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Standardisation of spirometry

M. R. Miller, J. Hankinson, V. Brusasco, F. Burgos, R. Casaburi, A. Coates, R. Crapo, P. Enright, C. P. M. van der Grinten, P. Gustafsson, R. Jensen, D. C. Johnson, N. MacIntyre, R. McKay, D. Navajas, O. F. Pedersen, R. Pellegrino, G. Viegi, J. Wanger
European Respiratory Journal 2005 26: 319-338; DOI: 10.1183/09031936.05.00034805
M. R. Miller
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J. Hankinson
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V. Brusasco
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F. Burgos
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R. Casaburi
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A. Coates
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R. Crapo
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P. Enright
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C. P. M. van der Grinten
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P. Gustafsson
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R. Jensen
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D. C. Johnson
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N. MacIntyre
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R. McKay
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D. Navajas
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O. F. Pedersen
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R. Pellegrino
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G. Viegi
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J. Wanger
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  • Article
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Figures

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  • Fig. 1—
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    Fig. 1—

    Spirometry standardisation steps.

  • Fig. 2—
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    Fig. 2—

    Expanded version of the early part of a subject's volume–time spirogram, illustrating back extrapolation through the steepest part of the curve, where flow is peak expiratory flow (PEF), to determine the new “time zero”. Forced vital capacity (FVC) = 4.291 L; back extrapolated volume (EV) = 0.123 L (2.9% FVC). -----: back extrapolation line through PEF.

  • Fig. 3—
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    Fig. 3—

    Flow chart outlining how acceptability and reapeatability criteria are to be applied. FVC: forced vital capacity; FEV1: forced expiratory volume in one second.

  • Fig. 4—
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    Fig. 4—

    Flow–volume loop of a normal subject.

  • Fig. 5—
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    Fig. 5—

    Flow–volume loop of a normal subject with end expiratory curvilinearity, which can be seen with ageing.

  • Fig. 6—
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    Fig. 6—

    Moderate airflow limitation in a subject with asthma.

  • Fig. 7—
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    Fig. 7—

    Severe airflow limitation in a subject with chronic obstructive pulmonary disease.

  • Fig. 8—
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    Fig. 8—

    Variable intra-thoracic upper airway obstruction.

  • Fig. 9—
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    Fig. 9—

    Variable extra-thoracic upper airway obstruction.

  • Fig. 10—
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    Fig. 10—

    Fixed upper airway obstruction shown by three manoeuvres.

  • Fig. 11—
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    Fig. 11—

    Tracing of tidal breathing followed by an expiratory manoeuvre to residual volume (RV), followed by a full inspiration to total lung capacity (TLC) to record inspiratory vital capacity (IVC) and inspiratory capacity (IC). FRC: functional residual capacity; ERV: expiratory reserve volume.

  • Fig. 12—
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    Fig. 12—

    Tracing of tidal breathing followed by an inspiratory manoeuvre to total lung capacity (TLC) to record inspiratory capacity (IC), followed by a full expiration to residual volume (RV) to record expiratory reserve volume (EVC). FRC: functional residual capacity.

  • Figure13
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Tables

  • Figures
  • Table. 1—

    Indications for spirometry

    Diagnostic
     To evaluate symptoms, signs or abnormal laboratory tests
     To measure the effect of disease on pulmonary function
     To screen individuals at risk of having pulmonary disease
     To assess pre-operative risk
     To assess prognosis
     To assess health status before beginning strenuous physical activity programmes
    Monitoring
     To assess therapeutic intervention
     To describe the course of diseases that affect lung function
     To monitor people exposed to injurious agents
     To monitor for adverse reactions to drugs with known pulmonary toxicity
    Disability/impairment evaluations
     To assess patients as part of a rehabilitation programme
     To assess risks as part of an insurance evaluation
     To assess individuals for legal reasons
    Public health
     Epidemiological surveys
     Derivation of reference equations
     Clinical research
  • Table. 2—

    Recommended minimum scale factors for time, volume and flow on graphical output

    Instrument displayHardcopy graphical output
    ParameterResolution requiredScale factorResolution requiredScale factor
    Volume#0.050 L5 mm·L−10.025 L10 mm·L−1
    Flow#0.200 L·s−12.5 mm·L−1·s−10.100 L·s−15 mm·L−1·s−1
    Time0.2 s10 mm·s−10.2 s20 mm·s−1
    • #: the correct aspect ratio for a flow versus volume display is two units of flow per one unit of volume.

  • Table. 3—

    Summary of equipment quality control

    TestMinimum intervalAction
    VolumeDailyCalibration check with a 3-L syringe
    LeakDaily3 cmH2O (0.3 kPa) constant pressure for 1 min
    Volume linearityQuarterly1-L increments with a calibrating syringe measured over entire volume range
    Flow linearityWeeklyTest at least three different flow ranges
    TimeQuarterlyMechanical recorder check with stopwatch
    SoftwareNew versionsLog installation date and perform test using “known” subject
  • Table. 4—

    Procedures for recording forced vital capacity

    Check the spirometer calibration
    Explain the test
    Prepare the subject
     Ask about smoking, recent illness, medication use, etc.
     Measure weight and height without shoes
    Wash hands
    Instruct and demonstrate the test to the subject, to include
     Correct posture with head slightly elevated
     Inhale rapidly and completely
     Position of the mouthpiece (open circuit)
     Exhale with maximal force
    Perform manoeuvre (closed circuit method)
     Have subject assume the correct posture
     Attach nose clip, place mouthpiece in mouth and close lips around the mouthpiece
     Inhale completely and rapidly with a pause of <1 s at TLC
     Exhale maximally until no more air can be expelled while maintaining an upright posture
     Repeat instructions as necessary, coaching vigorously
     Repeat for a minimum of three manoeuvres; no more than eight are usually required
     Check test repeatability and perform more manoeuvres as necessary
    Perform manoeuvre (open circuit method)
     Have subject assume the correct posture
     Attach nose clip
     Inhale completely and rapidly with a pause of <1 s at TLC
     Place mouthpiece in mouth and close lips around the mouthpiece
     Exhale maximally until no more air can be expelled while maintaining an upright posture
     Repeat instructions as necessary, coaching vigorously
     Repeat for a minimum of three manoeuvres; no more than eight are usually required
     Check test repeatability and perform more manoeuvres as necessary
    • TLC: total lung capacity.

  • Table. 5—

    Summary of within- and between-manoeuvre acceptability criteria

    Within-manoeuvre criteria
     Individual spirograms are “acceptable” if
      They are free from artefacts 3
       Cough during the first second of exhalation
       Glottis closure that influences the measurement
       Early termination or cut-off
       Effort that is not maximal throughout
       Leak
       Obstructed mouthpiece
      They have good starts
       Extrapolated volume <5% of FVC or 0.15 L, whichever is greater
      They show satisfactory exhalation
       Duration of ≥6 s (3 s for children) or a plateau in the volume–time curve or
        If the subject cannot or should not continue to exhale
    Between-manoeuvre criteria
     After three acceptable spirograms have been obtained, apply the following tests
      The two largest values of FVC must be within 0.150 L of each other
      The two largest values of FEV1 must be within 0.150 L of each other
     If both of these criteria are met, the test session may be concluded
     If both of these criteria are not met, continue testing until
      Both of the criteria are met with analysis of additional acceptable spirograms or
      A total of eight tests have been performed (optional) or
      The patient/subject cannot or should not continue
     Save, as a minimum, the three satisfactory manoeuvres
    • FVC: forced vital capacity; FEV1: forced expiratory volume in one second.

  • Table. 6—

    Range and accuracy recommendations specified for forced expiratory manoeuvres

    TestRange/accuracy (BTPS)Flow range L·s−1Time sResistance and back pressureTest signal
    VC0.5–8 L, ±3% of reading or ±0.050 L, whichever is greater0–14303-L Calibration syringe
    FVC0.5–8 L, ±3% of reading or ±0.050 L, whichever is greater0–1415<1.5 cmH2O·L−1·s−1 (0.15 kPa·L−1·s−1)24 ATS waveforms, 3-L Cal Syringe
    FEV10.5–8 L, ±3% of reading or ±0.050 L, whichever is greater0–141<1.5 cmH2O·L−1·s−1 (0.15 kPa·L−1·s−1)24 ATS waveforms
    Time zeroThe time point from which all FEVt measurements are takenBack extrapolation
    PEFAccuracy: ±10% of reading or ±0.30 L·s−1 (20 L·min−1), whichever is greater; repeatability: ±5% of reading or ±0.15 L·s−1 (10 L·min−1), whichever is greater0–14Mean resistance at 200, 400, 600 L·min−1 (3.3, 6.7, 10 L·s−1) must be <2.5 cmH2O·L−1·s−1 (0.25 kPa·L−1·s−1)26 ATS flow waveforms
    Instantaneous flows (except PEF)Accuracy: ±5% of reading or ±0.200 L·s−1, whichever is greater0–14<1.5 cmH2O·L−1·s−1 (0.15 kPa·L−1·s−1)Data from manufacturers
    FEF25–75%7.0 L·s−1, ±5% of reading or ±0.200 L·s−1, whichever is greater±1415Same as FEV124 ATS waveforms
    MVV250 L·min−1 at VT of 2 L within ±10% of reading or ±15 L·min−1, whichever is greater±14 (±3%)12–15<1.5 cmH2O·L−1·s−1 (0.15 kPa·L−1·s−1)Sine wave pump
    • BTPS: body temperature and ambient pressure saturated with water vapour; VC: vital capacity; FVC: forced vital capacity; ATS: American Thoracic Society; FEV1: forced expiratory volume in one second; FEVt: forced expiratory volume in t seconds; PEF: peak expiratory flow; FEF25–75%: mean forced expiratory flow between 25% and 75% of FVC; MVV: maximum voluntary ventilation; VT: tidal volume.

  • Table. 7—

    List of abbreviations and meanings

    ATPDAmbient temperature, ambient pressure, and dry
    ATPSAmbient temperature and pressure saturated with water vapour
    BTPSBody temperature (i.e. 37°C), ambient pressure, saturated with water vapour
    CCentigrade
    CFCChlorofluorocarbons
    cmCentimetres
    COHbCarboxyhaemoglobin
    DL,CODiffusing capacity for the lungs measured using carbon monoxide, also known as transfer factor
    DL,CO/VADiffusing capacity for carbon monoxide per unit of alveolar volume, also known as KCO
    DMMembrane-diffusing capacity
    DTDwell time of flow >90% of PEF
    EFLExpiratory flow limitation
    ERVExpiratory reserve volume
    EVBack extrapolated volume
    EVCExpiratory vital capacity
    FA,XFraction of gas X in the alveolar gas
    FA,X,tAlveolar fraction of gas X at time t
    FEF25-75%Mean forced expiratory flow between 25% and 75% of FVC
    FEFX%Instantaneous forced expiratory flow when X% of the FVC has been expired
    FEV1Forced expiratory volume in one second
    FEVtForced expiratory volume in t seconds
    FE,XFraction of expired gas X
    FIFX%Instantaneous forced inspiratory flow at the point where X% of the FVC has been inspired
    FI,XFraction of inspired gas X
    FIVCForced inspiratory vital capacity
    FRCFunctional residual capacity
    FVCForced vital capacity
    H2OWater
    HbHaemoglobin
    HgMercury
    HzHertz; cycles per second
    ICInspiratory capacity
    IVCInspiratory vital capacity
    KCOTransfer coefficient of the lung (i.e.DL,CO/VA)
    kgKilograms
    kPaKilopascals
    LLitres
    L·min−1Litres per minute
    L·s−1Litres per second
    lbPounds weight
    MEFX%Maximal instantaneous forced expiratory flow where X% of the FVC remains to be expired
    MFVLMaximum flow–volume loop
    mgMilligrams
    MIFMaximal inspiratory flow
    mLMillilitres
    mmMillimetres
    MMEFMaximum mid-expiratory flow
    msMilliseconds
    MVVMaximum voluntary ventilation
    PA,O2Alveolar oxygen partial pressure
    PBBarometric pressure
    PEFPeak expiratory flow
    PH2OWater vapour partial pressure
    PI,O2Inspired oxygen partial pressure
    θ (theta)Specific uptake of CO by the blood
    RTRise time from 10% to 90% of PEF
    RVResidual volume
    sSeconds
    STPDStandard temperature (273 K, 0°C), pressure (101.3 kPa, 760 mmHg) and dry
    TBTuberculosis
    TGV (or VTG)Thoracic gas volume
    tITime taken for inspiration
    TLCTotal lung capacity
    TrTracer gas
    ttotTotal time of respiratory cycle
    VAAlveolar volume
    VA,effEffective alveolar volume
    VCVital capacity
    VcPulmonary capillary blood volume
    VDDead space volume
    VIInspired volume
    VSVolume of the expired sample gas
    μgMicrograms
  • Table. 8—

    List of parameters#

    ID (patient identification)
    Patient name
    Data type (SP followed by E = expiratory or I = Inspiratory, followed by S = single or B = best curve)
    Barometric pressure (mmHg)
    Temperature (°C) used in BTPS calculation
    Relative humidity (%)
    FVC quality attribute (A, B, C, D or F)
    FEV1 quality attribute (A, B, C, D or F)
    Effort attribute (A, B, C, D or F)
    Interpretation code (see ATS interpretation scheme)
    Deleted manoeuvre (Y or N)
    Acceptable manoeuvre (Y or N)
    Technician quality control code (A, B, C, D or F)
    Computer quality code (A, B, C, D or F)
    Plateau achieved (Y or N)
    Review (N or R for “needs review” or “was reviewed”)
    Date of review (DD/MM/YYYY)
    Reviewer initials
    BTPS factor (x.xxx)
    Spirometer manufacturer
    Spirometer model
    Spirometer serial number
    Spirometer type
    Testing facility name
    City
    State/region
    Zip/post code
    Country
    E-mail
    Phone number
    Calibration date (DD/MM/YYYY)
    Calibration time (HH:MM)
    Calibration result (P or F for “passed” or “failed”)
    Date (DD/MM/YYYY)
    Time (HH:MM)
    Technician ID (technician identification code or initials)
    Manoeuvre number
    Age (integer years)
    Height (cm)
    Weight (kg)
    Sex (M or F)
    Race (2-character race code)
    Date of birth (DD/MM/YYYY)
    Reference values source (first author surname and date of publication, e.g. “Knudson 1983”)
    Reference values correction factor (x.xx, 1.00 for no correction)
    Testing position (standing, sitting or supine)
    Test type (pre-, post-, bronchodilator, methacholine concentration or dose)
    FVC (mL)
    Extrapolated volume (mL)
    FEV1 (mL)
    FEV6 (mL)
    PEF (mL·s−1)
    FEF25–75% (mL·s−1)
    VC (mL)
    Forced expiratory time (s)
    Time to PEF (ms)
    Predicted FVC (mL)
    Predicted FEV1 (mL)
    Predicted FEV6 (mL)
    Predicted FEV1/FVC% (xxx.x%)
    Predicted FEV1/FEV6% (xxx.x%)
    Comments text
    Original sampling interval (ms)
    Blank 1 or FEF25%
    Blank 2 or FEF50%
    Blank 3 or FEF75%
    Blank 4 or FEF90%
    Blank 5
    Blank 6
    Blank 7
    Blank 8
    Blank 9
    Blank 10
    Number of data points
    Flow data points (mL·s−1; variable number contained in number of data points)
    Carriage return
    Line feed
    • #: All text type variables should be enclosed with double quotes (“) to prevent confusion with control or data separator type characteristics.

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Standardisation of spirometry
M. R. Miller, J. Hankinson, V. Brusasco, F. Burgos, R. Casaburi, A. Coates, R. Crapo, P. Enright, C. P. M. van der Grinten, P. Gustafsson, R. Jensen, D. C. Johnson, N. MacIntyre, R. McKay, D. Navajas, O. F. Pedersen, R. Pellegrino, G. Viegi, J. Wanger
European Respiratory Journal Aug 2005, 26 (2) 319-338; DOI: 10.1183/09031936.05.00034805

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Standardisation of spirometry
M. R. Miller, J. Hankinson, V. Brusasco, F. Burgos, R. Casaburi, A. Coates, R. Crapo, P. Enright, C. P. M. van der Grinten, P. Gustafsson, R. Jensen, D. C. Johnson, N. MacIntyre, R. McKay, D. Navajas, O. F. Pedersen, R. Pellegrino, G. Viegi, J. Wanger
European Respiratory Journal Aug 2005, 26 (2) 319-338; DOI: 10.1183/09031936.05.00034805
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  • Article
    • Abstract
    • BACKGROUND
    • FEV1 AND FVC MANOEUVRE
    • VC AND IC MANOEUVRE
    • PEAK EXPIRATORY FLOW
    • MAXIMUM VOLUNTARY VENTILATION
    • TECHNICAL CONSIDERATIONS
    • ABBREVIATIONS
    • Appendix
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
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