- Meredith C McCormack, MD, MHS
Meredith C McCormack, MD, MHS
- Assistant Professor of Medicine
- Medical Director, Pulmonary Function Laboratory Pulmonary and Critical Care Medicine Johns Hopkins University
Spirometry is used to measure forced expiratory flow rates and volumes. It is the most commonly used pulmonary function test and is useful in the evaluation of patients with respiratory symptoms (eg, dyspnea, cough, wheeze) or risk factors for respiratory disease (eg, smoking, occupational exposures, family history).
In the office setting, spirometry is typically used to detect, confirm, and monitor obstructive airway diseases (eg, asthma, chronic obstructive pulmonary disease [COPD]) [1-4]. In this setting, the clinician must be knowledgeable about issues related to equipment, performance of the forced expiratory maneuver, and interpretation of the data to obtain reliable and clinically useful information [5-7]. International guidelines for performance of office spirometry have been published .
The performance of spirometry in the office setting will be reviewed here. More general issues related to pulmonary function tests, the interpretation of flow volume loops, and the technique of bronchoprovocation testing are discussed separately. (See "Overview of pulmonary function testing in adults" and "Flow-volume loops" and "Bronchoprovocation testing".)
The majority of spirometers manufactured since 1990 are accurate, although some flow-sensing office spirometers can produce falsely high results [9-11]. The National Lung Health Education Program (NLHEP) has published guidelines for office spirometers and has a list of features (eg, graphic output) that should be available .
To avoid cross-contamination between patients when using permanent flow sensors, it is preferable to employ single use disposable flow sensors that practically eliminate the risk of inhalational cross contamination. Disposable one-way mouthpieces may also be used; otherwise, patients should be instructed not to inhale from the spirometer prior to forced exhalation maneuvers. Volume sensing spirometers maintain accuracy over many years, but are more difficult to clean and are rarely used for office spirometry.
- Enright P, Quanjer P. Don't diagnose mild COPD without confirming airway obstruction after an inhaled bronchodilator. COPD 2007; 4:89.
- Han MK, Kim MG, Mardon R, et al. Spirometry utilization for COPD: how do we measure up? Chest 2007; 132:403.
- Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following diagnosis of COPD. Chest 2006; 129:1509.
- US Preventive Services Task Force (USPSTF), Siu AL, Bibbins-Domingo K, et al. Screening for Chronic Obstructive Pulmonary Disease: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315:1372.
- Enright, PL, Studnicka, M, Zielinski, J. Spirometry to detect and manage COPD and asthma in the primary care setting. Eur Respir Mon 2005; 31:1.
- Walters JA, Hansen EC, Johns DP, et al. A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD. Thorax 2008; 63:408.
- Lusuardi M, De Benedetto F, Paggiaro P, et al. A randomized controlled trial on office spirometry in asthma and COPD in standard general practice: data from spirometry in Asthma and COPD: a comparative evaluation Italian study. Chest 2006; 129:844.
- Levy ML, Quanjer PH, Booker R, et al. Diagnostic spirometry in primary care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations: a General Practice Airways Group (GPIAG)1 document, in association with the Association for Respiratory Technology & Physiology (ARTP)2 and Education for Health3 1 www.gpiag.org 2 www.artp.org 3 www.educationforhealth.org.uk. Prim Care Respir J 2009; 18:130.
- Townsend MC, Hankinson JL, Lindesmith LA, et al. Is my lung function really that good? Flow-type spirometer problems that elevate test results. Chest 2004; 125:1902.
- Liistro G, Vanwelde C, Vincken W, et al. Technical and functional assessment of 10 office spirometers: A multicenter comparative study. Chest 2006; 130:657.
- Schermer TR, Verweij EH, Cretier R, et al. Accuracy and precision of desktop spirometers in general practices. Respiration 2012; 83:344.
- Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program. Chest 2000; 117:1146.
- Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26:319.
- Leone N, Courbon D, Thomas F, et al. Lung function impairment and metabolic syndrome: the critical role of abdominal obesity. Am J Respir Crit Care Med 2009; 179:509.
- Enright PL. Office spirometry. In: Atlas of office procedures, 1999. Vol 2, p.299.
- Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948.
- Vandevoorde J, Verbanck S, Schuermans D, et al. Forced vital capacity and forced expiratory volume in six seconds as predictors of reduced total lung capacity. Eur Respir J 2008; 31:391.
- Swanney MP, Jensen RL, Crichton DA, et al. FEV(6) is an acceptable surrogate for FVC in the spirometric diagnosis of airway obstruction and restriction. Am J Respir Crit Care Med 2000; 162:917.
- Miller MR, Quanjer PH, Swanney MP, et al. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest 2011; 139:52.
- Stanojevic S, Wade A, Stocks J, et al. Reference ranges for spirometry across all ages: a new approach. Am J Respir Crit Care Med 2008; 177:253.
- Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J 2012; 40:1324.
- O'Donnell DE. Breathlessness in patients with chronic airflow limitation. Mechanisms and management. Chest 1994; 106:904.
- Hnizdo E, Glindmeyer HW, Petsonk EL, et al. Case definitions for chronic obstructive pulmonary disease. COPD 2006; 3:95.
- Swanney MP, Ruppel G, Enright PL, et al. Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax 2008; 63:1046.
- García-Rio F, Soriano JB, Miravitlles M, et al. Overdiagnosing subjects with COPD using the 0.7 fixed ratio: correlation with a poor health-related quality of life. Chest 2011; 139:1072.
- Jing JY, Huang TC, Cui W, et al. Should FEV1/FEV6 replace FEV1/FVC ratio to detect airway obstruction? A metaanalysis. Chest 2009; 135:991.
- Jensen RL, Crapo RO, Enright P. A statistical rationale for the use of forced expired volume in 6 s. Chest 2006; 130:1650.
- Bellia V, Sorino C, Catalano F, et al. Validation of FEV6 in the elderly: correlates of performance and repeatability. Thorax 2008; 63:60.
- Vollmer WM, Gíslason T, Burney P, et al. Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study. Eur Respir J 2009; 34:588.
- Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med 1999; 159:179.
- Scanlon PD, Connett JE, Waller LA, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir Crit Care Med 2000; 161:381.
- Buffels J, Degryse J, Decramer M, Heyrman J. Spirometry and smoking cessation advice in general practice: a randomised clinical trial. Respir Med 2006; 100:2012.
- Enright P. Does screening for COPD by primary care physicians have the potential to cause more harm than good? Chest 2006; 129:833.
- Boros PW, Enright PL, Quanjer PH, et al. Impaired lung compliance and DL,CO but no restrictive ventilatory defect in sarcoidosis. Eur Respir J 2010; 36:1315.
- Joo MJ, Au DH, Fitzgibbon ML, et al. Determinants of spirometry use and accuracy of COPD diagnosis in primary care. J Gen Intern Med 2011; 26:1272.
- Poels PJ, Schermer TR, Akkermans RP, et al. General practitioners' needs for ongoing support for the interpretation of spirometry tests. Eur J Gen Pract 2007; 13:16.
- Schermer TR, Smeele IJ, Thoonen BP, et al. Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care. Eur Respir J 2008; 32:945.
- National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). Full text available online: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on August 12, 2009).
- Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007; 147:633.
- Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: Updated 2011. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Available from http://www.goldcopd.org (Accesssed on January 8, 2013).
- QUALITY CONTROL
- COACHING THE PATIENT
- ADEQUACY OF TEST
- Forced vital capacity
- Forced expiratory volume in six seconds
- Forced expiratory volume in one second
- Ratio of FEV1/FVC
- Other flow measures
- Choosing the best values
- Flow-volume loops
- POST-BRONCHODILATOR SPIROMETRY
- SUMMARY AND RECOMMENDATIONS