Office Spirometry: Indications and Interpretation

 

Am Fam Physician. 2020 Mar 15;101(6):362-368.

Author disclosure: No relevant financial affiliations.

High-quality, office-based spirometry provides diagnostic information as useful and reliable as testing performed in a pulmonary function laboratory. Spirometry may be used to monitor progression of lung disease and response to therapy. A stepwise approach to spirometry allows for ease and reliability of interpretation. Airway obstruction is suspected when there is a decreased forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, but there is no strong evidence to clearly define what constitutes a significant decrease in this ratio. A low FVC is defined as a value below the 5th percentile in adults or less than 80% of predicted in children and adolescents five to 18 years of age. The FEV1/FVC ratio and FVC are used together to identify obstructive defects and restrictive or mixed patterns. Obstructive defects should be assessed for reversibility, as indicated by an improvement of the FEV1 or FVC by at least 12% and 0.2 L in adults, or by more than 12% in children and adolescents five to 18 years of age after the administration of a short-acting bronchodilator. FEV1 is used to determine the severity of obstructive and restrictive disease, although the values were arbitrarily determined and are not based on evidence from patient outcomes. Bronchoprovocation testing may be used if spirometry results are normal and allergen- or exercise-induced asthma is suspected. For patients with an FEV1 less than 70% of predicted, a therapeutic trial of a short-acting bronchodilator may be tried instead of bronchoprovocation testing.

Approximately 1% to 4% of all visits to primary care offices are for dyspnea.1 The proper use of pulmonary function tests can help differentiate many of the causes of dyspnea, monitor the progression of chronic pulmonary disease, and assess response to treatment. In a cross-sectional study, primary care physicians underestimated the severity of chronic obstructive pulmonary disease (COPD) in 41% of patients and overestimated severity in 29% of patients when compared with immediate, in-office spirometry. Overall, physician rating of severity was accurate in only 30% of patients.2 Spirometry is recommended as part of the diagnostic workup in patients with presumed COPD or asthma by the American Thoracic Society/European Respiratory Society (ATS/ERS)3; the Global Initiative for Chronic Obstructive Lung Disease (GOLD)4; the Global Initiative for Asthma5; and the American Academy of Allergy, Asthma, and Immunology.6 High-quality spirometry performed in a family physician's office is comparable to testing performed in a pulmonary function laboratory.7,8 A video of office-based spirometry is available at https://bit.ly/2JAIYGx. Although there are different types of pulmonary function tests, this article focuses on office-based spirometry.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Spirometry is recommended as part of the diagnostic workup in patients with presumed COPD or asthma.36

C

Expert opinion from national and international organizations (ATS/ERS; Global Initiative for Chronic Obstructive Lung Disease; Global Initiative for Asthma; and American Academy of Allergy, Asthma, and Immunology)

Screening for COPD with spirometry is not recommended in asymptomatic adults.10

C

U.S. Preventive Services Task Force found no studies that directly assessed the effect of screening in asymptomatic adults on morbidity, mortality, or health-related quality of life

Full pulmonary function testing should be performed in patients with a restrictive pattern on spirometry and in patients with a mixed pattern if the forced vital capacity does not improve significantly after administration of a bronchodilator.15

C

Expert opinion from ATS/ERS

Bronchoprovocation testing should be performed in patients with normal results on pulmonary function testing but a history that suggests exercise- or allergen-induced asthma.25

C

Expert opinion from ATS/ERS


ATS = American Thoracic Society; COPD = chronic obstructive pulmonary disease; ERS = European Respiratory Society.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Spirometry is recommended as part of the diagnostic workup in patients with presumed COPD or asthma.36

C

Expert opinion from national and international organizations (ATS/ERS; Global Initiative for Chronic Obstructive Lung Disease; Global Initiative for Asthma; and American Academy of Allergy, Asthma, and Immunology)

Screening for COPD with spirometry is not recommended in asymptomatic adults.10

C

U.S. Preventive Services Task Force found

The Authors

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ROBERT C. LANGAN, MD, FAAFP, is program director at the St. Luke's Family Medicine Residency Program, Sacred Heart Campus, Allentown, Pa....

ANDREW J. GOODBRED, MD, FAAFP, is associate program director at the St. Luke's Family Medicine Residency Program, Anderson Campus, Easton, Pa.

Address correspondence to Robert C. Langan, MD, FAAFP, 450 Chew St., Ste. 101, Allentown, PA 18102 (email: robert.langan@sluhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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