Protocol for Spirometry: Volunteers in Medicine

Spirobank G USB                             

Warren S. Goff, DO                      
6-28-2011                                    

Volunteers in Medicine Spirometry Program

First Insert the Mouthpiece into the disposable Turbine and Insert the Turbine end fully into the round aperture as pictured above and twist to lock it in place.

 The Turbine also comes pre-packaged and attached.

Setting up the Spirometer:

1. Click to begin
   
    
   


 

2. Click the button under ESC  to Start.
   
   .
   
    (The Tool Button lets one setup the spirometer.)
                  This has already been done!)
   
   One may choose the Predicted Equation Set used by the Spirobank under Tools.
   Knudson USA is the default that I provided.
   When the USB connection with the Laptop is established, one may choose a different set of equations.
   NHANES set is the best choice and it is the Reference Set used in the interpretation program (below)
    
3. Click Under the Person Icon  to enter the demographic information to calculate the predicted values.



4.  Clicking starts a new patient's study. Any study already stored in the unit will be erased! 
   
    
   
                                   
   
   The Small Arrow indicates the value to change: .
   Use the Up or Down arrows to change the values to the left.
   The On Key moves forward to the next value.
   The Left Arrow moves to the Prior Menu.
   When the S column is selected this menu appears:
   
    
5. Scroll through and select the proper Sex. The icon animates when Selected. Click OK to Select Gender.
   
   
   
   Scroll down to choose an Ethnic Group for a Correction Factor to be added to the calculations. Click On to select.

 The parameters needed to calculate the Predicted Values are Age, Sex, Race and Height. Weight is also requested.
 


 

6. At this point all demographic information is complete.
   
   One can now proceed to the test.
   
   You may scroll through the 3 additional icons  as before and Click On to Select.
   
                                    
   
   For our purposes this will be the only needed selection.
   
   A Dynamic Spirogram will be performed (Forced Expiration and Inspiration).
   
                                    
   
   This option allows a Slow Vital Capacity (SVC) and Static Volumes to be Measured. Also, a Maximal Voluntary Ventilation (MVV) measurement can be performed. These will not be reviewed in the present Protocol and are generally not required on a routine basis.
   The MVV is a good measure of effort and reserve.
   The SVC is useful to compare with the FVC to assess for Air Trapping.
   
                            
    Choosing this Icon allows you to scroll through the results already stored in memory. As stated, the Spirobank G stores only one study at a time.
    
7. At this point you may perform the Spirometry!

1. Please explain to the patient what to expect.
2. First place the provided Nose Clip securely over both nares. (You should clean them with alcohol between patients.)
3. The test may be performed either sitting or standing.
1. It is important to note the position of the patient for the test as future studies will need to be performed in the same position for comparison sake.
2. In my opinion, the standing position is best as most predicted regression equations are generated in this manner.
3. In obese individuals, a sitting Spirogram may introduce a Restrictive Component to the test, as the compression of the Abdominal Contents restricts diaphragmatic excursion.
4. On the other hand, some patients will become dizzy with the forced maneuver and a seated posture might be preferred.
5. A chair or table to sit on must be readily available in either instance.
• It is essential to obtain a Maximal Effort from the patient.
1. The examiner must make it clear that we need this to the patient.
2. Take a mouthpiece and demonstrate what is expected first. Have the patient practice the technique also.
1. The subject is to take as deep an inspiration as possible.
2. The examiner states "Take a DEEP BREATH...DEEP...DEEP...DEEP..."
3. At this point the mouthpiece is placed in between the sealed lips (not between the teeth and make sure the tongue is not in the mouthpiece)
4. The patient is told to Blow Out as hard, fast and as long as possible.
5. The examiner extorts" "BLOW...BLOW...BLOW...KEEP BLOWING..."
6. Then when the forced expiration has finished, the patient is told to "BREATH IN HARD...KEEP GOING...KEEP GOING..."
7. It's important to use a LOUD, ANIMATED voice
3. The spirometer records the trial and comments on the adequacy.
4. One must perform 3 efforts and 2 out of the three must be adequate and the values reproducible. One should wait an amount of time in between efforts to allow the patient to recover. Sometimes, 5-10 minutes are required.
• This will appear after each effort:
   
  
  One may scroll through the results and then proceed with the next one.
  Up and Down scrolls through the present screen.
  Enter switches to the next screen.
  The Back arrow returns to . Selecting   returns to and you may obtain the next effort.
   
• When 3 efforts have been recorded, the unit acknowledges the adequacy and provides a simple interpretation.
• This is all that the unit will store. A Simple Spirogram on a Single patient is now complete.
• We will also often need a Post-Bronchodilator trial. This must be performed as a second test. Neither the Spirobank-G or the WinSpiro PC program includes a Pre- and Post BD algorithm and the response must be calculated manually. My program will hopefully alleviate this limitation with a few caveats (later).
• Therefore, once the Simple Spirogram has been completed, you should immediately connect the unit to the PC via USB and run the WinSpiro
• At this point you will enter the patient's name and demographic information. All that the WinSpiro PC-program does is generate a Acrobat (pdf) file with the data and graphs.
• Please make sure that you include in the name of the file either Pre- or Post- if two studies have been done. This will allow comparison calculations later.
   

If you fail to dump the data to the WinSpiro program and start a second study on the Spirobank G,
all previous data will be lost!
 
 

Here is an example of the Print Out PDF from WinSpiro Express Software:




The graphic provides the results of all 3 trials in two formats.
The top graph is a Volume-Time Study while the bottom graph is a Flow-Volume Loop.
An inspiratory limb on the FVL is provided which is useful in identifying an Extrathoracic Upper Airway Obstruction.
The loops are also essential in assessing the Adequacy of Effort.
All three trials values are tabulated and the best ones from each study are listed on top.

A Post-Bronchodilator Study is performed in exactly the same fashion.

            One first administers an inhaled bronchodilator such as 2 puffs of an Albuterol HFA.
           This is a great opportunity to teach the patient the proper technique for using the medication.
           One may use a spacer device to facilitate dosing or a use nebulized Albuterol.

                                                   DO NOT USE a long acting bronchodilator!

               Generally, one should wait 10-15 minutes before assessing the response to inhaled bronchodilators.
               After this interval, repeat from number # 7 above.

Volunteers in Medicine Spirometry Program

Version 1.0
By Warren S. Goff, DO
6-30-2011

This program is written in Visual Basic 6.0 and is based upon a variety of rules and conventions for the interpretation of Spirometry, both pre- and post- Bronchodilator.

It has been customized for the Spirobank G USB using the WinSpiro Express PC software. It only interprets a Dynamic Study (e.g. Flow Volume Loop and Volume Time Curve).

The parameters may all be entered by hand.

At present one can drag and drop the pdf file generated by the WinSpiro PC Program into the Pre- or Post- BD labels. The data is parsed from the PDF presuming a consistent, reproduceable format from WinSpiro. One must verify that the correct values have appeared.

The program is a work in progress. There are no guarantees as to the accuracy of the results and they must be reviewed and confirmed by a clinician. The user agrees to hold Dr. Goff harmless in these regards by Accepting the Disclaimer.



The program is open source and the source code is included in the installation directory.

Below is the only documentation provided:

After installation an icon appears on the Desktop:

When the program is executed the following window appears:

One may manually type in a set of values. You must provide at least a Pre-Bronchodilator complete set.
If the Post-Bronchodilator values are not provided, the Pre-BD values will be interpreted alone.
Otherwise they will be compared.

One may drag a previously saved pdf file (from WinSpiro) onto the Pre- and/or Post-Bronchodilator   Labels and the Spirometric fields should be inserted as in the animation below:



One may also drag the Post-BD pdf file to the Post-Bronchodilator Label resulting in the following example:



Alternatively, one can drag and drop another WinSpiro PDF file to the Post-Bronchodilator box for comparison sake.
This feature allows one to compare spirometries over time. The significance of changes are based upon the time interval for comparison and they are not standardized. Therefore the Post-BD comparison report may not be appropriate.
Significant changes over days and weeks have been suggested:

Changes        FVC   FEV1     FEF25-75%
-Daily
   Normal       5%    5%       13%
   Obstruct    11%   13%       23%

-Weekly
   Normal      11%   12%       21%
   Obstruct    21%   23%       30%

This menu set has been added to allow comparisons over time based upon the above values.

 The WinSpiro PDF File is also copied to the Patient Subdirectory. One may open and view the WinSpiro PDF File later.



The data can also be saved to a separate file (.pft) and be re-opened. One may open the Patient Directories and select a PDF file to drag and drop again.

With all of the data completed,  click GO  and the Predicted Values (NHANES III) will be calculated, tabulated and a report generated.

The following options now appear:

Choosing Dynamic  displays the Actual Values, the Predicted Values and the Percent Predicted:

Upon closing this window, click GO  again and Choose :

Upon closing this window, click GO  again and Choose :

Upon closing this window, click GO  again and Choose to Preview the Print Out:

A larger view can be generated by clicking

Finally you may Print  the Report to the available printers:

The GOLD Criteria for COPD Criteria are summarized below.

The GOLD Criteria are based upon Post-Bronchodialtor values only.

These recent criteria for the indications for Spirometry and Treatment for COPD have been incorporated:

The Help Options allow you to read this Tutorial, download the compiled program or visit the webpages.

In addition, a Tutorial on Flow Volume and Volume Time Loops is provided.

Addendum: Features will be added and suggestions appreciated...

References:

1. American Thoracic Society: The Standardization of Spirometry NOVEMBER 11, 1994
2. MIR Turbine Instruction Guide
3. CDC - Spirometry - Spirometry Training Program NHANES III Reference Values - NIOSH Workplace Safety and Health Topic
4. PFT Powerpoint Lecture Slides
5. Spirometric Reference Values from a Sample of the General U.S. Population JOHN L. HANKINSON, JOHN R. ODENCRANTZ, and KATHLEEN B. FEDAN
6. CyberJournal of Medicine