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Spirometry in Primary Care Practice(*)

Authors: Tam Eaton, Steve Withy, Jeffrey E. Garrett, Jill Mercer, Robert M. L. Whitlock and Harry H. Rea Date: Aug. 1999

From: Chest(Vol. 116, Issue 2) Publisher: Elsevier B.V.

Document Type: Article Length: 4,638 words

The Importance of Quality Assurance and the Impact of Spirometry Workshops

Objective: To determine the quality of spirometry performed in primary care practice and to assess the impact of formal training.

Design: Randomized, controlled prospective interventional study.

Setting: Primary care practice, Auckland City, New Zealand.

Participants: Thirty randomly selected primary care practices randomized to "trained" or "usual" groups. One doctor and one practice nurse were nominated to participate from each practice.

Interventions: "Trained" was defined as participation in an "initial" spirometry workshop at week 0 and a "maintenance of standards" workshop at week 12. "Usual" was defined as no formal training until week 12, when participants they attended the same "initial" workshop provided for the trained group. The study duration was 16 weeks. Each practice was provided with a spirometer to be used at their clinical discretion.

Measurements and results: Spirometry data were uploaded weekly and analyzed using American Thoracic Society (ATS) criteria for acceptability and reproducibility. The workshops were assessed objectively with practical and written assessments, confirming a significant training effect. However, analysis of spirometry performed in clinical practice by the trained practitioners revealed three acceptable blows in only 18.9% of patient tests. In comparison, 5.1% of patient tests performed by the usual practitioners had three acceptable blows (p [is less than] 0.0001). Only 13.5% of patient tests in the trained group and 3.4% in the usual group (p [is less than] 0.0001) satisfied full acceptability and reproducibility criteria. However, 33.1% and 12.5% of patient tests in the trained and usual groups, respectively (p [is less than] 0.0001), achieved at least two acceptable blows, the minimum requirement. Nonacceptability was largely ascribable to failure to satisfy end-of-test criteria; a blow of at least 6 s. Visual inspection of the results of these blows as registered on the spirometer for the presence of a plateau on the volume-time curve suggests that [is less than] 15% were acceptable.

Conclusions: Although a significant training effect was demonstrated, the quality of the spirometry performed in clinical practice did not generally satisfy full ATS criteria for acceptability and reproducibility. Further study would be required to determine the

clinical impact. However, the ATS guidelines allow for the use of data from unacceptable or nonreproducible maneuvers at the discretion of the interpreter. Since most of the failures were end-of-test related, the [FEV.sub.1] levels are likely to be valid. Our results serve to emphasize the importance of effective training and quality assurance programs to the provision of successful spirometry in primary care practice. (CHEST 1999; 116:416-423)

Key words: primary care practice; quality assurance; randomized controlled; spirometry; spirometry workshops

Abbreviations: ATS = American Thoracic Society; PEF = peak expiratory flow

Spirometry is pivotal to the screening, diagnosis, and monitoring of respiratory disease and is increasingly advocated in primary care practice. Earlier this year, CHEST published a comprehensive supplement entitled "Strategies in Preserving Lung Health and Preventing COPD and Associated Diseases."[1] This major new initiative is known as the National Lung Health Education Program and is directed at primary care physicians. The campaign is clearly underpinned by spirometry. COPD is a leading cause of both morbidity and mortality, not only in the United States but also in most developed countries, including New Zealand.[2,3] However, airflow obstruction is also a marker of increased risk of death from heart disease, lung cancer, and stroke.[4-6] A recent consensus statement of the European Respiratory Society emphasized the importance of spirometry in allowing the early diagnosis of COPD in asymptomatic patients.[7] Smoking cessation strategies then may be more appropriately directed, potentially yielding an immense public health gain.

Although spirometry is often described as a simple screening test, due consideration is essential not only of equipment selection, but, importantly, of test performance and correct interpretation of the results. In 1991, the American Thoracic Society (ATS) Statement on Lung Function Testing stated: "The largest single source of within subject variability is improper performance of the test."[8] This was persuasively addressed in the Lung Health study, particularly with regard to the importance of ongoing maintenance of standards.[9,10] Hence, effective training and quality assurance are vital prerequisites for successful spirometry.[11] While well-established criteria for acceptability and reproducibility have been widely disseminated, it is by no means certain that these are adhered to in clinical practice. Excepting research studies and accredited pulmonary function laboratories,[12] there are no formal quality assurance programs in place. Quality assurance is crucial to prevent misleading results and misdiagnoses. If spirometry is to be promoted as a screening tool in primary care practice, it is important that careful attention is paid to ensuring that quality standards are met.

No previous study has formally assessed spirometry performance in primary care practice. The development of "smart" spirometers has enabled the quality of spirometry performed in clinical practice to be objectively assessed using the ATS criteria for acceptability and reproducibility.[11] We aimed to determine both the quality and the impact of training on spirometry performed in primary care practice.

MATERIALS AND METHODS

Participants

A randomized, controlled prospective study was performed to examine the quality of spirometry in primary care practice. Practitioners were invited to participate by an introductory letter, sent to 301 primary care practices; 119 of 301 practices (40%) accepted. Thirty of 119 practices (25%), each nominating one doctor and one nurse, were randomly selected to make up the final study group. Local ethics committee approval was obtained.

Three separate evaluations were performed:

1. Spirometry quality (using ATS criteria) was examined in all patient tests (n = 1,012);

2. Practical and written assessments were used to quantify the training effect of the spirometry workshops; and

3. Indications for (n = 580) and interpretations of (n = 559) spirometry were inspected using a randomly selected subgroup.

Study Design

As shown in Figure 1, practices were randomly assigned to spirometry training ("trained" group, n = 15) or to the performance of spirometry without prior instruction ("usual" group, n = 15).

In the trained group, the doctors and practice nurses attended an "initial" spirometry workshop at week 0 and a further "maintenance of standards" workshop at week 12.

In the usual group, the spirometer was delivered to the doctor and nurse with instructions for its operation, but no training in spirometry performance was given. At week 12, they attended the same spirometry workshop provided in week 0 for the trained group.

Spirometry Workshops

The initial workshop was 2 h in duration and comprised theoretical and practical aspects of spirometry performance, with particular attention paid to acceptability and reproducibility criteria and the importance of quality assurance (see "Appendix"). The spirometry workshops were led by the clinical director of our pulmonary function laboratory, two consultant pulmonologists, a clinical respiratory scientific officer, and charge respiratory technician. All had [is greater than] 15 years of experience in the field. This workshop was held at week 0 for the trained group and week 12 for the usual group. The trained group received a 90-rain "maintenance of standards" workshop at week 12. Quality assurance was emphasized.

Following the workshops, the results of the written and practical assessments and feedback on the spirometry they had performed in the previous 12 weeks (provisionally analyzed for acceptability and reproducibility) were discussed individually with each practitioner.

Spirometers

Each practice was provided with a handheld spirometer (2120 U; Vitalograph Limited; Buckingham, UK) certified by Dr. R.O. Crapo, MD (Medical Director of the Pulmonary Laboratory at LDS Hospital, Salt Lake City, UT) as meeting ATS standards.[11] This unit uses a pneumotachograph flow sensor. A perceived advantage of the unit was the provision of "built-in" quality assurance features, based on ATS criteria.[11] Prompts were displayed after each blow for an unacceptable blow (eg, slow start, or abrupt end), for recommending the performance of three or more blows, and giving the variability between the two largest values for [FEV.sub.1] and for FVC.

Data Collection

During the study period, only the nominated doctor and/or practice nurse from each practice used the spirometer. Both groups were provided with the clinical indications for spirometry.[13] They were advised to use the spirometer entirely at their clinical discretion. The spirometer had a 100-test memory, allowing data to be uploaded at weekly intervals; in this way any study effect on the generation of spirometry by the participants was minimized. A unique patient identification code was entered. Standard demographic data (age, sex, height, and ethnicity) were entered with the derivation of normal predicted values.[14,15] For study purposes, only expiratory parameters were measured: [FEV.sub.1], FVC, peak expiratory flow rate, and forced expiratory flow (midexpiratory phase).

Primary Outcome Assessments

Spirometry Quality Assurance: All the spirograms generated by the practitioners during the study period were analyzed for acceptability and reproducibility as specified by the ATS quality criteria.[11]

Acceptability Criteria: Individual spirograms were judged "acceptable" if all of the following were satisfied: good start (as defined by an extrapolated volume [is less than] 5% of FVC or 150 mL, whichever is greater); satisfactory exhalation for [is greater than or equal to] 6 s; free from abrupt end; and free from cough.

Reproducibility Criteria: After three acceptable spirograms were identified, the following tests were applied. Were the two largest FVC values within 200 mL of each other? Were the two largest [FEV.sub.1] values within 200 mL of each other? If both these criteria were satisfied, the test was judged reproducible.

"Good start" has also been defined by time-to-peak expiratory flow (PEF). Time-to-PEF is not currently a standard recommendation in the ATS criteria[11] and, hence, was not used in the overall analysis of acceptability. However, the spirometry unit used in this study incorporated quality prompts with poor start (defined as a time-to PEF [is greater than] 85 ms), as did the Lung Health study.[9]

Since blows of [is less than] 6 s may be acceptable if a plateau is reached, a random selection of these blows was scrutinized

by two experienced pulmonologists. All blows [is less than] 4 s were automatically judged nonacceptable. A plateau was defined as no visible change in volume for at least 1 s.

Practical and Written Spirometry Assessments: Both groups were formally assessed on practical performance of spirometry at week 19. (see "Appendix"). Each practitioner was asked to perform spirometry on a "naive subject" and was scored on a scale of 1 to 10 by one of five trained examiners. Although the examiners were not blinded, scoring bias was minimized by using stringent objective criteria. A score of 8 was judged "acceptable." The trained group completed a written assessment before and immediately after the week 0 workshop. The same assessment was repeated before the week 12 workshops in both groups. The assessment included only material presented at the workshop. We developed a video of "poorly performed" spirometry containing five errors to be identified. The written and practical assessments were fed back to the trained group at week 12 (ie, the formative assessment).

Indications for and Interpretation of Spirometry: At the end of the study, each practice was provided with 25 patient identifications, randomly selected from their patients who had performed spirometry in the preceding 16 weeks. Patient demographic data were recorded, and the doctor was asked to specify the indication for spirometry (eg, screening of an asymptomatic smoker). For each spirometric record, the doctor was asked to provide an interpretation, choosing from the following possibilities: normal, early small airways disease, obstruction, restriction, mixed obstruction/restriction, inability to interpret due to inadequate spirometry, and other. These records were then reviewed by two experienced pulmonologists. The same information was provided as was available to the primary care physician; patient demographic data, "indication," forced expiratory indexes with normal predicted values, the expiratory curve, and the acceptability and reproducibility prompts. Primary care physician interpretations were then marked as "correct" or "incorrect."

Statistical Analysis

Data were normally distributed and were presented as mean (SD). Proportions were compared by Fisher's Exact Test. Changes in scores were analyzed using paired Student's t test. Logistic regression was used to explore predictors of "acceptable" spirometry. A p value [is less than] 0.05 was considered significant. All analyses were performed on a personal computer (IBM-compatible) using appropriate software (SAS, version 6.1 for Windows; SAS Institute; Cary, NC).

RESULTS

A total of 1,012 patient tests (2,928 blows) were performed. The mean number (SD) of patient tests per practice per week was 2.3 (2.4). Patient demographic data included the following: mean age, 46.0 years (range, 5 to 90 years); and patients were equally divided by gender (male/female ratio, 1:0.98). The majority of patients were either white (83%) or Maori/Pacific Islander (12.5%), reflecting the ethnic distribution in the Auckland region.

Spirometry Quality Assurance

Spirometry quality for weeks 0 to 11 is shown in Table 1. Patient tests satisfied ATS criteria for acceptability and reproducibility more frequently in the trained group than in the usual group (p [is less than] 0.0001). Nonacceptability was largely ascribable to failure to satisfy end-of-test criteria (Table 2). From a total of 2,928 blows, 825 (28%) were [is greater than] 6 s, and 1,380 (47%) were [is less than] 4 s and were rejected automatically. The remaining 723 blows (25%) of 4 to [is less than] 6 s duration may have been acceptable on further scrutiny. Visual inspection of 245 blows (33%) demonstrated a plateau in 90 (37%). This finding suggests that [is less than] 15% of blows that were judged unacceptable on the grounds of inadequate duration were acceptable. Individual blows were more often unacceptable in the usual group (p [is less than] 0.0001); however, following the week 12 workshop, a clear training effect was observed (p [is less than] 0.0001) (Fig 2). The proportion of acceptable blows was then consistent with the trained group. Lung function and spirometry quality assurance data were tabulated by age (Table 3). On logistic regression, the major determinant of an acceptable maneuver was "training" (p = 0.0001). Blows were more often unacceptable at the extremes of age ([is less than] 10 years and [is greater than] 80 years; p = 0.01), in women (p = 0.05), and in non-Europeans (p = 0.006).

Data Trained Usual

No. of patient tests 275 471 No. of blows 923 1,285 Patient tests 3 blows 242 (88.0) 369 (78.3) [is greater than or equal to] 3 acceptable blows 52 (18.9) 24 (5.1) [is greater than or equal to] reproducible blows 37 (13.5) 16 (3.4) [is greater than or equal to] 2 acceptable blows([dagger]) 91 (33.1) 59 (19.5)

Data p Value

No. of patient tests No. of blows Patient tests 3 blows 0.0008 [is greater than or equal to] 3 acceptable blows <0.0001 [is greater than or equal to] reproducible blows <0.0001 [is greater than or equal to] 2 acceptable blows([dagger]) <0.0001

Data Trained Usual

No. of blows 923 1,285 Blows with poor start([dagger]) 32 (3) 32 (2) Blows with unsatisfactory exhalation Duration < 6 s 565 (61) 1,078 (84) Abrupt end 263 (28) 674 (52) Blows with cough 16 (2) 26 (2) Blows with poor start([dagger]) 296 (32) 461 (36)

Data p Value

No. of blows Blows with poor start([dagger]) NS Blows with unsatisfactory exhalation Duration < 6 s <0.0001 Abrupt end <0.001 Blows with cough NS Blows with poor start([dagger]) NS

Table 1--Spirometry Quality Assurance Data From Weeks 0 to 11 Comparing Trained With Usual Practitioners(*)

(*) Values given as No. (%), unless otherwise indicated.

([dagger]) The ATS statement specifically states that "the only criterion for unacceptable subject performance is fewer than two acceptable curves."(11)

Table 2--Spirometry Quality Assurance Data From Weeks 0 to 11 and Reasons for Lack of Acceptability(*)

No. of Age, yr Patients [FEV.sub.1], %pred [FVC.sub.1], %pred

< 10 50 85.8 (16.4) 87.9 (16.8) 10-19 163 87.7 (19.4) 94.3 (20.8) 20-29 240 97.7 (21.5) 97.7 (22.3) 30-39 344 99.2 (22.2) 98.9 (21.6) 40-49 348 97.3 (23.3) 96.4 (24.3) 50-59 291 95.7 (23.2) 93.8 (23.1) 60-69 315 83.4 (21.4) 79.1 (18.2) 70-79 197 85.2 (21.8) 83.7 (20.6) 80-89 35 83.1 (22.5) 82.7 (25.0)

Patient Tests With [is greater than or equal to] 3 Acceptable Age, yr [FEV.sub.1]/FVC, %pred Blows, No. (%)([dagger])

< 10 102.3 (10.2) 0 (0) 10-19 95.5 (13.2) 0 (0) 20-29 101.6 (11.8) 2 (2.1) 30-39 101.4 (13.9) 11 (8.6)

(*) Values given as No. (%) unless otherwise indicated. NS = not significant.

([dagger]) Poor start defined as the extrapolated volume > 5% FVC or 150 mL, whichever amount is greater.

([double dagger]) Poor start defined as time-to PEF > 85 ms, as in the Lung Health study?

Table 3--Lung Function and Spirometry Quality Assurance Data Characterized by Age(*)

40-49 99.9 (14.8) 11 (9.0) 50-59 99.3 (17.1) 15 (12.9) 60-69 101.0 (20.5) 22 (20.0) 70-79 98.7 (32.2) 14 (18.2) 80-89 95.5 (20.3) 1 (5.9)

(*) Values given as mean [+ or -] SD. %pred = percent predicted.

([dagger]) Weeks 0 to 11.

Practical and Written Spirometry Assessments

The practical spirometry assessment performed at week 12 demonstrated a higher proportion of practitioners performing "acceptable" spirometry in the trained group (16/24 [67%]) than in the usual group (4/25 [16%]) (p = 0.0004) (Fig 3). Written assessments were performed by the trained group before and after their spirometry workshop at week 0, with mean preworkshop scores of 16 (range, 14.3 to 17.7) for doctors and 6.2 (range, 4.5 to 7.8) for nurses. Immediately after the workshop, scores improved to a mean scores of 26.3 (range, 23.7 to 28.8) and 17.6 (range, 15.3 to 20), respectively (p [is less than] 0.0001) (Fig 4). At week 12, immediately before the maintenance of standards workshop, the scores had fallen for doctors to a mean of 23.5 (range, 21.7 to 25.3; p = 0.02) but had not for nurses (mean, 17.1; range, 13.6 to 20.6).

Indications for and Interpretation of Spirometry

A random selection of 580 of 1,012 patient tests (57%) were further analyzed. Patient demographics did not differ significantly in this subgroup. The indications given for performing spirometry were the following: management of asthma (41%); investigation of respiratory symptoms (22%); COPD (14%); screening of asymptomatic smokers (8%); and insurance/medical exams (3%). Practitioners believed that results of spirometry testing helped in counseling smokers in 13% of patient tests. A total of 559 patient tests were assessed by two experienced pulmonologists. The primary care physician's interpretation was judged correct in 296 of 559 patient tests (53%). The proportion of correct interpretations did not differ significantly between the trained and usual groups of primary care physicians.

DISCUSSION

This is the first study to formally address the quality of spirometry performed in primary care practice. Spirometry performed in clinical primary care practice did not generally satisfy ATS criteria for acceptability and reproducibility, both before and after formal training, although a significant training effect was observed. Is it possible the ATS criteria are unnecessarily rigorous? Published data would suggest not. The Lung Health Study demonstrated that in only 2.1% of test sessions were participants unable to produce three acceptable FVC maneuvers, with the two best [FEV.sub.1] values matching within 5% or 100 mL.[9] This was more stringent than the ATS criteria of 200 mL that we used.[11] However, a direct comparison with the Lung Health study may not be entirely appropriate due to differences in the study population; patients with COPD may find it easier to comply, especially with end-of-test criteria. The primary aim of our study was to address the quality of spirometry performed in clinical practice. This necessarily required the use of well-defined standard objective criteria. We believe that these criteria served the purpose of assessing the effect of training, but this study was not designed to assess the impact of poorly performed spirometry on clinical practice.

There is a danger of undue negativity based on an uncritical "interpretation" of our data. The ATS statement allows for the use of data from unacceptable or nonreproducible maneuvers at the discretion of the interpreter. We appreciate that a blow of [is less than] 6 s may be acceptable if a plateau has been achieved. Further analysis suggested that this was only achieved in a small proportion of blows. It is likely that primary care practitioners, practice nurses, and, indeed, the patients have been well schooled in the use of a peak flow meter for asthma. Since asthma was given as the indication for testing in 40% of eases, this may be a possible explanation for the relatively "good starts" but unacceptably "short" blows. However, since the majority of test failures were end-of-test related, the [FEV.sub.1] level is likely to be valid and could be used for serial monitoring. Failure to meet the ATS criteria does not necessarily imply that the test performance was clinically invalid or unusable. Satisfaction of rigid criteria is likely to be crucial only when abnormalities are marginal. In most eases, results are likely to be interpretable if values are within normal limits or are substantially deranged. However, minor abnormalities should be interpreted with great care.

Our spirometry workshops were successful, as judged by the traditional performance criteria of written, and practical assessments. These assessments were incorporated into our workshops both to reinforce educational goals and to provide objective measures of the efficacy of our training. The pre-workshop written assessment exposed low baseline knowledge. Immediately postworkshop, the scores improved significantly, albeit representing short-term recall only. The results of retesting at week 19, demonstrated the need for continuing education to maintain standards. Our training program was very consistent in the magnitude of its training effect. Following week 12, when the usual groups had received the "initial" spirometry workshop

given to the trained group at week 0, both groups were achieving a very similar proportion of acceptable blows. The practical assessments also demonstrated a significant training effect. However, although statistically significant, the improvement associated with training may not have been of clinical value. An acceptable practical assessment did not necessarily translate into acceptable spirometry when performed in clinical practice. Prior to the development of "smart" spirometers, we did not have the ability to objectively assess spirometry performed in clinical practice. It is perhaps not unexpected that the results were appreciably different from those obtained using more traditional assessments. It is well recognized that knowledge may not reliably predict behavior.[16]

Although we primarily addressed the quality of spirometry performance, the interpretations of spirometry were incorrect in almost 50% of the eases reviewed. Accurate interpretation is highly dependent not only on a well-performed procedure, but also on an appreciation of physiology, appropriate choice of normal values, and clinical knowledge of the patient. Our results indicate an important gap in knowledge and understanding that dearly requires more training and experience than our workshops could provide.

It is certainly possible that longer, more intensive workshops may have produced better results. However, if spirometry is to be widely available in primary care practice, the sheer logistics of training and maintaining standards among large numbers of practitioners dictates a condensed and pragmatic training program. Our workshops did pay particular attention to the acceptability and reproducibility criteria and to the importance of quality assurance. Following the workshops, all practitioners at week 12 also received individual feedback on their written and practical assessments. Most importantly, we thought, they were given individual feedback on the quality of the spirometry they had performed in the previous 19, weeks, which had been provisionally analyzed for acceptability and reproducibility. The Lung Health Study demonstrated that, even in a dedicated research setting with meticulous attention to quality, technician performance fell over time.[9] However, the quality of spirometry not only improved dramatically, but was maintained with regular monitoring of test session quality and prompt individual feedback. We selected the Vitalograph 2120 spirometer with its inbuilt quality assurance prompts with the expectation that it would improve the quality of spirometry. This, unfortunately, did not appear to be the ease, although, to our knowledge, a comparison of performance quality between spirometers with and without quality prompts has not been done.

Even when a spirometer is available on-site, underuse remains a problem, as demonstrated by a Canadian study.[17] Despite almost 60% of doctors having direct access to spirometry equipment, primary care doctors had a low index of suspicion for COPD and markedly underused spirometry. In our study, the mean number of patient tests per week was only 2.3. The reasons for this are likely to be multifactorial and may change with further education and the use of incentives. Acknowledging the recent National Lung Health Education Program publication,[1] it is disappointing that, despite education, spirometer was dearly underutilized in the early diagnosis of COPD and in supporting smoking cessation strategies, where it has a crucial role.[18-20] The public health implications for appropriately targeted smoking cessation programs using screening spirometry are very promising.

Recent British Thoracic Society guidelines for COPD[21] acknowledge that health planners may need to consider options for the provision of spirometry in primary care practice other than having the appropriate equipment on-site. The provision of spirometry, where quality issues can be addressed and maintained, may only be achieved by limiting spirometry to a smaller number of community clinics or pulmonologists or by increasing access to pulmonary function laboratories where quality- control measures should already be in place.[12]

However, ideally, spirometry would be available on-site in the primary care practice. Our results serve as a reminder of the importance of effective training and quality-assurance programs in the provision of successful spirometry.

ACKNOWLEDGMENT: The authors are grateful to Dr. J Kolbe for his valued advice on manuscript preparation.

REFERENCES

[1] The National Lung Health Education Program Executive Committee. Strategies in preserving lung health and preventing COPD and associated diseases: the National Lung Health Education Program (NLHEP). Chest 1998; 113(suppl): 123S-155S

[2] Morbidity and Mortality Chartbook on Cardiovascular, Lung, and Blood Diseases. Bethesda, MD: National Heart, Lung and Blood Institute, 1994

[3] Core Services Committee. Core health services for 1995/6: hospital discharge data 1990-9,3. Wellington, New Zealand: Core Services Committee, 1994; Appendix 2

[4] Tockman M, Comstock G. Respiratory risk factors and mortality: longitudinal studies in Washington County, Maryland. Am Rev Respir Dis 1989; 140(suppl):S56-S63

[5] Kuller LH, Ockene J, Meilahn E, et al. Relation of forced expiratory volume in 1 second ([FEV.sub.1]) to lung cancer mortality in the mnltiple risk factor intervention trial (MRFIT). Am J Epidemiol 1990; 132:265-274

[6] Wannamethee SG, Shaper AG, Whincup PH, et al. Smoking cessation and the risk of stroke in middle-aged men. JAMA 1995; 274:155-160

[7] Siafakes NM, Vermeire P, Pride NB, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). Eur Respir J 199,5; 8:1398-1420

[8] American Thoracic Society. Lung function testing: selection of reference values and' interpretative strategies. Am Rev Respir Dis 1991; 144:1202-1218

[9] Enright PL, Johnson LJ, Connett JE, et al. Spirometry in the Lung Health Study: 1. Methods and quality control. Am Rev Respir Dis 1991; 143:1215-1223

[10] Enright PL, Connett JE, Kanner RE, et al. Spirometry in the Lung Health Study: II. Determinants of short-term intraindividual variability. Am J Respir Crit Care Med 1995; 151: 406-411

[11] American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995; 152:1107-1136

[12] Gardner RM, Clansen JL, Crapo RO, et al. Quality assurance in pulmonary function laboratories. Am Rev Respir Dis 1986; 134:625-627

[13] Crapo RO. Pulmonary function testing. N Engl J Med 1994; 331:25-30

[14] Morris JF. Spirometry in the evaluation of pulmonary function. West J Med 1976; 125:110-111

[15] Polgar G, Promadhat V. Standard values. In: Polgar G, Promadhat V, eds. Pulmonary function testing in children: techniques and standards. Philadelphia, PA: W. B. Saunders, 1971; 87-21.2

[16] Kolbe J, Vamos M, Elkind G, et al. Differential influences on asthma knowledge and self-management behavior in acute severe asthma. Chest 1996; 110:1463-468

[17] Kesten S, Chapman KR. Physician perceptions and management of COPD. Chest 1993; 104:254-258

[18] Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995; 155:1933-1941

[19] Ockne JK, Hymowitz N, Sexton M, et al. Comparison of the patterns of smoking behavior change among smokers in the Multiple Risk Factor Intervention Trial (MRFIT). Prey Med 1982; 11:621-638

[20] Morris JF, Temple W. Spirometric `lung age' estimation for motivating smoking cessation. Prev Med 1985; 14:655-662

[21] British Thoracic Society. Guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52(suppl 5):S22-S23

APPENDIX: PROGRAM FOR SPIROMETRY WORKSHOPS

Initial

1. Brief review of first principles.

2. Definitions of the variables to be measured: [FEV.sub.1], FVC, peak expiratory flow rate, forced expiratory flow (midexpiratory phase) with labeling of the spirogram and flow-volume curves.

3. Physiology of flow-volume curves.

a. the importance of obtaining good-quality spirometry;

b. definitions of acceptability and reproducibility (ATS criteria[11]); and

c. examples of expiratory flow curves: poor quality vs good quality.

Table A1--Practical Spirometry Assessment Score Sheet

Performance of FVC Maneuver(11) Score

Instruct subject on test Correct posture with head elevated 1 Inhale completely 1 Place mouthpiece and seal lips around it 1 Exhale as hard, as fast, and as long as possible 1 Ensure that subject understands (and demonstrate) 1

4. Definition of ambient temperature pressure saturated and body temperature pressure saturated.

5. Derivation of normal predicted values.

6. Interpretation of results: normal, early small airways disease, obstruction, restriction.

7. Indications for spirometry.

8. Quality issues:

9. Performance of spirometry (theory): postbronehodilator testing.

10. Demonstration of spirometry unit: maintenance, calibration, and transmission of infection issues.

11. Practical experience: entry of patient identification, demographic data, and performance of spirometry (based on ATS performance criteria[11]).

Maintenance of Standards

1. Quality assurance: revision of the importance of quality assurance; individual feedback on the quality of their spirometry from the preceding 19. weeks.

2. Interpretation of 16 representative flow-volume curves (30 min).

3. Practical performance of spirometry: basic revision plus individual feedback from each individual's practical spirometry assessment (Tables A1 and A2).

Perform maneuver Repeat instructions during performance as required 1 Coach vigorously 2 Express intention to repeat for minimum of three maneuvers 1 View results Cheek for acceptability and reproducibility 1 Maximum score 10 Table A2--Written Spirometry Assessment(*)

Spirometry Data Score

Video of poorly performed spirometry with five significant errors to be identified 5 Definitions of lung function indices 4 Labeling of a spirogram 4 Labeling of flow-volume curve 5 Parameters from which normal predicted values are derived 4 ATPS versus BTPS 1 Labeling of expiratory flow curves (normal, obstructed, or restricted) 3 Quality criteria 2 Labeling of poor-quality curves (poor start, variable effort, early termination, or cough) 4 Maximum score 32

(*) ATPS = ambient temperature pressure saturated; BTPS =: body temperature pressure saturated.

(*) From the Department of Respiratory Medicine and Clinical Physiology (Drs. Eaton, Garrett, and Whitlock, and Mr. Withy), Green Lane Hospital, Auckland New Zealand. and Department of General Medicine (Dr. Rea), Middlemore Hospital, Auckland, New Zealand.

This study was supported by a grant from the Northern Regional Health Authority and the Asser Trust.

Manuscript received June 29, 1998; revision accepted March 23, 1999.

Correspondence to: T. Eaton, MBChB, Department of Respiratory Services, Green Lane Hospital, Auckland 3, New Zealand3

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Please note: Some tables or figures were omitted from this article.

Copyright: COPYRIGHT 1999 Elsevier B.V. http://chestjournal.chestpubs.org/

Source Citation Eaton, Tam, et al. "Spirometry in Primary Care Practice(*)." Chest, vol. 116, no. 2, Aug. 1999, p. 416. Gale Academic OneFile,

https://link.gale.com/apps/doc/A55653616/AONE?u=sshe_sru&sid=AONE&xid=54e201dc. Accessed 1 May 2020.

Gale Document Number: GALE|A55653616