Learning Objectives
third
Outline
Spirometry (airflow)
1. Ferguson GT et al. Chest. 2000;117:1146-1161. 2. NLHEP. Chest. 1998;113(suppl):123S-163S. 3. NCAP. J Respir Dis.
2000;21(suppl):S5-S21. 4. CDC. MMWR. 1990;39(RR-12):2-10. 5. Anthonisen NR et al. JAMA. 1994;272:1497-1505.
6. Kanner RE. Med Clin North Am. 1996;80:523-547.
Spirometry
Spirometry
8
7
6
5
4
3
2
1
0
-2
-3
-4
-5
Normal
Predicted
Actual
COPD
8
6
1 sec
TLC
RV
Flow (L/s)
Flow (L/s)
2
0
-2
-4
IC
6
1 sec
IC
-6
Volume (L)
Volume (L)
Normal Values
(based on age, sex, height, weight, ethnicity)
Pulmonary function
test
Normal value (95% confidence interval)
FEV1
80% to 120%
FVC
80% to 120%
FEV1/FVC ratio
TLC
80% to 120%
FRC
75% to 120%
RV
75% to 120%
DLCO
>60% to <120%
Spirometry Interpretation
Step 1: Acceptability and Reproducibility
Step 2: Differentiation between obstructive disorders and
restrictive disease
Step 3: Bronchodilator challenge (albuterol) for reversible
airway obstruction
Step 4: Lung volumes and diffusion may aid to distinguish
asthma from COPD and may provide clues regarding
restrictive lung disease
Multiple measurements (usually at least 3) should be
done on each subject
Spirometry Interpretation
Diagnosis of COPD1
FEV1 <80% predicted
FEV1/FVC <70% predicted
Acceptability
Normal
Cough
Variable effort
Normal
Obstruction
Restriction
Severe obstruction
FEV1> 80%;Normal
Mild disease: FEV1 = 60-80%
predicted
Moderate disease: FEV1 =
40-60% predicted
Moderate
Bronchodilator Challenge
10
Contraindications to Spirometry
1. Acute disorders affecting test performance (e.g.,
vomiting, nausea, vertigo)
2. Hemoptysis of unknown origin (FVC maneuver may
aggravate underlying condition.)
3. Pneumothorax
4. Recent abdominal or thoracic surgery
5. Recent eye surgery (increases in intraocular
pressure during spirometry)
6. Recent myocardial infarction or unstable angina
7. Thoracic aneurysms (risk of rupture because of
increased thoracic pressure)
TJ. BARREIRO and I PERILLO, AFP, 2004
11
Spirometry vs.
Full Pulmonary Function tests
PFTS:
Pulmonary Preoperative Assessment
1. Prior to lung resection/pneumonectomy
2. Chronic lung disease: screening for disease using PFTs is not
warranted without suggestive history and physical. However, in
those with known lung disease (COPD, asthma) can estimate
disease severity and prompt intervention1
3. The degree of airways obstruction (or an elevated pCO2 for
patients with COPD) predicts the risk of postoperative
pulmonary complications, such as atelectasis, pneumonia, and
the need for prolonged mechanical ventilation. DLCO < 40%
predicts post-operative pulmonary complications.
4. If spirometry demonstrates moderate to severe obstruction and
the surgery can be delayed, a prophylactic program of
pulmonary hygiene, including smoking cessation, inhaled
bronchodilators or steroids, and antibiotics for bronchitis, can
reduce risk
12
Outline
Spirometry (airflow)
13
Six-Minute Walk1
14
Supplemental Oxygen
Improves1-4:
Outline
Spirometry (airflow)
15
Outline
Spirometry (airflow)
16
COPD
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. CDC. MMWR. 1999;48:664-678. 3. Higgins MW et al. In: Clinical
Epidemiology of COPD. 1990:23-43. 4. Mannino et al. http://www.cdc.gov/mmwr/preview/mmwrhtml/00052262.htm.
5. NLHEP. Chest. 1998;113(suppl):123S-163S.
Emphysema
17
Others include1:
Air pollution
Poor nutrition
Childhood respiratory infections
Preexisting bronchial hyperreactivity
a1-Antitrypsin deficiency (genetic, rare)
Occupational and environmental exposure (eg, coal dust, silica)
1. NCAP. J Respir Dis. 2000;21(Suppl):S5-S21. 2. Buist AS, Vollmer WM. In: Textbook of Respiratory Medicine. 1994:1259-1287.
18
100
75
50
Disability
25
Death
0
25
50
Age (y)
75
19
FEV1
Socioeconoic
Ipact
1 (mild)
50% to 79%
of predicted
O Majority of patients
O Minimal impact on HRQOL
O Modest cost
2 (moderate)
35% to 49%
of predicted
O Minority of patients
O Significant impact on HRQOL
O High cost
3 (severe)
<35% of
predicted
O Minority of patients
O Profound impact on HRQOL
O Very high cost
HRQOL, health-related quality of life; cost, per capita health care expenditure
Spirometric severity criteria adapted from American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121.
20
41
Pharmacologic interventions1-3
Antidepressants (bupropion/Zyban)
Nicotine replacement therapy
Combination pharmacotherapy
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Jorenby DE et al. N Engl J Med. 1999;340:685-691. 3. Appel D. Am Rev Respir
Dis. 1987;135:354.
21
Case 1
HPI: 70 yo male referred for SOB. Lifelong smoker (2ppd for at least 50
yrs, quit about 2 years ago). + DOE, can not work on his ranch much
anymore. Admits to cough and clear sputum in the morning. Has
lost about 20# in the last year.
EXAM: T 37.6, 85, 143/75, RA O2 sat 90%, drops to 85% with walking
Pul: barrel chested, decreased BS throughout, soft exp
wheeze B.
Cor: RRR with loud P2
Ext: no edema
LAB: WBC 6.8, Na 134, BUN 11, glucose 86. RA ABG: 7.43/37/56
Spirometry:
CXR:
Management:
22
23
Case 1
Spirometry: Severe Airflow Limitation
Assessment: Severe COPD, hypoxemia with exertion
Management: Oxygen, Inhaled Bronchodilators (Tiotropium,
Albuterol, Salmeterol), education regarding COPD
Follow-up clinic visit: Improved DOE (alb use about 1-2x per
week), repeat spirometry showed FEV1 = 1.1 and FEV1/FVC
ratio of 43% (moderate COPD by ATS criteria)
Asthma
24
Asthma
COPD
Onset
Anytime
(often childhood/early
adulthood)1
Usual etiology
Cigarette smoking,
exposure
to other risk factors1
Course
Usually intermittent1
Chronic, progressive1
Airflow limitation
Largely reversible1
Partially reversible1
Clinical features
Persistent or worsening
dyspnea, chronic cough/
sputum1
Inflammatory cell
Eosinophils, macrophages3
Neutrophils,
macrophages3,4
Response to
steroids
Inhibits inflammation5
Little or no effect on
inflammation4
25
26
Pre-operative Assessment
27
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. NLHEP. Chest. 1998;113(suppl):123S-163S. 3. Ferguson GT et al. Chest
2000;117:1146-1161. 4. Higgins MW et al. JAMA. 1993;269:2741-2748.
28
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77S121.
29