22/4/2019 Office spirometry - UpToDate

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Office spirometry
Author: Meredith C McCormack, MD, MHS
Section Editor: James K Stoller, MD, MS
Deputy Editor: Helen Hollingsworth, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2019. | This topic last updated: Jul 24, 2018.

INTRODUCTION

Spirometry is used to measure forced expiratory flow rates and volumes. It is the most commonly
used pulmonary function test and is useful in the evaluation of patients with respiratory symptoms
(eg, dyspnea, cough, wheeze) or risk factors for respiratory disease (eg, smoking, occupational
exposures, family history).

In the office setting, spirometry is typically used to detect, confirm, and monitor obstructive airway
diseases (eg, asthma, chronic obstructive pulmonary disease [COPD]) [1-4]. In this setting, the
clinician must be knowledgeable about issues related to equipment, performance of the forced
expiratory maneuver, and interpretation of the data to obtain reliable and clinically useful information
[5-7]. International guidelines for performance of office spirometry have been published [8].

The performance of spirometry in the office setting will be reviewed here. More general issues related
to pulmonary function tests, the interpretation of flow volume loops, and the technique of
bronchoprovocation testing are discussed separately. (See "Overview of pulmonary function testing in
adults" and "Flow-volume loops" and "Bronchoprovocation testing".)

EQUIPMENT

Office spirometers should meet equipment specifications as described in international guidelines [9-
12]. The majority of spirometers manufactured since 1990 are accurate, although some flow-sensing
office spirometers can produce falsely high results [13-15]. Reference standards are discussed
separately. (See "Selecting reference values for pulmonary function tests".)

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To avoid cross-contamination between patients when using permanent flow sensors, it is preferable to
employ single use disposable flow sensors that practically eliminate the risk of inhalational cross
contamination. Disposable one-way mouthpieces may also be used; otherwise, patients should be
instructed not to inhale from the spirometer prior to forced exhalation maneuvers.

Volume sensing spirometers maintain accuracy over many years, but are more difficult to clean and
are rarely used for office spirometry.

QUALITY CONTROL

Office spirometers should accurately measure the forced expiratory volume in one second (FEV1),
forced expiratory volume in six seconds (FEV6), and forced vital capacity (FVC) and also provide
quality checks and error messages.

In addition to internal calibration performed by the device, daily calibration checks with a three liter
syringe are recommended, since permanent flow sensors can become clogged with secretions [10].
When performing a calibration check, the three liter syringe should be discharged into the spirometer
three times. The volumes read by the machine should be within 3.5 percent of three liters. If the
spirometer reading remains outside these limits after replacing the flow sensor, the device should be
removed from use until checked by the manufacturer.

It is also essential that the nurse or technician enter correct values for age, height, and gender, as
these values are used to generate the appropriate predicted values for the individual patient. Height
should be measured with shoes off, preferably using a stadiometer, rather than relying on the
patient's stated height. Percent predicted values that are higher or lower than expected are a clue that
an incorrect age or height value may have been entered. Waist circumference should also be
measured because abdominal obesity is a common cause of a mildly low FVC [16].

PROCEDURE

Patients are usually seated during spirometry, unless otherwise noted. Nose clips or manual
occlusion of the nares help to prevent air leakage through the nasal passages, although spirometry
can be performed without nasal occlusion [10]. The deep inhalation should occur before the
mouthpiece is placed in the mouth. Immediately after the deep inhalation, the mouthpiece is placed
just inside the mouth between the teeth. The lips should be sealed tightly around the mouthpiece to
prevent air leakage during maximal forced exhalation. Exhalation should last at least 6 seconds.

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The patient is allowed to rest for several seconds and the procedure is repeated. Usually, three
maneuvers are performed, although additional tests may be needed if one or more of the curves are
unacceptable.

COACHING THE PATIENT

The most important task of the nurse or technician is to obtain maximal, reproducible efforts from the
patient.

Even with the use of accurate instruments, office spirometry results may be misleading if the patient's
efforts are submaximal. Unlike most other medical tests in which the patient remains passive,
accurate spirometry results require significant exertion on the part of the patient.

The technician must instruct and encourage the patient to perform the breathing maneuvers in three
phases (figure 1):

● Phase 1: Coach the patient to take as deep a breath as possible

● Phase 2: Loudly prompt the patient to blast out the air into the spirometer
● Phase 3: Encourage the patient to continue exhaling for at least six seconds (three seconds for
children)

ADEQUACY OF TEST

An adequate test usually requires three acceptable and reproducible forced vital capacity (FVC)
maneuvers. The clinician and technician must learn to recognize the patterns of acceptable and
unacceptable efforts, since poorly performed maneuvers often mimic disease patterns. Detection of
poorly performed maneuvers requires direct inspection of both flow-volume curves and volume-time
spirograms (figure 2) [9,17].

An acceptable maneuver requires a sharp peak in the flow curve and an expiratory duration greater
than six seconds (figure 3). Two or three acceptable maneuvers should be available for analysis.

Reproducibility is determined by comparing the FVC values of the maneuvers. The two highest
values for FVC should be within 0.15 L of each other [10,18]. Similarly, the two highest values for
forced expiratory volume in one second (FEV1) should be within 0.15 L of each other.

INTERPRETATION

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All tracings from the forced expiratory maneuvers should be examined for acceptability and
reproducibility, according to the criteria mentioned above. The study should then be classified as
normal, borderline, or abnormal, the latter showing either an obstructive or a restrictive pattern (figure
3). The severity of any obstructive impairment is then assessed (figure 4). (See 'Forced expiratory
volume in one second' below and "Overview of pulmonary function testing in adults".)

Forced vital capacity — The forced vital capacity (FVC) (also known as the forced expiratory
volume) is the maximal volume of air exhaled with a maximally forced effort from a position of full
inspiration and is expressed in liters [10]. The highest FVC from the three acceptable forced
expiratory maneuvers is used for interpretation [10].

The FVC may be reduced by suboptimal patient effort, airflow limitation, restriction (eg, from lung
parenchymal, pleural, or thoracic cage disease), or a combination of these. An approach to the
interpretation of abnormal values is provided in the figures (figure 4) [9]. The specific values assigned
to mild, moderate, and severe disease vary among the different guidelines; we have included in the
figure the ones that we find most consistent for predicting the degree of impairment [13,18]. In
general, a moderately or severely low FVC needs further evaluation with full pulmonary function tests
[19]. (See "Overview of pulmonary function testing in adults".)

The slow vital capacity (SVC) is the maximal volume of air exhaled after a maximal inspiration, but
without a forced effort. The SVC is rarely measured outside of hospital-based pulmonary function
labs. For normal subjects, the slow and forced vital capacities are very close, whereas patients with
airflow limitation tend to have a much lower FVC than SVC. (See "Overview of pulmonary function
testing in adults", section on 'Spirometry'.)

Forced expiratory volume in six seconds — The forced expiratory volume in six seconds (FEV6) is
sometimes used as a surrogate for FVC [10,20]. The FEV6 has the advantage of being more
reproducible than the FVC and less physically demanding for the patient.

Forced expiratory volume in one second — The forced expiratory volume in one second (FEV1) is
the maximal volume of air exhaled in the first second of a forced exhalation that follows a full
inspiration, expressed in liters [10]. The FEV1 reflects the average flow rate during the first second of
the FVC maneuver. The FEV1 is the most important spirometric variable for assessment of the
severity of airflow obstruction (figure 4). The highest FEV1 from the three acceptable forced expiratory
maneuvers is used for interpretation, even if it does not come from the maneuver with the highest
FVC [10].

In patients with asthma, the FEV1 declines in direct and linear proportion with clinical worsening of
airways obstruction, and it increases with successful treatment of airways obstruction. The FEV1

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should be used for determining the degree of obstruction (mild, moderate, or severe) and for serial
comparisons when following patients with asthma or chronic obstructive pulmonary disease (COPD).

The measured FEV1 is usually expressed as a percent of the predicted value for determination of
normality (figure 4). The lower limit of normal (LLN) FEV1 is more accurately defined by the fifth
percentile of healthy never-smokers, instead of the traditional 80 percent of predicted [21]. The
reference equations used by most spirometry software for determining predicted values in North
America are derived from the NHANES III study [18,22]. Reference equations from the Global Lung
Function Initiative, which assessed healthy individuals age 3 to 95 years across ethnic and
geographic groups in 26 countries, may also be used and can be applied to both pediatric and adult
patients [23]. These reference equations are endorsed by the American Thoracic Society, the
American College of Chest Physicians, the European Respiratory Society, the Australian and New
Zealand Society of Respiratory Science, the Thoracic Society of Australia and New Zealand, and the
Asian Pacific Society for Respirology. The reference equations from the Global Lung Initiative [23] or
NHANES III [24] may be used. (See "Selecting reference values for pulmonary function tests".)

As a rough guideline, the predicted FEV1 for a 50 year-old of average height is about 4 L for a man
and 3 L for a woman. When predicted values have not been calculated, patients with severe COPD
generally have an FEV1 less than one liter, while those with moderate COPD have an FEV1 between
1 and 1.5 liters. It is unusual for patients with COPD to have dyspnea due to airflow obstruction when
the FEV1 is greater than 50 percent predicted [25]. (See "Selecting reference values for pulmonary
function tests".)

Ratio of FEV1/FVC — The FEV1/FVC ratio is the fraction of the forced vital capacity that can be
exhaled in the first second. It is the most important parameter for detecting airflow limitation in
diseases like asthma and COPD (figure 4). However, once it has been determined that a patient has
airways obstruction, the FEV1/FVC ratio is not useful for gauging severity of disease, since the FVC
also tends to decrease with increasing obstruction. The FEV1, not the FEV1/FVC ratio, should be
used to monitor patients with asthma or COPD. (See "Pulmonary function testing in asthma" and
"Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging".)

The use of the fifth percentile LLN for FEV1/FVC to detect airway obstruction reduces the
misclassification associated with using a fixed threshold of 0.7 [21,26-29].

When FVC maneuvers are routinely stopped after six seconds, the FEV1/FEV6 should replace the
FEV1/FVC [30]. The advantages of the FEV1/FEV6 include less frustration for the patient and
technician trying to achieve an end-of-test plateau, less chance of syncope, shorter testing time, and
better repeatability, without loss of sensitivity or specificity [20,31-33]. The appropriate lower limit of
normal for FEV1/FEV6 from NHANES III should be used [22,24].

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Other flow measures — The transition from normal function to moderate airflow obstruction is
generally gradual. Physiologists have searched for a test that is more sensitive than the FEV1 for
detection of airflow obstruction in its early stages. None has proven to be as reliable as the index
obtained by dividing the FEV1 by the FVC. The forced expiratory flow between 25 and 75 percent of
the FVC (also known as FEF25-75 or maximal mid-expiratory flow rate) should not be used to detect
"small airways disease" in adults, due to poor reproducibility [10].

Choosing the best values — Report the highest FVC and the highest FEV1 from three spirometric
maneuvers, even if they are derived from different maneuvers [10].

Flow-volume loops — The flow-volume loop is a plot of inspiratory and expiratory flow (on the Y-
axis) against volume (on the X-axis) during the performance of maximally forced inspiratory and
expiratory maneuvers. Changes in the contour of the loop can detect upper airway obstruction. The
analysis of flow-volume loops is discussed separately. (See "Flow-volume loops".)

Post-bronchodilator spirometry — In patients who have evidence of airflow limitation on baseline

spirometry, and no prior diagnosis of asthma or COPD, post-bronchodilator spirometry may be useful.
If post-bronchodilator spirometry is normal, COPD is ruled out. The assessment of bronchodilator
responses in patients with asthma-like symptoms is described separately. (See "Pulmonary function
testing in asthma", section on 'Bronchodilator responses'.)

LIMITATIONS

Office spirometry has some important limitations, even when all of the above described quality
measures are employed. As examples:

● Abnormal spirometry results have little if any value in prompting smokers to quit [34-38]. All
patients who smoke should be advised to stop smoking and provided smoking cessation
assistance.

● In a patient with asthma, normal airflow at the time of office visits does not exclude serious
airflow obstruction at other times.

● Patients with early interstitial lung disease or sarcoidosis may have normal spirometry and need
further testing of gas transfer with a diffusing capacity of the lungs for carbon monoxide (DLCO)
and/or exercise oximetry to identify the cause of dyspnea [39].

● Misclassification rates due to suboptimal spirometry performance or interpretation are relatively

high in the office setting [6,40]. Among eight general practices, rates for successfully meeting
American Thoracic Society (ATS) quality standards were below 80 percent [6]. Therefore,

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continuous quality review and feedback to nurses and technologists performing office spirometry
are necessary and results should be verified by repeat testing in a Pulmonary Function Test
(PFT) laboratory when important clinical decisions will be made based on the results [41,42].

RISKS

Spirometry is a low risk procedure and has few side effects [9]. During the test, some patients may
experience dizziness. The forced expiratory maneuver causes an increase in the pressure in the
chest, abdomen, head, and eyes. In general, patients who have recently (eg, less than six weeks)
had abdominal, intracranial, or eye surgery or a pneumothorax should not perform spirometry,
although data are limited.

Spirometry requires exertion and should be avoided in patients with unstable angina or a recent
myocardial infarction.

Rarely, performance of a forced expiratory maneuver will precipitate acute bronchoconstriction. This
seems more likely to occur when a patient's asthma or COPD is poorly controlled. Treatment includes
administering inhaled albuterol and supplemental oxygen.

MONITORING

Office spirometry is also useful for monitoring control of asthma The National Asthma Education and
Prevention Program advises the following frequencies for spirometry testing when caring for patients
with asthma [43]:

● At the time of initial assessment

● After treatment is initiated and symptoms and peak flow have stabilized

● During periods of progressive or prolonged loss of asthma control

● At least every one to two years

For patients with chronic obstructive pulmonary disease (COPD), repeat spirometry is advised
whenever there is a substantial increase in symptoms or decrease in exercise tolerance [4,44,45].

SOCIETY GUIDELINE LINKS

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Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Pulmonary function testing".)

SUMMARY AND RECOMMENDATIONS

● Spirometry is used to detect and monitor obstructive airway disease in patients with respiratory
symptoms and risk factors. (See 'Introduction' above.)

● Office spirometers should accurately measure the forced expiratory volume in one second
(FEV1) and either the forced vital capacity (FVC) or the forced expiratory volume in six seconds
(FEV6). Calibration checks should be performed daily with a three liter syringe. (See 'Quality
control' above.)

● Since poorly performed maneuvers often mimic disease patterns, the clinician and technician
must learn to recognize the patterns of unacceptable efforts (figure 2). (See 'Quality control'
above.)

● An acceptable maneuver requires a sharp rise in the flow volume curve to the peak flow and an
expiratory duration greater than six seconds. At least three good quality maneuvers should be
performed. (See 'Quality control' above.)

● Report the highest FVC and the highest FEV1 from three spirometric maneuvers, even if they are
derived from different maneuvers. The fifth percentile lower limit of normal (LLN) for FEV1/FVC is
preferred over the commonly accepted fixed threshold of 0.7, as it reduces the misclassification
rate for detecting airway obstruction. (See 'Choosing the best values' above and 'Ratio of
FEV1/FVC' above.)

● Reduction of the FEV1/FVC and the FEV1 suggests airway obstruction (figure 4). (See
'Interpretation' above.)

● The FEV1/FEV6 is preferred over the FEV1/FVC when the FVC maneuvers are routinely stopped
after six seconds. (See 'Ratio of FEV1/FVC' above.)

● The FEV1 should be used for determination of the degree of impairment and for serial
comparisons. FEV1/FVC ratio is not useful for gauging severity of disease, since the FVC also
tends to decrease with increasing obstruction. (See 'Interpretation' above.)

● Office spirometry results should be verified by formal testing in a pulmonary function test (PFT)
laboratory when important clinical decisions will be made based on the results. (See
'Interpretation' above.)

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ACKNOWLEDGMENT

The editorial staff at UpToDate would like to acknowledge Paul Enright, MD, who contributed to an
earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

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Technique for performing spirometry

Unlike most other medical tests in which the patient remains passive, accurate
spirometry requires a coordinated maximum effort. The technician should
instruct and encourage the patient to perform the breathing maneuvers in three
phases: Phase 1: coach the patient to take as deep a breath as possible; Phase
2: loudly prompt the patient to BLAST out the air into the spirometer; Phase 3:
encourage the patient to continue exhaling for several more seconds.

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Unacceptable spirometry

Flow-volume curve patterns from unacceptable forced vital capacity maneuvers.

Curve A (red) hesitating start; curve B (blue) submaximal blast (poor peak flow
effort); curve C (green) excessive coughing at the beginning of the maneuver;
curve D (orange) premature termination of effort.

FVC: forced vital capacity.

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Flow-volume curve variations

Flow-volume curves from (A) a healthy person or from patients with (B) severe
obstruction (emphysema), (C) severe restriction from interstitial disease
(radiation fibrosis), (D) upper airways obstruction (tracheal stenosis), and (E)
poor effort.

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Interpretation of office spirometry: Obstructive pattern

If the FEV 1 /FVC ratio is normal AND the FEV 1 is greater than 80 percent of predicted, then the
spirometry is normal.
If the FEV 1 /FVC is reduced and the FEV 1 is >80 percent predicted, spirometry may be normal;
this finding may be due to a prolonged exhalation phase leading to overestimation of the FVC.
If the FEV 1 /FVC ratio is normal, but the FVC is mildly reduced (70 to 80 percent of predicted),
the cause may be abdominal obesity or poor technique.
If the FEV 1 /FVC ratio is normal, but the FVC is below 80 percent of predicted, consider
referring the patient to a pulmonary function laboratory for measurement of lung volumes and
diffusing capacity (DLCO) to assess for a possible restrictive ventilatory defect (eg, interstitial
lung disease or respiratory muscle weakness).

FEV 1 : forced expiratory volume in one second; FVC: forced vital capacity.
* The FEV 1 decreases with age, so the lower limit of normal (LLN) should be used to detect airway
obstruction rather than the absolute value of FEV 1 /FVC.

Adapted from: Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function
tests. Eur Respir J 2005; 26:948.

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Contributor Disclosures
Meredith C McCormack, MD, MHS Nothing to disclose James K Stoller, MD, MS Grant/Research/Clinical
Trial Support: Alpha-1 Foundation [Alpha-1 antitrypsin detection (Pooled human alpha-1 antiprotease)].
Consultant/Advisory Boards: CSL Behring; Grifols; Shire [Alpha-1 antitrypsin detection (Pooled human alpha-1
antiprotease)]; Arrowhead Pharmaceuticals [Alpha-1 antitrypsin deficiency]; Vertex; Inhibrx; 23andMe [Alpha-1
antitrypsin deficiency]; Alpha-1 Foundation [Member, Board of Directors (Alpha-1 antitrypsin deficiency)];
American Respiratory Care Foundation [Member, Board of Directors (Respiratory therapy issues)]. Helen
Hollingsworth, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy

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