Spirometry

Physical Description 1. Age 2. Height or [blank_start]Arm[blank_end] Span. Without [blank_start]shoes[blank_end]. Multiply by [blank_start]2.54[blank_end] to get cm 3. Gender 4. Weight 5. Race 3.

[blank_start]Occupational[blank_end] History Inquire about: Mine / [blank_start]Quarry[blank_end] work Mill [blank_start]Work[blank_end] Farming Gas / Fume exposure Dusty [blank_start]Environment[blank_end]

Smoking History Differentiate between cigars, pipes and [blank_start]cigarettes[blank_end] Pack [blank_start]years[blank_end] Does pt still [blank_start]smoke[blank_end]

Medical / Surgical History Disease: [blank_start]Asthma[blank_end], TB, Chronic [blank_start]Bronchitis[blank_end], Recurrent Colds, pneumonia, infections Record presence of: Hay [blank_start]fever[blank_end] / allergies

Withholding Medications SABA: [blank_start]4[blank_end] hrs LABA: [blank_start]12[blank_end] hrs Methylxanthines: [blank_start]12[blank_end] hrs Slow Release Methylxanthines: [blank_start]24[blank_end] hrs Anticholinergics: [blank_start]8[blank_end] hrs Cromolyn Sodium: [blank_start]8[blank_end] - [blank_start]12[blank_end] hrs Other Meds: Inquire about Inhaled steroids, cardiac meds, antibiotics, beta blockers

Vital Signs RR: [blank_start]10[blank_end] - [blank_start]20[blank_end] HR: [blank_start]60[blank_end] - [blank_start]100[blank_end] BP: 120/80 Sensorium: Alert, oriented and able to follow [blank_start]commands[blank_end]

Other Respiratory Modalities: Evaluate O2 [blank_start]therapy[blank_end], aerosol [blank_start]therapy[blank_end], pulmonary [blank_start]rehab[blank_end] Contraindications: [blank_start]Hemoptysis[blank_end] within 24 hrs, unstable [blank_start]vitals[blank_end], unable to [blank_start]cooperate[blank_end] Prohibited activities No alcohol within [blank_start]4[blank_end] hrs, no exercise within [blank_start]30[blank_end] minutes, don't wear [blank_start]tight[blank_end] clothing, don't eat large meal within [blank_start]2[blank_end] hours. Other considerations: Room [blank_start]temperature[blank_end], barometric [blank_start]pressure[blank_end], dentures stay in unless they are [blank_start]loose[blank_end], wear nose clips, sitting position

Testing: Slow Vital Capacity (SVC): Max [blank_start]expiration[blank_end] after a [blank_start]full[blank_end] inspiration L or mL corrected to [blank_start]BTPS[blank_end] ATPS x [blank_start]factor[blank_end] = BTPS BTPS is based on: ambient [blank_start]temperature[blank_end], Barometric [blank_start]Pressure[blank_end], Humidity Measures: Vital [blank_start]Capacity[blank_end] [blank_start]Tidal[blank_end] Volume Inspiratory [blank_start]Reserve[blank_end] Volume Expiratory [blank_start]Reserve[blank_end] Volume

Slow Vital Capacity ATS Standards End Level of [blank_start]3[blank_end] breaths before SVC must not vary more than [blank_start]100[blank_end] mL Large Variances may indicate a [blank_start]leak[blank_end] At least 2 acceptable maneuvers within [blank_start]5[blank_end]% or [blank_start].15[blank_end] L SVC should be within [blank_start]5[blank_end]% of best FVC SVC higher than FVC indicates [blank_start]obstructive[blank_end] disease, but evaluate pt effort

Vital Capacity (VC) Max [blank_start]inspiration[blank_end] then max [blank_start]expiration[blank_end] Typical Value: 4800 mL decreased with restrictive disease VC = [blank_start]IRV[blank_end] + Vt + ERV VC = IC +[blank_start]ERV[blank_end] VC = TLC - [blank_start]RV[blank_end] Tidal Volume (Vt) Normal resting breathing voume Typical value: 500 mL Decreased with restrictive disease Vt x RR = [blank_start]Minute Volume[blank_end] Vt - [blank_start]IC[blank_end] - IRV Vt = VC - IRV - [blank_start]ERV[blank_end] Vt = TLC - [blank_start]IRV[blank_end] - ERV - RV Inspiratory Reserve Volume (IRV) Largest volume of air that can be inspired above VT Typical Value 3100 mL Decreased with restrictive disease IRV = IC - [blank_start]Vt[blank_end] IRV = VC - [blank_start]ERV[blank_end] - Vt Expiratory Reserve Volume (ERV) Largest volume of air that can be expired from [blank_start]resiting[blank_end] end level Typical Value: 1200 mL Decreased with restrictive diseases ERV = [blank_start]VC[blank_end] - IC ERV = FRC - [blank_start]RV[blank_end]

Inspiratory Capacity (IC) Largest Volume of air that can be inspired from resting end level [blank_start]expiratory[blank_end]. Typical Value 3600 mL Decreased with restrictive disease IC = [blank_start]IRV[blank_end] + Vt IC = VC - [blank_start]ERV[blank_end] IC = [blank_start]TLC[blank_end] - FRC

Forced Vital Capacity (FVC): Max inspiration followed by a [blank_start]forced[blank_end] expiration If SVC [blank_start]>[blank_end] FVC suspect obstructive disease If SVC [blank_start]<[blank_end] FVC question pt effort Exhale until a volume pleateau OR [blank_start]15[blank_end] seconds Modified maneuver: After [blank_start]4[blank_end] seconds, relax and exhale gently.

FVC Measurements: Peak Expiratory Flowrate (PEFR) Maximum [blank_start]flowrate[blank_end] achieved during FVC 10 L/s Nonspecific in significance because it is very dependent on [blank_start]patient[blank_end] effort Measured in L/s ATPS corrected to BTPS Forced Expiratory Flow 200-1200 Average flowrate that occurs during FVC after the first [blank_start]200[blank_end]mL has been expired Typical: 6 L/s Significance: Measures airflow in [blank_start]big[blank_end] airways. Decreased with mechanical airway problems and [blank_start]obstructive[blank_end] disease, can be decreased d/t poor effort Forced Expiratory Flow 25%-75% Average flowrate during the [blank_start]middle[blank_end] half of FVC Typical: 4-5 L/s ATPS corrected to BTPS Significance: Measures flow in the [blank_start]small[blank_end] airways, is [blank_start]decreased[blank_end] in obstructive disease. Most sensitive to detect [blank_start]small[blank_end] airway disease. Can appear erroneously [blank_start]decreased[blank_end] if FVC and FEV1 are greatly increased in post bronchodilator studies. Forced Expiratory Volume/Time (FEVtime) Volume Expired of time interval Common: FEV.5, FEV1, FEV2, FEV3, FEV6 ATPS corrected to BTPS Significance: Decreased flows indicate obstructive disease, FEV1 used to assess improvement in post BD studies, allow 10-15 minutes in between pre/post tests. FEVT / FVC% Forced expiratory volume for time interval expressed as a percentage of total FVC Minimum acceptable values: FEV.5/FVC = [blank_start]60[blank_end]% FEV1/FVC = [blank_start]70[blank_end]% FEV2/FVC = [blank_start]94[blank_end]% FEV3/FVC = [blank_start]97[blank_end]% FEV6/FVC = [blank_start]99[blank_end]% Significance: [blank_start]decreased[blank_end] with obstructive disease, [blank_start]normal[blank_end] with restrictive.

FVC to Generate Flow-Volume Loop A forced expiratory maneuver followed by forced inspiratory maneuver Recorder plots flow ([blank_start]vertical[blank_end]) and volume ([blank_start]horizontal[blank_end]) for inspiration and expiration Expiration is [blank_start]above[blank_end] baseline, inspiration [blank_start]below[blank_end] baseline Important to coach max effort without [blank_start]coughing[blank_end] PEF is measured with pt at [blank_start]TLC[blank_end] PIF is measured with pt at [blank_start]RV[blank_end] Forced Expiratory Flow at 25%, 50%, and 75% of VC % is amount of [blank_start]FVC[blank_end] that has been exhaled Decreases in FEF50% and FEF75% indicate [blank_start]obstructive[blank_end] disease These values can be more sensitive in detecting small airway obstruction than FEV1. Forced Inspiratory Flow at 25%, 50% and 75% of Inspiratory Vital Capacity Measured on inspiratory side of loop useful when compared to expiratory Values for determining a site of large [blank_start]obstruction[blank_end] - particularly the [blank_start]50[blank_end]% value Maximum Forced Expiratory Flow (FEFmax) Highest flow achieved on expiratory curve Analagous to [blank_start]PEF[blank_end] FEFmax used to determine [blank_start]effort[blank_end]

Flow Volume Studies: FEF50%/FIF50% Ratio of forced expiratory flow to forced inspiratory flow at 50% of VC Helpful in evaluating [blank_start]upper airway[blank_end] obstruction Normal: [blank_start].8[blank_end] - [blank_start]1.2[blank_end] Variable Extrathoracic Obstruction [blank_start]increases[blank_end] ratio > [blank_start]1.2[blank_end] Variable intrathoracic obstruction [blank_start]decreases[blank_end] ratio < [blank_start].8[blank_end] Fixed airway obstruction would cause equally reduced flows Formula: FEF50% / FIF50%

Fixed Airway Obstruction: Appears as decreased FEF50% and decreased FIF50% with values approximately [blank_start]equal[blank_end]. Example: Tracheal [blank_start]Stenosis[blank_end]

Variable Extrathoracic Obstruction: Appears as [blank_start]normal[blank_end] expiratory flows with [blank_start]decreased[blank_end] inspiratory flows FEF50% / FIF50% is [blank_start]increased[blank_end] > [blank_start]1.2[blank_end] Example: [blank_start]Vocal Cord[blank_end] paralysis

Variable Intrathoracic Obstruction [blank_start]Normal[blank_end] inspiratory flows with [blank_start]decreased[blank_end] expiratory flows FEF50% / FIF50% is [blank_start]decreased[blank_end] < [blank_start].8[blank_end] Ex: Tumor near the carina

Flow Vol. Loops Restriction: Decreased lung [blank_start]volumes[blank_end] with [blank_start]normal[blank_end] flows Loop is [blank_start]tall[blank_end] and [blank_start]skinny[blank_end] Asthma: Increase in resistance in [blank_start]small[blank_end] airways causes a [blank_start]decrease[blank_end] in expiratory flows [blank_start]Scooped[blank_end] out portion on expiratory loop Emphysema: Increased small airways [blank_start]resistance[blank_end] along with loss of [blank_start]elastic recoil[blank_end] = a reduction of expiratory flows more pronounced than asthma

Pre/Post Bronchodilator testing: Determines degree of [blank_start]reversible[blank_end] obstruction Indications: FEV1 <[blank_start]80[blank_end]%, cough of unknown [blank_start]etiology[blank_end], asthma, suspected hyperresponsiveness Loops can be superimposed to readily detect improvement SABA is given via MDI, SVN, or IPPB FEV1 must improve by at least [blank_start]12[blank_end]% and [blank_start].2[blank_end] L to be considered reversible. Forumla: (post FEV1 - pre FEV1) / pre FEV1 = % change If FVC increases in post, it is suggestive of [blank_start]air trapping[blank_end]

Spirometry Evaluation: 2 Major characteristics that Spirometry measures: Lung [blank_start]Volumes[blank_end] & [blank_start]Flows[blank_end] Decreased [blank_start]Flows[blank_end] indicate obstructive disorder. CBABE: [blank_start]Cystic Fibrosis[blank_end], [blank_start]Bronchitis[blank_end], [blank_start]Asthma[blank_end], [blank_start]Emphysema[blank_end] Decreased [blank_start]Volumes[blank_end] indicates restrictive disorder Neuromuscular: Myasthenia Gravis, Gullian Barre, Muscular Dystrophy Cardiovascular: CHF Pulmonary: pneumonia, atelectasis, pulmonary fibrosis Trauma: head trauma, rib fractures, flail chest

Interpretation: >= [blank_start]80[blank_end]% Predicted : Normal <[blank_start]80[blank_end]% Predicted: Mild dysfunction <[blank_start]70[blank_end]% Predicted: Moderate dysfunction <[blank_start]60[blank_end]% predicted: Moderate/severe dyfunction <[blank_start]50[blank_end]% Predicted: Severe Dysfunction <[blank_start]35[blank_end]% predicted: Very Severe Dysfunction

FVC: ATS Standards Maximal effort and smooth curve Minimum of [blank_start]6[blank_end] seconds effort or [blank_start]2[blank_end] second plateau Start of test needs to be [blank_start]abrupt[blank_end] with no hesitation 3 acceptable tests Best Test has the highest [blank_start]FVC[blank_end] + [blank_start]FEV1[blank_end] Adults should stand or sit Coughing shows as an upward deflection Early termination is a short horizontal line at end of expiration Back extrapolation % = (back extrapolated vol / FVC) x 100 Spirogram acceptability: Free from artifact: No [blank_start]cough[blank_end] or glottis closure in 1st seond. No early [blank_start]termination[blank_end]. No variable effort. No leak. no obstructed mouthpiece. Good Start: Extrapolated volume of <[blank_start]5[blank_end]% of FVC OR time to PEF less than [blank_start]120[blank_end] ms Satisfactory Exhalation: 6 seconds and or volume plateau, reasonable duration or plateau, OR subject cannot continue to exhale.

Maximum Voluntary Ventilation Largest Volume of Air inhaled and exhaled over a [blank_start]12[blank_end] second period Value is extrapolated to 1 minute and reported in L/min corrected to BTPS Typical : [blank_start]170[blank_end] L/m Provides info about: status of [blank_start]respiratory[blank_end] muscles, compliance of [blank_start]lungs[blank_end] and [blank_start]thorax[blank_end], airway [blank_start]resistance[blank_end] Pt Breathes as DEEPLY and as RAPIDLY as possible for 12 seconds Significance: Large reductions = sever obstruction. Effort dependent: If FEV1 x [blank_start]35[blank_end] > MVV - question pt effort

Obstructive Spiro Results: [blank_start]Normal[blank_end] FVC, [blank_start]decreased[blank_end] FEV1/FVC Restrictive Spiro Results: [blank_start]Decreased[blank_end] FVC, [blank_start]normal[blank_end] FEV1/FVC

Pediatric Spirometry Same equipment [blank_start]5[blank_end] years an older can usually perform acceptable spirometry Loops that meet criteria for good start of test and are free from artifact in the first second are considered [blank_start]usable[blank_end]. If kid stops inhaling when flow is within [blank_start]10[blank_end]% of PEF it is early termination and [blank_start]unusable[blank_end].

Spirometry ATS Standards After [blank_start]3[blank_end] [blank_start]acceptable[blank_end] tests: Check that the 2 largest FVC are within .[blank_start]15[blank_end] liters Check that the 2 largest FEV1 are withink .[blank_start]15[blank_end] liters Save best 3 maneuvers