COPD:

Spirometry
Clare Hawkins, MD, MS
Program Director, San Jacinto Methodist Hospital Family Medicine Residency,
Baytown, TX

Isaac M. Goldberg, MD
Faculty, San Jacinto Methodist Hospital Family Medicine Residency, Baytown,
TX

Educational Objectives
At the end of this presentation, the
learner should be able to
Utilize spirometry to diagnose and stage
COPD
Overcome barriers to the use of office
spirometry
Achieve confidence with spirometry
interpretation

Background
Objective measure of airway function for accurate
diagnosis of Chronic Obstructive Pulmonary
Disease (COPD)
World Health Organization Global Obstructive Lung
Disease Consensus/ Evidence guideline (GOLD)
American Thoracic Society (ATS)
European Respiratory Society (ERS)
National Committee for Quality Assurance (NCQA)

Background
Alternate ways to diagnose COPD
Clinical Findings Late
- Increased AP diameter, tympanitic chest
- Signs of respiratory distress

Peak flow reading not adequately sensitive or specific

Radiographic findings occur late in disease
CT scanning more accurate, but findings also occur
late in disease

Background
Who should receive spirometry?
Early diagnosis relies on the recognition of the clinical
features
-

Persistent cough
Chronic sputum production
Breathlessness on exertion
Reduction in activity (often attributed to natural aging)

About 20% of COPD patients identified in NHANES

study with obstruction never smoked
- Only 1/5 were explained by asthma

Background
Other testing considerations

Recurrent or chronic respiratory symptoms

Occupational exposure to respiratory irritants
Family history of respiratory diseases and symptoms
NCQA established use of spirometry as required
quality measure for accurate COPD diagnosis
Routine periodic use not recommended

Background
Screening

Not recommended in the absence of respiratory

symptoms (dyspnea, cough)
No threshold amount of smoking pack-years for
screening in the absence of respiratory symptoms
Not recommended by USPSTF or ACP 2011
Guideline

Background
Family physicians able to do quality spirometry
Quality of care increases with use of spirometry
- To prevent overdiagnosis of COPD, attention to quality
spirometry is important

Suggestions to maintain quality of spirometry

-

Know technique
Have staff coach the patient
Do sufficient numbers of tests
Maintain and calibrate the equipment
Understand interpretative algorithms

Background
Why do office spirometry?
Diagnostic accuracy. 30% of time diagnosis changes.
- Was not COPD; heart failure or asthma
- Was COPD rather than asthma
- If spirometry normal, then expensive meds discontinued

Respect. Patients respect physicians who use

technology (Future of Family Medicine)
Patient convenience. You can avoid an unnecessary
referral and additional visit
Diagnostic power: You can connect diagnostic
information with rest of clinical encounter
Financial benefit to practice.

Equipment
Older volume/time loop
- Drum technique from John
Hutchinson 1844

Newer flow/volume loop

using flow transducer
- Smaller Machines, Mobile
- Disposable Mouthpiece
No other infection
transmission
precautions necessary

Equipment
Numerous manufacturers produce quality instruments
Reviews conducted by National Lung Health Education
Program (NLHEP) regarding appropriateness of
spirometers for office practice
- http://www.nlhep.org/spirometer-review-process.html
- Simplicity (fewer numbers)
- Reliability

Equipment
Calibration
Daily calibration must be done with 3 L syringe
Syringe must have accuracy of at least 15 ml
Spirometer must have accuracy of 105 mL or
0.105 L (calibration volume = 2.90 to 3.11)
Calibration log/printouts must be kept
- Date and time of calibration
- Individual performing
- Comments

Technique
Forced expiratory maneuver

Coach patient to get a maximal effort

Six seconds of effort required though most of air pushed
out in the first second
Pace of expired air is most important variable; therefore
it should be released with explosive force

Technique
Minimum 6 second exhalation with 2 second plateau
Tracing should have no artifacts
At least 3 acceptable maneuvers (<5 % variation)
- ATS criteria
Empty bladder for females (concern if incontinence)
Can be seated or standing
Nose plug optional

Technique
None of the following should occur:

Unsatisfactory start, with excessive hesitation or false start

Air leak
Coughing during the first second
Early termination of forced expiration
Glottis closure

Obstructed mouthpiece
- Tongue
- False teeth
- Chewing gum

Technique
Reliability
Spirometry overdiagnoses COPD if insufficient effort
Concerns that family physicians will not perform
quality testing and overdiagnose people with
obstructive lung disease
Imperative that patients be coached on robust, forced
expiratory maneuver

Technique
Contraindications

Hemoptysis of unknown origin

Pneumothorax
Unstable cardiovascular status or recent MI or PE
Thoracic, abdominal, or cerebral aneurysms
Recent eye, thorax or abdomen surgery

Technique
Barriers
Inaccessibility of Equipment
Concern patient effort and cooperation are insufficient
Difficulty remembering interpretive algorithm
Frustration by ambiguous results
Difficulty working 30-minute spirometry into office flow
Central location for spirometry versus going room to
room
Lack of staff training
Poor integration with electronic health record
Lack of adequate reimbursement

Measurements
Abbreviation

Characteristic measured

FEV1

Forced expired volume in 1 second

FVC

Forced vital capacity

FEV1 /FVC Ratio Ratio of the above

PEFR

Peak expiratory flow rate

FEF 25-75%

Forced expiratory flow between 25-75% of the vital

capacity

Measurements
Normal values
Individual variation according to age, height, ethnicity
and gender
-

Height - Tall people have larger lungs

Age - Respiratory function declines with age
Sex - Lung volumes smaller in females
Race - Studies show Blacks and Asians have smaller lung
volumes (-12%)
- Posture - Little difference between sitting and standing;
reduced in supine position

Measurements
Bronchodilator reversibility testing
Beta-agonist
- Short-acting wait 20 minutes before retesting
- Long-acting wait 2 hours before retesting

Do not take bronchodilator the day of testing

- Measured reversibility will be limited if the patient is
bronchodilated for the pretest.

Measurements
Definition of reversibility
Pre-Bronchodilator
- FEV1/FVC <70% of predicted

Post-Bronchodilator
- Increase 12% AND at least 200 cc

Reversibility = Asthma!

Measurements
Pre-Bronchodilator

Post-Bronchodilator

Predicted

Measured

Measured

% change

FVC

2.66

1.32

50

1.26

47

-4

FEV1

2.02

0.54

26

0.50

25

-6

FEV1/FVC

76

41

-35

39

-37

-2

PEF

315

114

36

120

38

FEF 25

4.96

0.40

0.30

-28

FEF 50

2.85

0.20

0.20

-----

FEF 75

0.78

0.10

13

-----

-----

198

FEF 25-75

1.02

0.19

10

0.18

10

-6

Measurements
Severity of obstruction
FEV1
Mild
Moderate
Severe
Very severe

% of predicted
>80
50 to 79
30 to
<30

Severity of restriction
FVC

% of predicted

Mild

>65 to 80

Moderate

>50 to 65

Severe

<50

Case Study 1
A 53-year-old white male presents for annual
visit. Although he quit 10 years ago he is a
previous cigarette smoker with a 20 pack-year
history. During the past 12 months, he has had
3 episodes of bronchitis. His history of tobacco
use and recent episodes of acute bronchitis lead
you to perform spirometry.

Results
Pre-Bronchodilator

Post-Bronchodilator

Predicted

Measured

Measured

% change

FVC

4.65

4.65

100

4.95

106

FEV1

3.75

3.13

83

3.34

89

FEV1/FVC

80

67

-13

67

-13

PEF

511

462

90

522

102

12

FEF 25

7.86

5.7

73

6.00

76

FEF 50

4.46

2.3

52

2.10

47

-9

FEF 75

1.75

.5

29

0.60

35

18

FEF 25-75

3.76

1.77

47

1.78

47

Results
Pre-Bronchodilator Post-Bronchodilator
Predicted

Measured

Measured

% change

FVC

4.65

4.65

100

4.95

106

FEV1

3.75

3.13

83

3.34

89

80

67

-13

67

-13

FEV1/FVC

Is there obstruction?
FEV1/FVC = 67% of predicted; therefore, obstruction
present
Is there restriction?
FVC = 100% of predicted; therefore, no restriction
present

Results
Pre-Bronchodilator Post-Bronchodilator
Predicted

Measured

Measured

% change

FVC

4.65

4.65

100

4.95

106

FEV1

3.75

3.13

83

3.34

89

80

67

-13

67

-13

FEV1/FVC

What is the severity of obstruction?

FEV1 is 83% of predicted; therefore, the obstruction is mild
Is the obstruction reversible (is reversibility present)?
FEV1 increases from 83% to 89% (6% increase) and
increases from 3,130 cc to 3,340 cc (increase of 210 cc)
Interpretation:
Mild Obstruction with minimal
reversibility: Mild COPD

Common Obstructive
Pulmonary Disorders
Diffuse Airway Disease Upper-Airway Obstruction
Asthma
COPD
Bronchiectasis
Cystic fibrosis

Foreign body
Neoplasm
Tracheal stenosis
Tracheomalacia
Vocal cord paralysis

Diagnostic Flow Diagram for Obstruction

Is FEV1 / FVC Ratio Low? (<70%)
Yes

Obstructive Defect
Is FVC Low? (<80% pred)
Yes

No

Combined Obstruction &

Restriction /or Hyperinflation

Pure Obstruction

Improved FVC with

-agonist

Reversible Obstruction
with -agonist

No

Further Testing with

Full PFTs

Yes

Yes

Suspect
Asthma

No

Suspect
COPD
Adapted from Lowry.

Case Study 2
A 33 year old female presents to the office
complaining of dyspnea and cough for the past 2
days. Her cough is productive of a white mucous.
Her past medical history is significant for asthma
since childhood, obesity, gastroesophageal reflux
disease (GERD), and an occasional migraine
headache. She is a nonsmoker and has no known
allergies.

Case Study 2 (cont)

Her current medications include the following:
Albuterol 2 puffs po qid prn wheezing, cough, or
dyspnea
Fluticasone 110 micrograms 2 puffs po bid
Ranitidine 150 mg po bid
Her father recently died secondary to advanced
COPD.
Due to her symptoms, you order spirometry.

Results
Pre-Bronchodilator Post-Bronchodilator
Predicted

Measured

Measured

% change

FVC

3.78

1.92

51

2.7

71

34

FEV1

3.24

1.11

34

1.61

50

36

86

58

-28

60

-26

FEV1/ FVC

Obstruction?
FEV1/FVC = 60%; therefore, obstruction present
Restriction?
FVC = 51% of predicted; therefore, restriction present

Results
Pre-Bronchodilator Post-Bronchodilator
Predicted

Measured

Measured

% change

FVC

3.78

1.92

51

2.7

71

34

FEV1

3.24

1.11

34

1.61

50

36

86

58

-28

60

-26

FEV1/ FVC

What is the severity of obstruction?

60%; therefore, moderate obstruction
Is the obstruction reversible (is reversibility present)?
FEV1 increases from 34% to 50% (16% increase) and increases by 500 cc
What is the severity of restriction?
71% of predicted; therefore, mild restriction
Interpretation: Moderate obstruction with reversibility (Moderate obstruction)

Common Restrictive Pulmonary

Disorders
Parenchymal

Pleural

Interstitial Lung Diseases

Fibrosis
Granulomatosis (TB)
Pneumoconiosis
Pneumonitis (lupus)

Loss of Functioning Tissue

-

Atelectasis
Large Neoplasm
Resection

Effusion
Fibrosis

Chest Wall

Kyphoscoliosis
Neuromuscular Disease
Trauma

Extrathoracic

Obesity
Abdominal Trauma

Diagnostic Flow Diagram for Restriction

Is FEV1 / FVC Ratio Low? (<70%)
No

Is FVC Low?(<80% pred)

Yes

No

Restrictive Defect

Normal Spirometry

Further Testing with

Full PFTs; consider
referral if moderate to
severe

Adapted from Lowry, 1998

Results

Lowry 1998

Results
Full Pulmonary Function Testing (PFTs)
Assessment of Oxygenation
- Transcutaneous oxygen saturation
- Arterial blood gasses

Diffusion test to evaluate alveolar exchange (DLCO)

Plethysmography
- To objectively assess lung volumes
- Delineate air-trapping versus restriction

May also include Spirometry

Spirometry and Smoking Cessation

Lung age calculation
- Use to motivate smoking cessation.

Mixed results
- Normal results may give the impression that its
acceptable to continue smoking.
- Avoid fatalism with abnormal results.

Research results recently favor use

- ACP and AHRQ advise only if symptomatic.

Spirometry and Smoking Cessation

Spirometry and Smoking Cessation

Coding and Reimbursement

Diagnosis

ICD-9 Code

Cough

786.2

Simple chronic bronchitis

491.0

Mucopurulent chronic bronchitis

491.2

Acute bronchitis

466.0

Chronic obstructive pulmonary disease

496.0

Shortness of breath

786.5

Restrictive lung disease

Asthma

515
493.91

Coding and Reimbursement

Procedure

CPT Code

Reimbursement*

Single spirometry

94010

$32.82

Pre-post spirometry

94060

$57.71

Pulmonary stress test simple

94620

$71.77

Medication administration
bronchodilator supply separate

94640

$13.34

Demonstration / instruction

94664

$14.79

Smoking Cessation <8x/ yr

99406

$12.98

Equipment
Office spirometer
*Reimbursement based upon Medicare payments 2009

Cost
$1,000 2,500

Estimated Return on Investment

Tests /week (#)

Reimbursement/year*

ROI $1,995 in weeks

$6,864

15

$10, 296

10

$13,728

10

$17,160

15

$25,740

20

$34,320

25

$42,900

*Based upon CPT code 94010

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