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Welcome

to the Spirometry Course


Developed by:
• Felip Burgos: Hospital Clínic of Barcelona
•Jordi Giner: Hospital de la Santa Creu i Sant Pau of Barcelona
•SIBELMED

Barcelona 2015

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Let's Begin

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Spirometry History

Let's Begin

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History of Spirometry

Let's Begin
Etymologically, spirometry means
the measurement of breath or breathing.
The term is attributed to Lavoisier (1862),
who discovered oxygen and gave it its name.

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First Attempt to Measure Lung Capacity
Galen (AD 129-200)
Doctor and Greek philosopher

In his experiment, he asked a child to breath into a bladder, observing that the
volume entering the bladder did not vary with each breath.
(he did not record any measurements).

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The First Spirometer
John Hutchinson (1811-1861) Inventor of the spirometer.

• Born in Newcastle
• He studied medicine at the University of London and surgery at Southampton.
• He worked for 2 years at London Brompton Hospital, where he developed his
spirometry working theories and principles (1846).
• As we know it today, spirometry was developed by him when designing the
spirometer model.

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John Hutchinson (1811-1861)

He observed that the volume of air that could be exhaled from the lungs when
completely inflated (Vital Capacity or VC) was a good indicator of an individual's
longevity.
When this measure was compromised, premature death was expected.
(PROGNOSIS VALUE).

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Other Early Spirometers
Spirometer made in 1850 (Pixxi Family, Paris 1850) and by Dr. S.W.
Mitchell (1859).

Portable Spirometers
(Circa 1900).

Water Spirometer (Godart, 1960)

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First Spirometry Performed at Hospital
de la Santa Creu i Sant Pau.
(Barcelona 1958)

Unknown Author / Fons Escuela Claret

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Ventilation Diagram
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VC: Vital Capacity Vt: Tidal Volume


RV: Residual Volume ERV: Expiratory Reserve Volume
TLC: Total Lung Capacity FRC: Functional Residual Capacity
IRV: Inspiratory Reserve Volume
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What is Spirometry?
• Spirometry is a test which is essential to study lung function. It measures the
volume of air moved during a maximum and forced exhale.
• It is useful for studying respiratory problems (asthma, COPD, etc.) and to evaluate
possible occupational pulmonary disorders.

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Spirometry
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VEMS: Volume Expiratoire Maximum Seconde (Maximum Expiratory Volume in one Second)
FEV1: Forced Expiratory Volume in the first Second
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COPD ASTHMA
Chronic Obstructive Pulmonary Chronic respiratory disease
Disease is characterized by a characterized by the inflammation of
chronic and irreversible obstruction the airways, hyperresponsive to a
of the airflow caused, mainly, by an wide variety of stimuli and reversible
inflammatory reaction to tobacco bronchial obstruction. (GINA; GEMA)
smoke. (GOLD; GESEPOC)
Flow (L/s)

Volume (L)
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Types of Spirometer
According to their properties According to their use
• Water / Dry • Pulmonary function laboratories
• Closed / Open • Patient screening
• Volumetric / Pneumotachometer

The most used are Pneumotachometers (Open)


Types of Pneumotachometer: Characteristics (pneumotachometers)
• They are the open type
• Lilly
• They are flow sensors
• Fleisch • Flow-time relation
• Turbine • Calculate volumes by
• Ultrasonic microprocessor
• Different types of curves:
• Venturi
• Volume/Time
• Other: Hot wire, Pitot, etc.... • Flow/Volume
Tachometer: From the Greek τάχος, tachos, ‘velocity’ and μέτρον, metron, ‘measure’
(In some bibliographies the pneumotachometer is referred to as pneumotachograph)
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Spirometer Requirements

• Measure a minimum volume of 8 liters and a flow of 0 to 14 l/s

• Measure a volume with a minimum precision of ± 3% or ± 50ml


(whichever is better)

• Signal accumulation during 30"

• Resistance to a 14 l/s flow less than 1.5 cmH2O

• Assessment of the start of the maneuver by retrograde extrapolation

• Simultaneous graph-plotting

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Water Bell Spirometer
Water Spirometer
Moves the
paper and
marker
The bell moves when
exhaling
Results are
plotted

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Bellows Spirometer
Closed and Dry Type
Moves the
paper and
marker
The results
appear

• Registers the forced expiration.


• The most used spirometer until the When exhaling the bellows inflate
pneumotachometer.

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Piston Spirometer
Closed and Dry Type

Moves the paper,


and plots results

When exhaling, the


piston and marker
• Sealed cylinder prevents air escaping. move

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LILLY Pneumotachometer (operating principle)
Measurement based on the difference in air-flow pressure before and after passing through a
known RESISTANCE (screen (A)), which is directly proportional to the airflow that passes through a
PRESSURE SENSOR. Once the flow is obtained, the microprocessor calculates the volumes by
mathematically integrating the flow with the time function.
Pneumotachometer diagram
LILLY

P1 P2

B Disposable Lilly
Pneumotachometer

Avoids cross contamination


A: Resistance
B: Pressure sensor or differential transducer
The differential transducer measures the pressure before the resistance (P1) and after the resistance (P2)
to calculate the flow; using integration of the flow the volume is obtained. 20
FLEISCH Pneumotachometer (operating principle)
Measurement based on the difference in airflow pressure before and after passing through a known
RESISTANCE (capillaries arranged in parallel(A)), which, is directly proportional to the flow of that
passes through a PRESSURE SENSOR. Once the flow is obtained, the microprocessor calculates the
volumes by mathematically integrating the flow with the time function.

Pneumotachometer diagram
FLEISCH
A
P1 P2

A: Resistance
B: Pressure sensor or differential transducer
The differential transducer measures the pressure before the resistance (P1) and after the resistance (P2)
to calculate the flow; using integration of the flow the volume is obtained.
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TURBINE (operating principle)
The TURBINE spirometer acquires physical signals and processes the information that the signal
provides in relation to the pulmonary function. During the process, physical energy is converted
into electrical energy. The units that produce this change are called transducers.

TRANSMITTER

The transduction function is performed in


two stages:
1. The volume to be measured passes
through the turbine and causes the rotor
to turn proportionally. RECEIVER

2. The turn is detected by a break in an


infrared light beam, whose sensor
converts the light received into a digital
electrical signal. 22
Ultrasonic (operating principles)
To calculate the flow, these transducers use the ultrasonic wave property: when they form a
certain angle with respect to the flow direction, ultrasonic waves that travel in the same
direction as the flow take less time to arrive to the receiver than those traveling in the opposite
direction.

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Spirometry Graphs

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Spirometry

Volume (L)
Flow (L/s)

Time (s)

Volume (L)
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Contribution of both graphs

Check for
correct end
Check the quality of
the maneuver
Flow (L/s)

Volume (L)
Ensure that the start
was sudden and
without hesitation Ensure that the start
was sudden and
without hesitation

Volume (L) Time (s)

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Functional Alterations:
• Obstruction
• No Obstruction

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Lungs
Lung of a healthy
person

Lung of the same


person with COPD

Bronchus
Normal airway Airway in Airway in COPD
asthma
Contracted
Muscle smooth smooth muscle
Relaxed still relaxed
smooth muscle Air trapped in
the alveolus
Inflamed
wall Inflamed and
swollen wall

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Spirometry

“Normal”
Airway
Flow (L/s)

Volume (L)

Volume (L) Time (s)

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Spirometry

Obstructed
Airway
Flow (L/s)

Volume (L)

Volume (L) Time (s)

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Spirometry

NON-Obstructive
Airway
Flow (L/s)

Volume (L)

Volume (L) Time (s)

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Spirometry

Mixed
Airway
Flow (L/s)

Volume (L)

Volume (L) Time (s)

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Spirometry parameters

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Spirometric Parameters
FVC : Forced Vital Capacity (FVC)
Volume of air expelled during a
Forced Spirometry forced expiration maneuver (L).
FEV1:
Forced Expiratory Volume in the first
second.
FEV1/FVC :
Volume (L)

Expresses the volume of air expelled


in the first second with respect to
FEV6 FVC the maximum that can be expelled
FEV1 during the forced expiration
maneuver.
FEV6:
Forced Expiratory Volume in the
Time (s)
sixth second (L).
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Spirometric Parameters

Forced Spirometry PEF (Peak Flow)


• Maximum expiratory flow or peak
flow.
• Maximum flow achieved during the
forced expiration maneuver.
PEF
• It is generated before having
expelled 15% of the FVC and must
Flow (L/s)

be maintained for a minimum of


10 ms (milliseconds)
• Expressed in L/sec.
• Effort-dependent parameter.

Volume (L)

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Spirometric Parameters

Forced Spirometry FEF 50 %


Maximum flow when the 50% of the
FVC has been exhaled.

FEF
FEF 25-75 %
Flow (L/s)

FEF 25 Maximum flow between 25% and


75% of the FVC (mid-expiratory
flows).
FEF 50

FEF 75 Mid-expiratory flows may early detect


obstruction (in the small tract), but
they are highly variable.

Volume (L)

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Spirometry

Obstructed
Airway

FVC ≈ FEV6 Inflamed and


swollen wall
FEV6
Volume (L)

1 sec
6 sec FVC
FEV1
FEV1

Time (s)
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FVC ≈ FEV6

6 sec

In patients with an obstruction in the airflow, the expiratory maneuver can be tedious and
prolonged, have insufficient relevance and wide variability; therefore, specific authors and consensus
suggest that, in these cases, the value of FEV6 (forced expiratory volume in the sixth second) is
comparable to the FVC. Likewise, the ratio FEV1/FVC would be replaced by FEV1/FEV6.

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Which parameters should we focus on?
On the screen we can see selected some of the 'most significant' parameters.
The other parameters, although important, have less relevance.

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“Normal” Spirometry

FEV1 3.9 (L) > 80% reference value


FVC 5.0 (L) Between 70% and 80%
Curve
FEV1/ FVC 78%
Flow / Volume Curve
Volume / Time

FVC
PEF
Flow (L/s)

Volume (L)
FVC
FEV1

Volume (L) Time (s)

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“Obstructive” Spirometry

FEV1 1.5 (L)


FVC 4.0 (L) Less than 70%
Curve FEV1/ FVC 38%
Flow / Volume Curve
Volume / Time

FVC
Flow (L/s)

Volume (L)
PEF

FVC
FEV1

Volume (L) Time (s)

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Spirometry
Progression of the Obstruction
COPD
Chronic Obstructive Pulmonary Disease is characterized by
a chronic and irreversible obstruction of the airflow
caused, mainly, by an inflammatory reaction to tobacco
smoke (GOLD, GESEPOC).
Flow (L/s)

Volume (L)
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“NON-Obstructive” Spirometry

FEV1 1.8 (L)


FVC 1.9 (L) Greater than 80%
Curve FEV1/ FVC 95%
Flow / Volume Curve
Volume / Time
FVC

PEF
Flow (L/s)

Volume (L)
FVC
FEV1

Volume (L) Time (s)

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Instructions and
Limitations

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Instructions
• Evaluation of the respiratory capacity whenever there are respiratory symptoms.
• Assessment of the respiratory impact of illnesses relating to other organs or
systems (heart, kidney, liver or neuromuscular disease, etc.).

• Respiratory functional disorder screening in relation to possible health-risk


diseases (tobacco, work related factors, allergic processes, etc.).

• Evaluation of the risks derived from surgical procedures.


• Evaluation of the presence of respiratory disorders on request from professional
incapacity or other types of legal evaluations.

• Assessment of the therapeutic response in view of different pharmaceuticals or


clinical pharmacological trials

• Epidemiological studies.

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Limitations
• Oral injuries.
• Facial hemiparesis.
• Nausea when introducing the mouthpiece or pneumotachometer.
• In poorly-treated tracheotomies or with excessive secretions.

Contraindications
• Mentally or physically impossibility to correctly perform a forced maneuver.
• Chest pain, pneumothorax, hemoptysis.
• Unstable angor.
• Retinal detachment.
• Litigant patient behavior.

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Reference Values
(Also denoted THEORETICAL)

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Reference Values (theoretical)
Objective:
Compare the measured values with the
corresponding values of Sex, Age, Size, Weight
and Ethnicity.

Material (reference equations):


FVC:
M 0.028 T + 0.0345 P + 0.0573 E - 3.21
F 0.0305 T + 0.0356 P + 0.0356 E - 3.04

Method:
The observed / reference values expressed
as a %.

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Reference Values (theoretical)
Recommended spirometric reference values in our environment

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Parameter Measuring
Method

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Expressing results
The results are expressed as a % with respect to the reference value
% Vref = Vobs/Vref x 100
(The percentage of the reference value is equal to the observed value divided by the reference value multiplied by 100)

Dispersion around the prediction equation


The 95% confidence interval or 95 percentile are the same; they calculate the lower limit of
the normal distribution (LIN) using the formula: LIN = VR - SEE x 1.645
99.7%
95.4%
68.3%

µ-3ơ µ-2ơ µ-ơ µ µ+ơ µ+2ơ µ+3ơ


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Performing Spirometry

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Decalogue
for Performing Spirometry
TRAINING
1 the expert that will perform the spirometry and having notions of
respiratory pathologies.

QUALITY CONTROL
2 Daily verification, with a known pattern, the correct operation of the
spirometer, since this proves that it is functioning within the
established limits.
The daily verification and/or calibration (with a syringe of at least
three liters) ensures verifiable quality control and confirms
professional good practice.

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Quality control (calibration)
Objective:
• To establish a relationship between the pattern unit (syringe) and the degrees of measurement.

Material:
• Syringe
(At least three liters).

• Weather station (Quality spirometers already have one incorporated; otherwise, use
conventional wall or desktop stations).

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Quality control (calibration)
Method:
• Daily calibration.
• High, moderate and low flow *.

To verify the correct operation of a spirometer, carry out a single


maneuver at moderate flow: from 2 to 5 l/s.
However, ideal verification/calibration to ensure good practice
should carry out high, moderate and low flows.

* Flow Level
Low: From 0.4 to 1.2 l/s
Moderate: From 2 to 5 l/s
High: From 6 to 12 l/s
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Quality control
Performing Verification/Calibration
Another method of representing the
calibration depending on the make and
model of the equipment.

ESP. 2.1%
INSP. 3.0%
Flow M. 1.8 l/s

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INFORM
3 The patient of the procedure to follow, the reasons behind it and
how to avoid problems, as well as of the importance of their
cooperation.

Pharmaceuticals to stop taking and duration Hours


Agonist ß2 short-acting 6
Agonist ß2 long-acting 12
Anticholinergics short-acting 6
Anticholinergics long-acting 24
Sustained release theophylline 36 - 48
AVOID
4 Before taking the test:
• Prior administration of bronchodilators. If they
have been administered, this should be recorded.
• Smoking.
• Vigorous exercise.
• Excessive eating and/or drinking.
• Tight clothing.
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5 FIND OUT
The size and weight of the patient with their shoes off and wearing
light clothing, as well as their age and sex, in order to calculate the
reference values.
For patients with acute chest deformity, measure their breadth
instead of their size (arms extended in a cross); this should be
registered in the report.
Breadth
How to calculate the breadth
Size = Breadth/ 1.06

7 SEAT
The patient in a comfortable chair with vertical back support
and do not incline them forwards.
• Seat the patient with their head up and legs uncrossed.
• Keep the nostrils occluded using nose clips.
• Place the mouthpiece into the transducer, bacterial filter or
disposable transducer (only use certified products).
• If the test is carried out with the patient lying flat, this must be
noted.
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6
EXPLAIN
In a clear and simple way how to perform the spirometry
maximum and forced maneuvers.

1. Inhale as much as possible


2. Place the mouthpiece into your mouth
3. Blow:
1. STRONGLY
2. CONTINUALLY
3. WITHOUT STOPPING UNTIL I SAY SO:
it may seem that there is no more air to come out,
but there is, I control it through the screen

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Encourage Very
good Blow
When performing spirometry, it is essential
to encourage the patient so that the
more
maneuver will be valid; they need to
cooperate in order to achieve a sudden,
maximum and prolonged effort.
(6 seconds).
Curve
Volume / Time
Volume (L)

Time (s)

Modern spirometers incorporate


incentives which are very useful in
meeting this objective.

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PERFORM
8 1. A slow, maximum inhalation, pause < 1 sec.
2. Maximum expiration, quick and forced with a sudden start.
• Perform a minimum of 3 and a maximum of 8 maneuvers,
ensuring that 2 of them are error-free and that the FVC and
the FEV1 differences are less than 5% or 150ml (100 if the
FVC is less than 1 liter).
• The duration time for each maneuver should not be less
than 6 seconds (3 seconds for children).
3. Check the lines.

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Characteristics of the Maneuver Line
The maneuver line is
characterized by the absence
of bumps and dips.
Concaved curve

• Without bumps
• Without dips

A concave curve should be


drawn.

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Repeat Criteria

Three (3) acceptable maneuvers,


in a maximum of eight (8) that
comply with these criteria:
The difference between the
best two, for the FVC and the
FEV1, should be less than
5% or 150ml
(100 ml if the FVC < 1 liter).

More than eight maneuvers tire


the patient and will make it
difficult to obtain better values.
Less than three maneuver may cause errors due to lack of patient training.

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Retrograde Extrapolation
Retrograde extrapolation is the method recommended to find the zero time point (start of the
maneuver).
The volume-time spirometry maneuver extends the time and volume base lines (blown-up diagram)
and the cutoff point is the extrapolated zero time point.

Note:
The extrapolated volume should
be equal to or less than 150ml or
5% of the FVC (the better of the
0time two criteria).
point
Modern spirometers
Volume (L)

automatically calculate it and,


should the value be exceeded,
give a maneuver error message.
Extrapolated
volume

Time (s)
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Initial Criteria
The start of the maneuver should be quick, sudden and without
hesitation.

Correct
Start
Volume (L)

Time (s)
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Initial Criteria

Maneuver with a poor start.

Maneuver with a correct start.


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Finalization Criteria
• Maneuver time longer than 6 sec.
• No changes for 1 sec; volume less than 25ml.

Incorrect curve, finished


quickly. Maneuver with a good finish.
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9 SELECT
The best FVC and FEV1 values even if they come from different
maneuvers; but they meet the previous criteria.
The rest of the parameters are taken from the maneuver with the
greater sum of FVC and FEV1 .

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Which Parameters Should be Reported?
Choose the best FVC and FEV1
values, even if they come from
different maneuvers.
Once the maneuvers have been
performed, report the best FVC and
the best FEV1 , even though they
may come from different
maneuvers.
The rest of the parameters are
taken from the maneuver with the
greater sum of the FVC and the
FEV1 . In the majority of modern
equipment these criteria are
automatically applied.
Ideally, choose parameters from error-free maneuvers (no warnings), although in many
cases this is difficult.

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Quality Grades
NLHEP
(National Lung Health Education Program)
SEPAR – PÉREZ PADILLA

Grade Description Grade Description


At least two acceptable maneuvers (error- Three acceptable maneuvers (error-free)
A free) with a difference between the best A with a difference between the best two FVC
FEV1 and FEV6 of less than 100 mL. and FEV1 of less than 150 ml
At least two acceptable maneuvers (error- Three acceptable maneuvers (error-free)
B free) with a difference between the best B with a difference between the best two FVC
two FEV1 of between 101 and 150mL. and FEV1 of between 151 ml and 200 ml
Two or three acceptable maneuvers (error-
At least two acceptable maneuvers (error-
C free) with a difference between the best C free) with a difference between the best two
FVC and FEV1 of between 201 ml and 250 ml
two FEV1 of between 151 and 200mL
Only one acceptable maneuvre (error-free) Two or three acceptable maneuvers (error-
or more than one but with a difference D free) with a difference between the best two
D between the best two FEV1 of more than FVC and FEV1 greater than 250 ml
200mL.
E An acceptable maneuver (error-free)

E No acceptable maneuver (error-free)


F No acceptable maneuver (error-free)

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Bronchodilation test
Inhale Relaxed smooth muscle
Air trapped in
Contracted bronchodilator
the alveolus
smooth muscle

Inflamed
15 min
and swollen
wall

Airway in asthma Bronchodilated airway


4 inhalations (with camera)

PARAMETER PRE REF (%) POST (%)

FVC 3.21 3.89 85 3.56 7


PRE
POST FEV1 2.32 3.14 74 2.65 13
FEV1/FVC 69.91 79.38 88 74.37 6

The test is considered positive if it produces an


increase equal to or greater than:
• FVC: 12% or FEV1: 12%
• and additionally, a minimum of 200 ml

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CLEANING
10 Given that the transducer is directly exposed to the patient,
it must be kept in perfect physical and hygienic conditions.
Clean and disinfect it as per the manufacturer's instructions.
If this is not possible use soap and water and, wherever possible,
sterilize periodically the pieces exposed to the patient.
For potentially contagious patients (HIV+, hepatitis C, pulmonary
tuberculosis, etc.), use single-use pneumotachometers or carry
out the test at the end of the day using antibacterial filters.
Then, proceed to clean it thoroughly.

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Let's Begin

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