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PubMed1994

The "88% saturation test": a simple lung function test for young children.

OBJECTIVE: The 88% saturation test (88%-SAT) was developed as an alternative to standard spirometry for those young children unable to perform standard forced expiratory maneuvers. In adults, this test revealed rapid desaturation in those persons with a history of asthma when compared with healthy control subjects. Similar findings in children were tested. SETTING: Tertiary care hospital. PATIENTS: Thirty-three former premature infants (28.3 +/- 2.3 weeks gestation), aged 5 to 7 years, who were participating in a follow-up study, were enrolled in this study. DESIGN: The study compared the 88%-SAT with standard spirometry and respiratory health characteristics ascertained through a parental questionnaire. The 88%-SAT consists of continuous measurement of hemoglobin saturation by pulse oximetry (SaO2) while the subject breathes a nonhumidified 12% oxygen and nitrogen mixture for 10 minutes or until SaO2 decreases to 88%, whichever occurs first. Abnormal 88%-SAT was defined as a decrease of SaO2 to 88% within the 10-minute period, and abnormal spirometry was defined using standardized values. RESULTS: Of the 20 children who successfully completed both spirometry and the 88%-SAT, 10 had normal spirometry results and did not desaturate to 88%, and 5 had abnormal spirometry and 88%-SAT results. Four children did not desaturate during the 88%-SAT, but had abnormal spirometry results, and one child had abnormal 88%-SAT results, but normal spirometry. Ten additional children completed the 88%-SAT, but not standard spirometry. Three children were unable to complete either test. Of those 30 children tested, 7 (23%) had a history of reactive airways disease, and all 7 had abnormal 88%-SAT results. The 88%-SAT had greater sensitivity (100% vs 75%) and specificity (87% vs 63%) than spirometry in identifying children with known reactive airways disease. The mean McCarthy general cognitive index (GCI) of the group performing both spirometry and the 88%-SAT (n = 20) achieved a mean (+/- SD) GCI of 96.2 +/- 16.7, and the group (n = 30) that completed the 88%-SAT had a mean (+/- SD) GCI of 75.2 +/- 26.3 (chi 2 P < .012). The 10 children able to perform only the 88%-SAT had a mean GCI (+/- SD) of 72.8 +/- 26.9, and the 3 children unable to perform either test had a mean GCI (+/- SD) of 63 +/- 11. CONCLUSIONS: Our data suggest that the 88%-SAT may be more effective than spirometry for identifying reactive airways disease in young, uncooperative, or developmentally delayed children. The dry air of the hypoxic inspired gas may function as an airway challenge, leading to decreased oxygenation in patients with reactive airways.

Child↗
PubMed2002

Quality assurance of asthma clinical trials.

Accuracy and repeatability of spirometry measurements are essential to obtain reliable efficacy data in randomized asthma clinical trials. We report our experience with a centralized spirometry quality assurance program that we implemented in our phase III asthma trials. Six asthma trials of 4 to 21 weeks in duration were conducted at 232 clinical centers in 31 countries. Approximately 23,100 prebronchodilator and 13,700 postbronchodilator spirometry tests were collected from 2523 adult and 336 pediatric asthmatic patients. The program used a standard spirometer (the Renaissance spirometry system) with maneuver quality messages and automated quality grading of the spirometry tests. Each clinical center transmitted spirometry data weekly to a central database, where uniform monitoring of data quality was performed and feedback was provided in weekly quality reports. Seventy-nine percent of all patients performed spirometry sessions with quality that either met or exceeded American Thoracic Society standards and improved over time. Good-quality spirometry was associated with (1) less severe asthma; (2) active treatment; (3) infrequent nocturnal awakenings; (4) age above 15 years; and (5) low body weight. Maneuver-induced bronchospasm was rare. Good-quality spirometry was observed in multicenter asthma clinical trials that employed a standard spirometer and continuous monitoring. Both within- and between-patient variability decreased. Spirometry quality improved with time as study participants and technicians gained experience.

Adolescent↗
PubMed1995

Adherence to established guidelines for preoperative pulmonary function testing.

Guidelines for ordering preoperative spirometry have been proposed by GM Tisi (1979) and more recently by the American College of Physicians (ACP). Requests for preoperative spirometries represent a significant portion of all requests for screening spirometry at our institution and utilize significant man-hours of technician time. We determined the percentage of these requests that did not meet the ACP guidelines and characterized why these requests were being generated. We sampled 441 screening spirometries performed by the Walter Reed Pulmonary Function Laboratory over a 4-week period. One hundred thirty-eight (31%) of these were done preoperatively and complete data were available in 135 cases. Patients in the analyzed group had a mean age of 59 years (+/- 14 years), ranging from 20 to 84 years of age. Fifty-two (39%) requests did not meet ACP guidelines. Most of these requests were associated with either normal spirometry (n = 34) or only mild spirometric abnormalities (n = 14). Spirometry revealed severe obstruction in only one case when the request was not indicated. No cases of moderate obstruction, severe restrictive pattern, or possible upper airway obstruction were found in the group of requests in which spirometry was not indicated. Of the requests that did not meet ACP guidelines, 21 met Tisi's broader guidelines. Most of these requests were found exclusively in patients older than 70 years of age (n = 13) and the morbidly obese (n = 4). Of the 31 studies that did not meet either set of guidelines, 25 occurred in asymptomatic, current, or prior smokers. In conclusion, during a 4-week study period at our institution, 39% of preoperative spirometry requests did not meet ACP guidelines. Most of the patients had been referred because of age greater than 70 years, morbid obesity, and a current/prior history of smoking. However, the literature does not support obtaining preoperative spirometry in such patients except for those undergoing only lung resection. We recommend stricter adherence to the ACP guidelines as a means of decreasing the number and cost of unnecessary spirometries being performed.

Adult↗
PubMed2003

Attitudes of physicians toward objective measures of airway function in asthma.

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) recommends pulmonary function testing as part of asthma evaluation. The objectives of this study were to determine the use of spirometry in patients with asthma by primary care physicians and asthma specialists, and to identify barriers to use of spirometry. METHODS: We developed, validated, and administered a mailed survey to primary care physicians and asthma specialists in the general community. We asked about the use of spirometry, access to spirometry, and barriers to spirometry use. RESULTS: Of 975 eligible subjects, 672 (69%) completed the survey. Asthma specialists were more likely to have an office spirometer (78% [216/277] vs. 43% [169/395], P <0.001) than were primary care physicians, and more likely to report measuring pulmonary function in at least 75% of their patients with asthma (83% [223/270] vs. 34% [131/388], P <0.001). In logistic regression analysis, factors most strongly associated with reported spirometry use (in at least 75% of patients) among asthma specialists were owning a spirometer, disagreeing with the statement that the test requires excessive use of office resources, and agreeing that spirometry is a necessary part of the asthma evaluation. Among primary care physicians, owning a spirometer, agreeing that the data are necessary for accurate diagnosis, and believing that they were trained to perform and interpret the test were most strongly associated with reported spirometry use. CONCLUSION: Pulmonary function testing is underutilized by physicians, with rates of utilization lowest among primary care physicians. Providing primary care physicians with better access to spirometry, through provision of a machine and appropriate training in its use and interpretation, may improve compliance with the NAEPP recommendations.

Adolescent↗
PubMed2006

Use of office spirometers in Flemish general practice: results of a telephone survey.

BACKGROUND: While office spirometry is seen as potentially useful and feasible in general practice, little is known about its use in Flemish general practice. Our aim was to describe the use of spirometers by Flemish GPs, characteristics of their spirometry practice, training needs and preferences, and attitudes towards office spirometry. METHODS: A telephone survey was set up in a random sample of Flemish GPs. Interviews were carried out by a GP researcher using a structured piloted questionnaire. RESULTS: 197 out of 243 eligible GPs (81%) were interviewed. Most GPs (66%) had never used an office spirometer, 17.3% were using one and 16.7% stopped using one. Time constraints (54%) and insufficient knowledge and skills (27%) were the main reasons for not using an office spirometer (any longer). GPs particularly used their spirometer to diagnose COPD and asthma, and less frequently in follow-up. GPs (67.9%), especially current users (91.2%), considered spirometry as a GP task. Spirometry training should be provided (86%) and spirometry by GPs should be reimbursed (79.5%). More information on spirometry would be very useful (62.3%), with a marked preference for training in small groups (86.8%). CONCLUSION: Although office spirometry is not widespread in Flemish general practice, GPs show an undoubted interest in it. They need educational and financial support to overcome prevailing barriers in establishing office spirometry on a routine basis.

Analysis of Variance↗
PubMed2006

Discrepancy in the use of confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive pulmonary disease or congestive heart failure.

OBJECTIVE: To determine the prevalence of confirmatory use of spirometry in patients admitted to a tertiary-care facility with the diagnosis of chronic obstructive pulmonary disease (COPD), including those with respiratory failure, and compare that to the use of confirmatory 2-dimensional echocardiography (2-D echo) in patients admitted with the diagnosis of congestive heart failure (CHF), to determine preferential confirmatory testing practices. SETTING: Academic tertiary-care hospital. METHODS: A 6-month retrospective review of charts of patients with a primary or secondary discharge diagnosis of COPD, respiratory failure, and CHF, using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Pulmonary function and echocardiography laboratory databases were reviewed to determine if the patients had had spirometry or 2-D echo performed during the 8 years prior to the study period. RESULTS: Five hundred fifty-three patients were discharged with the diagnosis of COPD, and 173 patients (31%) had had spirometry. In contrast, 789 patients had the diagnosis of CHF, and a larger proportion of them (619 patients, 78%) had had 2-D echo (p < 0.001). Only 35% of the patients with respiratory failure and COPD had spirometry performed. There were a total of 219 patients with concomitant diagnoses of COPD and CHF. A majority of them (48%) had a 2-D echo as the only confirmatory test, 74 (34%) had both tests performed, 4 (2%) had spirometry only, and 36 (16%) had neither test performed. Of the patients with a diagnosis of COPD who had spirometry, 30% had spirometry findings consistent with restrictive or normal physiology. CONCLUSIONS: A large proportion of patients hospitalized with the diagnosis of COPD have never had a confirmatory test, including those with presumably advanced disease. Compared to patients with CHF, patients with COPD are less likely to have had the confirmatory test performed, even when both conditions coexist. Many patients with the clinical diagnosis of COPD have an inconsistent physiologic diagnosis. To impact the increasingly important problem of COPD, we must raise awareness of the need to confirm its diagnosis and severity with spirometry.

Electrocardiography↗
PubMedDate not supplied

Is screening for chronic obstructive pulmonary disease justified?

BACKGROUND: Many experts recommend spirometry to screen for chronic obstructive pulmonary disease (COPD) in asymptomatic patients; however, evidence for this recommendation has not been systematically reviewed. METHODS: We examined whether screening spirometry meets standard criteria for effective screening. We performed structured searches of MEDLINE, followed by a selective search of the CITATION index, to locate randomized trials of interventions for asymptomatic patients with COPD. In regard to smoking cessation, we included all controlled trials of smoking cessation programs that used spirometry. We also included all studies that assessed the ability of spirometry to predict successful smoking cessation by comparing baseline lung function in smokers who subsequently quit versus those who did not. RESULTS: With the exception of smoking cessation, all interventions for COPD have only been proven effective in symptomatic patients. Two studies found that multifaceted smoking cessation programs that included spirometry were efficacious. There was no effect in a third study that isolated the role of spirometry. Smokers with abnormal spirometric results are less likely than other smokers to quit over the ensuing year. CONCLUSIONS: There is no evidence that spirometry, as an isolated intervention, aids smoking cessation.

Cost of Illness↗
PubMed2004

Attaining a correct diagnosis of COPD in general practice.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common. Diagnosis should include objective evidence of airways obstruction and spirometry is recommended in guidelines and the general medical services contract in the UK. We assessed the impact of spirometry in general practice. METHOD: We determined by questionnaire the availability, staff training, use and the interpretation results of spirometry in 72% of general practices in Wales. We reviewed the diagnosis of COPD previously made in two general practices without spirometry. RESULTS: Most practices had a spirometer (82.4%) and used it (85.6%). Confidence in use and interpretation of results varied widely: 58.1% were confident in use and 33.8% confident in interpretation. Spirometry was performed more often if confident in use and interpretation (both P<0.001) and was related to greater training periods (P<0.001). Spirometric confirmation of COPD varied widely (0-100%, median 37%). Of the 125 patients previously diagnosed with COPD 61 had spirometric confirmation, while 25 had reversible obstruction (range 210-800 mls), 34 had normal and 5 had restrictive spirometry. CONCLUSION: Despite incentives to perform spirometry in general practice, lack of adequate training in use and interpretation suggests use is confounded and the diagnosis of COPD is likely to be made on imprecise clinical grounds.

Adult↗