continuing professional development

Spirometry in primary care

PHC180 Booker R (2008) Spirometry in primary care.
Primary Health Care. 18, 10, 37-47. Date of acceptance: August 7 2008.

reference values for these parameters

Summary
An evaluation of lung function is an essential part of the diagnosis and management of
respiratory disease but spirometry was, until recently, rarely available in primary care.
The emphasis in national chronic obstructive pulmonary disease (COPD) and asthma
guidelines on spirometry for diagnosis and monitoring, together with its inclusion in
the quality and outcomes framework (QOF) for COPD in the General Medical Services
contract, has led to its wider availability in this setting. Spirometry is a relatively easy
test, but is unreliable and confusing if not performed and interpreted correctly.
Authors
Rachel Booker RGN, DN (Cert), HV is an independent specialist respiratory nurse and
freelance medical writer
Keywords
Respiratory system and disorders; Spirometry; Primary care
These keywords are based on the subject headings from the British Nursing Index.
This article has been subject to double-blind review. For related articles and author
guidelines visit our online archive at www.primaryhealthcare.net and search using
the keywords.
Aims and learning outcomes
This article aims to describe the types of
spirometry equipment suitable for use in
primary care, their correct maintenance
and use, and how to obtain reliable,
technically acceptable recordings from
patients. The essential parameters of
lung function are defined and the effect
of various types of ventilatory defect
on these parameters explained.
After studying this article you will be able to:
}}Review the types of spirometer
available and discuss their usefulness
in various healthcare settings.
}}Describe spirometer maintenance and
infection prevention procedures.
}}Summarise the indications and
contraindications for spirometry.
}}Identify the main parameters of lung
function measured with a spirometer
and discuss the determination of
in various patient groups.
}} Describe spirometry procedures and
evaluate the technical acceptability
of a patient’s spirometry reading.
}} Identify the typical spirometry
readings associated with the more
common respiratory conditions.
The first spirometer, invented by John
Hutchinson, a 19th century surgeon, consisted
of a calibrated bell inverted in water. Air,
exhaled from fully inflated lungs, was captured
in the bell, and Hutchinson termed this volume
the ‘vital capacity’, theorising that its reduction
was associated with reduced life expectancy. It
was 150 years before his ideas gained credence.
A large epidemiological study (Kannel et
al 1980) demonstrated that reduced vital
capacity is a powerful predictor of premature
death from respiratory and cardiac disease
and a further study found that abnormal
spirometry is associated with an increase
in ‘all cause’ mortality (Hole et al 1996).
Despite evidence of its value, spirometry
was, until recently, rarely used in primary
care settings. National, evidence-based
guidelines for the management of asthma
(British Thoracic Society (BTS) and
Scottish Intercollegiate Guidelines Network
2007) and chronic obstructive pulmonary
disease (COPD) (BTS 1997, National
Collaborating Centre for Chronic Conditions
(NCCCC) 2004), recommend spirometry
for diagnosis and disease monitoring, and
the inclusion of spirometry in the Quality
and Outcomes Framework (QOF) of the
General Medical Services Contract (British
Medical Association 2003) have led to an
increase in its availability in this setting.
In the 21st century health care is driven
by objective measurements and clinical
evidence. We would not diagnose and
manage hypertension without measuring
the blood pressure, and it is equally
inappropriate to diagnose and manage
respiratory disease without measurements

primary health care | Vol 18 No 10 | December 2008 37

 respiratory disease
Figure 1
The bellows spirometer
Recording stylus
Bellows
(expanded)
Chart paper
Paper motor device
Bellows (collapsed) Expired air from subject
of lung function. Spirometers should be
as available as sphygmomanometers.
Types of spirometer
There are two basic types of spirometer:
Volumetric – measuring the volume
}}
of exhaled air directly.
Flow measuring – measuring airflow
}}
and extrapolating volume from flow.
Volumetric spirometers
The volumetric spirometer that is
occasionally used in general practice is
the bellows spirometer (Figure 1). Other
types are almost exclusively confined to
the pulmonary function laboratory.
Air exhaled into the bellows spirometer
causes the bellows to inflate. The stylus,
attached to the bellows, moves downwards as
the bellows inflates, pressing on the pressure-
sensitive recording paper on the front of
the spirometer. At the same time a motor
moves the recording paper horizontally,
Figure 2
Differential pressure pneumotachographs
Lilly Fleisch
Wire mesh Capillary
tubes
Differential pressure transducer
Differential pressure transducer
38 primary health care | Vol 18 No 10 | December 2008
taking six to 12 seconds to move its full
distance of travel, depending on the model
of spirometer. Thus, the stylus moves
vertically while the recording paper moves
horizontally, producing a trace of volume
exhaled against time – the volume time trace.
Bellows spirometers are very accurate, but
are quite large. They can be fitted on to a
stand and moved from room to room, but
are not suitable for taking out to a patient’s
home or transporting from site to site. A
wide range of flow measuring spirometers
are now available and these smaller, more
portable devices have largely superseded the
bellows spirometer in primary care settings.
Flow measuring spirometers
Three types of flow measuring spirometer are
in common use in primary care settings:
}} Differential pressure pneumotachographs.
}} Turbine/rotary vane.
}} Ultrasonic.
They range in size from ‘hand held’ to desk-top
models.
When air is blown down a partially
obstructed tube there is a pressure drop
beyond the obstruction. The extent of the
drop is dependent on the airflow rate. A
differential pressure pneumotachograph
instantaneously measures air pressure
before and after a partial obstruction and
calculates airflow rate and volume from the
pressure drop. The two most commonly used
differential pressure pneumotachographs
are the Lilly and the Fleisch (Figure 2).
In a turbine/rotary vane spirometer
(Figure 3) air blown into the spirometer spins
a low inertia vane. Each rotation of the vane
interrupts a light signal emitted from two
diodes, producing a digital pulse. The volume
Figure 3
Turbine/rotary vane spirometer
Mouthpiece
Light source
Swirl plate Moving vane
Optical sensor

of air is calculated from the number of pulses
and the flow rate from their frequency.
Ultrasonic spirometers use a piezoelectric
crystal to generate an ultrasonic beam. In
one type of ultrasonic spirometer partial
obstructions in the air tube break the airflow
into waves. Each wave passing through the
beam produces a pulse proportional to its
volume. The second type sends ultrasonic
signals between two piezoelectric crystals
within the airflow through the spirometer.
The speed of the signal passing from one
crystal to another is reduced or increased
depending on the speed of the airflow.
Choosing a spirometer
The purchase of a spirometer entails capital
and continuing costs. There are several
‘essential’ and ‘desirable’ features of a
spirometer (Table 1) and many practical
points to be thought through. It is a good idea
to obtain your preferred model for a trial,
to ensure it fulfils all your requirements.
Where will the spirometer be used? If it
does not need to be moved or taken out into
the community, then a bellows spirometer
may be suitable. A small hand-held spirometer
may be an attractive option for monitoring
patients in their home, but some have serious
limitations. Lack of a real-time graphic display
makes it impossible to verify the adequacy of
the patient’s technique and correct errors as
they are performing the test. Some need to
be downloaded onto a computer at the end
of the test to view graphs and lung function
data. Spirometers that only give a digital
display of the lung function parameters are
unsuitable for diagnostic spirometry and
the inability to ensure adequate technique
limits their usefulness. A small, desk-top
spirometer, or hand-held spirometer and
laptop computer may overcome difficulties
and be suitable for use in the community.
Most desk-top spirometers produce ‘real
time’ digital graphics and hard copy printouts.
However, some use heat sensitive paper and
the graphs will need to be photocopied for
long-term storage. The pressure sensitive
recording paper of a bellows spirometer
is similarly difficult to store. A facility to
download results, including graphs, to the
practice computer system can be particularly
useful. It will allow you to email spirometry
results for quality control or a second option.
Training, practice and continual use makes
perfect. A spirometer that is used infrequently
table 1
Spirometer features to consider
Essential Real-time graphic display of patient’s effort
}}
Hard copy of results, including volume/time and flow/volume graphics
}}
Memory facility that will save all the patient’s efforts
}}
Proven reliability and accuracy
}}
Desirable Easy-to-use software
}}
Facility to download to the practice computer/patient database
}}
Free ‘helpline’ and good technical support services
}}
Calibration syringe sold with the spirometer
}}
Training provided
}}
may not be a good investment in terms of
capital outlay and staff training. Spirometry
also requires co-operation and effort from
patients. Poorly trained or untrained staff are
unlikely to obtain high quality, meaningful
spirometry recordings from them (Eaton
et al 1999, Ponsioen et al 2002). This can
lead to confusion and potentially dangerous
misdiagnosis. All healthcare personnel using
a spirometer must be trained in the safe use of
the equipment, and must be able to recognise
and correct poor technique. Those responsible
for interpreting results and supervising others
should be trained to at least diploma level
and preferably certified as competent.
Spirometers are precision instruments
that need regular maintenance. Technical
support is also sometimes necessary. Cheap,
imported models may not come with access
to a free ‘helpline’ and servicing may be
difficult and costly. The cost and availability
of disposables, such as recording paper and
mouthpieces, can also vary considerably.
Now do Time out 1
Infection prevention
It is vital that you are conversant with and
follow infection prevention policies for
your place of work. Cross infection from
Time out 1
spirometry equipment is rare (Rutula et al What type of
1991, Leeming et al 1993), but the rising spirometer do you use
incidence of multidrug-resistant bacterial in your place of work?
infection makes this an important issue. One Compile a list of the
advantages and disadvantages
of the most effective methods of preventing
of this spirometer. Are there any
infection is to make sure that you wash
additional features that would
your hands between patients and before be useful?
and after handling spirometry equipment.
Disposable mouthpieces and nose clips If you do not use a spirometer
should be used. One-way, ‘valved’ disposable compile a list of the desirable
mouthpieces can prevent cross infection features of a spirometer for your
from accidental inhalation through the particular place of work and
spirometer. Use of disposable gloves for construct a business case for
handling mouthpieces will further reduce the the purchase of a spirometer,
cross infection risk. In primary care settings bearing in mind all the issues
that have been discussed.
inspiratory manoeuvres are rarely needed, but
primary health care | Vol 18 No 10 | December 2008 39
 respiratory disease
Time out 2
Find out what
infection prevention
policies are applicable
to spirometry in your place of
work.
If you do not already have a log
of cleaning procedures construct
a template for recording:
 Cleaning procedures.
 Which patients are tested on
the spirometer.
Time out 3
Determine the
normal range for a
‘biological control’.
 Record your own spirometry
every day (or that of a
colleague if you have a
respiratory condition) at the
same time of day, on the same
spirometer for 14 days. You
will need a minimum of ten
recordings.
 Calculate the mean (average)
for each spirometry
parameter.
 Add up all the readings for
that parameter and divide by
the number of recordings.
 Now calculate 5 per cent of
each of these values.
 Finally, calculate the normal
range for each of these values
by adding and subtracting this
5 per cent.
You can now use yourself (or
your colleague) to verify the
accuracy of your spirometer on
a weekly basis, in addition to the
daily calibration check.
40 primary health care | Vol 18 No 10 | December 2008
disposable viral and bacterial filter mouthpieces
are available to prevent contamination of
equipment if these are required (Kendrick et
al 2003). Spirometer parts in direct contact
with the patient must be washed in hot,
soapy water to remove saliva and mucus
prior to disinfection and sterilisation.
Unless spirometry measurements are urgently
needed for medical reasons, patients with
known, active respiratory infection should
not be tested. If spirometry is necessary, tests
should be carried out at the end of the day and
the equipment dismantled and sterilised after
use. Immunocompromised individuals, such
as chemotherapy patients or those with HIV,
AIDS or post transplant, should be tested at the
start of the day on newly sterilised equipment.
It is extremely important to adhere to the
manufacturer’s instructions for methods of
disinfection and sterilisation. Inappropriate
methods can destroy expensive equipment.
Cleaning and disinfection of spirometry
equipment should be routine and a log kept.
It is also helpful to keep a log of the date,
time and details of the patients tested on the
equipment to assist in risk assessment and
contact tracing, should it become necessary.
Now do Time out 2
Calibration and verification
Modern spirometers are generally robust
and reliable, but it is still important to
check that they are recording accurately.
Calibration checks must be done as a
daily routine, using a calibration syringe,
and a log kept. This is the only method of
demonstrating that the equipment is reliable.
A calibration syringe injects an exact volume
of air (one or three litres) into the spirometer.
It must be accurate to within 0.5 per cent;
15ml for a three litre syringe and 5ml for a
one litre syringe. It must be serviced at the
recommended intervals and kept next to the
spirometer, so that it is at the same temperature
and humidity. Calibration syringes are
delicate; if one is dropped you should assume
it is inaccurate until it has been serviced.
The spirometer must record within 3 per cent
of the syringe volume. The calibration of
some spirometers, for example, ultrasonic,
turbine and bellows spirometers, can only be
adjusted by an engineer. Others, for example,
some models of Fleisch pneumotachograph,
can be updated on a daily or sessional basis
if necessary. Spirometers using disposable,
single-patient-use flow sensors will need checks
to be performed on each new batch of sensors,
in addition to the routine daily checks.
If there is a significant change in temperature
during a spirometry session calibration should
be rechecked. A spirometer that is transported
to a patient’s home must be allowed to ‘settle’
for at least ten minutes. It needs to be left to
reach room temperature and humidity, and
its calibration checked before it is used. A
spirometer carried in the boot of a car on a cold
day and used straight away will be inaccurate.
The spirometer and the calibration syringe
must be routinely serviced and maintained
according to the manufacturer’s instructions.
For most models this is required annually and
may necessitate the spirometer being sent away.
The accuracy of the spirometer should
also be verified on a regular basis, using a
‘biological control’, for example, an individual
with no respiratory disease and known lung
function values. Once the normal range of
the biological control is known a spirometry
recording from that individual can be used
to verify the spirometer’s accuracy.
Now do Time out 3
Indications and contraindications
Spirometry should be a routine for any patient
presenting with cardio-respiratory symptoms;
cough, wheeze or breathlessness. Spirometry is
also used for routine occupational surveillance
of people exposed to hazardous substances at
work. It is also being increasingly requested
during routine medical checks for insurance
or diving. Spirometry is vital for any patient
suspected of having COPD. Early COPD
is asymptomatic and airflow obstruction
can only be detected with spirometry.
Another important role for spirometry
testing is to monitor patients with chronic
respiratory conditions, such as asthma and
COPD. Spirometry can be used to assess
response to therapy and to monitor for
any rapid, or unexpected deterioration.
Now do Time out 4
Spirometry is generally safe and there are
no absolute contraindications. There are,
however a few relative contraindications
(Table 2). It is important to assess each patient
and, in cases of doubt, to seek advice from
your local pulmonary function laboratory.
Spirometry measurements
A spirometer will give you some
essential information:
 table 2
Relative contraindications to spirometry
Relative contraindication
Haemoptysis of unknown origin
Pneumothorax
Unstable cardiovascular status: recent (within
one month) myocardial infarction, uncontrolled
hypertension or pulmonary embolism
Uncontrolled hypertension or history of
haemorrhagic cerebrovascular event
Recent thoracic, abdominal or eye surgery
Nausea, vomiting or pain
Measurements of volume – vital capacity
}}
(relaxed and forced) and forced expired
volume in one second (FEV1).
Measurements of airflow – ratio of
}}
FEV1 to forced and relaxed vital
capacity, peak expiratory flow.
These measurements are defined in Box 1.
Volume measurements
Vital capacity represents the total amount of
air an individual can breathe in and out of
their lungs in a single maximum breath and,
in primary care, is most commonly measured
as an expired volume. Expired vital capacity is
measured as a relaxed and a forced expiration.
FVC is reached after a maximum of 15 seconds
forced expiration, or when the expiratory
flow rate has fallen below 0.05 L/sec.
The abbreviation VC conventionally refers
to the expired relaxed vital capacity. It is
important to record this. In patients with
obstructive airways disease the narrowed
airways can collapse, trapping air in the lungs,
during forced expiration. This reduces the
volume of the FVC and, in patients with severe
airflow obstruction, the VC will be greater and
a more accurate measure of vital capacity.
Measurement of FEV1 is simple to do
and there are clearly defined reference
(predicted) values. It is affected in
all patterns of lung disease.
Measurement of airflow
Airflow is only measured directly with a
flow measuring spirometer. Volumetric
spirometers calculate flow from volume.
Peak expiratory flow (PEF) can be measured
with a flow measuring spirometer, but is
most commonly measured with a peak
Time out 4
Rationale
Discuss with
Exacerbation of the problem and possible major haemorrhage. your colleagues the
Possible active pulmonary tuberculosis leading to clinical situations where
contamination of equipment and cross infection risk. spirometry may be useful.
Aggravation of the condition. How could you incorporate
spirometry into your normal,
Forced expiration can worsen angina or cause potentially daily clinical practice and use
dangerous blood pressure changes. it to best advantage for early
diagnosis of respiratory disease?
Precipitation of cerebral bleed. Spirometry is vital for the early
detection of COPD. ‘The primary
care face of COPD’ (Booker
Pain or incisional hernias. Raised intraocular pressure post
2008) discusses which people
ophthalmic surgery undesirable.
are at particular risk and may
Effect on patient’s ability to co-operate and perform the test. help you develop strategies for
identifying and monitoring these
flow meter. The PEF recorded with a flow individuals.
measuring spirometer will be different from
that recorded with a PEF meter because the
blowing technique is different. The reference
values for PEF recorded with a spirometer
(Quanjer et al 1993) are also different from
those for PEF recorded with a peak flow
meter (Nunn and Gregg 1989) and it is
important to compare the patient’s readings
with the appropriate reference value.
The ratio of FEV1 to VC (FEV1 /VC) should
be used if the VC is greater than the FVC.
The FEV1 /FVC is also referred to as the
FEV1% or FER, depending on the model of
Box 1
Definitions of essential spirometry parameters (Miller et al 2005)
Vital capacity
The volume, measured at the mouth, between the positions of full inspiration and full expiration.
Expired relaxed vital capacity (VC)
The maximum volume of air that can be expired from the lungs during a relaxed, but complete
expiration from a position of full inspiration.
Forced expired vital capacity (FVC)
The maximum volume of air that can be expired from the lungs during a forced and complete
expiration from a position of full inspiration.
Forced expired volume in one second (FEV1)
The maximum volume of air that can be expelled from the lungs in the first second of a forced
expiration from a position of full inspiration.
Peak expiratory flow (PEF)
The highest flow achieved from a maximal forced expiratory manoeuvre started without
hesitation from a position of maximal lung inflation.
The ratio of FEV1 to VC (FEV1/VC)
The amount of air expired during the first second of a forced expiration from a position of
maximal inspiration expressed as a percentage of the total amount expired during a relaxed vital
capacity manoeuvre.
The ratio of FEV1 to FVC (FEV1/FVC)
The amount of air blown out in the first second of a forced expiration from a position of maximal
inspiration expressed as a percentage of the total amount expired (regardless of time) during
that forced manoeuvre.
primary health care | Vol 18 No 10 | December 2008 41
 respiratory disease
Time out 5
Devise an
information and
instruction sheet to give
to patients when they make
an appointment for spirometry,
using the information in Box 3
and Table 4.
This can help patients to prepare
for the test, will reinforce the
verbal instructions you give, and
can save you time.
table 3
Withholding bronchodilators prior to diagnostic spirometry
Drug Class
Short acting beta2 agonists
Short acting anticholinergics
Long acting beta2 agonists
Long acting anticholinergics
Sustained release theophyllines
42 primary health care | Vol 18 No 10 | December 2008
spirometer. These abbreviations all refer to the
same measurement. Box 2 gives examples of
how to calculate FEV1 /VC and FEV1 /FVC.
Reference values
The normal lung function value (reference
value) for any individual depends on their
age, height, gender and ethnic group. Lung
volumes increase during childhood and
adolescence, reach a peak at around 25 years
and decline into old age. Tall individuals
have larger thoraces and hence greater lung
volumes than short people. Males have
larger lung volumes in relation to their
height than females and anthropometric
differences between different racial groups
also influence lung function. For example,
negro racial groups tend to have longer legs
and shorter torsos than white Europeans,
and hence smaller lung volumes in relation
to their overall height. Large population
surveys in different populations have been
conducted to determine the reference
values for spirometry and tables of the
results, showing the mean reference value
for individuals within a range of age and
height, and either gender, are available.
The reference values recommended for use
in European populations are those developed
for the European Community for Coal and
Steel (Quanjer et al 1993). Charts of these
reference values are widely available and
they are incorporated in the software of
all electronic spirometers sold for use in
the UK. Correction factors can be applied
to these to adjust for ethnicity. However,
it can be difficult to determine whether to
apply a correction factor if the individual is
of mixed ethnic background. If correction
is applied it must be recorded and applied
consistently in subsequent tests and in cases
of doubt the advice of your local pulmonary
function laboratory should be sought.
Example Withhold prior to spirometry
salbutamol, terbutaline Two to four hours
ipratropium bromide Four to six hours
salmeterol, formoterol 12 to 24 hours
tiotropium bromide 24 to 36 hours
Slo-phyllin, Neulin SA, 24 to 36 hours
Uniphyllin continuus
Box 2
Calculation of ratio of FEV1 to VC and FVC
The FEV1/VC is calculated:
Measured FEV1
X 100
Measured VC
The FEV1/FVC is calculated:
Measured FEV1
X 100
Measured FVC
Actual data from population surveys
are limited for adolescents and the elderly.
Data from the 18-70 year old age group are
extrapolated to cover these groups and the
resulting reference values are therefore less
robust. This needs to be borne in mind when
interpreting spirometry from these individuals.
Patient preparation
Spirometry can be performed
opportunistically, but it is helpful to do this
as a planned procedure and give patients
instructions to enable them to prepare
(Box 3). Any bronchodilators the patient
is taking will need to be withheld for
diagnostic spirometry (Table 3) but this is
not necessary for routine, monitoring of
patients with known respiratory disease.
Now do Time out 5
Height, without shoes, must be accurately
measured. A proxy height measurement can
be used for individuals unable to stand or
with a kyphoscoliosis that prevents them
from standing upright. Measure across the
back from middle finger tip to middle finger
tip with the arms outstretched at 90o. The
patient should also be weighed and body
mass index calculated since this can help
in later interpretation of the spirometry.
Box 3
Preparation for spirometry
DO:
Wear loose and comfortable clothing
}}
that does not restrict breathing.
Arrive for your appointment in time to empty
}}
your bladder and relax before testing.
DO NOT:
Eat a substantial meal within two hours of the test.
}}
Smoke within one hour of the test or consume
}}
alcohol within four hours of the test.
Take vigorous exercise within
}}
30 minutes of the test.
 Figure 4
Technically acceptable, normal volume time and flow volume traces
Volume trace time
=M:
=<M (
C`ki\j
( ) * + , -
J\Zfe[j
Performing the test
Spirometry must be performed with the
patient sitting down. Forced expiratory
manoeuvres can cause dizziness or syncope
and patients are unsafe standing up. They
should be comfortably seated with both
feet on the floor, in a chair that gives them
good support. False teeth should be left in.
Relaxed expiratory manoeuvres
These should be performed first and a nose clip
used to prevent air leak. Instruct the patient to
take a rapid, but unforced, maximum breath
in, and to place the mouthpiece in their mouth,
so that their teeth and tongue do not obstruct
it, making a good seal with their lips. With
the minimum of delay between inhalation and
the start of exhalation, they should exhale
gently and steadily into the mouthpiece, until
they have completely emptied their lungs. You
will need to encourage them to ‘squeeze’ out
every last drop of air, but exhalation should
not be forced and there is no need for them
to empty their lungs within any particular
timeframe. Some electronic spirometers will
give an audible signal when airflow through
them has ceased. Allow the patient to rest
for at least one minute between efforts.
Forced expiratory manoeuvres
Nose clips are not essential, but can be
used if there are difficulties obtaining
reproducible tests. You will need to stress
the need for absolutely maximum effort.
Ask the patient to make a rapid, but
unforced, maximum breath in and place
the mouthpiece into their mouth, as before,
making a tight seal around it. They should
then immediately, using maximum effort,
exhale as hard and as fast as possible until
Flow volume trace
G\Xb\og`iXkfip]cfn
=cfn(&j\Zfe[
=M:
Mfcld\c`ki\j
they are unable to exhale any further. Once
again, active, verbal encouragement to keep
blowing as hard as they can is absolutely
essential. Allow the patient to rest for
at least one minute between efforts.
Reproducibility and technical errors
To ensure reproducibility you need a minimum
of three relaxed vital capacity measurements.
There should be less than 150ml difference
between the two best efforts. If necessary
further efforts, up to a maximum of four, can
be attempted. The highest reading is recorded.
A minimum of three forced manoeuvres
with less than 5 per cent difference between
the best two, technically acceptable FVC
and FEV1 readings are required. If the first
three attempts do not produce reproducible
results further efforts, up to a maximum of
eight, can be attempted, unless the patient
is becoming distressed. The highest FVC
and FEV1 are recorded and these can be
taken from different efforts if necessary.
A technically acceptable effort
is where the individual has:
}} Exhaled completely from maximum
inhalation to maximum expiration.
}} Exhaled immediately from the
position of maximal inspiration.
}} Used maximum effort for the
forced manoeuvre.
}} Used maximum effort from the
start of the forced manoeuvre.
}} Has not coughed.
The volume time trace needs to be smooth,
upwardly curving, free from irregularity and
should plateau for at least one second. The flow
volume trace needs to rise almost vertically
to a peak and should merge smoothly with
the horizontal axis of the graph (Figure 4).
primary health care | Vol 18 No 10 | December 2008 43
 respiratory disease

Figure 5
Slow start

++

=cfniXk\c`ki\j&j\Zfe[
**

=cfniXk\c`ki\j&j\Zfe[
Mfcld\c`ki\j
Mfcld\c`ki\j
))

(( =<M
=<M( (

'' (( )) ** ++ ,, --
K`d\j\Zfe[j
K`d\j\Zfe[j Mfcld\c`ki\j
Mfcld\c`ki\j

Figure 6
Failure to exhale to FVC

KiXZ\]X`cjkfgcXk\Xl
KiXZ\]X`cjkfgcXk\Xl

=cfnc`ki\j&j\Zfe[
=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j
Mfcld\c`ki\j

KiXZ\Ê[ifgjf]]Ë
KiXZ\Ê[ifgjf]]Ë

K`d\j\Zfe[j
K`d\j\Zfe[j Mfcld\c`ki\j
Mfcld\c`ki\j

There are a number of technical errors that At the start of the patient’s effort a loud,
render a test invalid. Coughing during the verbal instruction to ‘BLOW’ and a forceful
forced expiratory manoeuvre Gi\[`Zk\[
will invalidate
Gi\[`Zk\[ gesture such as G\Xb\og`iXkfip]cfn
stamping the foot can also help.
G\Xb\og`iXkfip]cfn
=cfnc`ki\j&j\Zfe[
=cfnc`ki\j&j\Zfe[

the FVC recording. It is a common problem, A common cause of reduced VC and FVC
Mfcld\c`ki\j

and will be apparent from observing the is a failure to exhale completely. The volume
Mfcld\c`ki\j

patient during the test. The volume time
trace will be irregular. Several minutes’
D\Xjli\[
D\Xjli\[ rest
between efforts can help, but if necessary
the relaxed manoeuvre can be used to assess
the vital capacity. If the patient has managed
to blow for one second without coughing
K`d\j\Zfe[j
K`d\j\Zfe[j
and produced a reproducible, good quality
FEV1, the ratio of FEV1 to VC can be used.
A slow or delayed start to the forced
expiratory manoeuvre is another common
problem. This can be detectedGi\[`Zk\[
in the graphic
Gi\[`Zk\[
time trace will fail to plateau and the flow
volume trace will not merge smoothly with
the horizontal axis (Figure 6). It is hard work
to squeeze every last drop of air out the lungs
and it is vital that you continually encourage
the patient throughout the manoeuvre.
Mfcld\c`ki\j
Mfcld\c`ki\j
Spirometry technique needs to be learned
and, while some individuals will grasp what
is needed quickly, others will need several
practice attempts before they get it right. A
poor effort from the patient will result in
=cfnc`ki\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
=cfnc`ki\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
display and print out. The volume time failure to meet reproducibility criteria. The
Mfcld\c`ki\j
Mfcld\c`ki\j

trace will have an ‘S’ shape at the start role of the health professional as the patient’s
and the flow volume trace will show a ‘coach’ cannot be stressed strongly enough.
D\Xjli\[
slower, more sloping rise (Figure 5). It can
D\Xjli\[ Spirometry requires a great deal of effort and
be overcome by further explanation to the co-operation from them, so it is vital that
patient, using phrases such as: ‘I need you to your instructions are clear and you give plenty
really blast the air out right from the start of encouragement. If possible you should
– almost like you wereK`d\j\Zfe[j
going to cough.’
K`d\j\Zfe[j demonstrate what Mfcld\c`ki\j
you want the patient to
Mfcld\c`ki\j

44 primary health care | Vol 18 No 10 | December 2008

Gi\[`Zk\[
Gi\[`Zk\[ Gi\[`Zk\[efidXcZlim\
Gi\[`Zk\[efidXcZlim\
&j\Zfe[
j\Zfe[
c`ki\j
c`ki\j

do, as well as giving a verbal explanation.
Now do Time out 6
Interpretation
Normal ventilatory function
The VC, FVC and FEV1 are expressed in
terms of the volume, in litres, and as a
percentage of the reference value (Box 4). A
healthy individual will have lung volumes
over 80 per cent of the reference value. The
FEV1 /VC and FEV1 /FVC are expressed as
a ratio, or as a percentage, for example,
0.75 or 75 per cent (Box 2). An individual
with unobstructed airways will be able to
exhale three quarters of their vital capacity
+
in the first second of a forced expiration.
In other words, the FEV1 should be around
75 per cent of* the vital capacity, giving a
ratio of FEV1 to VC or FVC of around 0.75.
Mfcld\c`ki\j
The time taken to exhale to FVC is normally
)
four to six seconds. Figure 4 shows normal
volume time and flow volume traces.
( =<M (
Obstructive ventilatory defects
Obstructive airways diseases are common.
' ( ) * + , -
There are more than five million people with
K`d\j\Zfe[j
asthma and around one million diagnosed
cases of COPD in the UK (BTS 2006). The
feature of these conditions is difficulty
with expiration. Inhalation is unaffected
and vital capacity in mild to moderate
KiXZ\]X`cjkfgcXk\Xl
airflow obstruction is usually normal; over
80 per cent of the reference value. However,
airway obstruction reduces the speed of
Mfcld\c`ki\j
exhalation. Thus, the volume of FEV1 falls
to less than 80 per cent of the reference value
and the ratio of FEV1 to vital capacity drops.
A ratio of less than 0.7 (70 per cent) is
generally considered diagnostic of airflow
Figure 7 K`d\j\Zfe[j
Obstructive volume time and flow volume traces
Gi\[`Zk\[
Mfcld\c`ki\j
D\Xjli\[
K`d\j\Zfe[j
Gi\[`Zk\[
c`ki\j
Box 4
Calculating lung volumes as a percentage of the reference value
Measured lung volume
x 100
Reference value for that lung volume
obstruction. Caution does however need
to be exercised when applying this rule Time out 6
to adolescents and the elderly. Lungs lose Consistent, verbal
elasticity as part of the normal ageing process. encouragement to
In a young person with elastic, compliant lungs ‘keep blowing’ is vital to
exhalation will be rapid and the FEV1 and ensure technically acceptable
ratio of FEV1 to VC are likely to be high. In spirometry.
an older person natural loss of lung elasticity Record the VC from a colleague,
or patient who is not familiar
will slow exhalation and produce a relative
with spirometry. Explain what
reduction in FEV1 and ratio of FEV1 to VC.
you want them to do, but do not
Thus, an FEV1 /FVC of 0.73 may be abnormal continually encourage them to
in a symptomatic adolescent and an FEV1 /FVC
=cfniXk\c`ki\j&j\Zfe[
continue blowing. Then repeat
of 0.69 may be normal in an asymptomatic the test with the same person
older person. It is therefore vital to consider while continually encouraging
the clinical presentation and other diagnostic them to ‘…blow, blow … Keep
tests, as well as the lung function, in all cases. blowing’.
The volume time trace will be ‘flattened’ and Is there a difference between
the time taken to reach FVC and for the trace the two recordings?
to plateau extended. The flow volume trace
will still rise rapidlyMfcld\c`ki\j
to a peak, but obstruction
of airflow will produce a typical ‘scooped out’
concave shape to the trace (Figure 7). The
flow volume trace can be particularly useful
in identifying early airflow obstruction.
Severe obstruction
Severe obstructive airways disease can cause
=cfnc`ki\j&j\Zfe[
air trapping. Small airways are normally
KiXZ\Ê[ifgjf]]Ë
‘squeezed’ during forced expiration and will
narrow slightly. When airways are already
narrowed, or where they are unsupported, such
as occurs in emphysema, forced expiration
can cause collapse of the airways; so-called
Mfcld\c`ki\j
G\Xb\og`iXkfip]cfn
=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j
primary health care | Vol 18 No 10 | December 2008 45
i\j&j\Zfe[
Gi\[`Zk\[efidXcZlim\
 +

=cfniXk\c`ki\j&j\Zfe[
* Gi\[`Zk\[ G\Xb\og`iXkfip]cfn

=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j
Mfcld\c`ki\j
)
respiratory disease
D\Xjli\[
( =<M (

Figure 8
' ( ) * + , -
Severely obstructedK`d\j\Zfe[j
volume time and flow volume traces
K`d\j\Zfe[j
Mfcld\c`ki\j
Mfcld\c`ki\j

Gi\[`Zk\[

=cfnc`ki\j&j\Zfe[
KiXZ\]X`cjkfgcXk\Xl Gi\[`Zk\[efidXcZlim\
Mfcld\c`ki\j

=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j

D\Xjli\[ KiXZ\Ê[ifgjf]]Ë

K`d\j\Zfe[j Mfcld\c`ki\j

K`d\j\Zfe[j
dynamic airway collapse. This reduces }} Thoracic spine Mfcld\c`ki\j
deformity –
the volume of the vital capacity. Thus, in scoliosis or kyphoscoliosis.
Gi\[`Zk\[
severe obstructive airways disease the FVC, }} NeuromuscularGi\[`Zk\[efidXcZlim\
disease – muscular

=cfnc`ki\j&j\Zfe[
FEV1 and FEV1 /FVC are all reduced. The dystrophy, motor neurone disease,
Mfcld\c`ki\jMfcld\c`ki\j

VC may be well preserved since this does Guillan Barre syndrome, paralysis
not involve forced expiratory effort. The
Gi\[`Zk\[ of the diaphragmG\Xb\og`iXkfip]cfn
and so on.

=cfnc`ki\j&j\Zfe[
volume time trace will be markedly flattened
D\Xjli\[ }} Obesity – excess fat on the thorax
and the flow volume trace will show a restricts respiratory muscle movement
dramatic drop in flow through the latter and excess fat within the abdomen
part of the expiration, producingD\Xjli\[
a ‘church restricts movement of the diaphragm.
steeple’ silhouette to K`d\j\Zfe[j
the trace (Figure 8). Respiratory causes Mfcld\c`ki\j
for restrictive spirometry
are comparatively rare. A common cause of
Restrictive ventilatory defects apparent restrictive defects is poor spirometry
The cause of a restrictive defect can be technique; failure to exhale to FVC.
K`d\j\Zfe[j Mfcld\c`ki\j
respiratory or non-respiratory. Intra- The feature of restrictive ventilatory defects
pulmonary causes include diseases that cause is reduced lung volume; VC, FVC and FEV1
fibrosis of lung tissue reducing the ability of will all be less than 80 per cent of the reference
the lung tissue to expand, such as fibrosing value and the FEV1 and FVC will be reduced
Gi\[`Zk\[
alveolitis or sarcoidosis. Pulmonary oedema in proportion to each other. Airways are not
=cfnc`ki\j&j\Zfe[

Gi\[`Zk\[efidXcZlim\
‘stiffens’ lung tissue producing a restrictive obstructed and the ratio of FEV1 to VC will
Mfcld\c`ki\j

ventilatory defect. Any condition that prevents be normal. Indeed, when lung volumes are
full expansion of the thoracic cavity can significantly reduced the FEV1 /FVC may be
also cause restrictive spirometry, such as:
D\Xjli\[ abnormally high and the time taken to reach

Figure 9
Restrictive volume K`d\j\Zfe[j
time and flow volume traces Mfcld\c`ki\j

Gi\[`Zk\[ Gi\[`Zk\[efidXcZlim\
=cfnc`ki\j&j\Zfe[
Mfcld\c`ki\j

D\Xjli\[

K`d\j\Zfe[j Mfcld\c`ki\j

46 primary health care | Vol 18 No 10 | December 2008

 table 4
Normal spirometry parameters and how these are affected in various ventilatory defects
Normal Obstruction Severe Obstruction Restriction

FVC More than 80 per cent of More than 80 per cent of Often less than 80 per cent of reference Less than 80 per cent of reference
reference value reference value value but less reduced than FEV1 value. Reduced in proportion to FEV1
VC Same as FVC May be higher than FVC Greater than FVC Same as FVC

FEV1 More than 80 per cent of Less than 80 per cent of Less than 30 per cent of reference value Less than 80 per cent of reference
reference value reference value value
FEV1/FVC Around 75 per cent (0.75) Less than 70 per cent (0.7) Usually less than 70 per cent (0.7) and In excess of 75 per cent (0.75) and
and more than 80 per cent of and less than 80 per cent 80 per cent of reference value – but may more than 80 per cent of reference
reference value of reference value be higher if there is significant air trapping value

FVC reduced to two to four seconds. A ratio
of greater than 0.85 in an adult is highly
suggestive of a restrictive defect, although
it may be normal in a child or adolescent.
The volume time trace will be a normal
shape, but will be small and, in a severe
restrictive defect, will plateau early. The
flow volume trace will appear narrow
and ‘domed’. The ‘scooping’ typical of
obstruction will not be present (Figure 9).
The spirometry parameters affected in
the types of ventilatory defect discussed
here are summarised in Table 4.
Conclusion
There are many indications for spirometry
and a wide variety of different spirometers
available, many of which are suitable for use
in general practice and community settings.
However, all spirometers require regular
maintenance, disinfection and calibration
checks. Most importantly, the healthcare
staff responsible for obtaining recordings
from patients and those interpreting
the results need to be adequately and
appropriately trained for the task. Once
taught they also need to continually practice
Time out 7
their skills in order to maintain them. Now that you have
When these requirements are met primary completed the article
care spirometry can provide a reproducible and you might like to write a
meaningful test that enables accurate diagnosis practice profile. Guidelines to
and rational treatment of respiratory disease n help you are on page 48.
Now do Time out 7
Resources and further reading
One day short courses and a diploma level module
}}
in spirometry (accredited with the Open University)
are available from Education for Health www.
educationforhealth.org.uk Successful graduates
of the diploma level module are also awarded the
BTS/ARTP certificate of competence in spirometry.
Training in spirometry, culminating in the award
}}
of the BTS/ARTP certificate of competence, is
available from The Association for Respiratory
Technology and Physiology.
http://fp.artpweb2.f9.co.uk/
One day short courses and academic modules in
}}
spirometry (accredited with Edge Hill University)
available from Respiratory Education UK
www.respiratoryeduk.com
Booker R (2008) Vital Lung Function.
}}
Class Health. London.

References
Booker R (2008) The primary
care face of COPD. Primary
Health Care. 18, 5, 37-48.
British Medical Association (2003)
New GMS Contract: Investing in
General Practice. BMA. London. Eaton T, Withy S, Garrett JE
British Thoracic Society (1997)
BTS guidelines for the
management of chronic
obstructive pulmonary disease.
Thorax. 52, (Suppl 5), S1-S28.
British Thoracic Society (2006)
Burden of Lung Disease.
British Thoracic Society,
London. www.brit-thoracic.
org.uk/Library/BTSPublications/
BurdenofLungDiseaseReports/
tabid/164/Default.aspx (Last
accessed: May 21 2008.)
British Thoracic Society, Scottish
Intercollegiate Guidelines
Network (2007) British
Guideline on the Management
of Asthma. Revised edition
2007. www.brit-thoracic.org.
uk (Last accessed: May 4 2008.)
et al (1999) Spirometry
in primary care practice:
the importance of quality
assurance and the impact
of spirometry workshops.
Chest. 116, 2, 416-423.
Hole DJ, Watt GC, Davey-Smith G
et al (1996) Impaired lung
function and mortality risk in
men and women: findings
from the Renfrew and Paisley
prospective population study.
British Medical Journal.
313, 7059, 711-715.
Kannel WB, Lew EA, Hubert HB
et al (1980) The value of
measuring vital capacity
for prognostic purposes.
Transactions of the
Association of Life Insurance
Medical Directors of
America. 64, 66-83.
Kendrick AH, Johns DP, Leeming JP
(2003) Infection control of
lung function equipment: a
practical approach. Respiratory
Medicine. 97, 11, 1163-1179.
Leeming JP, Kendrick AH,
Pryce-Roberts D et al
(1993) Use of filters for the
control of cross-infection
during pulmonary function
testing. Journal of Hospital
Infection. 23, 3, 245-246.
Miller MR, Hankinson J, Brusasco V
et al (2005) Standardisation
of spirometry. European
Respiratory Journal.
26, 2, 319-338.
National Collaborating Centre
for Chronic Conditions (2004) Quanjer PH Tammeling GJ,
Chronic obstructive pulmonary
disease: National Clinical
Guideline for management of
chronic obstructive pulmonary
disease in adults in primary
and secondary care. Thorax.
59, (Suppl 1), 1-232.
Nunn AJ, Gregg I (1989) New
regression equations for
predicting peak expiratory
flow in adults. British
Medical Journal. 298,
6680, 1068-1070.
Ponsioen BP, Bohnen AM, Martha I
et al (2002) Measurement of
FEV1 and FVC with a
hand held spirometer by
GPs: feasibility and validity.
Primary Care Respiratory
Journal. 11, 2, 68-69.
Cotes JE et al (1993) Lung
volume and forced ventilatory
flows: report working party
standardization of lung
function tests, European
Community for Steel and
Coal. Official statement of
the European Respiratory
Society. European Respiratory
Journal. 6 (Suppl 16), 5-40.
Rutula DR, Rutula WA, Weber DJ,
Thomann CA (1991) Infection
risks associated with spirometry.
Infection Control and Hospital
Epidemiology. 12, 89-92.

primary health care | Vol 18 No 10 | December 2008 47