Office Spirometry - UpToDate

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Espirometria de consultório
Autor: David A. Kaminsky, MD
Editor de seção: Meredith C McCormack, MD, MHS
Editor Adjunto: Paul Dieffenbach, MD
Todos os tópicos são atualizados à medida que novas evidências se tornam disponíveis e nosso processo de
revisão por pares é concluído.
Revisão da literatura atual até: fevereiro de 2023. | Última atualização deste tópico: 07 de março de 2023.
INTRODUÇÃO
A espirometria é usada para medir taxas e volumes de fluxo expiratório forçado. É o teste de
função pulmonar mais utilizado e é útil na avaliação de pacientes com sintomas
respiratórios (por exemplo, dispneia, tosse, sibilos) e no monitoramento da função pulmonar
em pacientes com doença pulmonar, sendo tratados com medicamentos que podem afetar
funcional ou em risco de doença pulmonar (por exemplo, tabagismo, exposições
ocupacionais, histórico familiar).
No consultório, a espirometria é normalmente usada para detectar, confirmar e monitorar

doenças obstrutivas das vias aéreas (por exemplo, asma, doença pulmonar obstrutiva
crônica [DPOC]) e monitorar doenças pulmonares restritivas conhecidas [ 1-5 ] . Nesse
cenário, o clínico deve ter conhecimento sobre questões relacionadas ao equipamento,
realização da manobra de expiração forçada e interpretação dos dados para obter
informações confiáveis e clinicamente úteis [ 6-8 ] . Diretrizes internacionais para realização
de espirometria de consultório foram publicadas [ 9,10 ]. A espirometria não é recomendada
como teste de triagem para adultos assintomáticos [ 4,11 ], mas facilita o diagnóstico de
doenças respiratórias.
O desempenho da espirometria no consultório será analisado aqui. Questões mais gerais

relacionadas aos testes de função pulmonar, a interpretação dos loops fluxo-volume e a
técnica do teste de broncoprovocação são discutidas separadamente. (Consulte "Visão geral
dos testes de função pulmonar em adultos" e "Loops de fluxo-volume" e "Teste de
broncoprovocação" .)
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CONSELHOS RELACIONADOS COM A PANDEMIA DE COVID-19
A espirometria e outras manobras de teste de função pulmonar (PFT) podem promover

tosse e geração de aerossóis e podem levar à disseminação da doença de coronavírus 2019
(COVID-19; SARS-CoV-2) por pacientes infectados. É difícil rastrear pacientes para infecção
ativa por COVID-19, particularmente aqueles com sintomas respiratórios subjacentes, e
pacientes infectados, mas assintomáticos, podem disseminar o vírus. Assim, concordamos
com as recomendações dos especialistas de que a espirometria e outros PFTs sejam
limitados a pacientes nos quais os resultados são essenciais para decisões imediatas de
tratamento [ 12,13 ]. O uso de nebulizadores para administrar broncodilatadores ou
metacolina deve ser evitado.
Measures to prevent spread of COVID-19 should include hand hygiene and personal
protective equipment (PPE; glove, gown, face mask and shield) for staff and anyone else in
the testing space (eg, interpreters). N95 masks or powered air purifying respirators (PAPR)
are preferred over surgical masks. Patients should be brought to a testing room using an
approach that avoids queuing or grouping individuals in a waiting area and that allows
adequate time between patients for sufficient air exchange. Enhanced cleaning of the
testing area should be performed between patients.
EQUIPMENT
Office spirometers should meet equipment specifications as described in international

guidelines [5,10,14,15]. The majority of spirometers manufactured since 1990 are accurate,
although some flow-sensing office spirometers can produce falsely high results [16-18].
Reference standards are discussed separately. (See "Selecting reference values for
pulmonary function tests".)
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 when only forced
exhalation maneuvers are being obtained.
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. A survey of 17 spirometers used in primary care
offices found only 1 of 17 met accuracy criteria; clearly manufacturers and practitioners need
to be aware of potentially significant quality issues related to office spirometry [19].
In addition to internal calibration performed by the device, daily calibration checks with a
three liter syringe are recommended [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 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 sex
at birth, 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 unexpectedly higher or lower than expected are a clue that an incorrect age or height
value may have been entered. Waist circumference, while not used to calculate predicted
normal values, can also be measured because abdominal obesity is a common cause of
mildly low values for FEV1 and FVC [20].
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 [21]. 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. The
patient should then be instructed to blast out the air without hesitation (within two seconds
of reaching full inflation). Exhalation should last until a plateau in exhaled volume is reached,
or a maximum of 15 seconds. However, if measuring FEV6 as a surrogate for FVC, then
exhalation need only last at least six seconds. To fully evaluate flow volume loops, it is
necessary to perform a complete inspiratory maneuver at the end of the test. The maximal
inspiration at the end of test requires vigorous coaching to achieve good quality results and
patients should be informed that this aspect of the maneuver feels somewhat
uncomfortable. (See "Flow-volume loops".)
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 technician or person performing the test 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: Strongly prompt the patient to blast out the air into the spirometer without
hesitation after reaching a full inspiration
● Phase 3: Encourage the patient to continue exhaling until a plateau in exhaled volume
or 15 seconds is reached, unless just measuring FEV6 in which case the exhalation
should last at least six seconds (three seconds for children)
Patients in whom a flow volume loop is needed will need to perform an additional phase of
deep and forceful inspiration to total lung capacity immediately after phase 3.
ADEQUACY OF TEST
An adequate test usually requires three acceptable and repeatable forced vital capacity (FVC)
maneuvers [10]. 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) [14,22].
An acceptable maneuver requires a sharp peak in the flow curve and an expiratory duration
that reaches a plateau of exhaled volume or 15 seconds, or greater than six seconds if
measuring FEV6 instead of FVC ( figure 3). At least three acceptable maneuvers should be
available for analysis.
Repeatability is determined by comparing the FVC and FEV1 values of the maneuvers. The
two highest values for FVC and for FEV1 should be within 0.15 L of each other (for adults; the
limit is 0.10 L for children) [10,23].
The grading system for the quality of spirometry factors in the number of acceptable
maneuvers and the degree of repeatability for FEV1 and FVC separately ( table 1) [10].
INTERPRETATION
All tracings from the forced expiratory maneuvers should be examined for acceptability and
repeatability, according to the criteria mentioned above. The study should then be classified
as normal or abnormal, the latter showing an obstructive, a possible restrictive, or a possible
mixed pattern. Lung volumes are necessary to confirm whether or not the patient has a
restrictive deficit. The severity of the ventilatory impairment is then assessed, according to
the algorithm ( algorithm 1). (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
( algorithm 1). In general, a low FVC needs further evaluation with full pulmonary function
tests to determine whether lung restriction is present [24]. Patients with obstruction and low
FVC frequently demonstrate air trapping or failure to complete a full exhalation rather than
an additional restrictive process. (See "Overview of pulmonary function testing in adults".)
When FVC is low, restriction is not confirmed by lung volumes, and there is not obstruction
(based on FEV1/FVC), this represents a "nonspecific" pattern. Nonspecific patterns are not
clearly indicative of any lung disease subtype but may be associated with either ongoing or
future obstructive or restrictive diseases [25]. Repeat testing to reassess lung function after
several months to a year may be useful.
Due to these potential problems with air trapping and incomplete exhalation, FVC is not
used to grade restriction severity. We prefer to assess the severity of restrictive deficits by
applying the z-score approach to total lung capacity measurements, when available. If lung
volumes are not available, FEV1 may be used to assess the severity of previously established
restriction, as was recommended in prior guidelines [23]. (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 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 [21,26]. 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 [21]. 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 ( algorithm 1). 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 typically declines with clinical worsening of airways
obstruction and increases with successful treatment of airways obstruction. The FEV1 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).
FEV1 may also be used to grade the severity of restrictive or mixed obstructive/restrictive
disorders once restriction has been confirmed by lung volumes; however, we prefer to grade
pure restriction using total lung capacity when this measurement is available
( algorithm 1) [23]. (See "Overview of pulmonary function testing in adults".)
The measured FEV1 should be reported based on z-score, instead of percent predicted. This
measurement strategy helps to avoid age, sex, and height bias and is associated with
important clinical outcomes [27,28]. The lower limit of normal (LLN) for FEV1 and other
spirometry measures is defined by z-score <-1.645, which is equivalent to the fifth percentile
in the distribution of healthy never-smokers. This replaces using a fixed percent of predicted
value, which does not incorporate demographic features [27,29]. An FEV1 within the normal
range may still represent a mild ventilatory impairment if obstruction or restriction is
confirmed using other measures.
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, are
recommended for both pediatric and adult patients [27,30]. These reference equations are
endorsed by multiple international expert groups and replace the older generation of
equations, including those derived from the NHANES III study [23,31]. (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
male and 3 L for a female. 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. Individuals with an FEV1 ≤75 percent of predicted are
more likely to report dyspnea, wheezing, or cough, than those with an FEV1 >75 percent
predicted [32]. (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
obstruction in diseases like asthma and COPD ( algorithm 1). 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 often decreases with increasing obstruction due
to air trapping or premature termination of exhalation. 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: Diagnosis and staging".)
The use of z-score <-1.645 or the fifth percentile LLN for FEV1/FVC to detect airway
obstruction reduces the misclassification associated with using a fixed threshold of 0.7
[29,33-36].
If FEV1/FVC is low, but FEV1 is normal, this is still considered indicative of mild airflow
obstruction. In some cases, a low FEV1/FVC in the presence of a low FEV1 is classified as
reflecting dysanapsis, or airways size being too small relative to lung volume size. While
dysanapsis may be a physiologically normal variant, it has also been associated with COPD
[37], bronchodilator responsiveness, and [38] severe asthma in children with obesity [39].
If FEV1/FVC is normal, but FEV1 is low, this may represent restriction, which should be
evaluated by lung volumes. When lung volumes are not available, this pattern has also been
labeled "Preserved Ratio Impaired Spirometry", or PRISm. It is unclear if PRISm is a distinct
phenotype of lung disease, but multiple studies have demonstrated that PRISm is associated
with increased cardiopulmonary disease and mortality [40-42].
When FVC maneuvers are routinely stopped after six seconds, the FEV1/FEV6 may replace the
FEV1/FVC [43]. 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 [26,44-46]. The
appropriate lower limit of normal for FEV1/FEV6 from NHANES III should be used [31,47];
unfortunately, the GLI equations do not include prediction equations for FEV6.
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
specificity and reproducibility [21].
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 less likely.
The assessment of bronchodilator responses in patients with asthma-like symptoms is
described separately. Note, however, that a bronchodilator response alone does not
distinguish asthma from COPD [48]. If the change in spirometry post-bronchodilator does
not support a diagnosis of obstructive lung disease, referral for bronchial challenge testing
(eg, with methacholine or exercise) may be helpful [49]. (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 [50-
54]. All patients who smoke should be advised to stop smoking and provided smoking
cessation assistance.
● In a patient with asthma, which is characterized by variability in clinical symptoms and

airflow obstruction, normal airflow at the time of office visits does not exclude airflow
obstruction at other times.
● Patients with early interstitial lung disease 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 [55].
● Misclassification rates due to suboptimal spirometry performance or interpretation are

relatively high in the office setting [7,19,56]. Among eight general practices, rates for
successfully meeting American Thoracic Society (ATS) quality standards were below 80
percent [7]. In 16 primary care offices involving 17 different spirometers, only 60
percent of patients had spirometry that met acceptability criteria [19]. Therefore,
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 [57,58].
● There are multiple barriers to performing in-office spirometry. One comprehensive

survey identified multiple barriers including lack of knowledge about how to interpret
spirometry, lack of resources (equipment, personnel, skills, time), and lack of belief in
importance of results [59]. Most of the barriers identified were also true for out-of-
office (ie, hospital) spirometry, indicating that implementing spirometry in general
faces many challenges.
RISKS
Spirometry is a low-risk procedure and has few side effects [14]. 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 [60]:
● 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 [4,61,62].
SOCIETY GUIDELINE LINKS
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 that reaches a plateau in expired volume or a duration of 15
seconds; however, if FEV6 is being measured instead of FVC, then only a duration of at
least six seconds is required. 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 fixed threshold of 0.7 because it reduces the
misclassification rate for detecting airway obstruction. (See 'Choosing the best values'
above and 'Ratio of FEV1/FVC' above.)
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● Reduction of the FEV1/FVC suggests airway obstruction ( algorithm 1) (see

'Interpretation' above). If FEV1/FVC is low but FEV1 is normal, this is still considered
obstruction but may also represent dysanapsis, which can be a normal variant.
● A normal FEV1/FVC but reduced FVC suggests restriction, which must be confirmed by
lung volume measurement. If restriction is not confirmed, this pattern has been
termed "nonspecific". If lung volumes are not available, a low FEV1 and normal
FEV1/FVC has also been referred to as Preserved Ratio Impaired Spirometry, or PRISm.
● The FEV1/FEV6 can be helpful instead of 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 in obstructive and mixed obstructive-restrictive disorders. It may also be
used in the absence of lung volumes for grading previously confirmed restriction.
FEV1/FVC ratio is not useful for gauging severity of ventilatory impairment, since the
FVC often decreases with increasing obstruction due to air trapping or premature
termination of exhalation ( algorithm 1). (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.)
● Despite the potential benefits, ongoing barriers to office spirometry implementation

include primary care provider uncertainty regarding the benefits of testing, lack of
resources, and lack of confidence in spirometric interpretation.
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Paul Enright, MD, who contributed to earlier
versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Enright P, Quanjer P. Don't diagnose mild COPD without confirming airway obstruction
after an inhaled bronchodilator. COPD 2007; 4:89.
2. Han MK, Kim MG, Mardon R, et al. Spirometry utilization for COPD: how do we measure
up? Chest 2007; 132:403.
3. Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following diagnosis of
COPD. Chest 2006; 129:1509.
4. US Preventive Services Task Force (USPSTF), Siu AL, Bibbins-Domingo K, et al. Screening
for Chronic Obstructive Pulmonary Disease: US Preventive Services Task Force
Recommendation Statement. JAMA 2016; 315:1372.
5. Ruppel GL, Carlin BW, Hart M, Doherty DE. Office Spirometry in Primary Care for the
Diagnosis and Management of COPD: National Lung Health Education Program Update.
Respir Care 2018; 63:242.
6. Enright PL, Studnicka M, Zielinski J. Spirometry to detect and manage COPD and asthma
in the primary care setting. Eur Respir Mon 2005; 31:1.
7. Walters JA, Hansen EC, Johns DP, et al. A mixed methods study to compare models of
spirometry delivery in primary care for patients at risk of COPD. Thorax 2008; 63:408.
8. Lusuardi M, De Benedetto F, Paggiaro P, et al. A randomized controlled trial on office

spirometry in asthma and COPD in standard general practice: data from spirometry in
Asthma and COPD: a comparative evaluation Italian study. Chest 2006; 129:844.
9. Levy ML, Quanjer PH, Booker R, et al. Diagnostic spirometry in primary care: Proposed
standards for general practice compliant with American Thoracic Society and European
Respiratory Society recommendations: a General Practice Airways Group (GPIAG)1
document, in association with the Association for Respiratory Technology & Physiology
(ARTP)2 and Education for Health3 1 www.gpiag.org 2 www.artp.org 3
www.educationforhealth.org.uk. Prim Care Respir J 2009; 18:130.
10. Graham BL, Steenbruggen I, Miller MR, et al. Standardization of Spirometry 2019
Update. An Official American Thoracic Society and European Respiratory Society
Technical Statement. Am J Respir Crit Care Med 2019; 200:e70.
11. United Kingdom National Screening Committee guidelines on COPD screening: https://v
iew-health-screening-recommendations.service.gov.uk/document/329/download (Acces
sed on February 24, 2023).
12. American Thoracic Society. Pulmonary Function Laboratories: Advice Regarding COVID-1
9. https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/p
ulmonary-function-laboratories.php (Accessed on March 31, 2020).
13. Wilson KC, Kaminsky DA, Michaud G, et al. Restoring Pulmonary and Sleep Services as
the COVID-19 Pandemic Lessens. From an Association of Pulmonary, Critical Care, and
Sleep Division Directors and American Thoracic Society-coordinated Task Force. Ann Am
Thorac Soc 2020; 17:1343.
14. Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health
assessment in adults: A consensus statement from the National Lung Health Education
Program. Chest 2000; 117:1146.
15. Culver BH, Graham BL, Coates AL, et al. Recommendations for a Standardized
Pulmonary Function Report. An Official American Thoracic Society Technical Statement.
Am J Respir Crit Care Med 2017; 196:1463.
16. Townsend MC, Hankinson JL, Lindesmith LA, et al. Is my lung function really that good?
Flow-type spirometer problems that elevate test results. Chest 2004; 125:1902.
17. Liistro G, Vanwelde C, Vincken W, et al. Technical and functional assessment of 10 office
spirometers: A multicenter comparative study. Chest 2006; 130:657.
18. Schermer TR, Verweij EH, Cretier R, et al. Accuracy and precision of desktop spirometers
in general practices. Respiration 2012; 83:344.
19. Hegewald MJ, Gallo HM, Wilson EL. Accuracy and Quality of Spirometry in Primary Care
Offices. Ann Am Thorac Soc 2016; 13:2119.
20. Leone N, Courbon D, Thomas F, et al. Lung function impairment and metabolic
syndrome: the critical role of abdominal obesity. Am J Respir Crit Care Med 2009;
179:509.
21. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J
2005; 26:319.
22. Enright PL. Office spirometry. In: Atlas of office procedures, 1999. Vol 2, p.299.
23. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests.
Eur Respir J 2005; 26:948.
24. Vandevoorde J, Verbanck S, Schuermans D, et al. Forced vital capacity and forced
expiratory volume in six seconds as predictors of reduced total lung capacity. Eur Respir
J 2008; 31:391.
25. Iyer VN, Schroeder DR, Parker KO, et al. The nonspecific pulmonary function test:
longitudinal follow-up and outcomes. Chest 2011; 139:878.
26. Swanney MP, Jensen RL, Crichton DA, et al. FEV(6) is an acceptable surrogate for FVC in
the spirometric diagnosis of airway obstruction and restriction. Am J Respir Crit Care
Med 2000; 162:917.
27. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive
strategies for routine lung function tests. Eur Respir J 2022; 60.
28. Quanjer PH, Pretto JJ, Brazzale DJ, Boros PW. Grading the severity of airways obstruction:
new wine in new bottles. Eur Respir J 2014; 43:505.
29. Miller MR, Quanjer PH, Swanney MP, et al. Interpreting lung function data using 80%
predicted and fixed thresholds misclassifies more than 20% of patients. Chest 2011;
139:52.
30. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for
the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J 2012;
40:1324.
31. Stanojevic S, Wade A, Stocks J, et al. Reference ranges for spirometry across all ages: a
new approach. Am J Respir Crit Care Med 2008; 177:253.
32. Jakeways N, McKeever T, Lewis SA, et al. Relationship between FEV1 reduction and
respiratory symptoms in the general population. Eur Respir J 2003; 21:658.
33. Hnizdo E, Glindmeyer HW, Petsonk EL, et al. Case definitions for chronic obstructive
pulmonary disease. COPD 2006; 3:95.
34. Swanney MP, Ruppel G, Enright PL, et al. Using the lower limit of normal for the
FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax 2008;
63:1046.
35. García-Rio F, Soriano JB, Miravitlles M, et al. Overdiagnosing subjects with COPD using
the 0.7 fixed ratio: correlation with a poor health-related quality of life. Chest 2011;
139:1072.
36. Çolak Y, Afzal S, Nordestgaard BG, et al. Young and middle-aged adults with airflow
limitation according to lower limit of normal but not fixed ratio have high morbidity
and poor survival: a population-based prospective cohort study. Eur Respir J 2018; 51.
37. Smith BM, Kirby M, Hoffman EA, et al. Association of Dysanapsis With Chronic
Obstructive Pulmonary Disease Among Older Adults. JAMA 2020; 323:2268.
38. Vameghestahbanati M, Kirby M, Maltais F, et al. Dysanapsis and the Spirometric

Response to Inhaled Bronchodilators. Am J Respir Crit Care Med 2021; 204:997.
39. Forno E, Weiner DJ, Mullen J, et al. Obesity and Airway Dysanapsis in Children with and
without Asthma. Am J Respir Crit Care Med 2017; 195:314.
40. Wan ES, Balte P, Schwartz JE, et al. Association Between Preserved Ratio Impaired
Spirometry and Clinical Outcomes in US Adults. JAMA 2021; 326:2287.
41. Marott JL, Ingebrigtsen TS, Çolak Y, et al. Trajectory of Preserved Ratio Impaired
Spirometry: Natural History and Long-Term Prognosis. Am J Respir Crit Care Med 2021;
204:910.
42. Zheng J, Zhou R, Zhang Y, et al. Preserved Ratio Impaired Spirometry in Relationship to
Cardiovascular Outcomes: A Large Prospective Cohort Study. Chest 2023; 163:610.
43. Jing JY, Huang TC, Cui W, et al. Should FEV1/FEV6 replace FEV1/FVC ratio to detect airway
obstruction? A metaanalysis. Chest 2009; 135:991.
44. Jensen RL, Crapo RO, Enright P. A statistical rationale for the use of forced expired
volume in 6 s. Chest 2006; 130:1650.
45. Bellia V, Sorino C, Catalano F, et al. Validation of FEV6 in the elderly: correlates of
performance and repeatability. Thorax 2008; 63:60.
46. Vollmer WM, Gíslason T, Burney P, et al. Comparison of spirometry criteria for the
diagnosis of COPD: results from the BOLD study. Eur Respir J 2009; 34:588.
47. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of
the general U.S. population. Am J Respir Crit Care Med 1999; 159:179.
48. Janson C, Malinovschi A, Amaral AFS, et al. Bronchodilator reversibility in asthma and
COPD: findings from three large population studies. Eur Respir J 2019; 54.
49. Coates AL, Wanger J, Cockcroft DW, et al. ERS technical standard on bronchial challenge
testing: general considerations and performance of methacholine challenge tests. Eur
Respir J 2017; 49.
50. Buffels J, Degryse J, Decramer M, Heyrman J. Spirometry and smoking cessation advice
in general practice: a randomised clinical trial. Respir Med 2006; 100:2012.
51. Enright P. Does screening for COPD by primary care physicians have the potential to
cause more harm than good? Chest 2006; 129:833.
52. Bize R, Burnand B, Mueller Y, et al. Biomedical risk assessment as an aid for smoking
cessation. Cochrane Database Syst Rev 2012; 12:CD004705.
53. Wilt TJ, Niewoehner D, Kane RL, et al. Spirometry as a motivational tool to improve
smoking cessation rates: a systematic review of the literature. Nicotine Tob Res 2007;
9:21.
54. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients
their lung age: the Step2quit randomised controlled trial. BMJ 2008; 336:598.
55. Boros PW, Enright PL, Quanjer PH, et al. Impaired lung compliance and DL,CO but no
restrictive ventilatory defect in sarcoidosis. Eur Respir J 2010; 36:1315.
56. Joo MJ, Au DH, Fitzgibbon ML, et al. Determinants of spirometry use and accuracy of
COPD diagnosis in primary care. J Gen Intern Med 2011; 26:1272.
57. Poels PJ, Schermer TR, Akkermans RP, et al. General practitioners' needs for ongoing
support for the interpretation of spirometry tests. Eur J Gen Pract 2007; 13:16.
58. Schermer TR, Smeele IJ, Thoonen BP, et al. Current clinical guideline definitions of
airflow obstruction and COPD overdiagnosis in primary care. Eur Respir J 2008; 32:945.
59. Yamada J, Lam Shin Cheung J, Gagne M, et al. Barriers and Enablers to Objective Testing
for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical
Domains Framework. Chest 2022; 161:888.
60. National Asthma Education and Prevention Program: Expert panel report III: Guidelines
for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and
Blood Institute, 2007. (NIH publication no. 08-4051). Full text available online: www.nhlb
i.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on August 12, 2009).
61. Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic
obstructive pulmonary disease: a clinical practice guideline from the American College
of Physicians. Ann Intern Med 2007; 147:633.
62. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Di
agnosis, Management and Prevention of chronic obstructive pulmonary disease: 2020 R
eport. http://www.goldcopd.org (Accessed on December 16, 2020).
Topic 6968 Version 29.0
GRAPHICS
Técnica para realizar a espirometria
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.
Graphic 55460 Version 1.0
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.
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) fixed central airway
stenosis (or variable intrathoracic airway obstruction), and (E) poor
effort.
Grading system for repeatability of FEV 1 and FVC (graded separately)
Number of Repeatability: Repeatability:

Grade
measurements Age >6 years Age ≤6 years*
A ≥3 acceptable Within 0.150 L Within 0.100 L*
B 2 acceptable Within 0.150 L Within 0.100 L*
C ≥2 acceptable Within 0.200 L Within 0.150 L*
D ≥2 acceptable Within 0.250 L Within 0.200 L*
E ≥2 acceptable >0.250 L >0.200 L*
or 1 acceptable N/A N/A
U 0 acceptable and ≥1 N/A N/A

usable
F 0 acceptable and 0 N/A N/A

usable
The repeatability grade is determined for the set of prebronchodilator maneuvers and the set of
post-bronchodilator maneuvers separately. The repeatability criteria are applied to the
differences between the two largest FVC values and the two largest FEV 1 values. Grade U
indicates that only usable but not acceptable measurements were obtained. Although some
maneuvers may be acceptable or usable at grading levels lower than A, the overriding goal of the
operator must be to always achieve the best possible testing quality for each patient.
FEV 1 : Forced expiratory volume in one second; FVC: forced vital capacity; N/A: not applicable.
* Or 10% of the highest value, whichever is greater; applies for age 6 years or younger only.
Reprinted with permission of the American Thoracic Society. Copyright © 2020 American Thoracic Society. All rights
reserved. From: Graham BL, Steenbruggen I, Miller MR, et al. Standardization of Spirometry 2019 Update. An Official
American Thoracic Society and European Respiratory Society Technical Statement. Am J Respir Crit Care Med 2019;
200:e70. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic
Society.
Classification and grading of ventilatory impairments based on spirometry [1
FEV 1 : forced expiratory volume in one second; FVC: forced vital capacity; LLN: lower limit of normal, the
5th percentile.
* Low refers to levels below the 5th percentile, or a z-score <–1.645; absolute values are not used due to
changes in spirometry with age and other factors.
¶ A reduced FVC does not prove a restrictive process. Confirmation of restriction requires evaluation of
lung volumes in a pulmonary function laboratory (ie, total lung capacity z-score <–1.645 or below fifth
percentile).
Δ A reduced FVC with normal FEV 1 /FVC and lung-volumes is a "nonspecific" pattern that may be followed
over time. One-third of patients with nonspecific patterns develop obstructive or restrictive disease in th
next three years.
◊ Many patients with reduced FEV 1 /FVC and low FVC have simple obstruction with air-trapping or failure
to complete exhalation.
§ The severity of obstructive and mixed obstructive/restrictive ventilatory impairments are physiological
graded by decrement in FEV 1 . Patients with restriction should have restrictive impairment confirmed an
graded based on total lung capacity, but may be monitored by changes in FEV 1 . FEV 1 may also be used
as an alternative method to grade severity of confirmed restriction when only spirometry or % predicted
values are available.
¥ O escore Z é o método preferido para classificar a gravidade com base nas diretrizes da European
Respiratory Society/American Thoracic Society (ERS/ATS) de 2022 porque reduz o viés devido à idade,
sexo e outros fatores. Alguns softwares de espirometria continuam relatando a porcentagem prevista,
portanto, também incluímos a categorização com base nesse método de relatório. A classificação de
gravidade prevista percentual foi adaptada de diretrizes anteriores e modernizada, reduzindo o número
de categorias distintas.
Referências:
1. Stanojevic S, Kaminsky DA, Miller MR, et al. Padrão técnico ERS/ATS sobre estratégias interpretativas para testes de função
pulmonar de rotina. Eur Respiro J 2022; 60:2101499.
2. Pellegrino R, Viegi G, Brusasco V, et al. Estratégias interpretativas para testes de função pulmonar. Eur Respir J 2005;
26:948.
Gráfico 139645 Versão 2.0
Contributor Disclosures
David A Kaminsky, MD Other Financial Interest: MGC Diagnostics Inc [Speaker/faculty
cardiorespiratory diagnostics course]. All of the relevant financial relationships listed have been
mitigated. Meredith C McCormack, MD, MHS Consultant/Advisory Boards: Aridis [Pulmonary function
testing];Boehringer Ingelheim[COPD and asthma];Celgene [Asthma];GlaxoSmithKline [Chronic
obstructive pulmonary disease]. All of the relevant financial relationships listed have been
mitigated. Paul Dieffenbach, MD No relevant financial relationship(s) with ineligible companies to
disclose.
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31/03/2023, 18:13 Office spirometry - UpToDate

Reimpressão oficial do UpToDate ®

No consultório, a espirometria é normalmente usada para detectar, confirmar e monitorar

O desempenho da espirometria no consultório será analisado aqui. Questões mais gerais

CONSELHOS RELACIONADOS COM A PANDEMIA DE COVID-19

A espirometria e outras manobras de teste de função pulmonar (PFT) podem promover

Office spirometers should meet equipment specifications as described in international

To avoid cross-contamination between patients when using permanent flow sensors, it is

the curves are unacceptable.

COACHING THE PATIENT

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

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

● In a patient with asthma, which is characterized by variability in clinical symptoms and

● Misclassification rates due to suboptimal spirometry performance or interpretation are

● There are multiple barriers to performing in-office spirometry. One comprehensive

Rarely, performance of a forced expiratory maneuver will precipitate acute

● At the time of initial assessment

● During periods of progressive or prolonged loss of asthma control

● At least every one to two years

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Reduction of the FEV1/FVC suggests airway obstruction ( algorithm 1) (see

● Office spirometry results should be verified by formal testing in a pulmonary function

● Despite the potential benefits, ongoing barriers to office spirometry implementation

Use of UpToDate is subject to the Terms of Use.

8. Lusuardi M, De Benedetto F, Paggiaro P, et al. A randomized controlled trial on office

38. Vameghestahbanati M, Kirby M, Maltais F, et al. Dysanapsis and the Spirometric

Técnica para realizar a espirometria

Graphic 55460 Version 1.0

Flow-volume curve patterns from unacceptable forced vital capacity

FVC: forced vital capacity.

Graphic 57832 Version 2.0

Flow-volume curve variations

Flow-volume curves from (A) a healthy person or from patients with

Graphic 65057 Version 2.0

Grading system for repeatability of FEV 1 and FVC (graded separately)

Number of Repeatability: Repeatability:

A ≥3 acceptable Within 0.150 L Within 0.100 L*

B 2 acceptable Within 0.150 L Within 0.100 L*

C ≥2 acceptable Within 0.200 L Within 0.150 L*

D ≥2 acceptable Within 0.250 L Within 0.200 L*

E ≥2 acceptable >0.250 L >0.200 L*

or 1 acceptable N/A N/A

U 0 acceptable and ≥1 N/A N/A

F 0 acceptable and 0 N/A N/A

Graphic 129852 Version 1.0

Classification and grading of ventilatory impairments based on spirometry [1

Gráfico 139645 Versão 2.0

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