Basics of spirometry

Dr. Maha Yousif

Assist. Lecturer of Chest Diseases
Minufiya University, Egypt
E-mail: drmahayousif@gmail.com

Oct. 2008
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 Contraindications to spirometry

• No absolute contraindications.
• FVC manoeuvre raise intra-cranial, intra-thoracic and intra-
abdominal pressures so, Relative contraindications may
be:

◆ Recent eye, thoracic or abdominal surgery

◆ Recent myocardial infarction, uncontrolled hypertension or pulmonary
embolism
◆ Recent cerebrovascular haemorrhage or known cerebral or
abdominal aneurysm
◆ Pneumothorax
◆ Haemoptysis of unknown origin (FVC maneuver may aggravate
underlying condition.)
◆ Acute disorders affecting test performance (e.g. vomiting, nausea,
vertigo)

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 Patient preparation

Before the test

◘ Avoid:
• Acohol 4h
• Large meal 2h
• Smoking 1h
• Vigorous exercise 30min

◘ Wear loose , comfortable clothing.

◘ relaxed, and have time to visit the toilet.

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• For bronchodilator reversibility testing withhold
bronchodilators prior to the test:

◘ Short-acting inhaled β2 agonists for 2–4h.

◘ Short-acting inhaled anticholinergics for 4–6 h.
◘ Long-acting inhaled or oral β2 agonists for 12–24 h
◘ Long-acting inhaled anticholinergics for 24–36 h.
◘ Theophyllines for 12 h.
◘ Sustained release theophyllines for 24 h.

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 Calibration

• To ensure accurate recording of the tested lung

volumes.
• Daily routine.
• A spirometer that is transported from one location to
another and exposed to changes in temperature
should be re-calibration before use.

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 Performing the test

• Explain the procedure.

• Check any contraindications,complied instructions as
withholding bronchodilators, not smoking,……
• Accurately measure height, standing (without shoes)
• If patients are unable to stand, or have a severe spinal
deformity such as a scoliosis, height can be estimated by
measuring arm span.
• Enter the patient data to the software.
N.B:
7. False teeth, unless they are very ill-fitting and loose, should be left in.
8. Record any deviations from the ideal so that subsequent tests can
be carried out under the same conditions

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 Correct position of head and body

• Seating Position:
(The standing position is not advised),
The test position should be noted on the
report.

• Upright position:

• Position of the head :

upright or slightly leaned back. (If the
neck is flexed forward the upper airways
are narrowing.

• No leaning forward during the test.

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 Slow expiratory vital capacity( SVC,EVC).

Should be tested before any forced maneuvres

SVC Maneuvre
• 1) Breath normally (Facultative)
• 2) Execute a maximal slow inspiration
• 3) Execute a maximal slow expiration
• 4) Breath at rest
Wait a minute or so before attempting another recording

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 Slow Vital Capacity (SVC)

Main parameters measured are:

• EVC: Slow expiratory vital capacity( SVC).
• IVC : Inspiratory Vital cpacity
• ERV: Expiratory reserve volume
• IRV: Inspiratory reserve volume
Others are:
• VE: Expired Volume per minute
• Vt : Tidal Volume
• Rf: Respiratory Frequency
• Ttot: Duration of a complete respiratory cycle 10
• Ti/Ttot, Vt/Ti
 Forced Vital Capacity

FVC Manoeuvre
• 1) Breath normally (Facultative)
• 2) Execute a Forced Maximal inspiration
• 3) Execute a Forced maximal expiration
• 4) Execute a maximal inspiration (Facultative)
• 5) Breath at rest
Wait at least 1 minute before attempting another recording
N.B
Normally, the SVC and FVC are nearly equal. But in airway
obstruction SVC > FVC.

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 Forced Vital Capacity

The Main Measured Parameters are:

• FVC Forced Expiratory Vital Capacity.
• FEV1 Forced Expired Volume after one second.
• FEV1/FVC% Percentage of FEV1 against the FVC.
• PEF Expiratory Peak flow.
• MEF 25-75% (FEF 25-75% )Mean Forced expiratory
flow.
The representative graphs are:
• The flow-volume curve (loop).
• The volume-time curve.

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Flow / volume curve Volume / time curve

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 The volume/time curve

• A normal volume/time curve has a typical shape. There

is a rapid rise to the trace as three-quarters of the air is
expired in the first second
• The trace plateaus between 4 and 6 seconds

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 The flow/volume curve

A normal flow/volume curve

has a typical shape

◘ Rises almost vertically to

PEF
◘ The trace merges smoothly
with the horizontal axis of
the graph at FVC

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 Mid-expiratory flow rates (MEF25, MEF50, MEF75)

• MEF25: ‘The maximum flow

achievable when 75% of the
FVC has been expired’ (when
25% of the FVC remains in the
lungs).
MEF75: refers to the maximum flow
achievable when 75% of the FVC remains
in the lungs and the MEF50 is the
maximum flow rate achievable when the
lungs are half-empty
• a sign of early airflow
obstruction (small airway
disease).
• Some spirometers use the
equivalent of MEF: the forced
expiratory flow (FEF25, FEF50
and FEF75).
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• Peak expiratory flow: the highest flow achieved from a maximal
forced expiratory manoeuvre started without hesitation from a
position of maximal lung inflation’
• occurs very early in a forced expiration – within the first
tenth of a second
• airflow from the larger airways
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 Common errors
Coughing

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• Failure to expire to FVC:
The volume/time trace will fail to plateau
The flow/volume trace will not merge with the horizontal
axis and will ‘drop off’

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• Slow start to the forced expiratory manoeuvre:
• Will give an ‘S’ shape to the start of the volume/time trace,
The flow/volume trace will have a sloping, rather than
vertical start

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• Air leak:
The volume/time trace will ‘dip’ downwards, rather than
rise steadily to a plateau

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 Technical acceptability

• Maximum effort for the forced manoeuvre

• Immediate exhalation from the position of maximal
inspiration
• No coughing
• Complete exhalation.
• Traces are smooth and free of irregularity
• The volume/time trace should plateau for at least 1
second and there should not be an ‘S’ shape to the
beginning of the trace

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• The flow/volume trace should rise almost vertically to a
peak and the trace should merge smoothly with the
horizontal axis at the end of the blow

• At least three technically acceptable manoeuvres should

be obtained, ideally with less than 0.2 L (5%) variability
for FEV1 (and FVC) between the highest and second
highest result. Quote the largest value.

• If the difference is > 5% this means Sub-maximal effort.

(repeat the test)

• Reductions in PEF and FEV1 have been shown when

inspiration is slow and/or there is a 4–6 s pause at total
lung capacity (TLC) before beginning exhalation
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 Spirometry interpretation

• Spirometry parameters are considered to be within the

normal range if:

• The FEV1, FVC and VC are between 80% and 120% of

the reference value for someone of that age, gender,
height and ethnic group
• The FEV1/FVC is about 75% (0.75) or over 80% of the
reference value for someone of that age, gender, height
and ethnic group

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 Obstructive abnormality

• Spirometry parameters compatible with airflow

obstruction are:

◘ A reduced FEV1/FVC, or FEV1/VC. Values of less than

70% and/or less than 80% of the reference value
◘ An FEV1 of less than 80% of the reference value
N.B: When the slow vital capacity is higher than the FVC,
the FEV1/VC should be calculated
◘ Once the diagnosis of obstructive abnormality is made,
comment on:
Severity of obstruction.
Reversibility of obstruction

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 Severity of obstruction

• The severity of reductions in the FEV1% pred

can be characterized by the following scheme:

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 Reversibility test

• Response to β agonist is assessed after 10-15

min after inhalation of (100 mcg each, 400 mcg
total dose) albuterol administered through a
valved spacer device. When concern about
tremor or heart rate exists, lower doses may be
used. Response to an anticholinergic drug may
be assessed 30 minutes after 4 inhalations (40
mcg each, 160 mcg total dose) of ipratropium
bromide.

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 Reversibility test
• FVC before and after bronchodilator

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 Restrictive abnormality

• Spirometry parameters compatible with a restrictive

abnormality are:

◘ An FEV1, FVC and VC reduced to less than 80% of their

reference value
◘ A normal or high FEV1/FVC, or FEV1/VC (about 75%).
The FEV1/FVC will be over 80% of the reference value
◘ The severity of restriction is based on the degree of
reduction in FVC % Pred.the same classification as
obstructive abnormality.

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 Mixed abnormality

• Reduced FVC & a low FEV1/FVC% ratio.

• Means: a combination of both obstruction and
restriction, or airflow obstruction with gas trapping.
It is necessary to measure the patient's total lung
capacity to distinguish between these two
possibilities.

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Examples of lesions of the major airway detected
with the flow-volume loop
• Variable extrathoracic lesions
◘ Vocal cord paralysis
◘ Subglottic stenosis
◘ Hypopharyngeal or tracheal tumour
◘ Goiter
• Variable intrathoracic lesions
◘ Tumor of lower trachea (below sternal notch)
◘ Tracheomalacia
◘ Strictures
◘ Wegener's granulomatosis or relapsing polychondritis
• Fixed lesions
◘ Fixed neoplasm in central airway (at any level)
◘ Vocal cord paralysis with fixed stenosis
◘ Fibrotic stricture
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 Maximum Voluntary Ventilation (MVV)

• Normally, the MVV is approximately = FEV1×40. If the

FEV1 is 3.0 L, the MVV should be approximately 120
L/min.
• MVV/(40×FEV1)< 0.80 indicates that the MVV is low
relative to the FEV1, means:
◘ a major airway obstruction
◘ neuromuscular diseases (amyotrophic lateral sclerosis,
myasthenia gravis, polymyositis).
◘ Poor patient performance due to weakness, lack of
coordination,
◘ the subject is massively obese? The MVV tends to
decrease before the FEV1 does.
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 Maximum Voluntary Ventilation (MVV)

MVV Manoeuvre
• Breath in and out deeply and rapidly for 12 second.

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Obstructive abnormality: very severe, Restrictive
abnormality: moderate (mixed). 39
Obstructive abnormality: very severe, Restrictive
abnormality: severe (mixed). 40
Obstructive abnormality: severe, Restrictive abnormality:
mild (mixed). 41
Moderate restrictive abnormality 42
Normal spirometry 43
Mild restrictive abnormality 44
Restrictive abnormality: moderatey severe 45
Obstructive abnormality: moderately severe. 46
The End