Despite its benefits, screening spirometry has not been widely adopted, even though it is less invasive and easier than many other screenings. Long-held beliefs that have dissuaded use of spirometry screening are not necessarily true.
Everywhere you look, consumers are offered health screening testsfrom simple blood pressure checks to fingerstick blood glucose and cholesterol screening to more sophisticated tests such as mammography and colonoscopy. In 2000, the National Lung Health Education Program (NLHEP) issued a consensus statement supporting the use of office spirometry for lung health assessment in adults.1 Ideally, primary care practitioners (PCPs) will offer screening spirometry in their offices to children and adults at risk for or experiencing symptoms of lung disease. If the results are abnormal, the PCP should refer the patient for more sophisticated pulmonary function testing. Screening spirometry also may be used to monitor the effectiveness of treatment plans for patients already diagnosed with asthma or COPD.
However, screening spirometry has not been as widely adopted as many other screening tests, even though it is less invasive than most and easier to do. Charles Irvin, PhD, identified four common misconceptions that contribute to the reduced use of screening spirometry.2
Myth One: Spirometry Is a Poor Test of Little Benefit
In the past few years, authoritative publications have recommended screening spirometry for diagnosis, symptom assessment, and to monitor treatment effectiveness. The NLHEP recommends the widespread use of office spirometry by primary care providers for at-risk patients.1 The organizations theme is Test Your LungsKnow Your Numbers.3 In addition, two current clinical practice guidelinesGuidelines for the Diagnosis and Management of Asthma from the National Asthma Education and Prevention Program4 and Global Strategy for the Diagnosis, Management, and Prevention of COPD from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)5recommend spirometry for disease screening and for monitoring treatment effectiveness. Experts who perform extensive reviews of the literature develop these consensus statements. The fact that these three major groups promulgating standards of care for patients with obstructive lung disease agree that patients should be regularly evaluated with spirometry refutes the myth that spirometry is a poor test and of little benefit.
Myth Two: Equipment Is Expensive, Works Poorly
Today, advances in microcomputer technology have allowed the development of small, handheld units that meet the technical requirements of the NLHEP1; cost $1,000 or less; automatically calculate results, compare to normal values, and produce tracings; and are as reliable as standard laboratory spirometers.6 Schoh and associates compared the results of a screening spirometer with a standard laboratory spirometer in people who volunteered to be tested at a hospital-sponsored community health fair. The researchers found excellent correlations between the two spirometers for measurement of FEV1, FVC (FEV6), and FEV1/FEV6 ratio.6
Check the manufacturers specifications for the device and compare them to those recommended by the American Thoracic Society (ATS) Standardization of Spirometry.7
Screening spirometry is a reimbursable procedure. If a spirometer costs between $1,000 and $3,000 and is depreciated over 5 years, the cost per test, including disposables (mouthpiece, paper), is approximately $5 per test. While there are regional differences, reimbursements are generally between $30 and $55 dollars per test. These numbers do not include the cost savings of preventing a hospital admission and better control of symptoms that improve quality of life and enhance productivity in society.8,9
Myth Three: Spirometry Is Hard to Do Right
Compared to taking a blood pressure reading, it is true that spirometry is more complicated. The patient and the clinician administering the test must both give a best effort. The ATS standards state, Prompt the subject to blast, not just blow the air from their lungs, then continue to encourage him/her to fully exhale. Throughout the maneuver, enthusiastically coach the subject by word and body language.7 It does take an outgoing personality and a special skill to cheer on patients as they do the test, and not everyone feels comfortable doing it. Respiratory care practitioners are the ideal consultants to work with primary care physicians and their office staff members to teach them about screening spirometry, proper technique, and ways to get the best, most consistent results from patients.
While proper spirometry technique needs to be learned, the myth that it is too hard is dispelled by the volume of research published in the medical literature that focuses on spirometry values.2 In just one example, researchers in Buffalo, NY, reported on a study that investigated the predictive value of pulmonary function testing over a 29-year follow-up period between 1960-1961 and 1999. Researchers concluded that FEV1% predicted is a statistically significant predictor for both all-cause and IHD [ischemic heart disease] mortality in both genders .10
The Lung Health Study used spirometry to study benefits of smoking cessation and determined that smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyperresponsiveness.10
If spirometry is a complicated test that is difficult to do correctly, researchers would not use it as a gold standard for assessing lung function as extensively as they do.
Myth Four: Numbers Are Difficult to Interpret
Having studied interpretation of both spirometry results and 12-lead electrocardiograms (ECG), it is difficult for me to understand how anyone who has mastered the ability to interpret the ECG cannot easily learn spirometry. There are far fewer variables, and findings tend to be less subtle in spirometry. In addition, spirometry provides both numeric and graphic data reports, so physicians can work with whichever data form they find most comfortable. Once again, this is an ideal opportunity for respiratory care practitioners to raise their visibility and educate medical students and residents about simple spirometry interpretation.
Now is our chance to take the charge from the National Lung Health Education Program and get the word out about spirometry. Talk with your patients, colleagues, friends, and family about spirometry. Encourage them to ask their primary health care provider if a screening test is right for themthey just might find themselves breathing a little easier.
Special Note: The Respiratory Institute established by GlaxoSmithKline has created a new initiative, Project Spirometry. Primary care practitioners and pediatricians will have an opportunity to receive comprehensive spirometry education and a complimentary 60-day loan of a screening spirometer for hands-on, clinical experience to learn the value of office spirometry. For more information, contact your local GSK representative; call (888) 825-5249; press 6 for general information, then 4 (for all other questions).
Patricia Carroll, RN, BC, RRT, CEN, MS, is the owner of Educational Medical Consultants in Meriden, Conn, and is the Health Care Coordinator for Shelter NOW, a homeless shelter in Meriden, Conn, where she is planning a screening spirometry program.
1. 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;117:1146-1161.
2. Irvin CG. To blow or not to blowthat is the question. Respir Care. 2002;47:1145-1147.
3. National Lung Health Education Program. Spirometry. 2002. Available at: http://www. nlhep.org/spirom1.html. Accessed January 18, 2003.
4. National Institutes of Health. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. 1997. Publication No. 97-4051.
5. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med. 2001;163:1256-1276. Available at: http://www.goldcopd.com. Accessed January 18, 2003.
6. Schoh RJ, Fero LJ, Shapiro H, et al. Performance of a new screening spirometer at a community health fair. Respir Care. 2002;47:1150-1157.
7. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med. 1995;152:1107-1136.
8. Spirometrics. SpiroNotes 1(7): Financial aspects of spirometry. 2002. Available at: http://www.spirometrics.com/SpiroNotes.htm. Accessed January 18, 2003.
9. AccuChecker. Spirometry. May 25, 2002. Available at: http://www.accuchecker.com/AccuLibrary/Arti-
cles/spirometry.asp. Accessed January 18, 2003.
10. Schunemann HJ, Dorn J, Grant BJB, Winkelstein W, Trevisan M. Pulmonary function is a long-term predictor of mortality in the general population. Chest. 2000;118:656-664.
11. Scanlon PD, Connett JE, Waller LA, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161:381-390.