Spirometrie in de Huisartspraktijk. Johan Buffels, MD, PhD Jan Degryse, MD, PhD

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?

Volume (L)

8

Normal spirogram: Volume / time

6 FVC 4

Man 176 cm 76 kg

FEV1

2

5

Time (s)

10

15

Normal spirogram: Flow/Volume 12

PEF

Flow (L/s)

8 4

0 -4 -8

Volume (L)

Man 176 cm 76 kg

Interpretation of spirometry FVC

(Nl)

FEV1

FEV1/FVC

Nl

Restrictive lung disease

Obstructive lung disease Reversibility Yes

No


• • • •


Waarom spirometrie? • • • • •

Screening? Case finding? (Differentieel) diagnose? Evaluatie van exacerbaties? Follow-up therapie?



Adjusted odds ratio of death (all causes)

Mortality and FEV1 2 Men Women

1,5

1

0,5

0 <73

73-87

88-96 97-107

FEV1 (%pred)

>107

Screening vs Case finding Screening

Case Finding

• • • • •

• • • • •

Population-based Man in the street May not have symptoms May be a smoker No reimbursement

Individual patients Person visiting a doctor Respiratory symptoms Has COPD risk factors Covered by insurance

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

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


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 -) 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

226 (30.5%) Precontemplation

279 (37.7%)

Preparation

102 (13.8%)

Success

48 (6.5%) Relapse

n (incremental after x time)

221 attempts (18.3% of all smokers) Action

85 (11.5%)

SPIROSTOP: success rates

GENDER 6M 12M 24M SPIROMETRY 6M 12M 24M OAD?* 6M 12M 24M NRT/Bupropion** 6M 12M 24M

% Success MALE 28.6% 22.7% 16.5% YES 34.3% 22.5% 19.1% OBSTR 33.3% 23.3% 20.0% R/ 37.4% 27.3% 22.2%

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

% Success FEMALE 37.9% 22.1% 17.9% NO 29.0% 20.4% 14.0% NORMAL 36.7% 22.4% 18.4% NO R/ 29.8% 17.9% 11.9%

P value 0.312 0.994 0.924 0.670 0.987 0.580 0.570 0.850 0.962 0.119 0.073 0.048

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 pharmacotherapy on the deterioration of lung function in COPD, but some indications • We do NOT screen for COPD: we screen for obstructive airway disease



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 II.Matig ernstig COPD III.Ernstig COPD IV.Zeer ernstig COPD

FEV1 > 80% voorspeld 50% < FEV1 < 80% 30% < FEV 1 < 50% FEV1< 30% of verwikkeling na bronchodilatatie.



Differences between COPD and asthma (Vermeire PA, 1993) ASTHMA

COPD

Young 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

COPD

Chronic airway obstruction

Seldom

Almost always

Variable airway obstruction

Almost always

Seldom

Reversible airway obstruction

Almost always

Almost never

Airway hyperresponsiveness

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 uncertain diagnosis (data on file)

IPAG questionnaire

Specific history taking

Specialist’s advice

Office spirometry

Physical examination

Control visit after 3 months


DIDASCO2 Diagnostic certainty

Study population Asthma COPD Asthma+COPD Other obstr disease

Certain diagnosis 157 (13.9) 50 (15.7) 95 (17.5) 2 (1.3) 10 (19.7)

Almost certain diagnosis 446 (39.6) 132 (41.5) 251 (46.3) 37 (24.3) 26 (50.0)

• Spirometry was documented in o 31% of patients with asthma o 37% of patients with COPD

Uncertain diagnosis 523 (46.4) 136 (42.8) 196 (36.2) 113 (74.3) 16 (30.8)


IPAG questionnaire


Spirometry Course Specialist’s advice

Office spirometry





IPAG questionnaire



Office spirometry




IPAG questionnaire

VRAAG Wat is uw leeftijd?

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. Moet u de jongste jaren meer hoesten? Had u gedurende de jongste 3 jaar ademhalingsproblemen die u thuis hielden, of werkonbekwaam, of binnenshuis, of in bed? Werd u ooit gehospitaliseerd wegens ademhalingsproblemen? Was u de jongste jaren vaker kortademig dan vroeger? Hoeveel slijmen hoest u gewoonlijk op? Als u verkouden bent, valt het gewoonlijk op uw borst? Neemt u medicatie om beter te kunnen ademen?

Keuzemogelijkheden 40-49 jaar 50-59 jaar 60-69 jaar 70 jaar of ouder 0-14 pak/jaren 15-24 pak/jaren 25-49 pak/jaren 50+ pak/jaren

Punten 0 5 9 11 0 3 7 9

Ja Neen Ja Neen Ja Neen Ja Neen Geen, of minder dan 2 soeplepels 2 soeplepels of meer per dag Ja Neen Ja Neen

0 1 0 3 6 0 1 0 0 4 4 0 5 0

Validation of IPAG Questionnaire 100 90 80 70 60

%

50 40 30 20 10 0

Asthma

COPD

Other

CUT-OFF 18 PTS

FINAL DIAGNOSIS 100 90 80

CUT-OFF 21 PTS

70 60

%

50 40 30 20 10 0

Asthma

COPD

Other


IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry





IPAG questionnaire



Office spirometry




DIDASCO2 Comorbidity

Diabetes Coronary Disease Heart Failure Atrial Fibrillation Arterial Hypertension Dementia Stroke or TIA Peripheral Vascular Disease Malignancy Osteoporosis Social Problems Relational Problems Alcohol Problems Depression Obesity Mean n Diseases/Conditions

Male 19.0 19.8 9.4 7.8 43.8 0.6 4.2 14.8 9.4 4.6 13.2 10.7 13.0 13.0 22.3 2.9 (2.7-3.1)

Female 14.3 9.9 7.7 4.5 43.3 2.6 4.9 6.0 6.2 12.2 13.7 9.6 4.7 20.8 22.3 2.6 (2.4-2.8)

Asthma 14.4 9.7 5.6 3.4 38.2 1.9 2.5 5.3 7.2 8.8 10.7 8.8 4.7 15.4 23.8 2.2 (2.0-2.4)

COPD 18.6 19.7 11.4 8.9 45.9 1.8 6.6 15.1 10.5 8.9 17.2 10.9 13.5 18.5 22.9 3.2 (3.0-3.4)

No Obstr 22.9 5.7 2.9 1.4 40.0 1.4 2.9 5.7 1.4 2.9 10.0 7.1 5.7 12.9 17.1 2.1 (1.6-2.5)

% congruent diagnoses compared with label after spirometry

Congruent Diagnoses (%)

120 100 80 60 40 20 0 FILE

IPAG

CLIN

SPIRO

Diagnostic Steps Asthma

COPD

Asthma+COPD

Other OAD

No OAD

Mean certainty

Mean rate of diagnostic certainty

4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 FILE

IPAG

CLIN

SPIR

Diagnostic Steps Asthma

COPD

Asthma+COPD

Other OAD

No AOD

Tests done by the pulmonologists

TEST Spirometry Bronchodilator reversibility test Diffusion capacity Bronchial provocation test Exhaled nitric oxide X-ray of the chest CT scan of the chest Allergy tests Ventilation/perfusion scan Oxygen saturation Body plethysmography Six minutes walking test Other

n 114 32 61 5 2 39 9 19 3 15 8 1 5

% 93 26 50 4 2 32 7 16 2 12 7 1 4

Diagnostic value of each step ASTHMA Sens (%,95%CI) Spec (%,95%CI) Pos LHR (95%CI) Neg LHR (95%CI) Preval (%) PPV (%) NPV (%) Diagnostic gain

IPAG/Fin 51.6 (33.0-69.8) 88.8 (80.5-94.5) 4.65 (2.36-9.14) 0.54 (0.38-0.79) 28.8 65.4 81.6 36.6

CLIN/Fin 58.1 (39.1-75.4) 85.6 (76.6-92.1) 4.02 (2.24-7.22) 0.49 (0.32-0.75) 21.5 52.4 88.5 30.9

SPIRO/Fin 64.5 (45.4-80.8) 90.9 (82.9-96.0) 7.10 (3.49-14.44) 0.39 (0.24-0.63) 25.6 71.4 87.8 45.8

PULM/Fin 87.1 (70.1-96.3) 83.5 (74.3-90.5) 5.28 (3.26-8.56) 0.15 (0.06-0.39) 23.5 61.3 96.5 37.8

IPAG/Fin 83.0 (69.2-92.3) 78.4 (67.3-78.1) 3.84 (2.44-6.06) 0.22 (0.11-0.41) 31.4 62.9 91.1 31.5

CLIN/Fin 73.8 (58.0-86.1) 78.5 (67.8-86.9) 3.43 (2.17-5.42) 0.33 (0.20-0.56) 38.8 68.3 82.4 29.5

SPIRO/Fin PULM/Fin 68.3 (51.9-81.9) 85.7 (71.4-94.5) 89.7 (80.8-95.5) 92.5 (84.4-97.2) 6.66 (3.34-13.26) 11.43 (5.24-24.92) 0.35 (0.22-0.56) 0.15 (0.07-0.32) 39.7 30.2 81.9 82.1 80.8 93.9 42.4 51.9

COPD Sens (%,95%CI) Spec (%,95%CI) Pos LHR (95%CI) Neg LHR (95%CI) Preval (%) PPV (%) NPV (%) Diagnostic gain






• • • •


Kwaliteit van « office spirometry »

• • • •

Kwaliteit van de toestellen Kwaliteit van de afname ATS/ERS criteria De invloed van training/retraining

Simplicity

Spirobank OneFlow SpiroStar

Datospir 70

SpiroPro

MicroLoop

DatoSpir 120

Pneumotrac

FVC

Bias, limits of agreement (L)

1,000 0,500 0,000 Spirobank

SpiroPro

-0,500 -1,000 Device

SpiroStar

FVC SpiroStar 1,5

Underestimation

Difference (L)

1 0,5 0 -0,5 0

1

2

3

4

5

6

7

-1

Overestimation

-1,5

2

R = 0.16, p=0.004

-2 Mean (L)

Bias, limits of agreement (L)

FEV1 0,60 0,40 0,20 0,00 -0,20 -0,40 -0,60 -0,80 -1,00

Spirobank

SpiroPro SpiroStar

Device

Difference L

FEV1 SpiroPro 0,4 0,3 0,2 0,1 0 -0,1 0 -0,2 -0,3 -0,4 -0,5

1

2

3

4 2

R = 0.28, p=0.001

Mean L

5

6

Bias, lim its of agreem ent (L/m in)

PEF 400 300 200 100 0 -100

Spirobank

SpiroPro

-200 Device

SpiroStar

DIDASCO study

• What is the accuracy of spirometry performed with 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

A

5.00

fev1j

4.00

3.00

2.00

AA

A A A AA A A A AA A A A A A A AA AAAAAA AAAA A AAAA A AA AA A A AAA A A A A A A A A AAA AA AAA A AA A A A A AA AA A A AA A A A AA A A A A A AA A AA A A A A A A A A A A A A AA AAAA A A A A A A A A A A A A AAA A A A A A A A A AA A A A AAA A A A A A AA AA A A AAA A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AA A AA A A AA A A AAAAA AA A A A A A A A A A AA AA A A A A AAAAA A A A A AA A A A A A A A A A AA AAA AA AA A A AAA A AA A A A AA A AA A A A A AA AAA A AA A A AA A A A A AAAA AA A A A A A A AAAA AA A A A A A AA A A A A A A AAA AA A AA AA A A AA AA A A A A AAA AA A A A A A A AAA A A A AA A A A A AA AA AA A A A A A A AA AA A A A A AA A AA AA AAA A AA A A AA A A A A A A A A A A A AAA AAA AA AA A A A AA A A A A A A A A A A A A A A AA A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AA AA AA A A AA A A A A A A A A AA AA A A AA A A A A A A A AA A A A A A AA A A A A AA A A A AA A AA A A A A A A A A AA A A A A A A AAA A A A A AA AA A A AA A A A AAA A A A A A A A A A A A A AA AAAAA A A A AA A A A A A A A A A A AA A A AA AA A A AAA AAAAA A A A A A AA AAA A AA A A AA A A AA A AAA A A AA A AA AA AAAA AA AA AAA A AAAAAAAA A A AAA A A A AA A A A A A AA A AAA AA AA A AA A AA A A AA A A A AA AA A A A AAA AA A A AAA AA A AA A A A A AAAA A A A A A A A A A A A A AA A A A A AA A A A A A A AA A

1.00 2.00

3.00

fev1s

4.00

Linear Regression with 95.00% Individual Prediction Interval

fev1j = 0.42 + 0.92 * fev1s R-Square = 0.90

Spirobank/Jaegher FVC

7.00

6.00

fvcj

5.00

4.00

A

3.00

AA A AA AAA AAA A A A A A A A A A A A A AAAA AA AA AA AAAA A A A A AA A AA AA A A A A A A A A A A A AAA AAAAA AA A A AAAA AA AAA A AAAAA A AA A A A A A AAA A A A A A A A A A A A A AAA A AA A AA A A A A AA A AAAA AA A AA A AA A A A A A A AA A A AAA AAA A A A A A A A A A A A A A A A A A A A A A A A A A A A AA A A A AAA A A A A A A A A A A AAA A A A AA AA A A A AAA A A A A A A A A A A A A A AA A A AA AA A A A A A A AA AA A A A A A AAA A A A AA A AAAA A A A A A AAA A A AA A A A A A AA A A A AA A A A A AA A A A A A A A A A A A A A A A A A A A A A A A A AA AA A AA A A A A A A A A A AA A A AA A A AAA A A A AAA A A A A A A AAA AA A AA A A AA AA A AAA AA A AA A A A A A AA AA AA A AA A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AAA A A A A A A A A AA AA A A A AA A A A A A AA A A A A AA A A A A A A A A A A A AAA A A AAA A A A A A A A AAAAAAA AA A A A A A A A A A A A A A A A A A A AA A A A AA A A AA A A AA A A A A A A A A A A A A A A A A A AAA AAAA A A A AAAAA A A AA A A AAA A A AA A A A AA AAAA AA A A A A A A A A A A A AA A AA A A A A A A A A A A A A A A A A AA AA A AA A A A AA A AA A A A A AA AA A A AA A A A A A AA A A AAAA AA A A AAA A A A A A A A A A A AAA A A AAA A AAAAA A A A A A A A A A A A A A A A A AA AAA A A AA A AA AA AA AA A A A A A A A

A A A A A AAA A AA AAA A AA A A AAAA A

2.00

2.00

3.00

4.00

fvcs

5.00

6.00

Linear Regression with 95.00% Individual Prediction Interval

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. Johan Buffels, MD, PhD Jan Degryse, MD, PhD

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