3/18/16 - spirometry 360 · 3/18/16 1 4/15 spirometry 360 provider and coach combined pediatrics...

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SPIROMETRY 360 Provider and Coach Combined

Pediatrics Learning Lab:Putting Spirometry into Practice

Allen Dozor, MD Jim Stout, MD, MPH

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4/15 Spirometry 360™ ©University of Washington 2

Disclaimer

Spirometry Fundamentals and the case-based Spirometry 360 Learning Labs are the online training components of the evidence-based Spirometry 360 training and feedback program. These cases were carefully chosen, peer-reviewed, and refined to meet specific learning objectives for primary care providers. The cases were derived from the medical history and lung function results of de-identified patients cared for by pulmonologists and family physicians who are Spirometry 360 faculty, and clinical experts in respiratory care.

References: Stout et al. Academic Pediatrics 2012;12(2):88–95.


Session Objectives

•  Review spirometry test elements and interpretation

•  Discuss how to incorporate spirometry into a busy primary care practice

•  Explore the advantages of planned visits for primary care asthma management

•  Lay out the business case for spirometry

•  Introduce inspiratory flow loops and discuss their appropriateness in primary care

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Resources

•  Spirometry 360: www.spirometry360.org–  Asthma and COPD cheat sheets–  Sample asthma encounter form–  Business case

•  Other resources –  RAMP asthma action plans (available on Spirometry 360 website)–  National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov–  Improving Chronic Illness Care: www.improvingchroniccare.org


Improving Individual Spirometry Test Quality—A Few Tips

•  Try more efforts, but first:–  (Re)-explain/demonstrate maneuver–  Confirm understanding

•  Watch all aspects of technique

•  Repeat on a different day or a with a different coach

•  Refer ambiguous cases to pulmonary lab

References: 1. Miller MR, et al. Eur Respir J. 2005;26(2):319-338. 2. Levy ML, et al; Prim Care Resp J; 2009;18(3):130-147.


Review of Basics

12 yr. old MaleHeight: 60”Weight: 80 lbs

Efforts: 3FVC VAR: 20 mlFEV1 VAR: 10 ml

Measurement Best Pred %Pred Trial 2 Trial 3FVC(L) 2.56 3.03 85 2.58 2.51

FEV1(L) 1.91 2.72 70 1.89 1.90

FEV1/FVC 0.75 0.73 0.76

FEF25-75(L/s) 1.47 3.63 41 1.34 1.53

PEF(L/s) 5.93 5.83 5.50

FET(s) 6.81 5.90 5.91

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Case Study—Incorporating Spirometry into Asthma Care




FEV1(L) 1.91 2.72 70 1.89 1.90

FEV1/FVC 0.75 0.73 0.76

FEF25-75(L/s) 1.47 3.63 41 1.34 1.53

PEF(L/s) 5.93 5.83 5.50

FET(s) 6.81 5.90 5.91


Quiz Question 1




FEV1(L) 1.91 2.72 70 1.89 1.90

FEV1/FVC 0.75 0.73 0.76

FEF25-75(L/s) 1.47 3.63 41 1.34 1.53

PEF(L/s) 5.93 5.83 5.50

FET(s) 6.81 5.90 5.91

How would you classify this patient’s asthma control? Choose the best answer:A. Well controlled

B. Not well controlled

C. Very poorly controlled

D. It’s difficult to say with the information provided


Quiz Question 1—ANSWER




FEV1(L) 1.91 2.72 70 1.89 1.90

FEV1/FVC 0.75 0.73 0.76

FEF25-75(L/s) 1.47 3.63 41 1.34 1.53

PEF(L/s) 5.93 5.83 5.50

FET(s) 6.81 5.90 5.91

How would you classify this patient’s asthma control? Choose the best answer:A. Well controlled

B. Not well controlled

C. Very poorly controlled

D. It’s difficult to say with the information provided

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EPR-3 Asthma Guidelines

SEVERITY

CONTROL

TREATMENT

0 – 4 5 – 11 12+ AGE RANGE


Classifying Asthma Control


Drivers of Asthma Severity and Control

Lung Function•  FEV1 %

predicted •  FEV1/FVC

Symptom Frequency

•  Day and night•  SABA use

Oral Steroid Bursts

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Symptom Seasonality

Lung Function•  FEV1 %

Predicted •  FEV1/FVC

Symptom Frequency

•  Day and Night

•  SABA Use

Oral Steroid Bursts

Winter Summer


EPR-3 Guidelines: Treatment Steps

More information: Lamanske R, et al. Step-up Therapy for Children with Uncontrolled Asthma Receiving Inhaled Corticosteroids. N Engl J Med. 2010; 362:975. doi: 10.1056/NEJMoa1001278


Quiz Question 2

5 yr. old FemaleHeight: 47”Weight: 75 lbs



FEV1(L) 1.44 1.36 106 1.47 1.37

FEV1/FVC 0.90 0.99 0.93

FEF25-75(L/s) 1.82 1.75 104 2.01 1.76

PEF(L/s) 2.69 3.32 81 2.86 2.55

FET(s) 1.84 1.04 1.51

How would you describe this case? Choose the best answer:A.  5-year-olds cannot perform

spirometry adequately and therefore the test should not have been done

B.  Spirometry was of limited quality and therefore should be interpreted cautiously

C.  Peak flow is low, suggesting she may be inadequately controlled

D.  Spirometry is within normal range despite limited effort, suggesting that she has no obstruction when she is well

E.  B and D

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FEV1(L) 1.44 1.36 106 1.47 1.37

FEV1/FVC 0.90 0.99 0.93

FEF25-75(L/s) 1.82 1.75 104 2.01 1.76

PEF(L/s) 2.69 3.32 81 2.86 2.55

FET(s) 1.84 1.04 1.51

How would you describe this case? Choose the best answer:A.  5-year-olds cannot perform

spirometry adequately and therefore the test should not have been done

B.  Spirometry was of limited quality and therefore should be interpreted cautiously

C.  Peak flow is low, suggesting she may be inadequately controlled

D.  Spirometry is within normal range despite limited effort, suggesting that she has no obstruction when she is well

E.  B and D


Quiz Question 3



FEV1(L) 2.75 2.61 105 2.73 2.64

FEV1/FVC 0.90 0.90 0.90

FEF25-75(L/s) 3.18 3.12 102 3.16 3.18

PEF(L/s) 5.70 6.06 94 5.91 5.58

FET(s) 1.93 1.88 1.89



Quiz Question 3


A 14-year-old girl with asthma has stopped her daily medications and insists she feels well and doesn’t need them anymore.Choose the best answer:A.  Spirometry is not reliable because of

“early termination”B.  Spirometry is normal,

off medications, which suggests that she may no longer need therapy

C.  Spirometry should not be considered, because her forced exhalation times were less than 2 seconds

D.  Spirometry shows significant obstruction, proving that she needs to go back on her daily anti-inflammatory therapy


FEV1(L) 2.75 2.61 .105 2.73 2.64

FEV1/FVC 0.90 0.90 0.90

FEF25-75(L/s) 3.18 3.12 102 3.16 3.18

PEF(L/s) 5.70 6.06 94 5.91 5.58

FET(s) 1.93 1.88 1.89


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A 14-year-old girl with asthma has stopped her daily medications and insists she feels well and doesn’t need them anymore.Choose the best answer:A.  Spirometry is not reliable because of

“early termination”B.  Spirometry is normal,

off medications, which suggests that she may no longer need therapy

C.  Spirometry should not be considered, because her forced exhalation times were less than 2 seconds

D.  Spirometry shows significant obstruction, proving that she needs to go back on her daily anti-inflammatory therapy


FEV1(L) 2.75 2.61 .105 2.73 2.64

FEV1/FVC 0.90 0.90 0.90

FEF25-75(L/s) 3.18 3.12 102 3.16 3.18

PEF(L/s) 5.70 6.06 94 5.91 5.58

FET(s) 1.93 1.88 1.89



Quiz Question 4


Best Pred %Pred Trial 3 Trial 4FVC(L) 1.05 1.57 67 0.90 0.89

FEV1(L) 1.04 1.46 71 0.88 0.85

FEV1/FVC 0.99 0.98 0.96

FEF25-75(L/s) 1.59 1.87 85 1.45 1.71

PEF(L/s) 2.59 3.60 72 2.30 2.34

FET(s) 1.12 0.88 0.71



Quiz Question 4


A 6-year-old girl plays soccer and her mother is concerned that she isn't able to keep up with the other kids.

Choose the best answerA.  Her effort is insufficiently reproducible to

permit interpretationB.  Her vital capacity (FVC) is reduced (less

than 80% of predicted) most likely due to a restrictive lung disease

C.  Her FVC is falsely reduced because of early termination of her expiration

D.  Spirometry is consistent with obstructive lung disease, suggesting she has asthma

E.  A & C


FEV1(L) 1.04 1.46 71 0.88 0.85

FEV1/FVC 0.99 0.98 0.96

FEF25-75(L/s) 1.59 1.87 85 1.45 1.71

PEF(L/s) 2.59 3.60 72 2.30 2.34

FET(s) 1.12 0.88 0.71


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A 6-year-old girl plays soccer and her mother is concerned that she isn't able to keep up with the other kids.

Choose the best answerA.  Her effort is insufficiently reproducible to

permit interpretationB.  Her vital capacity (FVC) is reduced (less

than 80% of predicted) most likely due to a restrictive lung disease

C.  Her FVC is falsely reduced because of early termination of her expiration

D.  Spirometry is consistent with obstructive lung disease, suggesting she has asthma

E.  A & C


FEV1(L) 1.04 1.46 71 0.88 0.85

FEV1/FVC 0.99 0.98 0.96

FEF25-75(L/s) 1.59 1.87 85 1.45 1.71

PEF(L/s) 2.59 3.60 72 2.30 2.34

FET(s) 1.12 0.88 0.71



Planned Asthma Visits

•  Barriers to spirometry–  Technique–  Office flow

•  Identify asthma patients in advance–  Search for ICD-9 493.xx–  Search for bronchodilator and other asthma medication use,

if available in your system

•  Use an asthma registry–  From file cards to EHR

•  Book enough time to cover prevention, treatment, spirometry and education


Planned Asthma Visits

Gain efficiencies by:–  Working as a team (delegate jobs and roles)

–  Define and use an asthma-centric space

–  Restructure work flow if needed

–  Use a structured encounter form to assist quick and thorough documentation

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Asthma Care Templates in EHR’s

•  Transition from paper medical records to electronic health records

•  Preventive asthma care templates–  Not yet widely available

•  Template example funded by the Patient Centered Outcomes Research Institute (PCORI)–  First deployed in Seattle, WA in 2015


ACT Template – Asthma Control Test


Asthma Control Test Cut-Points

Asthma Control Test (ACT)•  5 items•  12 years through adulthood •  Scoring:

–  20 or higher: Well controlled–  16-19: Not well controlled–  15 or lower: Very poorly controlled

Childhood Asthma Control Test (C-ACT) •  7 items•  4-11 years •  Scoring:

–  20 or higher: Well controlled–  13-19: Not well controlled–  12 or lower: Very poorly controlled

Other Assessment Tools: •  Asthma Therapy Assessment Questionnaire (ATAQ)•  Asthma Control Questionnaire (ACQ)

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Triggers Template


Severity Template


Medication Step Template

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Asthma Action Plan


Common Management Plan Template


Summary Template

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Establishing Spirometry in a Busy Primary Care Setting

•  Centrally locate spirometry equipment

•  Generally, only two or three people should be trained in doing the test

•  Untrained personnel should not be testing patients

•  Each provider NEEDS to know how to operate equipment and also perform spirometry


Establishing Spirometry in a Busy Primary Care Setting

•  Train receptionist/nurse to recognize which patients will need spirometry–  Review patient schedule each day

•  Provide each patient with a copy of results for his/her future reference

References: Deane K, et al. Help smokers quit: Tell them their lung age. The Journal of Family Medicine. 2007; 57: 584-586.


Visualization of Asthma Triad

Reference: A.D.A.M. Step 2: What is Asthma? 2002. https://www.wakemed.org/adam/careguides/asthma/asthma_step2.html

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Common Barriers to Practice Change

•  Not enough time

•  Not enough patients to test

•  Too hard to make changes in my practice

•  Too hard to justify the time spent

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Solutions to Barriers

•  Not enough time–  Get out of acute care cycle–  Cluster asthma visits–  Restructure visits

•  Not enough patients to test–  Immediate: claims data, enlist

coworkers–  Long term: utilize reminder

system, registry, EHR

•  Too hard to make changes in my practice–  Start small–  Utilize QI tools

•  Too hard to justify the time spent–  Consider clinical and business

case


Employing Small Steps of Change

PDSA Cycle

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The Business Case for Spirometry

* Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines.

** Medicare allowable amounts vary by geographic region.

CPT Code* Description Unadjusted 2015 Medicare Allowable**1

94010 Forced Expiratory Capacity test $37

94060 Evaluation of wheezing (pre- and post-bronchodilator)

$62

94375 Respiratory flow volume loop $40


Quiz Question 5Measurement Best Pred. %Pred. Trial 1 Trial 3

FVC(L) 4.03 2.37 170 3.89 3.88

FEV1(L) 3.59 2.23 161 3.45 3.42

FEV1/FVC 0.89 0.89 0.88

FET(s) 5.14 4.88 4.80

17 yr. old FemaleHeight: 4’ 3’’Weight: 140 lbs.



Quiz Question 5Measurement Best Pred. %Pred. Trial 1 Trial 3

FVC(L) 4.03 2.37 170 3.89 3.88

FEV1(L) 3.59 2.23 161 3.45 3.42

FEV1/FVC 0.89 0.89 0.88

FET(s) 5.14 4.88 4.80



A 17-year-old girl with life-long asthma is here for a routine visit and has no significant complaints.Choose the best answer:A.  Spirometry is probably normalB.  Her vital capacity (FVC) is very high, suggesting

the patient might have unexplained emphysema or is very hyperinflated

C.  It is almost impossible to have such large values; there must be a technical problem with this spirometry session

D.  A & C

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Quiz Question 5—ANSWER Measurement Best Pred. %Pred. Trial 1 Trial 3

FVC(L) 4.03 2.37 170 3.89 3.88

FEV1(L) 3.59 2.23 161 3.45 3.42

FEV1/FVC 0.89 0.89 0.88

FET(s) 5.14 4.88 4.80



A 17-year-old girl with life-long asthma is here for a routine visit and has no significant complaints.Choose the best answer:A.  Spirometry is probably normalB.  Her vital capacity (FVC) is very high, suggesting

the patient might have unexplained emphysema or is very hyperinflated

C.  It is almost impossible to have such large values; there must be a technical problem with this spirometry session

D.  A & C

Reference: 1. Pellegrino R, et al. Eur Respir J. 2005;26(5):948-968. 2. Shin H, Sears M, Hancox R. Prevalence and correlates of a ‘knee’ pattern on the maximal expiratory flow-volume loop in young adults. Asian Pacific Society of Respirology. 2014; 17:1052-1058. doi: 10.1111/resp.12352.


Response to High Percent Predicted Results•  Check height, gender, and age

•  Check reference set used

•  Don’t put a lot of emphasis on percent predicted values in the very young patients

•  Review patient’s previous tests–  Look for trends in measurements–  Especially FEV1/FVC


Quiz Question 6A 15 year old boy with asthma complains of dyspnea on exertion during Lacrosse games, despite pre-treatment with albuterol. He denies any asthma symptoms otherwise, and insists he adheres to his daily asthma meds.

Choose the best answer:A.  Spirometry shows moderate obstruction, so his

symptoms are not likely due to poorly controlled asthma

B.  Spirometry is normal, which rules out exercise-induced bronchospasm as an explanation for his symptoms

C.  With normal spirometry, good adherence to medications, and pre-treatment with albuterol, it is unlikely that his symptoms are due to exercise induced bronchospasm

D.  Spirometry is normal, which rules out vocal cord dysfunction (VCD) as an explanation for his symptoms

Measurement Best Pred. %Pred. Trial 4 Trial 3FVC(L) 4.57 4.86 94 4.48 4.52FEV1(L) 3.91 4.55 86 3.96 3.88FEV1/FVC 0.85 0.88 0.86FEF25-75(L/s) 4.48 4.57 98 4.67 4.71PEF(L/s) 7.69 8.94 86 8.43 7.81FET(s) 5.28 4.14 4.06


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Quiz Question 6—ANSWER A 15 year old boy with asthma complains of dyspnea on exertion during Lacrosse games, despite pre-treatment with albuterol. He denies any asthma symptoms otherwise, and insists he adheres to his daily asthma meds.

Choose the best answer:A.  Spirometry shows moderate obstruction, so his

symptoms are not likely due to poorly controlled asthma

B.  Spirometry is normal, which rules out exercise-induced bronchospasm as an explanation for his symptoms

C.  With normal spirometry, good adherence to medications, and pre-treatment with albuterol, it is unlikely that his symptoms are due to exercise induced bronchospasm

D.  Spirometry is normal, which rules out vocal cord dysfunction (VCD) as an explanation for his symptoms

Measurement Best Pred. %Pred. Trial 4 Trial 3

FVC(L) 4.57 4.86 94 4.48 4.52FEV1(L) 3.91 4.55 86 3.96 3.88FEV1/FVC 0.85 0.88 0.86FEF25-75(L/s) 4.48 4.57 98 4.67 4.71PEF(L/s) 7.69 8.94 86 8.43 7.81FET(s) 5.28 4.14 4.06



Vocal Cord Dysfunction

•  Formal diagnosis: direct visualization via scope (specialty referral)

•  Underlying causes: anxiety, GERD, post-nasal drip

•  Inspiratory spirometry loop can be strongly suggestive (proceed with caution)

•  Current treatment strategy: “throat relaxed breathing” training via patient education videos or a trained speech therapist


Inspiratory Flow Volume Loops

•  FV loops adds an inspiratory effort to the end of the FVC expiratory maneuver

•  The inspiratory loop is quite effort-dependent and is more difficult to perform well

•  FV loops are not routine for most primary care in the US and require additional training to perform well

Reference: 1. Pellegrino R, et al. Eur Respir J. 2005;26(5):948-968. 2. Sharing in Health. Pulmonary Function Tests. http://www.sharinginhealth.ca/respiratory/investigations/pulmonary_function_tests.html.

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•  Prepare the patient and execute the flow volume loop effort

–  Breathe in deeply—up to the top

–  Blow out as hard and as completely as possible (FVC)

–  At the end of the expiration (FVC), inhale as deeply, forcefully, and as completely as possible—all the way up to the top

Reference: Miller MR, et al. Eur Respir J. 2005;26(2):319-338.



•  Detection of:–  Central and upper airway obstruction–  Extra-thoracic obstruction

Reference: 1. Pellegrino R, et al. Eur Respir J. 2005;26(5):948-968. 2. Miller RD, Hyatt RE. Mayo Clin Proc. 1969; 44:145-161.

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Quiz Question 7Which flow volume loop is most consistent with a fixed tracheal obstruction:

1.  A2.  B3.  C4.  D5.  E

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Reference: Pellegrino R, et al. Eur Respir J. 2005;26(5):948-968.

Quiz Question 7—ANSWERWhich flow volume loop is most consistent with a fixed tracheal obstruction:

1.  A2.  B3.  C4.  D5.  E


Review

•  Asthma control–  Measured as severity over time–  Levels of control

•  Well-controlled•  Very poorly-controlled•  Not-controlled

–  Drivers•  Lung function (FEV1 % Predicted

and FEV1/FVC)•  Symptom frequency (day/night and

SABA use)•  Oral steroid bursts

•  Unusual tests–  Check demographics (height, gender,

and age)–  Check reference set –  Percent predicted values for very

young patients can be unreliable–  Review patient’s previous tests

•  Look for trends in measurements–  Refer to specialist


Review•  Planned asthma visits–  Barriers to spirometry

•  Technique•  Office flow

–  Identify asthma patients in advance•  Search for bronchodilator and other

asthma medication use, if available in your system

–  Use an asthma registry

–  Book enough time to cover spirometry, treatment, prevention, and education

–  Work as a team

•  Establish spirometry in your practice–  Centrally locate equipment–  2 – 3 staff should be trained to

perform spirometry–  PDSA cycle

•  Inspiratory flow volume loops–  Used for detection of:

•  Central and upper airway obstructions•  Extra-thoracic obstructions

–  In general, not appropriate in primary care

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Thanks for watching!

•  Additional resources:–  http://www.spirometry360.org/spiro360resources/–  http://www.spirometry360.org/otherresources/

•  Interested in getting feedback on your spirometry tests? Visit http://www.spirometry360.org/feedback for more information

•  Have any questions? Contact us at [email protected]

3/18/16 - spirometry 360 · 3/18/16 1 4/15 spirometry 360 provider and coach combined pediatrics...

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