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PEFR Measurement and Spirometry

Written by: Michael Patrick Johnston from Manchester University,

What is peak flow?

PEFR (peak expiratory flow rate) is a form of pulmonary function test. It measures the fastest
rate of air that can be expired.
The convenient size of the peak flow meter makes regular measurement of forced expiration
possible at home. The significance of its moderate 'pocketability' is that patients can write down
multiple readings in a day, recording them in a peak flow diary. This provides information on:
diurnal variability
response to bronchodilators
monitoring severity of disease
The main use of peak flow is in asthma. Although it reveals some information about COPD it
tends to underestimate the severity and therefore is unreliable.

What is spirometry?
Spirometry is a form of pulmonary function test. Patients blow into a tube as strongly as
possible, expiring until they have no breath left.
What do all the acronyms mean?
FEV1: forced expiratory volume in one second
VC: vital capacity - how much air you can breath out after as deep a breath as possible.
Crucially it is not 'forced'...
FVC: forced vital capacity. Essentially the vital capacity but blowing out as strongly as possible.
*In normal young people VC and FVC are most likely to be equal. However, in emphysematous
lungs elasticity of the airways is lost. This elasticity is what normally keeps the airways patent
during expiration. If the elasticity is not present the airways can become closed on forceful
expiration and so not all the air is expelled. The key word to describe this phenomenon in
OSCEs is 'trapping'. It is important to be aware of this disparity between VC and FVC in
emphysematous patients.

When is spirometry indicated?

Spirometry is a cheap, non-invasive, valuable investigation, available in both primary and
secondary care. It is also a dynamic investigation, with the following uses:
Confirm diagnosis of obstructive (e.g. COPD) or restrictive lung disease;
Assessment of disease severity
Measuring deterioration of disease

Most general practices have their own spirometer. In secondary care formal request may be
necessary but many thoracic departments have a spirometer in each ward. If this is the case in
your teaching hospital take the opportunity to do patients' pulmonary function. It is not
uncommonly requested by the consultant. It is a basic piece of equipment so you only need to
do it once to be covered for any potential OSCE station.

Interpretation - Part 1
1. Details
2. Reproducibility
Look at the variability (Var). BTS states that there must be at least two values within 3% of each
other for the result to be reliable.

3. Is it technicaly acceptable?
Did they cough during the expiration?
Did they take an extra breath during expiration?
Maybe they had a slow start?
Was it a sub-maximal effort?
All of these produce dents and artefacts in the cruve produced. It may be difficult to achieve a
perfectly accurate graph but the result should be as smooth as possible.

Interpretation - Part 2
Is the ratio FEV1/FVC <70%?
Yes: obstructive lung disease

No: may be restrictive lung disease

Our patient above appears to have an obstructive pattern. Another clue towards this is the shape
of the curve, which will have a flatter gradient the more obstruction there is.

Interpretation - Part 3 (Obstructive pattern)

Is this pattern reversible? Or is it fixed?
To test for reversibility either:
a) Repeat test 15 minutes after: salbutamol inhaler through spacer (400mcg)
b) Repeat test 15 minutes after: salbutamol nebuliser (5mg)
To determine reversibility it is the FEV1 figure we are interested in. Has the amount of air the
patient can forcefully blow out in one second increased after a bronchodilator? Is there
'reversibility'? An increase of 400ml is said to be significant. Look in the 'Best spirometry result'
section below (same patient again) and determine whether his obstructive disease is reversible
or not.

Our patient's FEV1 increased from 1.21L to 1.63L, a difference of greater than 400ml. His airway

disease follows a reversible obstructive pattern, e.g. asthma.

Interpretation - Part 3 (Restrictive pattern)

It is important to check for restrictive lung disease regardless of whether an obstructive pattern
is present or not. Clearly COPD patients and other obstructive disease individuals can have an
element of restrictive pattern as well.
Is the % predicted FVC < 80%?

Our 72 year old Caucasian man with reversible obstructive disease has a % predicted FVC of
91%. This is greater than 80% and so there is no additional restrictive element.
Clearly, in other situations there will be patients with no obstructive disease but a restrictive
pattern. These can be divided into pulmonary problems and non-pulmonary causes:
1. Pulmonary: fibrosis; pneumoconiosis; pulmonary oedema; parenchymal lung tumours;
2. Non-pulmonary: neuromuscular disorders; postural problems (e.g. thoracic cage deformity or
kyphoscoliosis); obesity; pregnancy.

Additional example

Is there satisfactory reproducibility?

Is it technically acceptable?
Is the pattern obstructive or restrictive, or combined?
If there is an obstructive pattern, is it reversible or fixed?
If the obstruction is fixed, what grade of severity is their COPD?
FEV1 80%

Stage 1 - Mild

FEV1 50-79%

Stage 2 - Moderate

FEV1 30-49%

Stage 3 - Severe

FEV1 < 30%

Stage 4 - Very severe

ABG Sampling and Interpretation
Metered Dose Inhaler (MDI) Usage
Nebuliser Usage
Oxygen Therapy
PEFR Measurement and Spirometry
Respiratory Examination
Chronic Obstructive Pulmonary Disorder (COPD)
Interstitial Lung Disease
Lung Cancers
Pleural Effusion
Pulmonary Embolism
Chest Pain
Shortness of Breath
Basic Principles
Control of Breathing
Gas Exchange
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