Swine Flu!!!
 Spirometry:
Case Based Discussion
 Pulmonary Function Test
Interpretation
• Assess quality and reproducibility
• Pattern Recognition
– Obstructive ventilatory defect
• Asthma, CF, COPD
– Restrictive ventilatory defect
• Interstitial lung disease, chest wall deformities, neuromuscular
disease
– Special cases - UAO
• Bronchodilator response
 Reproducible Test

Am J Respir Crit Care Med. Vol 152:1107-1136, 1995

 Non-Reproducible Test

Am J Respir Crit Care Med. Vol 152:1107-1136, 1995.

Robert Hyatt, et al. Interpretation of Pulmonary Function Tests:
A Practical Guide, 3rd Edition. 2009.
 Patterns of Major Airway
Obstruction

Robert Hyatt, et al. Interpretation of Pulmonary Function Tests:

A Practical Guide, 3rd Edition. 2009.
Measure My Lung
Function!!!!!
 Case 1
• A 7-year old male presents to your clinic in
November complaining of nightly cough for the
past 2 months
• He denies symptoms of GE Reflux.
• He has visited the emergency room twice in the
past year where he received albuterol with good
symptomatic relief
• You obtain pre/post bronchodilator spirometry in
your office
Case # 1 Spirometry
Case # 1 Numbers
Hang in There Almost
Finished!!!!!!
 Case #2 Randy
• History
– 6-year-old male with a history of asthma since
infancy
– States that he never coughs or wheeze during
the day, and maybe 1 night/month especially at
night
– Currently on an ICS, Flovent 44 ug 2p BID
with MPAC
– Does not perceive his asthma as limiting his
activity, but has difficulty keeping up with his
friends due to wheezing
– Parents believe that his asthma is well
controlled
• Physical exam
– Normal vital signs
– Chest: No wheezes but mildly prolonged
expiratory phase
– Heart: Normal
• Spirometry
– FEV1: 60% of predicted
Racing to Control
Asthma
The End!!!!!!
Questions and
Comments !!!!