QU

ICK

GL

AN

CE

GU

IDE

TO

SP

IRO

ME

TR

Y

Mild

ly o

bstr

ucte

d �o

w lo

op

Mod

erat

ely

obst

ruct

ed �

ow lo

op

Seve

rely

obs

truc

ted

�ow

loop

Nor

mal

�ow

loop

Inte

rstit

ial p

ulm

onar

y �b

rosi

s �o

w lo

op (r

estr

ictiv

e lu

ng

dise

ase)

FVC

Peak

�ow

Exam

ples

of o

bstr

ucte

d an

d re

stric

ted

�ow

loop

s

Def

init

ion

s:

Fo

rced

Vit

al C

apac

ity

(FV

C):

the

volu

me

deliv

ered

dur

ing

an e

xpira

tion

mad

e as

fo

rcef

ully

and

com

plet

ely

as p

ossi

ble

star

ting

from

full

insp

iratio

n F

orc

ed E

xpir

ato

ry V

olu

me

in t

he

firs

t se

con

d (

FE

V1)

: the

vol

ume

deliv

ered

in

the

�rst

sec

ond

of a

n FV

C m

aneu

ver

Ob

stru

ctio

n: �

ow li

mita

tion

is o

bser

ved

durin

g sp

irom

etry

. If

the

obse

rved

FEV

1/FV

C

ratio

is d

own

10 o

r mor

e fr

om th

e pr

edic

ted,

obs

truc

tion

is p

rese

nt.

R

estr

icti

on

: Spi

rom

etry

with

low

FVC

(< 8

0%) c

an o

nly

sugg

est r

estr

ictio

n. F

urth

er

test

ing

is n

eede

d to

con

�rm

.

A

ctua

l

Pred

icte

d %

Pre

dict

ed

FVC

(L)

3.62

3.41

106

FEV1

(L)

4.00

4.03

99

A

ctua

l

Pred

icte

d %

Pre

dict

ed

FVC

(L)

3.64

3.41

107

FEV1

(L)

3.99

4.03

99

A

ctua

l

Pred

icte

d %

Pre

dict

ed

FVC

(L)

3.70

3.41

109

FEV1

(L)

4.07

4.03

101

Exam

ples

of u

nacc

epta

ble

test

s

Slow

sta

rt

of te

st

Roun

ded

peak

Ea

rly

term

inat

ion

Coug

h in

�r

st s

econ

d

Acc

epta

bilit

y cr

iter

ia fr

om th

e A

mer

ican

Tho

raci

c So

ciet

y: G

loba

l Lun

g Fu

nctio

n In

itiat

ive

(GLI

)-201

2 m

ulti-

ethn

ic re

fere

nce

rang

es a

re re

com

men

ded.

N

HA

NES

III r

efer

ence

val

ues

rem

ain

appr

opria

te w

here

mai

ntai

ning

con

tinui

ty is

impo

rtan

t. Fo

llow

ing

a gr

adin

g sy

stem

rang

e of

A-F

, spi

rom

etry

test

s w

ith g

rade

sof

A-C

are

clin

ical

ly u

sefu

l.

Spiro

met

ry m

ust e

stab

lish

a so

lid b

asel

ine

mee

ting

all c

riter

ia fo

r acc

epta

bilit

y an

d re

peat

abili

ty.

Use

GLI

-201

2 m

ulti-

ethn

ic re

fere

nce

rang

es w

hen

avai

labl

e. N

HA

NES

III r

efer

ence

val

ues

rem

ain

appr

opria

te fo

r pat

ient

s8-8

0, w

here

mai

ntai

ning

con

tinui

ty is

impo

rtan

t. Fo

r chi

ldre

n ag

es 5

-8,

Wan

g re

fere

nce

valu

es a

re re

com

men

ded

whe

n G

LI-2

012

is n

ot a

vaila

ble.

GLI

-201

2 ha

s a

grad

ing

syst

em ra

nge

of A

-F, s

piro

met

ry te

sts

with

gra

des

of A

-C a

re c

linic

ally

use

ful.

Follo

w a

ll O

SHA

and

JC

AH

O s

tand

ards

for i

nfec

tion

cont

rol.

Not

e: T

estin

g ch

ildre

n <

age

5 is

like

ly to

be

unsu

cces

sful

.

Co

ntr

ain

dic

atio

ns:

•

Rece

nt s

urge

ry

•W

ithin

one

mon

th o

f a m

yoca

rdia

l inf

arct

ion

•Re

cent

pne

umot

hora

x •

Una

ble

to u

nder

stan

d di

rect

ions

or i

nabi

lity

to s

eal m

outh

piec

e

CP

T c

od

es f

or

spir

om

etry

: 94

010

spiro

met

ry 9

4060

spi

rom

etry

with

bro

ncho

dila

tor (

pre-

and

pos

t-te

st)

Whe

n us

ing

thes

e CP

T co

des,

bet

ter r

eim

burs

emen

t hap

pens

whe

n cu

rren

t sym

ptom

s ar

e as

soci

ated

with

the

appr

opria

te IC

D9

code

for a

sthm

a or

CO

PD.

Ref

er t

o a

sp

ecia

list:

•If

patie

nt h

as s

ever

e o

bst

ruct

ion

•If

patie

nt h

as a

res

tric

tive

pat

tern

•

If pa

tient

do

es n

ot

resp

on

d t

o m

edic

atio

ns

Co

ach

ing

pat

ien

ts t

hro

ug

h s

pir

om

etry

: In

stru

ct p

atie

nt to

bre

athe

nor

mal

ly. W

h en

pat

ient

is re

ady,

hav

e hi

m/h

er ta

ke h

is/

her d

eepe

st b

reat

h an

d bl

ow a

s ha

rd a

s he

/she

can

as

long

as h

e/sh

e ca

n. T

here

is a

le

arni

ng c

urve

for s

piro

met

ry. U

se p

ositi

ve re

info

rcem

ent t

o bu

ild o

n th

e pa

tient

’s

succ

esse

s. (F

or

ex

ampl

e, “T

hat w

as re

ally

goo

d; th

is ti

me

take

an

even

dee

per

brea

th.”)

Alw

ays

dem

onst

rat

e th

e sp

irom

etry

man

euve

r, es

peci

ally

if la

ngua

ge is

a

barr

ier o

r com

mun

icat

ion

issu

es a

rise.

Ap

pro

pri

ate

bro

nch

od

ilato

r u

se:

If te

stin

g fo

r rev

ersi

bilit

y, g

ive

patie

nt 4

puf

fs o

f bro

ncho

dila

tor w

ith a

spa

cer o

r a

stan

dard

neb

uliz

ed d

ose.

Wai

t 15

min

utes

aft

er la

st d

ose

to p

erfo

rm p

ost-

bron

chod

ilato

r man

euve

r. If

a pa

tient

can

not p

erfo

rm a

ccep

tabl

e ba

selin

e m

aneu

vers

acc

ordi

ng to

Am

eric

an T

hora

cic

Soci

ety

crite

ria o

r the

re is

no

evid

ence

of

airf

low

obs

truc

tion,

do

NO

T gi

ve a

bro

ncho

dila

tor.

Refe

renc

es:

1. R

epea

tabi

lity

crite

ria fo

r the

Am

eric

an T

hora

cic

Soci

ety:

Thr

ee (3

) acc

epta

ble

test

s m

ust b

e pe

rfor

med

with

two

(2) t

ests

hav

ing

FEV1

and

FV

C w

ithin

.15L

or 1

50m

L of

eac

h ot

her.

2.M

iller

M, H

anki

nson

J, B

rusa

sco

V, e

t al.

Stan

dard

isat

ion

of s

piro

met

ry. E

urop

ean

Res

pira

tory

Jou

rnal

. 200

5;26

:319

–338

. 3.

Pelle

grin

o R,

Vie

gi G

, Bru

sasc

o V,

et a

l. In

terp

reta

tive

stra

tegi

es fo

r lun

g fu

nctio

n te

sts.

Eur

opea

n R

espi

rato

ry J

ourn

al. 2

005;

26:9

48–9

68.

4.G

loba

l Str

ateg

y fo

r the

Dia

gnos

is, M

anag

emen

t, an

d Pr

even

tion

of C

hron

ic O

bstr

uctiv

e Pu

lmon

ary

Dis

ease

. U

pdat

ed 2

007.

Ava

ilabl

e at

ht

tp://

ww

w.g

oldc

opd.

com

.5.

Nat

iona

l Hea

rt, L

ung

and

Bloo

d In

stitu

te N

atio

nal A

sthm

a Ed

ucat

ion

and

Prev

entio

n Pr

ogra

m.

Exp

ert P

anel

Rep

ort 3

: Gui

delin

es fo

r th

e D

iagn

osis

and

Man

agem

ent o

f Ast

hma.

200

7. A

vaila

ble

at h

ttp:

//w

ww

.nhl

bi.n

ih.g

ov.

Sp

iro

met

ry:

a m

easu

re o

f ai

rflo

w (

ho

w f

ast)

an

d v

olu

me

(ho

w m

uch

)

Supp

orte

d by

Boe

hrin

ger I

ngel

heim

Pha

rmac

eutic

als,

Inc.

Repe

atab

ility

cri

teri

a fo

r the

Am

eric

an T

hora

cic

Soci

ety:

Rec

omm

ende

d re

peat

abili

ty c

riter

ia o

f 150

ml.

SP

IRO

ME

TR

Y I

NT

ER

PR

ETA

TIO

N

Wha

t is

the

obse

rved

ratio

(FEV

1/FV

C)

com

pare

d to

pre

dict

ed?

Dow

n 10

or g

reat

er =

air�

ow o

bstr

uctio

n

AT

S/E

RS

* D

egre

e o

f se

veri

ty o

f o

bst

ruct

ion

bas

ed o

n F

EV

1

Deg

ree

of s

ever

ityFE

V1 %

pre

dict

edM

ild

>70

M

oder

ate

60-6

9 M

oder

atel

y se

vere

50

-59

Seve

re

35- 4

9 Ve

ry s

ever

e

<35

•Air�

ow o

bstr

uctio

n th

at is

not

sig

ni�c

antly

reve

rsib

le

does

NO

T ru

le o

ut a

sthm

a.

•To

help

di�

eren

tiate

CO

PD fr

om a

sthm

a w

ith a

irway

re

mod

elin

g/�x

ed o

bstr

uctio

n, fu

rthe

r tes

ting

optio

ns

incl

ude:

DL,

CO, c

hest

x-r

ay, a

nd c

hest

CT.

No

Yes

Is it

reve

rsib

le?

FE

V1

≥ 12

% a

nd

≥ 20

0 m

L in

you

ths

and

adul

ts 1

2+

≥ 15

% a

nd

≥ 20

0 m

L in

chi

ldre

n <

12

Sam

ple

writ

ten

asth

ma

inte

rpre

tatio

n:

The

FEV

1/F

VC ra

tio b

eing

dow

n m

ore

than

10

from

pre

dict

ed i

s co

nsis

tent

with

air�

ow o

bstr

uctio

n. T

he F

EV1

bei

ng 7

7%

of p

redi

cted

sug

gest

s a

mild

air�

ow o

bstr

uctio

n (b

ased

on

the

2005

ATS

/ERS

gui

de fo

r sev

erity

of o

bstr

uctio

n). T

he p

ost

bron

chod

ilato

r stu

dy re

veal

s a

sign

i�ca

nt re

spon

se to

alb

uter

ol w

ith th

e FE

V1 i

ncre

asin

g 15

% o

r 550

cc. T

his

�ndi

ng is

co

nsis

tent

with

dia

gnos

is o

f ast

hma

alth

ough

clin

ical

cor

rela

tion

is n

eede

d to

con

�rm

. (Ba

sed

on th

e 20

07 N

AEP

P gu

idel

ines

fo

r ast

hma

seve

rity)

, thi

s 28

yea

r old

mal

e w

ith a

bas

elin

e FE

V 1 o

f 77%

has

mod

erat

e pe

rsis

tent

ast

hma.

Sam

ple

writ

ten

COPD

inte

rpre

tatio

n:

The

FEV

1/FV

C ra

tio b

eing

dow

n m

ore

than

10

from

pre

dict

ed is

con

sist

ent w

ith a

ir�ow

obs

truc

tion.

The

FEV

1

bein

g 51

% o

f pre

dict

ed s

ugge

sts

a m

oder

atel

y-se

vere

air�

ow o

bstr

uctio

n (b

ased

on

the

2005

ATS

/ERS

gu

idel

ines

for s

ever

ity o

f obs

truc

tion)

. N

o si

gnif

ican

t res

pons

e to

alb

uter

ol w

as re

veal

ed a

s th

e FE

V1 o

nly

incr

ease

d 2%

. Fur

ther

test

ing

reve

aled

a d

i�us

ion

capa

city

of 5

0% o

f pre

dict

ed. T

he la

tera

l che

st �

lm s

how

ed

sign

s of

hyp

erin

�atio

n an

d �a

tten

ed d

iaph

ragm

and

the

ches

t CT

had

clas

sic

chan

ges

seen

in e

mph

ysem

a.

(Bas

ed o

n th

e 20

07 G

OLD

gui

delin

es fo

r CO

PD s

ever

ity),

this

74

year

old

fem

ale

with

a b

asel

ine

FEV 1

of 5

1%

has

Stag

e II

mod

erat

e CO

PD.

PR

E-B

RO

NC

H

O

bser

ved

Pred

icte

d %

Pre

dict

ed

FVC

(L)

5.

25

5

.68

92

FE

V1 (L

)

3.59

4

.64

77

FE

V1/F

VC (%

)

68

82

PR

E-B

RO

NC

H

O

bser

ved

Pre

dict

ed

% P

redi

cted

FV

C (L

) 5.

25

5.

68

9

2 FE

V1 (L

) 3.

59

4.

64

7

7 FE

V1/F

VC (%

)

68

82

PO

ST

-BR

ON

CH

Obs

erve

d %

Pre

dict

ed P

ost

% C

hang

e FV

C (L

) 5.

35

94

2 FE

V1 (L

) 4.

14

89

15

FEV1

/FVC

(%)

77

1

3

PR

E-B

RO

NC

H

O

bser

ved

Pred

icte

d %

Pre

dict

ed

FVC

(L)

2.

09

2

.78

75

FE

V1 (L

)

1.06

2

.08

51

FE

V1/F

VC (%

)

50

75

PR

E-B

RO

NC

H

O

bser

ved

Pre

dict

ed

% P

redi

cted

FV

C (L

)

2.

09

2.

78

75

FEV1

(L)

1.0

6

2.

08

51

FEV1

/FVC

(%)

5

0

75

PO

ST

-BR

ON

CH

Obs

erve

d %

Pre

dict

ed P

ost

% C

hang

e FV

C (L

) 2.

03

7

3

-

3 FE

V1 (L

) 1.

07

5

2

2

FE

V1/F

VC (%

)

53

5

* A

mer

ican

Tho

raci

c So

ciet

y/Eu

rope

an R

espi

rato

ry S

ocie

ty

AS

TH

MA

C

OP

D

Is th

is a

goo

d te

st?

(Acc

epta

bilit

y an

d re

peat

abili

ty

crite

ria o

n re

vers

e)

Chec

k FV

C. I

f nor

mal

(≥8

0%),

rest

rictio

n ca

n be

rule

d ou

t. If

redu

ced,

furt

her

test

ing

is n

eede

d to

di�

eren

tiate

rest

rict

ion

from

obs

truc

tion

with

air-

trap

ping

.

5-11

yea

rs

12 +

yea

rs

Nor

mal

FEV

1/FV

C:

8-19

yr

85%

20-3

9 yr

80

%40

-59

yr

75%

60-8

0 yr

70

%

Nor

mal

FEV

1 b

etw

een

exac

erba

tions

FE

V 1 >

80%

pre

dict

ed

FE

V1 /F

VC >

85%

Nor

mal

FEV

1 bet

wee

n ex

acer

batio

ns

FEV

1 > 8

0% p

redi

cted

FE

V1/

FVC

norm

al

FEV1

> 8

0% p

redi

cted

FEV1

/FVC

> 8

0%

FEV

1 ≥

80%

pre

dict

ed

FEV

1/FV

C no

rmal

FEV 1

= 6

0-80

% p

redi

cted

FEV1

/FVC

= 7

5-80

%

FEV

1 60-

80%

pre

dict

ed

FEV

1/FV

C re

duce

d 5%

FEV

1 < 6

0% p

redi

cted

FE

V1/

FVC

< 75

%

FEV

1 < 6

0% p

redi

cted

FE

V1/

FVC

redu

ced

> 5%

Inte

rmitt

ent

Mild

M

oder

ate

Seve

re

Per

sist

ent

As

thm

a S

ever

ity

CO

PD

Sev

erit

y

Stag

e I:

mild

St

age

II: m

oder

ate

Stag

e III

: sev

ere

FEV

1/FV

C <

70%

FE

V1

≥ 80

% p

redi

cted

FE

V1/

FVC

< 70

%

FEV

1 50-

80%

pre

dict

ed

FEV

1/FV

C <

70%

FE

V1 3

0-50

% p

redi

cted

Stag

e IV

: ver

y se

vere

FEV

1/FV

C <

70%

FE

V1 <

30%

pre

dict

ed o

r FE

V1 <

50%

pre

dict

ed p

lus

chro

nic

resp

irato

ry fa

ilure

DM

6060

5C S

uppo

rted

by

Boeh

ringe

r Ing

elhe

im P

harm

aceu

tical

s, In

c.

Cons

iste

nt w

ith a

sthm

a di

agno

sis