Practical - Spirometry 2024
A. Spirometry
Learning Objectives:
1. Be able to conduct a spirometry test
2. Understand the physiological basis of normal and abnormal spirometry results
3. Interpret the spirometry readings
Indications for Spirometry (Graham et al., 2019)
Diagnosis
o Evaluate symptoms, signs or abnormal laboratory test results
o Measure physiologic effect of disease or disorder
o Screen individuals at risk of having pulmonary disease
o Assess pre-operative risk
o Assess prognosis
Monitoring
o Assess response to therapeutic intervention
o Monitor disease progression
o Monitor patients for exacerbations of disease and recovery from exacerbations
o Monitor people for adverse effects of exposure to injurious agents
Disability/ impairment evaluations
o Assess patients as part of the rehabilitation program
Relative contraindications for spirometry
Due to increases in myocardial demand or changes in blood pressure
o Acute myocardial infarction within 1 wk
o Systemic hypotension or severe hypertension
o Significant atrial/ventricular arrhythmia
o Noncompensated heart failure
o Uncontrolled pulmonary hypertension
o Acute cor pulmonale
o Clinically unstable pulmonary embolism
o History of syncope related to forced expiration/cough
Due to increases in intracranial/intraocular pressure
o Cerebral aneurysm
o Brain surgery within 4 wk
o Recent concussion with continuing symptoms
o Eye surgery within 1 wk
Due to increases in sinus and middle ear pressures
o Sinus surgery or middle ear surgery or infection within 1 wk
Due to increases in intrathoracic and intraabdominal pressure
o Presence of pneumothorax
o Thoracic surgery within 4 wk
o Abdominal surgery within 4 wk
o Late-term pregnancy
Infection control issues
o Active or suspected transmissible respiratory or systemic infection, including tuberculosis
o Physical conditions predisposing to transmission of infections, such as haemoptysis
o significant secretions, or oral lesions or oral bleeding
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Practical - Spirometry 2024
Preparation before lung function test
Avoid smoking within 1 hour before testing (to avoid acute bronchoconstriction)
Avoid performing vigorous exercise within 1 hour before testing (to avoid potential exercise-
induced bronchoconstriction)
Avoid wearing clothing that substantially restricts full chest and abdominal expansion (to avoid
external restrictions on lung function)
Measurement of Lung Function
Spirometer:
Position of the mouthpiece and noseclip
Take a deep breath in
Blow out as hard and fast as you can and
hold for 6 seconds
Inhale with maximal effort until
completely full
Repeat for a minimum of three
manoeuvres, usually no more than eight for
adults
Check FEV1 and FVC repeatability and
insert the side without serial number perform more manoeuvres as necessary
Peak Flow Meter:
Place the indicator at the base of the
numbered scale
Take a deep breath in
Place the peak flow meter in your mouth
Blow out as hard and fast as you can in a
single blow.
Repeat for a minimum of three manoeuvres
PEFR regression equations
Male Female
HK Chinese -543.707 + 1.681 x Age + 5.784 x Height (cm) -274.267 + 1.390 x Age + 3.699 x Height (cm)
(Chan et al., 2009)
Middle-aged and Elderly 100.43–4.94 x age (years) + 3.47 x height 66.98–2.73 x age (years) + 2.31 x height (cm)
Chinese (Ji et al., 2021) (cm)+Mspline* +Mspline
Mspline is the age- and sex-specific parameter in Supplementary Table 1. Lookup tables for PEF.xlsx.
https://www.frontiersin.org/articles/10.3389/fpubh.2021.706524/full
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Practical - Spirometry 2024
(Ji et al., 2021)
Respiratory Pressure Meter (Hulzebos et al., 2018):
Maximum inspiratory pressure (PImax)
Sitting
Wearing a nose-clip and using a flanged
mouthpiece
Maximum inspiratory pressure is measured
from functional residual capacity upon a
maximal inspiratory effort against occluded
airway
Repeat three times and record maximal
value
Maximum expiratory pressure (PEmax)
Sitting
Wearing a noseclip and using a flanged
mouthpiece
Maximum expiratory pressure is measured
from total lung capacity performing a
maximal expiratory effort against occluded
airway
Repeat three times and record maximal
value
(ATS 2002)
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Practical - Spirometry 2024
Parameter Definition Male Female
Inspiratory Reserve Volume (IRV) Maximal volume of air that can be inhaled 3 1.9
from the end-inspiratory position
Tidal Volume (VT) Volume of gas inhaled and exhaled during 0.5 0.5
quiet breathing
Expiratory Reserve Volume (ERV) Maximal volume of air that can be 1.1 0.7
exhaled from the end-expiratory position
Residual Volume (RV) Volume of gas remaining the lungs after 1.2 1.1
maximal expiration
Functional Residual Capacity (FRC) Volume of gas remained in the lungs at 2.3 1.8
the end of normal quiet expiration
Vital Capacity (VC) Volume of gas that can be exhaled from 4.6 3.1
the lungs after maximal inspiration
Total Lung Capacity (TLC) Volume of gas in the lungs at maximal 5.8 4.2
inspiration, sum of VC and RV
Video demonstration
Case scenario:
A patient is referred to you because of excessive amounts of sputum in his chest. Upon arrival he does not
look cyanotic but is a little short of breath. He says he has difficulty breathing when climbing stairs.
Discussion (15 mins)
1. Which respiratory functions would you assess and why?
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Practical - Spirometry 2024
2. How would you assess the status of oxygenation non-invasively?
3. What respiratory function parameters would you obtain from a spirometry lung function test?
4. Express the normal relationship between vital capacity and expiratory time during a forced
expiratory breath graphically? Flow Volume Loop and Vitalograph
Illustrate a) normal; b) restrictive, and c) obstructive pattern in this relationship?
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Practical - Spirometry 2024
5. How would you determine if the pattern is related to large airway or small airway obstruction
(consider the shape of a Flow-Volume loop)?
Sample Recording of Spirometry
Name: _____________________________________ Age:________________ Gender:____________
Height:___________(m) Weight:________________(kg)
Trial 1 Trial 2 Trial 3 BEST
Predicted Actual (%pred) Actual (%pred) Actual (%pred) Actual (%pred)
value value value value value
FVC (L)
FEV1 (L)
FEV1/FVC
(%)
PEF (L/s)
PEF25-75%
MEF75%
MEF50%
MEF25%
Comments on your partner’s spirometry results:
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Practical - Spirometry 2024
Reference:
American Thoracic Society/ European Respiratory Society. ATS/ERS statement on respiratory muscle
testing. Am J Respir Crit Crae Med 2002; 166: 518-624
Chan MSH et al. A new reference PEFR nomogram for Hong Kong Chinese. The Journal of Hong
Kong College of Family Physician 2009; 31(3) (Letter to Editor)
Graham BL et al. Standardization of spirometry 2019 update. An official American Thoracic Society
and European Respiratory Society Technical Statement. Am J Respir Crit Care Med 2019; 200(8):
e70–e88
Hulzebos E et al. Reference values for respiratory muscle strength in children and adolescents.
Respiration 2018; 95:235-243
Ji C et al. Reference values and related factors for peak expiratory flow in middle-aged and elderly
Chinese. Front Public Health 9:706524. doi: 10.3389/fpubh.2021.706524
Additional notes:
If coughing -> drink water
If dizzy -> take rest
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