8/4/15 - spirometry 360 · quiz question 1 – assessing the volume/time curve which of the...

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Second Coach Session: Fixing Common Errors

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Jim Stout, MD, MPH Drew Martenson, RRT

4/15 Spirometry 360™ ©University of Washington

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.

Spirometry 360™ ©University of Washington 2

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


Resources

•  Spirometry 360 Cheat Sheets–  Spirometry Test Session Algorithm–  Spirometry Curve Examples–  Severity Guidelines–Asthma & COPD–  Asthma Encounter Form

•  CDC-NIOSH Resources–  NIOSH-CDC spirometry poster

http://www.cdc.gov/niosh/docs/2011-135/–  NIOSH quality assurance spirometry

publication www.cdc.gov/niosh/docs/2012-116/


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Session Objectives

•  Learn to identify and correct common spirometry errors through patient interaction and curve analysis

•  Discuss the limitations of machine-generated quality grades

•  Practice assessing spirometry quality



Common Errors for Spirometry 360 Participants—Baseline Evaluations

1.  Not enough spirometry tests performed2.  Submaximal blast–check flow/volume (FV) curves3.  Early termination–check volume/time (VT) curves4.  Insufficient number of efforts per test session5.  Partially obstructed mouthpiece–

check FV and VT curves6.  Incomplete inspiration

References: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed March 7, 2015. 2. Burton D, et al. Spirometer Users’ and Buyers’ Guide. Melbourne: National Asthma Council Australia, 2013.



REVIEW—Evaluate This Test


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Quiz Question 1 – Assessing the Volume/Time Curve

Which of the following can be said about the curve for this 11 year old?A.  The patient didn’t blow out

long enoughB.  The curve is acceptableC.  The correction is coaching

for longer blowD.  A and CE.  It is unacceptable because

of variable flowReferences: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. US Department of Healath and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.



Quiz Question 1 – ANSWER

Which of the following can be said about the curve for this 11 year old?A.  The patient didn’t blow out

long enoughB.  The curve is acceptableC.  The correction is coaching

for longer blowD.  A and CE.  It is unacceptable because

of variable flowReferences: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.



Use of Volume/Time Curve

•  Especially good for detecting end of test errors:–  First look to confirm a 1–2 second plateau–  If there’s no plateau, look at FET (forced expiratory time)

References: 1. Beydon N, et al. Am J Respir Crit Care Med. 2007;175:1304-1345. 2. Ruppel G. Manual of Pulmonary Function Testing, 9th edition. CV Mosby Co. 2008. p46.


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Spirometry 360 Guidelines for Length of Effort

•  Guidelines for length of effort—time needed to complete a blow—(FET) by age:

–  ≥ 10 years of age: ≥ 6 seconds–  7–9 years of age: ≥ 3 seconds

–  ≤ 6 years of age: ≥ 2 seconds

References: 1. Beydon N, et al. Am J Respir Crit Care Med. 2007;175:1304-1345. 2. Miller MR, et al. Eur Respir J. 2005;26(2):319-338.



Point to evidence of early termina1on Point to evidence of earlytermination

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Correcting Early Termination

•  Coach the subject to KEEP BLOWING until told to stop

•  Cue the patient counting with six fingers– 6…5…4…3…2…1

References: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013 2. Miller MR, et al. Eur Respir J. 2005;26(2):319-338.



Quiz Question 2 – Assessing the Flow Volume Curve

Which of the following can be said about the curve?A.  The curve displays early

terminationB.  The forced expiratory time

is three secondsC.  A and BD.  All criteria for acceptability are presentE.  The forced vital capacity is unaffected

by this problem

Reference: US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.



Quiz Question 2 – ANSWERWhich of the following can be said about the curve?A.  The curve displays early

terminationB.  The forced expiratory time

is three secondsC.  A and BD.  All criteria for acceptability are presentE.  The forced vital capacity is unaffected

by this problem



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Review of Flow Volume Curve

•  Assessing start of maneuver—want brisk rise and sharp peak

•  Assessing mid-flow—want smooth flow on down slope

•  Assessing end of maneuver—want no abrupt drop off of down slope

References: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. Miller MR, et al. Eur Respir J. 2005;26(2):319-338. 3. US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.



Quiz Question 3 – Assessing the Flow/Volume Curve

Which of the following can be said about the curve?A.  This curve shows a pattern

of taking a second breathB.  Despite variable flow, this curve

is acceptableC.  Variable flow makes this

effort non-acceptableD.  Tongue or other soft tissue

impeding flowE.  B and D

Reference: National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013.



Quiz Question 3 – ANSWERWhich of the following can be said about the curve?A.  This curve shows a pattern

of taking a second breathB.  Despite variable flow, this curve

is acceptableC.  Variable flow makes this

effort non-acceptableD.  Tongue or other soft tissue

impeding flowE.  B and D



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Which of the following can be said about the green FV curve?A.  Shows poor startB.  Shows sub-maximal effortC.  The correction is take a bigger

inhalationD.  All of the aboveE.  A and B

Flow(L/S)

Volume(L)

Reference: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.



Quiz Question 4 – ANSWER

Which of the following can be said about the green FV curve?A.  Shows poor startB.  Shows sub-maximal effortC.  The correction is take a bigger

inhalationD.  All of the aboveE.  A and B

Flow(L/S)

Volume(L)





Which of the following can be said about the curve?

A.  This FV curve is acceptable

B.  Poor effort yielding variable flow rates

C.  Early termination

D.  None of the above

Reference: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.

Flow (L/S)

Volume (L)


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Quiz Question 5 – ANSWERWhich of the following can be said about the curve?

A.  This FV curve is acceptable

B.  Poor effort yielding variable flow rates

C.  Early termination

D.  None of the above

Reference: 1. National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013. 2. US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.

Flow (L/S)

Volume (L)



How Would You Fix This Problem?

Volume (L)

Flow (L/S)




Which of the following can be said about the curve?A.  Variable flow ratesB.  Coughing throughout the expirationC.  A and BD.  Tongue or other soft tissue

obstructing flowE.  A and D


Volume (L)

Flow (L/S)


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Quiz Question 6 - ANSWERWhich of the following can be said about the curve?A.  Variable flow ratesB.  Coughing throughout the expirationC.  A and BD.  Tongue or other soft tissue

obstructing flowE.  A and D


Volume (L)

Flow (L/S)




Which of the following can be said about the curve?A.  Re-instruct patient on proper

technique and repeat test

B.  Two efforts are submaximal

C.  This test does not meet reproducibility criteria

D.  A, B and C


Volume(L)

Flow(L/S)



Quiz Question 7 – ANSWERWhich of the following can be said about the curve?A.  Re-instruct patient on proper

technique and repeat test

B.  Two efforts are submaximal

C.  This test does not meet reproducibility criteria

D.  A, B and C


Volume(L)

Flow(L/S)


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Quiz Question 8Which of the following can be said about the curve?A.  The patient was violently shaking

the spirometerB.  The patient was coughing during

the maneuverC.  The patient should keep trying

until he/she gets it rightD.  B and C




Quiz Question 8 – ANSWERWhich of the following can be said about the curve?A.  The patient was violently shaking

the spirometerB.  The patient was coughing during

the maneuverC.  The patient should keep trying

until he/she gets it rightD.  B and C




Responding to Cough

•  Stop and reassess

•  See if patient can continue

•  May signal time to stop

•  Never force patient to continue

•  Offer patient some water

•  Some efforts may still be valid

•  Cough in first second usually invalidates effort



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Automated Device Feedback

•  Assessing the curve quality—machine generated prompts–  Many spirometers help identify problems after an effort with prompts.

For example, the prompt may say:•  “Blast out faster” indicating the patient needs to blow out

more explosively•  “Blow out longer” indicating that the patient did not blow out

long enough

–  These alerts first indicate the maneuver was not acceptable and secondly offer corrective action

Reference: ndd Medical Technologies. EasyGuide: Operator's Manual. Andover, MA: ndd Medical Technologies: 2011.



Assessing Test Quality

•  Many brands of spirometers help assess the session by applying a quality “grade” upon completion of the session

•  These quality grades are not a substitute for your own review•  They often will not detect issues like air leak, cough and poor effort•  When you (or the device) have determined the test is suboptimal, try:–  Performing up to eight total efforts until three acceptable efforts are

achieved–  If the device allows, consider deleting obvious poor efforts as they occur—

use with caution. When in doubt, keep the test

Reference: 1. Burton D, et al. Spirometer Users’ and Buyers’ Guide. Melbourne: National Asthma Council Australia, 2013. 2. Hankinson J L, Quanjer P, Stocks J, et al. Use of FVC and FEV1 quality criteria to select subjects for inclusion in research studies. American Journal of Respiratory and Critical Care Medicine. 2011;183:A3309. 3. Miller MR, et al. Standardisation of spirometry. Eur Respir J 2005;26:325. http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2011.183.1_MeetingAbstracts.A3309. Accessed November 12, 2013.



Graded “A” by Device


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Spirometry 360 Grading SystemSpirometry 360 Grade Age Seven Years or Older1 Age Six or Younger2

A 3 acceptable efforts and variance ≤ 150ml (meets all ATS rules)

2 acceptable efforts and variance ≤ 100ml or 10% of FVC

B 2 or 3 acceptable efforts and variance ≤ 150ml

Not used

C* 2 acceptable efforts and variance ≤ 200ml

1 acceptable effort

UC (Use with Caution) 1 acceptable effort Not used

NP (Not Passing) No acceptable efforts or any acceptable efforts with variance > 200ml

No acceptable efforts

References: 1. Perez-Padilla R, et al; on behalf of the PLATINO Group. Spirometry quality-control strategies in a multinational study of the prevalence of chronic obstructive pulmonary disease. Respir Care. 2008;53:1019-1026. 2. Beydon N, et al. An official American Thoracic Society/European Respiratory Society Statement: Pulmonary function testing in preschool children. Am J Respir Crit Care Med. 2007;175:1304-1345.

* A test graded as “C” is typically still clinically useful.


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What Happened Here and How Would You Fix This?

8 yr old MaleHeight: 48”Weight: 58lbs

Measurement Best %Pred Trial 1 Trial 4 FVC(L) 1.09 66 0.99 0.87 FEV1(L) 0.72 49 0.52 0.59 FEV1/FVC(%) 66 53 68 PEF(L/s) 1.38 38 0.79 1.03 FET(s) 9.38 7.15 4.95 Efforts: 4 FVC VAR: 100ml FEV1 VAR: 130ml

Reference: Miller MR, et al. Standardisation of spirometry. Eur Respir J 2005;26:325.


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CDC Quality Assessment Guide

Reference: US Department of Health and Human Services (DHHS). National Institute for Occupational Safety and Health (NIOSH). Get Valid Spirometry Results Every Time. DHHS (NIOSH) Publication No. 2011-135. CDC Web site. http://www.cdc.gov/niosh/docs/2011-135. Accessed February 10, 2014.


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Grade options:A.  AB.  BC.  CD.  UCE.  NP

Spirometry 360™ ©University of Washington

Grade this test

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Grade options:A.  AB.  BC.  CD.  UCE.  NP

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Grade this test

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Knee Shape FV Curve in Teen—Normal Variant

Reference: 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.



Bonus Material

Unusual Spirometry



What Happened Here?


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Air Leak


•  Look for gradual loss of volume on VT and small loss of volume on FV curve

•  Solution: check seal around mouthpiece



What Happened Here?

Flow (L/S)

Volume (L)

Volume (L)

Time (Seconds)



Your Clue…


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Obstructed Mouthpiece

•  Check fingers and tongue placement

Volume (L)

Volume (L)

Time (Seconds)

Flow (L/S)




Extra Breath

Flow(L/S)

Volume (L)

Volume(L)

Time (Seconds)Reference: National Institute for Occupational Safety and Health (NIOSH). 2012 Spirometry Quality Assurance: Common Errors and Their Impact on Test Results. 2012. http://www.cdc.gov/niosh/docs/2012-116/pdfs/2012-116.pdf. Accessed November 11, 2013.



Find the errors. Choose all that apply:A.  Early terminationB.  Slow startC.  Variable flowD.  CoughE.  Sub-maximal effortF.  Extra breath


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Find the errors. Choose all that apply:A.  Early terminationB.  Slow startC.  Variable flowD.  CoughE.  Sub-maximal effortF.  Extra breath


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Review

•  How to identify and correct the most common errors–  Slow start–  Early termination–  Cough–  Variable flow–  Sub-maximal effort

•  Assessing test quality–  Your grade always supersedes an automated device grade!

•  Unusual spirometry–  Air leak? Obstructed mouthpiece?



Thanks for Watching!

•  Download resources–  Spirometry 360 Cheat Sheets –  CDC-NIOSH resources

•  Continue to Provider/Coach Combined Learning Lab to complete Coach training


8/4/15 - spirometry 360 · quiz question 1 – assessing the volume/time curve which of the...

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