Spirometrie in de Huisartspraktijk -...

Spirometrie in de

Huisartspraktijk

Johan Buffels, MD, PhD

Jan Degryse, MD, PhD

Spirometrie in huisartspraktijk

• Indicaties voor “office spirometry”

• Voorwaarden voor kwaliteit

• Mogelijke hinderpalen?

• Zelf uitvoeren of andere mogelijkheden?

5 10 15

2

4

6

8

Time (s)

Vo

lum

e (L

)

Normal spirogram:

Volume / time

Man

176 cm

76 kgFVC

FEV1

0

-4

-8

4

8

12

Flo

w (

L/s

)

PEF

Normal spirogram: Flow/Volume

Man

176 cm

76 kg

Volume (L)

Interpretation of spirometry

FVC

FEV1

FEV1/FVC

�

�

Nl

(Nl)

�

�

Restrictive lung

disease

Obstructive lung

disease

Reversibility

Yes No

Waarom spirometrie?

• Screening?

• Case finding?

• (Differentieel) diagnose?

• Evaluatie van exacerbaties?

• Follow-up therapie?

Mortality and FEV1

0

0,5

1

1,5

2

<73 73-87 88-96 97-107 >107

Men

Women

FEV1 (%pred)

Ad

juste

d o

dd

s r

atio

of d

ea

th

(all

ca

use

s)

Screening

• Population-based

• Man in the street

• May not have symptoms

• May be a smoker

• No reimbursement

Case Finding

• Individual patients

• Person visiting a doctor

• Respiratory symptoms

• Has COPD risk factors

• Covered by insurance

Screening vs Case finding

P. Enright et al. Respiratory Care 2003

Voorwaarden voor Screening

• Hoge prevalentie van en ernstige morbiditeit door de aandoening in de doelpopulatie

• Eenvoudige en goedkope test zonder ernstige neveneffecten

• Test met hoge sensitiviteit en specificiteit (weinig vals + en vals -)

• Opsporing in een vroeg stadium is zinvol: er bestaat een goede behandeling voor de op te sporen aandoening

Wilson, Proc R Soc Med 1971, Marshall, CMAJ 1996




• Test met hoge sensitiviteit en specificiteit (weinig vals + en vals -) Probleem bij astma!

• Opsporing in een vroeg stadium is zinvol: er bestaat een goede behandeling voor de op te sporen aandoening





• Test met hoge sensitiviteit en specificiteit (weinig vals + en vals -) Probleem bij astma!

• Opsporing in een vroeg stadium is zinvol: er bestaat een goede behandeling voor de op te sporen aandoening. Probleem bij COPD!


Screening for COPD? (USPSTF)

• Screening for COPD would theoretically benefit adults with a high probability of severe airflow obstruction who

might benefit from inhaled therapies.

• However, even in groups with the greatest prevalence

of airflow obstruction, hundreds of patients would need

to be screened with spirometry to defer 1 exacerbation.

• Although an unknown proportion of patients who

present with clinical symptoms of an exacerbation does

not receive a COPD diagnosis, the incremental benefit of early detection over clinical diagnosis for the

remainder of patients would, at most, be a deferral of

the first exacerbation.

Screening for COPD? (USPSTF)

• Good evidence indicates that history and clinical examination are not accurate predictors of airflow

limitation.

• Fair evidence indicates that fewer than 10% of those

identified by screening spirometry have severe or very

severe COPD, using current diagnostic criteria.

• All individuals with COPD, including those with mild or

moderate illness, would benefit from smoking cessation

and annual influenza vaccination

• No studies have examined whether performing spirometry increases influenza vaccination rates.

• Spirometry and smoking cessation: ???

Can spirometry enhance smoking cessation?

• Smokers with documented airflow obstruction have higher odds for smoking cessation(Bednarek, Thorax 2006)

• If randomized allocation to spirometry or not there is no significant difference in smoking cessation rate (Buffels, Respir Med 2006)

SPIROSTOP study

Contemplation

Preparation

ActionRelapse

Pre-

contemplation

Success102 (13.8%)

85 (11.5%)

48 (6.5%)

n (incremental after x time)

226 (30.5%)

279 (37.7%)

221 attempts

(18.3% of all smokers)

SPIROSTOP: success rates

% Success % Success P value

GENDER MALE FEMALE

6 M 28.6% 37.9% 0.312

12M 22.7% 22.1% 0.994

24M 16.5% 17.9% 0.924

SPIROMETRY YES NO

6M 34.3% 29.0% 0.670

12M 22.5% 20.4% 0.987

24M 19.1% 14.0% 0.580

OAD?* OBSTR NORMAL

6M 33.3% 36.7% 0.570

12M 23.3% 22.4% 0.850

24M 20.0% 18.4% 0.962

NRT/Bupropion** R/ NO R/

6M 37.4% 29.8% 0.119

12M 27.3% 17.9% 0.073

24M 22.2% 11.9% 0.048

* OAD = Obstructive Airway Disease ** NRT = Nicotine Replacement Therapy

GOLD vs LLN


Borderline COPD


So… no screening for COPD??

• Some indications that the message after spirometry matters: ELA (estimated lung age) Parkes, BMJ 2008

• No strict evidence for effects of early pharmacotherapyon the deterioration of lung function in COPD, but some

indications

• We do NOT screen for COPD: we screen for obstructive airway disease

Waarom spirometrie?

• Screening?

• Case finding?




Vermoeden van COPD

• Chronische hoest

• Chronische productie van sputum

• Blootstelling aan risico’s– Tabaksrook

– Professionele irritantia

• Dyspnee, met 4 kenmerken:– Progressief (verslecht met de tijd)

– Persisterend (dagelijks aanwezig)

– Slechter met inspanning

– Slechter bij surinfectie

COPD: een spirometrische

definitie (GOLD)

• Obstructief longlijden

• Niet volledig reversibele luchtwegobstructie

• Met een FEV1/FVC< 70% (arbitrair)

• Inschatting van de ernst volgens FEV1 waarde:– I.Mild COPD FEV1 > 80% voorspeld

– II.Matig ernstig COPD 50% < FEV1 < 80%

– III.Ernstig COPD 30% < FEV1 < 50%

– IV.Zeer ernstig COPD FEV1< 30% of verwikkeling

na bronchodilatatie.

Waarom spirometrie?

• Screening?

• Case finding?




Differences between COPD and

asthma (Vermeire PA, 1993)

ASTHMA COPDYoung age at onset of

disease

Often Almost never

Sudden onset of disease Often Almost never

Smoking hystory Sometimes Almost always

Allergy Often Seldom

Dyspnoea Often Sometimes

Wheezing Often Sometimes

Coughing Sometimes Often

Sputum production Seldom Often

Differences between COPD and

asthma (Vermeire PA, 1993)

ASTHMA COPDChronic airway

obstruction

Seldom Almost always

Variable airway

obstruction

Almost always Seldom

Reversible airway

obstruction

Almost always Almost never

Airway hyper-

responsiveness

Almost always Sometimes

Diurnal peak-flow

variability

Almost always Sometimes

• What is the diagnostic accuracy for asthma

and COPD of subsequent diagnostic steps

in a population older than 40 years with

probable obstructive airway disease?

Buffels, Respiration 2011

DIDASCO2: Inclusion

• 50 patients with probable OAD• (taking bronchodilators or wheezing)

• Diagnostic opinion:• Asthma

• COPD

• Asthma AND COPD

• Other OAD

• No OAD

• I don’t know

• Rate of certainty (ranging from 1 to 5)

Diagnostic steps

If uncertaindiagnosis

(data on file)

IPAG questionnaire

Specifichistory taking

Physicalexamination

Office spirometry

Specialist’sadvice

Control visitafter 3 months


DIDASCO2 Diagnostic certainty

• Spirometry was documented in

o 31% of patients with asthma

o 37% of patients with COPD

Certain

diagnosis

Almost certain

diagnosis

Uncertain

diagnosis

Study population 157 (13.9) 446 (39.6) 523 (46.4)

Asthma 50 (15.7) 132 (41.5) 136 (42.8)

COPD 95 (17.5) 251 (46.3) 196 (36.2)

Asthma+COPD 2 (1.3) 37 (24.3) 113 (74.3)

Other obstr disease 10 (19.7) 26 (50.0) 16 (30.8)

Diagnostic steps


(data on file)

IPAG questionnaire


Physicalexamination

Office spirometry




Spirometry

Course

IPAG questionnaire

VRAAG Keuzemogelijkheden Punten

Wat is uw leeftijd? 40-49 jaar 0

50-59 jaar 5

60-69 jaar 9

70 jaar of ouder 11

Hoeveel sigaretten rookt u gewoonlijk per dag (als u vroeger gerookt

hebt, hoeveel rookte u elke dag)?

Gedurende hoeveel jaar hebt u sigaretten gerookt?

Aantal pakken per dag = aantal sigaretten per dag/20

Pak/jaren = aantal pakken per dag x aantal jaren gerookt.

0-14 pak/jaren 0

15-24 pak/jaren 3

25-49 pak/jaren 7

50+ pak/jaren 9

Moet u de jongste jaren meer hoesten? Ja 0

Neen 1

Had u gedurende de jongste 3 jaar ademhalingsproblemen die u thuis

hielden, of werkonbekwaam, of binnenshuis, of in bed?

Ja 0

Neen 3

Werd u ooit gehospitaliseerd wegens ademhalingsproblemen? Ja 6

Neen 0

Was u de jongste jaren vaker kortademig dan vroeger? Ja 1

Neen 0

Hoeveel slijmen hoest u gewoonlijk op? Geen, of minder dan 2 soeplepels 0

2 soeplepels of meer per dag 4

Als u verkouden bent, valt het gewoonlijk op uw borst? Ja 4

Neen 0

Neemt u medicatie om beter te kunnen ademen? Ja 5

Neen 0

Validation of IPAG Questionnaire

100

90

80

70

60

50

40

30

20

10

0

%

Asthma COPD Other

100 90 80 70

60 50 40 30 20 10

0

%

Asthma COPD Other

CUT-OFF

18 PTS

CUT-OFF

21 PTS

FINAL DIAGNOSIS

Diagnostic steps


(data on file)

IPAG questionnaire


Physicalexamination

Office spirometry




Spirometry

Course

DIDASCO2 Comorbidity

Male Female Asthma COPD No Obstr

Diabetes 19.0 14.3 14.4 18.6 22.9

Coronary Disease 19.8 9.9 9.7 19.7 5.7

Heart Failure 9.4 7.7 5.6 11.4 2.9

Atrial Fibrillation 7.8 4.5 3.4 8.9 1.4

Arterial Hypertension 43.8 43.3 38.2 45.9 40.0

Dementia 0.6 2.6 1.9 1.8 1.4

Stroke or TIA 4.2 4.9 2.5 6.6 2.9

Peripheral Vascular Disease 14.8 6.0 5.3 15.1 5.7

Malignancy 9.4 6.2 7.2 10.5 1.4

Osteoporosis 4.6 12.2 8.8 8.9 2.9

Social Problems 13.2 13.7 10.7 17.2 10.0

Relational Problems 10.7 9.6 8.8 10.9 7.1

Alcohol Problems 13.0 4.7 4.7 13.5 5.7

Depression 13.0 20.8 15.4 18.5 12.9

Obesity 22.3 22.3 23.8 22.9 17.1

Mean n Diseases/Conditions 2.9 (2.7-3.1) 2.6 (2.4-2.8) 2.2 (2.0-2.4) 3.2 (3.0-3.4) 2.1 (1.6-2.5)

% congruent diagnoses comparedwith label after spirometry

0

20

40

60

80

100

120

FILE IPAG CLIN SPIRO

Co

ng

ruen

t D

iag

no

ses (

%)

Diagnostic Steps

Asthma COPD Asthma+COPD Other OAD No OAD

Mean rate of diagnostic certainty

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

FILE IPAG CLIN SPIR

Mean

cert

ain

ty

Diagnostic Steps

Asthma COPD Asthma+COPD Other OAD No AOD

Tests done by the pulmonologists

TEST n %

Spirometry 114 93 Bronchodilator reversibility test 32 26 Diffusion capacity 61 50 Bronchial provocation test 5 4 Exhaled nitric oxide 2 2 X-ray of the chest 39 32 CT scan of the chest 9 7 Allergy tests 19 16 Ventilation/perfusion scan 3 2 Oxygen saturation 15 12 Body plethysmography 8 7 Six minutes walking test 1 1 Other 5 4

Diagnostic value of each step

ASTHMA

IPAG/Fin CLIN/Fin SPIRO/Fin PULM/Fin

Sens (%,95%CI) 51.6 (33.0-69.8) 58.1 (39.1-75.4) 64.5 (45.4-80.8) 87.1 (70.1-96.3)

Spec (%,95%CI) 88.8 (80.5-94.5) 85.6 (76.6-92.1) 90.9 (82.9-96.0) 83.5 (74.3-90.5)

Pos LHR (95%CI) 4.65 (2.36-9.14) 4.02 (2.24-7.22) 7.10 (3.49-14.44) 5.28 (3.26-8.56)

Neg LHR (95%CI) 0.54 (0.38-0.79) 0.49 (0.32-0.75) 0.39 (0.24-0.63) 0.15 (0.06-0.39)

Preval (%) 28.8 21.5 25.6 23.5

PPV (%) 65.4 52.4 71.4 61.3

NPV (%) 81.6 88.5 87.8 96.5

Diagnostic gain 36.6 30.9 45.8 37.8

COPD

IPAG/Fin CLIN/Fin SPIRO/Fin PULM/Fin

Sens (%,95%CI) 83.0 (69.2-92.3) 73.8 (58.0-86.1) 68.3 (51.9-81.9) 85.7 (71.4-94.5)

Spec (%,95%CI) 78.4 (67.3-78.1) 78.5 (67.8-86.9) 89.7 (80.8-95.5) 92.5 (84.4-97.2)

Pos LHR (95%CI) 3.84 (2.44-6.06) 3.43 (2.17-5.42) 6.66 (3.34-13.26) 11.43 (5.24-24.92)

Neg LHR (95%CI) 0.22 (0.11-0.41) 0.33 (0.20-0.56) 0.35 (0.22-0.56) 0.15 (0.07-0.32)

Preval (%) 31.4 38.8 39.7 30.2

PPV (%) 62.9 68.3 81.9 82.1

NPV (%) 91.1 82.4 80.8 93.9

Diagnostic gain 31.5 29.5 42.4 51.9

Waarom spirometrie?

• Screening?

• Case finding?




Kwaliteit van « office spirometry »

• Kwaliteit van de toestellen

• Kwaliteit van de afname

• ATS/ERS criteria

• De invloed van training/retraining

Spirobank

Simplicity

SpiroPro

SpiroStar

Datospir 70

OneFlow

DatoSpir 120

MicroLoop

Pneumotrac

FVC

-1,000

-0,500

0,000

0,500

1,000

Spirobank SpiroPro SpiroStar

Device

Bia

s, lim

its o

f agre

em

ent

(L)

FVC SpiroStar

R2 = 0.16, p=0.004

-2

-1,5

-1

-0,5

0

0,5

1

1,5

0 1 2 3 4 5 6 7

Mean (L)

Dif

fere

nc

e (

L)

Underestimation

Overestimation

FEV1

-1,00

-0,80

-0,60

-0,40

-0,20

0,00

0,20

0,40

0,60

Spirobank SpiroPro

SpiroStar

Device

Bia

s, lim

its o

f a

gre

em

en

t

(L)

FEV1 SpiroPro

R2 = 0.28, p=0.001

-0,5

-0,4

-0,3

-0,2

-0,1

0

0,1

0,2

0,3

0,4

0 1 2 3 4 5 6

Mean L

Dif

fere

nc

e

L

PEF

-200

-100

0

100

200

300

400

Spirobank SpiroPro SpiroStar

Device

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s,

lim

its

of

ag

ree

me

nt

(L/m

in)

DIDASCO study

• What is the accuracy of spirometry performedwith the MIR Spirobank® spirometer?

• How accurately can trained primary care physicians perform spirometry by means of a portable electronic spirometer?

Degryse, Respiration 2012

Spirobank/Jaegher for FEV1

Linear Regression with

95.00% Individual Prediction Interval

2.00 3.00 4.00

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fev1j = 0.42 + 0.92 * fev1s

R-Square = 0.90

Spirobank/Jaegher FVC

Linear Regression with

95.00% Individual Prediction Interval

2.00 3.00 4.00 5.00 6.00

fvcs

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fvcj = 1.03 + 0.82 * fvcs

R-Square = 0.84

Sequential measurements of FEV1

Sequential measurements of FVC

Acceptable spirometry (ATS)

• No artefacts– cough, glottis closure, abrubt ending, variable effort, leaks

• Fast start

• Expiratory time > 6 sec Or acceptable plateau

Volume / time

Replacing FVC by FEV6 ?

• Easier for the patients

• Better reproducibility

• Less artefacts

FEV1/FVC or FEV1/FEV6 ?

• Easier for the patients

• Other reference values

• Cut-off 73%

New screening tool?

Reproducibility

• Maximum 5% variability in technically

acceptable trials

• Maximum 150 ml ∆∆∆∆ for FEV1 and FVC

• Report highest FEV1 and FVC from acceptable

trials

• Up to 8 trials to be performed

Improving Quality of Spirometry by Feedback

M.Upton, Public Health, 2000

Quality Control of Spirometry

V.Bellia,Am J Respir Crit Care Med, 2000

The Impact of Spirometry Workshops

T.Eaton, Chest, 1999

The Impact of Spirometry Workshops

Validity of Spirometric Testing in

General Practice.

T.Schermer, Thorax, 2003

Hinderpalen

• Onvoldoende competentie bij de huisarts

• Onvoldoende vergoeding voor de geleverde inspanning

• Geen zicht op indicaties

• Moeilijk in te plannen

• Onvoldoende mogelijkheden voor navorming

Mogelijke alternatieven

• Uitvoering door praktijkassistente

• Uitvoering door “respiratory nurse”

• “MCH”?

• On line feedback?

• Open longfunctielab

• “Kaderhuisartsen”? “GPwSI”?

Criteria for referral

to a chest physician

• Discrepancy between the clinical findings and the spirometric values

• Arguments for an occupational factor in the ethiology of the airway obstruction

• A postbronchodilator FEV1 of <50% predicted

• COPD before the age of 50

• Doubt about a possible cardiac origin of the dyspnoea

• Arguments for malignancy

• Signs of restrictive lung disease

• Any atypical disease history

Thank you for

your attention!

Questions ??

Spirometrie in de Huisartspraktijk -...

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