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QUESTION

IS OFFICE-BASED SPIROMETRY POSSIBLE? HOW DO I INTERPRET THE RESULTS?

Daniel J. Weiner, MD
Office-based spirometry is indeed possible, but not necessarily easy. The resources required are a cooperative patient, proper equipment, and experienced staff with adequate time. Most children over the age of 6 can perform spirometry, and there is good evidence that a substantial portion of 4- to 5-year-old children can as well. Younger or less cooperative patients may require more time to test. A number of manufacturers make spirometry equipment that is laptop-based and suitable for office use. Some manufacturers use disposable flow sensors, which may have some potential for erroneous results.1 Others use traditional differential pressure pneumotachs with disposable mouthpieces/ filters. These devices can be obtained for $1500 to $2500. Probably more important than the equipment, however, is having staff trained in coaching the patient to properly perform spirometry. Spirometry requires the patient to take a maximal inhalation followed by a maximal and prolonged exhalation. Submaximal efforts can give very inaccurate results, underestimating some parameters (vital capacity, forced expiratory volume in one second), while potentially overestimating others (forced expiratory flow between 25% and 75% of vital capacity, FEF25-75). Testing sessions also require that these difficult maneuvers be performed several times and demonstrate reproducibility. This can require a great deal of patience on the part of the staff, who must also be able to work with children of different ages. A healthy, cooperative patient might be able to perform an acceptable test in approximately 10 to 15 minutes, but a distractible patient performing the test for the first time might require 30 minutes. If the pediatrician wished to assess responsiveness to a bronchodilator (Figure 42-1), this requires the ability to administer bronchodilator (2 minutes by metered-dose inhaler, and 10 minutes by nebulizer), wait 15 minutes for bronchodilator effect, and then repeat spirometry (an additional 10 to 15 minutes). This time requirement may be difficult to accommodate in a busy office setting when routine visits themselves may be only 10 to 15 minutes long.

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Question 42

Figure 42-1. Flow volume curve before (green) and after (red) bronchodilator, demonstrating significant bronchodilator response. Pre-bronchodilator FEV1 74% predicted, FEV1/FVC ratio 58%, FEF25-75 36% of predicted. Postbronchodilator FEV1 118% predicted (23% increase), FEV1 92% predicted, FEF25-75 49% predicted (36% increase). These results are consistent with but not diagnostic for asthma.

Additionally, technician coaching is improved with regular experience. If spirometry is performed infrequently and irregularly, it is difficult to maintain good test quality. The feasibility of performing office spirometry has been examined in both adult and pediatric populations. In one study, 10 pediatric practices were each provided with 10 hours of didactic and hands-on instruction and were expected to perform at least 30 spirometries over 12 weeks.2 Feedback on the test quality was provided by pediatric pulmonologists. Thereafter, 109 children underwent spirometry both in the office setting and the hospital PFT laboratory. The good news is that 78% of the office tests were considered acceptable by American Thoracic Society criteria. The bad news was that 21% of studies were not interpreted correctly by the pediatricians. One of the conclusions of this study was that an integrated approach, involving both the primary-care center and the pulmonologist, is important to ensure quality results. The National Asthma Education and Prevention Program Expert Panel 3 recommends that when office spirometry shows severe abnormalities, or if questions arise regarding test accuracy or interpretation, further assessment should be performed in a specialized pulmonary function laboratory.3 Many spirometry software systems will provide a computerized interpretation of the results. I have found that these interpretations perform better for tests in adults than in children and perform poorly if the test quality itself is suboptimal. It is critical that pediatric reference equations be used by the computer when testing children; inappropriate use of adult equations can provide very misleading results. There are several excellent resources for learning about spirometry performance and interpretation,4,5 but doing this well also requires doing it frequently. If you choose to undertake office spirometry, consider exploring whether your local pediatric pulmonologist is able to assist with interpreting study results.

Is Office-Based Spirometry Possible?

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References
1. Townsend MC, Hankinson JL, Lindesmith LA, Slivka WA, Stiver G, Ayres GT. Is my lung function really that good? Flow-type spirometer problems that elevate test results. Chest. 2004;125:1902-1909. 2. Zancanato S, Meneghelli G, Braga R, Zacchello F, Baraldi E. Office spirometry in primary care pediatrics: a pilot study. Pediatrics. 2005;116:792-797. 3. National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. NIH publication no. 08-4051. 4. Spirometry fundamentals. University of Washington Interactive Medical Training Resources, Seattle, WA. Retrieved from www.depts.washington.edu/imtr/spirotrain/programs/spirofun/index.html. 5. Quanjer P. Become an expert in spirometry. Retrieved from www.spirxpert.com/.

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Contributing Authors
Julie Ryu, MD (Question 46) Associate Clinical Professor of Pediatrics University of California, San Diego Department of Pediatrics, Division of Respiratory Medicine Rady Childrens Hospital-San Diego San Diego, California Jonathan M. Spergel, MD, PhD (Questions 10, 11, & 12) Associate Professor of Pediatrics The Childrens Hospital of Philadelphia Division of Allergy and Immunology Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Concettina (Tina) Tolomeo DNP, APRN, FNP-BC, AE-C (Questions 28, 38, 39, 40, & 47) Nurse Practitioner Director of Program Development Yale University School of Medicine Section of Pediatric Respiratory Medicine New Haven, Connecticut Daniel J. Weiner, MD (Questions 41 & 42) Division of Pulmonary Medicine Co-Director, Antonio J. & Janet Palumbo Cystic Fibrosis Center Medical Director, Pulmonary Function Laboratory Childrens Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania Lisa B. Zaoutis, MD (Question 36) Assistant Professor of Pediatrics The Perelman School of Medicine at the University of Pennsylvania Director, Pediatric Residency Program The Childrens Hospital of Philadelphia Philadelphia, Pennsylvania

Jennifer LeComte, DO (Questions 17, 18, & 44) Internal Medicine-Pediatrics Pediatric Chief Resident Nemours at the Alfred I. duPont Hospital for Children Wilmington, Delaware Holger Link, MD (Question 25) Clinical Associate Professor Oregon Health & Science University Department of Pediatrics Division of Pediatric Pulmonology Doernbecher Childrens Hospital Portland, Oregon Stephen J. McGeady, MD (Questions 15, 19, & 45) Allergy, Asthma and Immunology Specialist Director, Allergy & Immunology Fellowship program Nemours at the Alfred I. duPont Hospital for Children Division of Allergy, Asthma & Immunology Wilmington, Delaware Sheela Raikar, MD (Question 16) Pediatric Gastroenterology Fellow Thomas Jefferson University Nemours at the Alfred I. duPont Hospital for Children Wilmington, Delaware Gabriela Ramirez-Garnica, PhD, MPH (Question 48) Nemours Childrens Clinic Orlando, Florida Amy Renwick, MD (Questions 21 & 27) Assistant Professor of Pediatrics Jefferson Medical College Philadelphia, Pennsylvania Director of Primary and Consultative Pediatrics Nemours at the Alfred I. duPont Hospital for Children Wilmington, Delaware

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