Spirometry

Handout adapted from MD Consult (accessed Sept 2010)

Before the test

1. Sit patient in comfortable chair. Note that if patient is standing during testing, it
will increase FVC
2. Review patient's respiratory history
3. Review patient's medication history
4. Explain clearly why the PFT is being performed, and exactly what the patient
needs to do to provide accurate results
5. Ensure that the patient understands the goal: to obtain maximal, reproducible
expiratory efforts
6. Best results are obtained when the patient takes a deep breath and then blows out
as hard and as fast as possible, for as long as possible
7. Consider demonstrating the technique to the patient
8. Allow the patient to practice the technique two or three times prior to recording
the actual results
9. If the patient is a smoker, recommend that they abstain from smoking for at least
1h prior to testing
10. Prepare the equipment and ensure that it is correctly calibrated

Performing the test

11. Place nose clips on the patient and ask them to breathe in and out several times so
they are comfortable
12. Instruct the patient to breathe in as deeply as possible to completely fill their
lungs, then quickly insert the mouthpiece in between their teeth. The mouthpiece
should form a seal with the lips
13. Ask the patient to blow out as hard and as fast as possible, for as long as possible.
Tell them to try and maintain the exhalation for 6s
14. Encourage the patient to continue to exhale until the forced vital curve flattens
out. This usually takes 5-6s
15. When the lungs are completely empty, ask the patient to breathe in as deeply as
they can to obtain the inspiratory portion of the forced vital curve, thereby
completing the evaluation
16. Next ask the patient to take several normal breaths (tidal breaths) and then instruct
them to perform a maximal inspiration to total lung capacity (TLC). Then ask
them exhale fast and hard to obtain the FVC
17. The test should be repeated a minimum of three times, up to a maximum of eight
times, until three acceptable curves are obtained
18. Readings are considered reproducible if two or three of the readings differ by 5%
or less
19. Only the best effort that meet the criteria for acceptability and reproducibility are
saved and recorded
Assessing Spirogram Acceptability

a. There are no artifacts on the spirogram. Potential artifacts include:

Coughs or closure of the glottis within the first second of exhalation

Early termination or cutoff
Effort that is variable
An air leak in the system
An obstructed mouthpiece

b. The start of the spirogram is considered acceptable if: The extrapolated volume is
less than 5% of the FVC or less than 0.15L (whichever is greater)

c. The exhalation is satisfactory if:

The exhalation lasts 6s and/or a plateau that lies within the volume-time curve, or
The duration is reasonable or the plateau is in the volume-time curve, or
The subject is unable to or should not continue to exhale

Assessing Spirogram Reproducibility

When three acceptable spirograms have been obtained, they must also adhere to the
following criteria:

The two largest FVC are within 0.15L of each other

The two largest FEV are within 0.15L of each other
If spirograms meet both these requirements, the testing session may be concluded

If spirograms fail to meet both these requirements, testing should continue until the
following occurs:

Both these criteria are met on analysis of additionalacceptable spirograms

A total of eight tests have been performed
The subject is unable to or should not continue

At a minimum, save the three best spirogram records

Characteristic Spirometric Patterns of Obstructive and Restrictive Lung Disease

In general:

Low flow with normal volume characterizes obstructive disease

Normal flow with low volume characterizes restrictive disease
In severe obstruction, gas trapping reduces FVC due to an increased residual
volume

Obstruction:

FVC: normal or elevated

FEV1: reduced
FEV1/FVC: reduced
FEF25%-75% : reduced

Restriction:

FVC: reduced
FEV1: normal or reduced
FEV1/FVC: increased
FEF25%-75%: normal, increased, or decreased

Differentiating COPD vs Asthma (per British Thoracic Society)

Risk/ Symptoms/ Testing COPD Asthma

Smoker / ex-smoker Nearly all Some

Symptoms < 35 years of age Rare Often
Chronic productive cough Common Uncommon
Breathlessness Persistent and Variable
Progressive
Nighttime waking with breathlessness or Uncommon Common
wheeze
Significant diurnal or day to day variability of Uncommon Common
symptoms
Obstructive pattern on Spirometry reversible No Usually
with bronchodilators