1 - Spirometry Simplified With CRF's PEFR PDF

Chest Research Foundation
COURSE MATERIAL FOR

________________________________________________________________________
SPIROMETRY
SIMPLIFIED
Organized by
CHEST RESEARCH FOUNDATION

Marigold, Kalyaninagar, Pune 411014, India
Tel: 020 27035361 /71 Fax: 020 27035371
E-mail: programmes@crfindia.com OR drmonica@crfindia.com

Visit our website: www.crfindia.com
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________________________________________________________________________
Contributors:
Dr Sundeep Salvi MD, DNB, PhD (UK)

Dr Bill Brashier MBBS, DTCD
Dr. Suruchi Mandrekar MBBS, FCPS(G.Med)
Dr. Gauri Joshi MBBS, DLO
Dr. Sneha Limaye MBBS
Dr. Rahul Kodgule
Dr. Monica Barne
Dr. Komalkirti Apte

Pune
12th April. 2008
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SPIROMETRY MANUAL
CONTENTS
Sr. Section Page No.
No.
1 Contributors 3
2 Contents 5
3 Abbreviations 7
4 Preface 8
5 Historical Perspective 9
6 Indications for Spirometry 9
7 Types of Spirometry 12
8 How to Perform Spirometry 13
9 How to Prepare the Equipment 15
10 How to Prepare the Subject 16
11 Positioning the Subject 17
12 How to coach the subject 17
13 Look for Acceptability and repeatability of the test 18
14 How to Record the Spirometer 18
15 Common Spirometric Indices 19
16 Interpret wisely 19
17 Algorithm for categorizing spirometric results 20
18 Classification of Airway diseases based on FEV1 21
19 Spirometry Values in healthy person 22
20 Spirometry In OLD 22
21 FEF 25-75% 24
22 Spirometry in Restrictive Lung Disease 25
23 Limitations of Spirometry 25
24 Infection Control 25
25 Factors to consider when purchasing Spirometer 26
26 Spirometry Graphs 27
27 Peak flow Meter 55
28 Predicted values of PEF(lt/mins) for men & women 64
29 List of Appendices: 76
1. ATS / ERS Task Force: Standardization of Lung
Function Testing General Considerations of Lung
Function Testing Eur Respir J 2005; 26: 153-161
2. ATS / ERS Task Force: Standardization of Lung
Function Testing. Standardization of Spirometry
Eur Respir J 2005; 26: 319-338
3. How to make sure your Spirometry Tests are of good quality.
Enright P. Respir Care 2003; 48: 773-776.
4. Office Spirometry for Lung Health Assessment in Adults:
Consensus Status from National Lung Health Education
Program. Ferguson G et al, Respir Care 2000; 45: 513-530
5. Technique and Equipment Pitfalls in Spirometry testing
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ABBREVIATIONS
(Commonly used terminology in the Spirometry Manual)
ATS American Thoracic Society

ATPS Ambient Temperature Pressure Saturation
BTPS Body Temperature Pressure Saturation
COPD Chronic Obstructive Pulmonary Disease
ERS European Respiratory Society
FEF 25-75% Forced Expiratory Flow between 25 and 75 percent of the FVC
FET Forced Expiratory Time
FEV1 Forced Expiratory Volume in One Second
FEV1/FVC Ratio of Forced Expiratory Volume in 1 second / Forced Vital Capacity
FVC Forced Vital Capacity
GINA Global initiative for Asthma

GOLD Global initiative for Chronic Obstructive Lung Disease
IC Inspiratory Capacity
ICS Inhaled Corticosteroid
LABA Long acting 2 Agonist
MAV Maximal Attained Value (also called Personal Best Value)

MVV Maximal Voluntary Ventilation
OB Obliterative Bronchiolitis
OLD/ OAD Obstructive Lung / Airway Disease
PEF Peak Expiratory Flow

PFM Peak Flow Meter
PFT Pulmonary Function Test
RV Residual Volume
SAO Small Airways Obstruction

SVC Slow Vital Capacity
TLC Total Lung Capacity
UAO Upper Airway Obstruction
VC Vital Capacity
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PREFACE:
According to National Center for Macroeconomics and Health, Government of

India, it has been estimated that there are 45 million asthma and COPD sufferers
in India and this number is expected to increase to 57.2 million over the next
decade.1 This health burden is much higher than those due to other non-
communicable diseases such as hypertension, ischemic heart disease, diabetes
and cancer.2 Unfortunately, a large number of people suffering with Obstructive
Airways Diseases (OAD) in India remain undiagnosed, wrongly diagnosed,
under-treated, untreated and wrongly treated. According to 2005 estimates, the
economic burden of asthma in India was 7641 crore rupees, whilst that due to
COPD was 25,209 crore rupees; had we diagnosed and treated asthma and
COPD patients better in India, we would have spent 2,200 crore rupees for
asthma and 2,941 crore rupees for COPD. Clearly a lot needs to be achieved to
diagnose and treat our patients suffering with asthma and COPD better.
Spirometry is the only objective tool that can not only diagnose Obstructive
Airways Diseases, but also help in managing them better. Currently, clinicians
diagnose asthma and COPD only by obtaining a history and listening to the lung
sounds with a stethoscope. However, this approach has been shown to under-
diagnose asthma and COPD by up to 65%, which means that more than half the
patients suffering with OAD remain undetected in clinical practice if the clinician
relies only on history and clinical examination. A nationwide study conducted by
Chest Research Foundation reported that less than 10% of general practitioners,
20% of general physicians and 50% of chest physicians utilize spirometry to
detect and manage patients with OAD. More than 75% of asthma and COPD
sufferers in India have never undergone spirometry testing.
Medical curriculum has rather been step-motherly towards spirometry with

undergraduate doctors being taught how to interpret complicated ECGs and X-
rays. Spirometry is poorly taught during medical education. Also, there is a
general belief that spirometry is an expensive and difficult test to perform, and
hence many doctors keep themselves away from this test.
With this background, Chest Research Foundation has taken an active initiative
to train clinicians about this important diagnostic tool, so that they can use this in
their practice to improve patient care. The objective of this course material is to
help understand the importance of Spirometry in clinical practice, improve the
quality of spirometry measurements and their interpretation, and to encourage
the use of spirometry in clinical practice.
We would like to have your feedback and recommendations for improving this
course material. Please feel free to call us or e-mail us your valuable comments
and suggestions.
1
Murthy KJR. NCMH Background papers Burden of Diseases in India. 2005.
2
Nongkynrih et al, Journal of Association of Physicians of India, Feb 2004; 52: 118-123.
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Historical Perspective:
Objective measures of lung function have always been a desire for physicians for
centuries. The earliest measurements of respiratory volumes are attributed to the
Italian mathematician Giovanni Borelli who in 1681 used a cylindrical glass tube
through which liquid was sucked, with the volume calculated from the bore of the
tube and the height of the meniscus. Stephen Hales, an English Clergyman and
Physiologist, in 1727 recorded the maximum volume of air, which he could expire
into a bladder, with the measurement made by subsequent displacement of
water according to the principle of Archimedes.
In 1844, Sir John Hutchinson from London started experimenting with a water
seal drum to accurately measure the volume of exhaled air, which he called the
Vital capacity. He published his work in 1846 and called this instrument
Spirometer. Hutchinson showed that measurement of VC was much more
sensitive for the detection of tuberculosis than auscultation via a stethoscope
(which had been invented by Laennec some 30 years earlier). Hutchinson
worked as an Insurance company doctor and proposed that the measurement of
VC be used to predict life expectancy. Sadly, even today, the insurance industry
often relies on the tape measure rather than the spirometer.
Unfortunately, the role of Spirometry was not appreciated by the medical

community and for a long time. It remained an unused tool. A resurgence of
interest in respiratory measurements took place in 1920s, which was driven by
three factors; problems with aviators in the 1st World War, need for objective
measures following the introduction of statutory compensation schemes for
workers with industrial lung disease, and the rise of thoracic surgery as a viable
specialty and the need to evaluate patient fitness. During the 1930s, there was
increasing recognition of asthma as a clinical problem. The maximum voluntary
ventilation (MVV), introduced by Hermannsen in 1933 became popular. In 1947,
Tiffeneau and Pinelli from Paris proposed the measurement of Forced Expiratory
Volume after 1 second as a replacement for MVV for assessing airflow
obstruction, because the MVV maneuver was too tiring for the patients. The
Flow-Volume curves were first described in 1960, and gave an elegant visual
synthesis of maximum expiratory and inspiratory flow over the whole FVC range.
It has now been almost 150 years since Spirometry was introduced to measure
lung function, but unfortunately, this instrument has not yet found an important
place in the physicians clinic and hospital, unlike the sphygmomanometer,
thermometer and X-ray. It is estimated that only 10-30% of primary care
physicians in the developed world have a spirometer in their clinic. In India, 10%
of General Practitioners, 20% of General Physicians and 50% of Chest
Physicians use Spirometry.
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What are the indications for Spirometry?
The most important indication for spirometry in clinical practice is to diagnose

Obstructive Airways Disease. Spirometry can also help in differentiating asthma
from COPD to a certain extent, and can also indicate whether the subject
performing the test has restrictive lung disease. Remember, restrictive lung
disease can only be confirmed by body plethysmography, which measures total
lung capacity and not by spirometry.
Cough can be the only presenting symptom in asthma many a times, which can
be difficult to diagnose in clinical practice. Spirometry can be a very useful tool to
detect airflow obstruction in these patients and can assist in making a diagnosis
of asthma.
COPD is now becoming a major health problem worldwide and is only predicted
to grow over the next 25 years. Early diagnosis is the key to prevent the rapid
decline in lung function that ensues once the disease process sets in. The lung is
a very tolerant organ, in the sense that symptoms of cough and breathlessness
in chronic smokers do not start until the disease is sufficiently progressed.
Spirometry has now been recommended as the most useful tool to detect COPD
in its early stages and should be performed as a routine screening test in all
smokers over the age of 40 years.
Smoking cessation can be quite a challenge in clinical practice. No matter how

strong the message is given in the clinic to quit smoking completely, the success
rate is rather depressing. Spirometry can be a useful tool to help motivate (or
rather scare) smokers to give up smoking. Studies conducted in Poland and
other countries have found that Spirometry can double the chance of smoking
cessation by using the concept of lung age. Spirometric measurements such as
FEV1 are expressed as lung ages. For example, a 50-year-old chronic smoker
who underwent spirometry showed a decreased FEV1 value, which
corresponded with that of a 70 year old man. Upon telling him that although he
was 50 years old, his lungs were 70 years old was sufficient to scare him to give
up smoking.
Non-smoking causes of COPD are becoming increasingly common in India. In

the west, where only 15-20% of all COPD cases are due to non-smoking causes,
in India non-smoking causes may be responsible for more than 50% of COPD
cases. Exposure to biomass fuel such as chullah smoke or kerosene smoke,
recurrent respiratory tract infections during childhood and exposure to hih levels
of outdoor air pollution are responsible for a large population of COPD in India. In
other words, in India you do not have to be a smoker to have COPD, and the
only way to detect this early is through spirometry.
Spirometry can easily help one differentiate between breathlessness due to a

cardiac cause and breathlessness due to a respiratory cause. However, a word
of caution here - the prevalence of Obstructive Airways Disease is common in
patients with ischemic heart disease and hypertension. A study recently
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conducted by Chest Research Foundation reported that, in contrast to the

general population where the prevalence of OAD was 3%, the prevalence of
OAD in patients with IHD was 20%. It has been suggested that spirometry be
performed routinely in patients with IHD to look for presence of underlying OAD.
Moreover, there is now a huge body of published evidence, which suggests that
spirometric indices, such as FEV1 and FVC can predict the risk of dying due to a
heart disease. In fact, the risk of dying due to a heart attack is as strong if one
has a low vital capacity as when one has an elevated serum cholesterol level.
The relationship between poor lung function and the risk of dying due to a heart
disease is now gaining more attention than ever before. Perhaps in the future,
spirometry will have the same status for predicting mortality amongst those with
IHD, as does high blood pressure, overweight, smoking and elevated cholesterol.
Management guidelines of COPD (Global Initiative for Obstructive Lung Disease)

and asthma (Global Initiative for Asthma) are based on severity, which is
essentially graded according to spirometric indices (mainly FEV1% predicted
values). Spirometry can therefore decide what treatment to advice based on
FEV1% predicted values. Moreover, response to treatment can be assessed with
spirometry. Change in FEV1 values after starting treatment can give an objective
assessment of the efficacy of treatment. The role of inhaled corticosteroids in
COPD is a topic for debate, but it has now been fairly well established that COPD
patients who have an FEV1 of less than 50%, inhaled corticosteroids can reduce
mortality as well as the number of COPD exacerbations. Whether the COPD
patient needs to be started on inhaled steroids can therefore be decided by what
the FEV1 values are.
Occupational asthma accounts for about 10-20% of all asthma cases. Objective
diagnosis of occupational asthma can only be made on Spirometry, although
peak expiratory flow rate values are more useful when recorded regularly over a
period of time. People who work in certain occupations such as oil paint industry,
soldering, welding, animal products, chemicals, steel factories and others, which
are known risk factors for asthma or COPD, should be routinely screened before
the start of their jobs to look for presence of underlying OAD.
If you are suspecting OAD, the most useful test to confirm this is spirometry.
Spirometry is therefore a very valuable diagnostic, therapeutic and management

tool in clinical practice and should be performed routinely in clinical practice.
To summarise the indications of spirometry in clinical practice:
Rapid and objective assessment of airflow obstruction and restrictive

conditions.
Differentiation between asthma and COPD.
Early detection and monitoring of disease progression (eg COPD).
Quantitative assessment of the severity of airflow obstruction.
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Incorporate guideline recommendations for therapy based on COPD and

asthma severity
Quantitative assessment of the response to therapy.
Population screening and case finding to detect airflow obstruction -
especially smokers and ex-smokers (with and without symptoms), and all
patients with respiratory symptoms.
Encouragement and motivation for smoking cessation, especially if
abnormal spirometry is obtained (provides a teachable moment).
Feedback to the patient about their disease and effect of medication.
More accurate and comprehensive assessment than peak flow.
Types of spirometers:
There are essentially two different types of spirometers Volume-displacement

spirometers and flow-sensor based spirometers. The volume-displacement
spirometers are the conventional spirometers that provide a direct measure of
respired volume from the displacement of a bell (water-sealed), piston (rolling
seal), or bellows (wedge bellows). The indices FEV1 and FVC are generally
manually calculated from the spirogram. These machines are more accurate for
measuring volumes than the flow spirometers, are robust and simple to use, easy
to maintain and provide a clear permanent record. But on the downside, they are
bulky, time consuming and less convenient for routine use in a busy doctors
clinic. Their use is generally restricted to research centers.
The flow-sensor based spirometers utilize a sensor that measures flow as a

primary signal and calculates volume by electronic (analogue) or numerical
(digital) integration of the flow signal. The most commonly used flow sensors
detect and measure flow from a pressure drop across a known, constant
resistance (e.g. Pneumotachograph), cooling of one or more heated wires
(anemometer), or by electronically counting the rotation of a turbine blade. More
recently, an ultrasonic-flow-sensor based spirometer has been introduced by ndd
technologies, Switzerland. The flow-based spirometers are lighter, portable and
provide a print out with all the spirometry indices desired. Some even provide an
interpretation of the result, but the appropriateness of these results depends on
the use of correct predicted normal values and criteria employed to classify
ventilatory defects and grade their severity.
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HOW TO PERFORM SPIROMETRY?
Spirometry should be performed only by well-trained personnel.
Remember Right Equipment, Right Technique and Right Interpretation are

crucial to obtain reliable results. The most important of these is Right Technique.
Spirometry is an effort-dependent test and that the subjects co-operation is vital
to obtain reliable tests. Poor subject preparation and coaching adversely affects
results, and cal lead to both under-diagnosis and over-diagnosis of diseases.
How to perform the test?
Preparing the equipment:

The most important step before the start of spirometry is to calibrate the
machine, using a one liter or three liter calibration syringe. All diagnostic
spirometers must be capable of being calibrated and this should be done
regularly (preferable daily). Although a calibration syringe may incur some
additional costs, it is worth investing right from the beginning because this will
ensure that the results obtained are accurate. Flow-sensors that use the
Pneumotachograph principle almost certainly need to be calibrated daily. The
most common error noted in this spirometer if not calibrated daily is that it gives
false over-reading of values FEV1 and FVC showing values between 200 -
500% higher than predicted normal are not uncommon. This is due to blockage
of the wire mesh in the pneumotach-based spirometers by dust particles, paper
particles, moisture from exhaled breath and even sputum particles.
Manufacturers generally portray that turbine-sensor based spirometers need not
be calibrated. This is not true. Even turbine-sensor based spirometers need
regular calibrations. With wear and tear the turbine sensor starts to under read
values, such that FEV1 and FVC may show values lower than predicted normal.
The only spirometer that is currently believed to need no calibration is the
ultrasonic-sensor based spirometer, because it works on a different principle.
Secondly, the person who is administering the test (the doctor or technician)
should be well trained in performing the test. Studies have shown that this is the
most important factor in ensuring a good quality spirogram.
Thirdly, get the patients exact age, and measure his height accurately. These
help in determining the normal predicted values. Measure the room temperature
and humidity and feed all these values along with the patients demography to
the Spirometer. Most Spirometers will have an inbuilt database of a range of
different predicted formulas. If there are local values available, it is preferable to
use these, otherwise the Udwadias formula (data from Mumbai) or 90% of the
European Community for Coal and Steel values should be used. It is critical to
choose the right predicted values, because these values are critical to quantify
the severity of airflow obstruction in patients with OLD.
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The important steps in performing spirometry are:
Prepare the Equipment
Prepare the Subject
Position the Subject
Demonstrate the Test
Coach the Subject, Perform the Test
Look for Acceptability and Repeatability
Record the Values
Interpret Wisely. Take clinical findings

into consideration
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Prepare the Equipment:
1. Check that the equipment has been properly cleaned.
2. Check if the equipment is working. Perform a test on self at the beginning of the
day.
3. Perform Calibration check daily and keep a log.
Why is it important to calibrate daily?

Most modern spirometers are based on flow sensors, where flow rate is converted to volumes
using mathematical equations. Volume measurements are therefore indirectly measured in the
Spirometer. It is important to ask the spirometer how much volume is being recorded if 1 litre or
3 litres is fed into it through a calibration syringe. If the sensor is accurate, it will record volumes
close to those injected inside.
4. Check that there are enough supplies, such as mouth pieces, nose clips, subject
record forms.
5. Measure Room Temperature. Most modern spirometers will have an inbuilt

temperature sensor, which is preferable. Note the barometric pressure.
It is recommended that ambient temperature should be accurately recorded to

within 1C, and that Spirometric testing should only be done with ambient
temperatures between 17-40C.
Why is it important to measure temperature accurately?

Air is at body temperature in the lungs and is saturated with water vapour. The ambient
temperature is usually much cooler and dryer, thus exhaled air contracts as it leaves the lungs
and enters the spirometer. The volume of air recorded by most spirometers is usually 6-10% less
than the actual volume of air exhaled by the test subject. The BTPS correction adjusts the
measured result obtained in the spirometer to what the volume was originally in the lungs.
For e.g. A subjects FVC as recorded by the Spirometer reads 5Lts at an ambient temperature of
21C (ATPS). The conversion factor that corresponds to 21C is 1.096. Therefore 5Lts x 1.096 =
5.48 Lts BTPS. Therefore, the recorded FVC of 5Lts at 21C (ATPS) actually represents a
volume of 5.48Lts (BTPS) in the subjects lungs at body temperature.
6. Check that the scales to measure weight and height are working properly.
Have an accurate height measuring device. Do not measure height
approximately, or ask the subject for his height. Remember, that a difference in
height of 2-4 cms will give significantly different predicted values for FEV1 and
FVC, which will change % predicted values.
7. Have a chair without wheels for subjects.
8. Have a waste basket ready for discarding used mouth pieces, and ensure that
there is a system in place for disposing medical waste.
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Prepare the Subject:
1. Explain the purpose of the spirometry.

Introduce yourself and tell the subject that you will be taking measurements to
check on the health of his / her lungs. Avoid using the word test, because some
subjects may develop test anxiety, will they pass the test and so on?
Point to the Spirometer and say that you will be using this to record the amount
of air he / she can exhale and how quickly he / she can do it.
Emphasize that the procedure does not hurt, but to get useful and valid results
he / she must breathe as hard and as fast as possible when told to do so, and
that the procedure must be repeated several times to obtain all the information
needed.
2. Check whether the test should be carried out or postponed

Certain conditions can affect the spirometry results, and hence should be
considered before performing the Spirometry.
Contraindications for Spirometry:

- Recent eye surgery (last 1 month)
- Recent Myocardial Infarction (within last 1 month)
- Recent abdominal surgery (last 1 month)
- Stroke that is affecting the face
Check if the subject has smoked cigarettes or bidis or pipes in the last 4-6 hours.
Smoking can have a short-term effect on the small airways, and hence will
produce false readings.
If the subject has used an inhaled short acting bronchodilator such as salbutamol
in the last 4-6 hours, then the spirometry readings may not be accurate and show
false high levels. Moreover, bronchodilator reversibility will be unreliable.
A cup of tea or coffee in the morning of the test will also affect FEV1 values
significantly.
A heavy meal will reduce the ability to take the deepest breath possible.
Therefore it may be wise to postpone spirometry for at least an hour after a
heavy meal.
A recent viral URTI may show airflow obstruction, and this should be noted
before hand.
Other drugs that should be avoided: Long acting 2-agonists and long acting
theophyllines for at least 12-24 hours.
Check if the patient is on a -blocker.
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Positioning the Subject:
1. Both sitting and standing positions are acceptable; however make a note of this
in the record.
Standing position may be preferable particularly for obese subjects, pregnant
women and children, since studies have shown that standing may produce a
larger FVC value. Put a chair behind the subject if he / she performs the test
standing. They may wish to use it between tests.
If subjects prefer to sit, encourage them to sit straight.
2. Instruct the subject to loosen tight clothing, such as ties, belts and shirts, which
tend to restrict hard and fast breathing.
3. Instruct the subject to elevate the chin and extend the neck slightly. This position
allows for the most forceful exhalation possible.
4. Use a nose clip to prevent air from escaping from the nose. If the subject finds
this uncomfortable, ask him to pinch his nose during the test.
5. Ask the subject if he / she has dentures. If the dentures are lose, it may be better
to remove them, however, if the dentures are tight fitting, them keeping them on
is preferable, because it offers a good tight seal around the lips.
Demonstrate the Test:
Do a practical demonstration using a mouth piece. A visual impression is a lot better

than a simple explanation of the procedure. Demonstrating the maneuver to the patient
will overcome 90% of the problems encountered and can be critical in achieving
satisfactory results.
Coach the Subject:
Remember the three phases:
I. Nice deeeeeeeep inhalation. Fill the chest with as much air as possible. Use
body language such as opening the chest, standing on the toes, opening the
eyes widely to illustrate the need to get as much air into the lungs as possible.
Out of all the three phases, this is the most important and vital step. If
inadequate breath is taken, the FEV1, FVC, FEF25-75% will all show under-
readings. The FEV1/FVC ratio will also be falsely elevated, thereby under-
diagnosing obstructive airways diseases.
II. The BLAST!!! Use voice power here to motivate the subject to blow as forcefully
as possible. This is important for PEFR and to a certain extent FEV1 values.
III. Continue to remove as much air is possible out from the lungs. Tell the subject to
blow out for as long as possible. Do not shout, but use encouraging words such
as keep on good, you can get more air out. FVC values are critically dependent
on this phase
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Look for Acceptability and Repeatability of the Test:
Because spirometry is an effort-dependent test, it is important to ensure that the subject

gave his/her best blow and performed the maneuver correctly. One way to do this is to
see if the subject did the test correctly. Although this is useful, it is by no means
completely reliable. The only way to confirm that the test was done properly is to look at
the acceptability and repeatability criteria. This is most important for quality assurance. If
you are given spirometric values for interpretation, do not comment on those unless you
have seen the flow-volume graph and volume-time graph for acceptability and
repeatability. Chances are that many a times the tests are not done properly.
Acceptability criteria:
No inadequate inspiratory effort only seen on flow-volume loop

No slow / hesitated start best seen to Volume/Time Graph
No cough best seen on Flow/Volume Graph
No poor effort see the shape of the expiratory loop on F-V Loop.
No early termination FET should be preferably 6 seconds or more. Less than 6
seconds may be permitted if the expiratory loop has reached a plateau on the V-
T curve for at least one second.
No glottic closure or obstruction of mouthpiece due to tongue
Repeatability Criteria:
The two highest values of the FVC and FEV1 taken from acceptable forced
expiratory maneuvers must show minimal variability. Difference between the two
best FEV1 and FVC maneuvers should be within 200mL. If more than 200mL the
values are not repeatable and hence not reliable.
How many Blows are required:
You must get at least 3 acceptable and 3 repeatable readings. However, up to a

maximum of 8 blows is recommended, because the subject is unlikely to give a better
blow if he has not been able to do it 8 times, and also, it is very tiring to make subjects
blow for 8 times. You may repeat the test at a later date.
Record the Spirometer:
Consistency in the record keeping system is important to ensure that all the information
needed is obtained.
At a minimum, the following information should be obtained each time spirometry is

performed:
- Test date and time
- Subjects name, identification number, age, height, sex and race
- Spirometer used
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- Temperature and Humidity

- Sitting or standing position used
- Which predicted values were used
- Test results
- Name and Signature of person who performed the test
- Grading of the Spirometry Result
- Make and keep backup copies in a file.
Definitions of Common Spirometric Indices
FVC (Forced Vital Capacity) is the maximum volume of air that can be expired (or
inspired) during a manoeuvre using maximal effort.
SVC (Slow Vital Capacity) is the maximum volume of air that can be exhaled slowly
following a full inspiration (or inhaled after a complete expiration). The SVC is similar
to the FVC in subjects without airflow obstruction, but is often larger in subjects with
airflow obstruction.
FEV1 (Forced Expired Volume in one second) is the volume of air that can be
forcefully expired in the first second of the maximal expiration. It is a measure of how
quickly full lungs can be emptied.
FEV1/FVC ratio is the FEV1 expressed as a percentage of the FVC and gives a
clinically useful indicator of airflow obstruction.
FEF25-75% (Forced Expiratory Flow between 25 and 75 percent of the FVC) is the
average expired flow over the middle half of the FVC manoeuvre. It is regarded as a
more sensitive but more variable measure of narrowing of the smaller airways than
provided by FEV1.
Interpret wisely:
Spirometry should be interpreted using the flow volume and volume time curves as well
as the absolute values for flows and volumes. The flow volume loop and volume time
curve are often overlooked but provide valuable information. Certain disease states have
characteristically shaped loops, so it is important to be able to recognize the different
patterns.
Always take the clinical picture into consideration.
Spirometry can sensitively and accurately diagnose airflow obstruction.
Spirometry can only suggest the presence of Restrictive Lung Disease. For confirming
Restrictive Lung Disease, measurement of Total Lung Capacity is required. Never rely
on Spirometry for confirming restrictive lung disorders.
You need only 3 parameters to interpret the Spirometry: FEV1, FVC and FEV1/FVC.
Follow the simple algorithm for categorizing spirometric results:
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Algorithm for categorizing spirometric results:
Is the test acceptable? Yes

Is the test reproducible? Yes
Are the reference values appropriate? Yes
FEV1 / FVC% < 70% FEV1 / FVC% > 70%

OBSTRUCTIVE NON-OBSTRUCTIVE
% pred FVC < 80%

MIXED AIRWAY DISEASE % pred FVC < 80% % pred FVC 80%
OBST + REST RESTRICTIVE NORMAL
Perform Bronchodilator Test Confirm by

with 200-400mcg Salbutamol measuring TLC
or 40mcg Ipratropium
If FEV1 increases by 12%

and 200mL
REVERSIBLE OBSTRUCTIVE
AIRWAY DISEASE
Classification of COPD severity (Post-bronchodilator)
Mild : FEV1/FVC <70% and FEV1 <80%

Moderate : FEV1/FVC <70% and FEV1 50-80%
Severe : FEV1/FVC <70% and FEV1 30-49%
Very severe : FEV1/FVC <70% and FEV1 <30%
Classification of Asthma severity
Intermittent : FEV1 80% and PEF variability <20%

Mild Persistent : FEV1 80% and PEF variability 20-30%
Moderate Persistent : FEV1 60-80% and PEF variability >30%
Severe Persistent : FEV1 <60% and PEF variability >30%
- 19 -
CLASSIFICATION OF OBSTRUCTIVE OR RESTRICTIVE OR MIXED AIRWAY

DISEASE BASED ON FVC AND FEV1 VALUES
100
0% OBSTRUCTIVE
LUNG DISEASESE NORMAL
80%
FVC
(%age MIXED OBSTRUCTIVE & RESTRICTIVE
predicted) RESTRICTIVE LUNG DISEASE LUNG DISEASE
70 100
FEV1 / FVC %age
- 20 -
Normal Spirometry
Normal values for FEV1 and FVC are based on population studies and vary
according to race, height, age, and gender. They are expressed in both absolute
numbers and percent predicted of normal. Some authors have suggested that
defining normal by 95% confidence intervals would be more statistically
appropriate, particularly at the extremes of age. Thus, a value below the 5th
percentile is defined as "below the lower limit of normal." However, many
laboratory and computer software programs continue to express results as
percentages of predicted normal values. A physician's interpretative strategy
should be adaptable to either reporting system.
Values for FVC and FEV1 that are over 80% of predicted are defined as within
the normal range. The FEV1/FVC ratio is expressed as a percentage, and a
normal young individual is able to forcibly expire at least 80% of his/her vital
capacity in one second. A ratio under 70% suggests underlying obstructive
physiology; however, the FEV1/FVC ratio declines as normal sequelae of aging.
Thus, at advanced ages, pathologic airways obstruction is diagnosed based
upon deviation from predicted FEV1/FVC values, with values below the 5th
percentile best selecting patients with obstructive defects.
Spirometry in OLD
The primary abnormality detected by spirometry is airways obstruction. In
obstructive lung diseases such as emphysema or chronic bronchitis, the FEV1 is
reduced disproportionately more than the FVC resulting in an FEV1/FVC ratio
less than 70%. This reduced ratio is the primary criteria for diagnosing
obstructive lung disease by spirometry.
As the obstruction becomes more severe and end expiratory air trapping
develops, the forced vital capacity may be reduced as well as the FEV1; however
there should continue to be a disproportionate reduction in FEV1 as evidenced
by the FEV1/FVC ratio.
Obstructive lung disease also changes the appearance of the flow volume curve.
As with a normal curve, there is a rapid peak expiratory flow, but the curve
descends more quickly than normal and takes on a concave shape, reflected by
a marked decrease in the FEF25-75. With more severe disease, the peak
becomes sharper and the expiratory flow rate drops precipitously. This results
from dynamic airway collapse, which occurs as diseased conducting airways are
more readily compressed during forced expiratory efforts. On the volume time
curve, this is seen as a slower ascent to maximum volume, with a gradual
upsloping versus the rapid rate seen in normal individuals. This equates with a
prolonged forced expiratory time demonstrable on physical exam.
- 21 -
A typical Flow-Volume curve from a subject

suffering with COPD. Note that the expiratory
loop shows a sharp and sudden drop from the
PEFR and there is a big concavity from the
PEFR to the FRC. It looks like the front logs of a
dog when he is sitting, therefore called dog leg
pattern. The inspiratory loop appears normal.
The American Thoracic Society recommends caution in diagnosing obstruction

when a patient has a reduced FEV1/FVC ratio but normal FEV1 and FVC. As
mentioned above, there is a normal age-related decline in the FEV1/FVC ratio,
so normal elderly patients without airway obstruction will have a ratio below 70-
80%. In this case, values below the predicted FEV1/FVC ratio aid in diagnosing
obstruction.
Does the subject have obstructive lung disease (OLD)?
If the FEV1 / FVC ratio is < 70%, the subject has OLD.
Is this OLD reversible?
Perform bronchodilator reversibility test by administering 200-400 mcg

Salbutamol by pMDI or dry powder inhaler and measure changes in FEV1 and
FVC after 15 mins. If the post-bronchodilator FEV1 improves by 12% and 200mL,
then this is reversible airways disease.
In subjects whom you are suspecting COPD, it would be better to test for
reversibility with 40mcg Ipratropium bromide by inhalation route.
What does Reversible Airway Disease mean?
Airway reversibility is one of the hallmarks of asthma. If a subject with history

suggestive of asthma shows presence of airway reversibility with salbutamol, you
may safely confirm a diagnosis of asthma.
However, remember that you may get good airway reversibility in patients with
COPD too. Presence of airflow reversibility therefore does not exclude the
diagnosis of COPD. Patients suffering with chronic asthma may not show good
airway reversibility.
- 22 -
Bronchodilator reversibility should be used as an adjunct to clinical presentation

to differentiate between asthma and COPD. Presence of reversible airways gives
about an 80% chance of the subject being an asthmatic. If the history and clinical
findings are suggestive of asthma as well, you may safely make a diagnosis of
asthma. If there is no airway reversibility in the presence of OAD, there is a 70%
chance that the subject may have COPD. If the history (smoking, exposure to
chullah smoke, recurrent chest infections during childhood) is suggestive of
smoking, then you may confirm your diagnosis of COPD. However, remember,
that many subjects with COPD may show good bronchodilator reversibility.
If there is no reversible airways disease in COPD subjects, should inhaled

bronchodilators be avoided?
No. Several studies have shown that in spite of showing poor bronchodilator
reversibility in the clinic, many subjects with COPD show good improvements in
quality of life and reduced exacerbations with the use of bronchodilators, in
particular, tiotropium. So these drugs should not be with-held.
What is the role of FEF25-75%?
FEF25-75% represents small airways. In early asthma or COPD, a reduced

FEF25-75% may by the only abnormality seen on Spirometry. For example:
subjects having mild asthma or mild COPD may have normal FEV1, normal FVC
and the FEV1/FVC ratio may be >70%, but FEF25-75% around 50%. This is
therefore indicative of early small airway disease.
While normal values for FEF25-75 have broader ranges than the other
spirometirc values, a mid-range flow less than 50% is most likely to be abnormal.
This is suggestive of small airways dysfunction and potentially early obstruction.
In the appropriate clinical setting, one may consider a trial of bronchodilators,
bronchoprovocative testing to exclude asthma, or interpret this observation as a
possible early indicator of smoking related lung disease.
Reduced FEF25-75% with normal FEV1 is strongly suggestive of early OAD,

both for asthma as well COPD. In the flow-volume loop this looks like concavity
starting from the PEFR to FVC. As the small airflow obstruction increases, the
concavity increases. A word of caution though FEF25-75% is not a robust
measure of lung function, i.e. the values may vary by as much as 30% when
measured at different times, unlike FEV1 values which may vary only by 3%. It is
therefore difficult to make a claim for legal compensation for a diagnosis of
occupational asthma solely based on a reduced FEF25-75% with normal FEV1
and FVC.
Whilst you require a 12% improvement in FEV1 after bronchodilator

administration to make a diagnosis of reversible airway disease, you require a
round 40-50% improvement in FEF25-75% to make a claim of reversibility.
- 23 -
Restrictive Lung Disease:
The shape of the flow volume loop is relatively unaffected in restrictive disease,
but the overall size of the curve will appear smaller when compared to normal on
the same scale. Similarly, there will be a rapid upslope on the volume time curve,
but such patients will reach a smaller vital capacity.
It is important to realize, however, that restrictive lung disease cannot be

diagnosed by spirometry alone. With severe airways obstruction the lung volume
remaining in the thorax after expiration (the functional residual capacity) may be
increased to such a degree that it limits inspiratory capacity and, hence, reduces
vital capacity. A reduced FEV1 and FVC are therefore only suggestive of true
restrictive disease, but it is necessary to measure lung volumes to accurately
diagnose restrictive physiology.
What are the limitations of Spirometry:
Although Spirometry can provide useful diagnostic and screening information, it

has few limitations. The results can show restrictive or obstructive patterns, but
they are not disease specific. For example, a low FEV1 and low FEV1/FVC ratio
may suggest obstructive airway disease, but it cannot tell whether it is due to
asthma, COPD or some other obstructive diseases. Here, additional information
such as history and clinical examination, with or without chest x-ray are required.
Spirometry often can detect obstructive diseases in their early stages, but for
some of the restrictive diseases, it may not be sensitive enough to show
abnormalities before extensive, and in some rare cases, irreversible damage has
been done. For example, silicosis and coal workers pneumoconiosis can be
easily detected on Chest X-ray, where the Spirometry values may be entirely
normal.
Infection Control:
Although the transmission of infection through spirometry has not been

documented, the theoretical risk should not be overlooked.
Always wash your hands before and after spirometry testing.
Instruct workers to attach, remove and discard the mouthpiece after each
session.
Do not perform spirometry in those who have an active respiratory
infection.
Consider using disposable spirometry filters.
Most hard surfaces may be disinfected by wiping with isopropyl alcohol.
- 24 -
Factors to Consider When Purchasing a Spirometer:
Ease of use.
Provision of real-time graphic display of the manoeuvre.
Provision of immediate quality feedback concerning the acceptability of
blows, including reproducibility.
Provision to interface with clinical software packages.
Provision of customisable final spirometry report.
Provision to print the final report.
Price and running costs.
Reliability and ease of maintenance.
Training, servicing and repair provided by supplier.
Ability to try the spirometer in your setting before you purchase.
Provision of a disposable sensor or a breathing circuit that can be easily
cleaned and disinfected.
Provision of appropriate normal reference values with lower limits of
normal.
Robustness.
Provision of a comprehensive operators manual.
Calibration requirements.
Conform to accepted spirometry performance standards.
Safety.
- 25 -
NORMAL FLOW-VOLUME LOOP

PEFR
FEF 25-75%
FLOW
25% 50% 75%
FVC
VOLUME
NORMAL VOLUME-TIME CURVE
FVC
FEV1/FVC nearly 70-90%

FEV1
VOLUME
1s 2s 3s 4s 5s 6s 7s
TIME
- 26 -
POOR EFFORT
(FLOW-VOLUME LOOP)
No Peak Poor effort is the most common

mistake seen in Spirometry.
Remember that Spirometry is an effort-
dependent test and if you do not have
FLOW
the best effort, the test is useless.

The Flow-Volume Loop is the best
place to see for Poor effort.
No peak on the mountain Poor Effort
VOLUME
POOR EFFORT
(VOLUME-TIME CURVE)
A poor effort cannot be easily picked
on a Volume-Time Curve.
Your spirometer must have a Flow-
Volume Loop or else you will miss poor
VOLU
efforts.
1 2 3 4 5 6 7
TIME
TIME
- 27 -
UNSATISFACTORY START
(Hesitation, air-leak, poor effort)
Poor start or hesitation can be easily

picked up especially in the Volume-
Time Curve.
Do not accept these readings because,
remember that Spirometry is an effort-
dependent test and poor effort will
FLOW
produce false FEV1 and FVC values.

Repeat the test again.
VOLUME
Hesitation
Unsatisfactory Start
(Hesitation, air-leak, poor effort)
You can appreciate here how

the FEV1 values may be
FEV1 falsely reduced. Many new
modern spirometers have a
Volume
correction for this error and

may be acceptable.
Time
1s 2 3 4 5 6
- 28 -
EARLY TERMINATION
(Glottis Closure, Tongue in mouth-piece)
FVC will be falsely Low

Time
Volume
EARLY TERMINATION
(Glottis Closure, Tongue in mouth-piece)
FVC will be falsely Low

VOLUME
1 2 3 4 5 6 7
TIME
- 29 -
COUGH IN THE FIRST SECOND

(FLOW-VOLUME CURVE)
Irregularity in the flow in the first

second, which contributes to
wrong FEV1 readings
FLOW
VOLUME
COUGH IN THE FIRST SECOND

(VOLUME-TIME CURVE)
FVC
Cough during Spirometry is common. If
it is particularly seen during the early
VOLUME
part of the expiration (within 1 sec),

then the test should be repeated, as it
will show false FEV1 values.
The Flow-Volume Loop is the best
place to look for presence of cough.
FEV1
1s 2s 3s 4s 5s 6s 7s
TIME - 30 -
Volume-Time graph for FET < 6 seconds
1. Reduced FVC
2. Therefore false high FEV1/FVC
Actual FVC
FVC
FEV1
FEV1/FVC = 74% FEV1/FVC = 66%

VOLUME
1s 2s TIME 6s
This is an example of how airflow obstruction may remain undetected in clinical practice
if the Forced Expiratory Time is less than 6 secs.
In this example, the patient blew for only 2 seconds. His FEV1/FVC becomes close to
70-80% because measured FVC is smaller. Had the subject exhaled for at least 6 secs,
the actual FVC would have been higher and the ratio of FEV1/FVC will then have shown
evidence of airflow obstruction.
This is very common in clinical practice. You may miss a large number of patients
suffering with Obstructive Lung Disease, only because the patient did not blow for up to
6 secs.
May times, healthy subjects may find it difficult to blow for up to 6 secs, because their
lung volumes are emptied very fast and they have no more air left in the lungs to empty.
Here, a time of less than 6 seconds is acceptable, but, you will find that the line has
already reached a plateau. If there is a plateau for at least 1 second, then the test may
be acceptable even if the FET is less than 6 seconds.
- 31 -
AIRWAY OBSTRUCTION
1. Obstruction begins in smaller airways.

2. Initially seen as reduction of flow
between 25% FVC and 75% FVC.
3. Which is depicted as concavity between
25% FVC and 75% FVC.
4. FEV1/FVC starts reducing and once
FEV1/FVC < 70% obstruction is
established
FLOW
VOLUME
ADVANCED AIRWAY OBSTRUCTION
1. As obstruction advances more

central airways are involved
2. Depicted as Concavity, reduced
FEV1, FVC and PEFR.
3. FEV1 reduces out of proportion to
FVC thus showing FEV!/FVC< 70%
FLOW
VOLUME
- 32 -
MILD OBSTRUCTION
FVC
1. Low FEV1
2. Normal or near normal FVC
3. FEV1/FVC >70%
VOLUME
FEV1
1s 2s 3s 4s 5s 6s 7s
TIME
SEVERE OBSTRUCTION
1. Low FEV1
2. Low FVC
3. FEV1 is lowered out of
proportion to FVC
4. FEV1/FVC <70%
FVC
VOLUME
FEV1
1s 2s 3s 4s 5s 6s 7s
TIME
- 33 -
RESTRICTIVE PATTERN
(FLOW-VOLUME LOOP)
1. FEV1 is reduced
2. FVC is reduced
3. FEV1/FVC normal or increased.
FLOW
VOLUME
RESTRICTIVE PATTERN
(VOLUME-TIME CURVE)
1. FEV1 is reduced
2. FVC is reduced
3. FEV1/FVC normal or increased.
VOLUME
1s 2s 3s 4s 5s 6s 7s
TIME
- 34 -
Applications of Spirometry in Clinical Practice
Introduction
The spirometer should be one of the most useful instruments in clinical practice today.
The modern spirometer must find its rightful place alongside the sphygmomanometer
and the electrocardiograph in clinics. Apart from its role in diagnosing obstructive and
restrictive lung disorders, abnormal spirometric indices are is an indicator of increased
risk for premature death from all causes. This fact has been known since the time of its
invention in 1846 by John Hutchinson, a surgeon, and the coining of the term vital
capacity Spirometry has a wide application throughout general medicine and
pulmonology.
Some Quotes about Spirometry

Lung function testing is now recognized as a measure of global health, predicting
all cause mortality and morbidity in adults
(Hole DJ et al, BMJ 1996: 313: 711-716
Weiss ST et al, Am J Epidemiol 1995; 142: 493-498
Freund KM et al, Ann Epidemiol 1993; 3: 417-424)
Bang KM et al, Chest 1993; 103: 536-540)
Background
.
Why has spirometry been so slow to be accepted in the mainstream of clinical
practice? Why is it not commonly used in the identification of early stages of
chronic obstructive pulmonary disease (COPD)? I believe that spirometry has
been a victim of too much mystique. says Thomas Petty. Spirometry can
distinguish asthma from COPD on the basis of objective improvement in airflow,
after use of bronchodilators, and, when indicated, corticosteroids. Spirometry is
also the key to the diagnosis and management of all of the restrictive pulmonary
diseases and helps in the management of OADs.
Spirometry regarded as a simple expression of a complex process is now an

integral part of evaluation, diagnosis and management of patients with
respiratory disorders. With technological advancements spirometry has become
simple ,inexpensive and reliable.
This section deals with the applications of spirometry in day-to -day clinical
situations.
Indications for spirometry in clinical practice
Diagnosis and management (assessing response to treatment) of asthma

Diagnosis and management (assessing response to treatment) of COPD
Identification of Restrictive Lung Diseases
Differentiating respiratory from cardiac cause for SOB
Diagnosis of occupational lung disease
Identifying upper airway obstruction and diseases associated with weakness of
respiratory muscles.
- 35 -
Assessing pre-operative risk prior to anesthesia and abdominal or thoracic

surgery.
Screening high risk populations (e.g. smokers, pre-employment in industries in
which occupational asthma is prevalent).
Role of spirometry
Two basic types of pulmonary function abnormalities, Restrictive and Obstructive
abnormalities can be described using spirometric parameters
FEV1/ FVC %
Low Normal
FVC% FVC%
Normal Low Low

Normal
Obstructive Mixed Defect Restrictive

Normal
Severe Obstruction
Repeat test after 200-400 mcg of Salbutamol,
Increase in FEV1 by 12% and 200ml
Yes, good BDR No, Poor BDR
Figure A: Interpretation of Spirometric Data
1. Restrictive abnormality: FVC(obs)<80% pred; FEV1/FVC>80%

Causes : Chest wall diseases, including skeletal and neuromuscular
disorder
Pleural diseases
Interstital diseases (ILD)
Parenchymal diseases
- 36 -
Spirometry in Restrictive Abnormality
Reduced FVC% predicted along with clinico-radiological correlation helps in

restrictive abnormality Fig1
FVC% predicted is used to determine the severity of restriction(Table1)
Table 1:Classification of Restrictive Lung Diseases on Spirometric Indices
Severity FVC%
Mild 60-80%
Moderate 45-60%
Severe <45
Case History
1. A 48 year old male was referred for dry cough and progressive dyspnoea
since 1year
O/E: Grade 3 clubbing
Fine end inspiratory crackles
CXR: Bibasilar reticular opacities
Graph
Fig2
Spirometry Report
- 37 -
Test Predicted Bronchodilator Change

Before After
FVC 3.38L 1.53 1.56
FVC% 45% 46%
FEV1 2.94L 1.5 1.55 3%,50ml
FEV1 % 51 57
FEV1/FVC% 98 99
Interpretation: Spirometry suggestive of Moderate to severe restrictive

abnormality (FVC is 45 %( borderline) predicted with FEV1/FVC ratio of 98%).
To confirm RLD abnormality by measuring TLC using body plethysmography.
Basis for interpretation: FVC less than 80%predicted and FEV1/FVC >80%
is suggestive of RLD.
FVC -45% pred indicates moderate to severe disease
Note , on visual inspection of the FV loop it clearly suggests a restrictive
abnormality but spirometric values are required to confirm and assess the
severity of restrictive abnormality
In restrictive abnormalities, The FEV1%is low in proportion to the low FVC and
unlike in obstructive abnormality, is not used as a parameter to indicate or
assess airway obstruction.
On follow-up it was interesting to know that an HRCT scan performed
subsequently confirmed a diagnosis of idiopathic pulmonary fibrosis (IPF )
Spirometry in Obstructive Abnormality : FEV1/FVC<70%

Causes : Bronchial asthma
COPD
Bronchiectasis
If an obstructive abnormality is present, it is important to know if it is associated
with a good bronchodilator response (BDR) which is indicated by improvement
in FEV1,by 200ml and 12%.If the FEV1 improves by 12%and 200ml with inhaled
salbutamol, the diagnosis of asthma appears stronger, however ,be aware that
even COPD and Bronchiectasis may show reversible airways diseases.
Note: FVC can be reduced in moderate -to -severe airflow obstruction due to air
trapping(which often improves after bronchodilator).Hence ,to interpret a
restrictive abnormality in these cases clinical and radiological correlation is
necessary.
Spirometry in Bronchial Asthma

Good bronchodilator response
Assessment of asthma severity (Global Initiative on Asthma-GINA
guidelines)See(Table2)
Management based on spirometric indices which guide asthma severity.See
(Table 3)
- 38 -
Table2: Asthma severity based on spirometry

Severity FEV1% predicted
Intermittent >/=80
Mild persistent >/=80
Moderate 60-80
persistent
Severe persistent </=60
Table 3:management of Asthma based on spirometric indices
Stepwise Approach to Asthma Therapy
Outcome: Asthma Control Outcome: Best

Possible Results
Controller:
High-dose
inhaled
corticosteroid When
Controller: plus long

asthma is
Controller: Medium-dose acting inhaled controlled,
Controller: Low-dose inhaled 2-agonist reduce
None inhaled corticosteroid plus (if needed) therapy
corticosteroid -Theophylline-SR
-Leukotriene
Monitor
-Long-acting inhaled
2- agonist
-Oral corticosteroid
Reliever: Rapid-acting inhaled 2-agonist Case

STEP 1: STEP 2: STEP 3:
Moderate
STEP 4:
STEP Down
Severe
History:
Intermittent Mild Persistent
Persistent Persistent 2
Alternative controller and reliever medications may be considered (see text). A 25
year old
female patient came to Chest Research Foundation (CRF) with a H/o Chest pain
and dry cough with occasional mucoid expectoration since 4years.The
symptoms increased over the last 2mnths .She confessed that she had not slept
soundly for 4 days due to cough. She visited several doctors, who prescribed her
various cough syrups and intermittent antibiotics, but she did not notice any
benefit. Her symptoms increased since 4days (monsoons)
H/o recurrent upper respiratory tract infections since 1 yr
H/o headache prior to a bout of cough which she noticed since1yr
She could not identify any precipitating factors for her cough.
O/E: Bilateral rhonchi
CXR: Clear
Provisional Diagnosis: Cough variant asthma
Fig 3--
- 39 -
Case 2: Spirometry Report

Test Predicted >200mcg change
Bronchodilator salbutamol
Before After
FVC 5L 4.2 4.5
FVC% 84% 90%
FEV1 4.5L 2.15 2.95 37%, 800 ml
FEV1% 47% 65%
FEV1/FVC 51% 65%
Interpretation
Obstructive lung disease with good bronchodilator response-Asthma, Severity
as per GINA guidelines is severe persistent asthma.(pre-bronchodilator FEV1-
47% predicted)
Basis for interpretation
FVC %> 80% and FEV1/FVC<70%
FEV1 <70% predicted
Improvement in of FEV1 >12% and 200ml
Ah/o persistent dry cough with severe airflow obstruction and significant
reversibility with salbutamol strongly suggested a diagnosis of Bronchial asthma.
Remarks:
Though history and graphs suggests obstructive lung disease ,spirometric values
are required to confirm, assess the severity of the obstructive abnormality and
estimate the bronchodilator response.(BDR)
In this case spirometry was even more important as this patient came with
atypical complaints of asthma .She was a classic case of a cough variant asthma
Spirometry was of great benefit as it helped to confirm the diagnosis of asthma.
She was treated with a combination of ICS+LABA and her symptoms
disappeared completely within 2weeks.
- 40 -
Case History: 3
35 year old female, presented with symptoms suggestive of bronchial asthma for
5yrs which increased since 1 month. She was mostly bed ridden and had not
slept peacefully in the last 2weeks.
On examination, she was using her accessory muscles of respiration and had
diminished breath sounds on auscultation
CXR clear
Fig4
Case 3A Spirometry Report

Test Predicted change
Bronchodilator
Before After
FVC 3.2 1.54 2.3
FVC% 48% 71%
FEV1 2.75 0.95 1.94 104%,990ml
FEV1% 34 72
FEV1/FVC 61% 84%
Interpretation : Severe obstructive abnormality with good BDR with salbutamol
Severe Persistent Bronchial Asthma:
FEV1/FVC<70%
FEV1<60%
Note: The significant decrease in FVC too (48% predicted)which is common in
severe obstructive airway disease.This occurs because of air trapping in the
lungs distal to constricted bronchi. In this case there was a significant
improvement in FVC with salbutamol too. Sometimes the FVC may decrease
markedly in obstructive airways disease, such that the comes to around
70%.tThis is called false normalization and indicates very severe airway
obstruction with air trapping. After giving a bronchodilator the FEV1and FVC
values improve and the ratio of FEV1/FVC may fall below 70%
- 41 -
Remarks: As chest x-ray was normal and history suggestive of bronchial asthma
the low vital capacity in the baseline spirometry was due to severe asthma
related to air trapping
(No clinical or radiological signs of restrictive lung disease).further more in
restrictive abnormality the FVC% will not show any improvement after a
bronchodilator.
She was prescribed Inhaled corticosteroids (ICS) and LABA in fixed dose
combination (Salmeterol/fluticasone).She came for a regular FUP visit after
3months and a spirometry was performed again at CRF (see Fig5 and spirometry
report 3B)
Fig 5: Follow up after 3months on ICS-LABA (Saraswati Soni)
Case 3B Spirometry Report

Bronchodilator
Before After
FVC 3.2 2.55 2.75
FVC% 79% 86%
FEV1 2.75 1.95 2.3 18%,350 ml
FEV1% 70 84
FEV1/FVC 76% 83%
Interpretation: Obstructive abnormality with good BDR. Significant improvements
in
spirometry after therapy(increase in FEV1 by 1000ml.)
Spirometry has played a pivotal role in assessing response to therapy in patient
FUP.
- 42 -
Spirometry in Asthma
Necessary for the diagnosis

To perform bronchodilator reversibility to confirm diagnosis
To determine the extent of airflow obstruction
To check for airway hyper reactivity using the bronchoprovocation test
Spirometry in COPD
Obstructive abnormality with poor bronchodilator response(BDR)

Decreased FEV1 with concomitant reduction in FEV1/FVC with a poor or absent
bronchodilator response (BDR)
Normal or reduced FVC.
FEV1/FVC% <70 is used to diagnose COPD, whereas FEV1% is used to grade
the severity.
The assessment of severity of COPD as per the Global Initative on Obstructive
LungDiseases (GOLD) guidelines is based on spirometry see Table 3
Role of spirometry in estimating severity of COPD

Spirometry is the gold standard for confirmation and assessing severity of COPD
Table 3 : Classification of severity of COPD based on spirometry (GOLDcriteria)

(Global initiative for Obstructive Lung Diseases)
0 At Risk Spirometry normal but symptoms
evident
1 Mild FEV1/FVC% <70 FEV1>80%predicted
2 Moderate FEV1/FVC% <70 FEV1 50-
80%predicted
3 Severe FEV1/FVC% <70 FEV1 30-
50%predicted
4 Very severe FEV1/FVC% <70 FEV1 <30%predicted
Case History 4
A 60-year old non-atopic male, with a history of cigarette smoking 30 pack-years,

presented with cough, sputum and dysnoea with wheeze since 6 years. These
symptoms had gradually progressed over the years and currently he felt
breathless on walking for 50 mts on flat ground
On examination he had bilateral rhonchi. See (Fig 6 and spirometry report)
- 43 -
Spirometry Report
Test Predicted Bronchodilator Change
Before After
FVC 2.3 L 1.8 1.8
FVC % 78% 78%

(Obs/pre)
FEV 1 1.95 L 0.75 0.75 (+0, 0ml)
FEV1% 38% 38%

(obs/pred)
FEV1/FVC 41% 41%
%
Interpretation: Spirometry suggestive of severe obstructive abnormality with no

reversibility with salbutamol

FEV1/FVC<70%
FEV1% between 30-50% predicted
Reversibility0%, 0ml
Severe OLD with poor bronchodilator reversibility and history of cigarette

smoking is strongly suggestive of a diagnosis COPD. As the FEV1% predicted is
38%, COPD severity is GOLD class 3.(severe)
- 44 -
Spirometry in COPD
If not detected early COPD would go on to cause substantial morbidity and

mortality
Treatment is available more effective when used at an early stage
A feasible testing & follow-up strategy is available that:
Minimizes false-positive or false-negative results
Is relatively simple & affordable
safe
Role of Spirometry in occupational asthma

Case History 5
Mr.Prakash Singh aged 49 years Comes to CRF with complaints of recurrent,

cough, breathlessness, tightness of chest since 5 years. These symptoms
are more during monsoon season and during winter season.
He also complains of cough during early morning hours.
There is no family h/o these symptoms.
He is a worker in a paint factory since 20 years. His symptoms aggravate on
Mondays and continue until Saturday. On Sundays he feels better.
O/E occasional wheeze both chest fields.

CXR was normal except increased bronchovascular markings.
His PFT reports are as follows.
Fig 7;Mr Prakash (OA)
- 45 -
- 46 -
Case 6A Spirometry Report(done on Sunday)

Bronchodilator
Before After
FVC 3.14 2.96 2.94
FVC% 94 94
FEV1 2.43L 2.4 2.4 0%,0ml
FEV1% 98 98%
FEV1/FVC 81% 81%
Mr Prakash was called again during his symptom days to verify his lung
functions. The report of which is as follows:
Case 6B Spirometry Report (done during symptoms, Wednesday)

Bronchodilator
Before After
FVC 3.14 2.96 2.94
FVC% 94% 94%
FEV1 2.43L 1.73 1.94 12% ,210ml
FEV1% 71% 77%
FEV1/FVC 58% 63%
In This case it was because of spirometry that we could diagnose an case of

occupational asthma ,.This patient was later taught to use a peak flow meter and
asked to record the values in morning and evening daily (see Fig8)
Fig 8: Peak flow rate graph
The above graph clearly shows an increase in PEFR during non working days .
Other Miscellaneous roles of Spirometry

Spirometry offers a therapeutic role and helps in quitting smoking.
- 47 -
Spirometry to monitor development of COPD in smokers
Fig 9 Role of Spirometry in monitoring development of COPD in susceptible smokers

Adapted from: Fletcher C, Peto R. Br Med J, 1:1645-1648,1977
After the age of 25 years, the lung function of a normal individual begins to
decline at the rate of reduction in FEV1 by approximately 30 ml per year (Fig 9)
Patients with COPD show an accelerated decline of lung function, almost upto 70
ml per year. However, only 15% of smokers develop COPD, probably due to a
genetic predisposition.
Thus, an annual monitoring of spirometry in smokers can help identify the

subgroup of smokers who are susceptible to the development of COPD. The
Lung Health Study was the first study to show that simple spirometry could detect
mild airflow obstruction, even in asymptomatic patients.
Role of spirometry in estimating Lung age in COPD to aid smoking

cessation
Spirometry is the gold standard for diagnosis of COPD. Spirometry can also be
used for assessing the lung age (measured FEV1) of a patient of COPD as
compared to the predicted FEV1 as per his chronological age. Demonstration of
this graphic illustration e.g. 45-year-old man with COPD with a lung age of an
80-year old (fig 10) is also helpful in encouraging smokers to quit smoking.
- 48 -
Figure 10: Lung Age In COPD

Adapted from: Petty TL. Can 'old' lungs be restored? Strategies for preserving
lung health and preventing and treating COPD. Postgrad Med. 1998;104:173-8,
181-2.
Spirometry in Pre-Operative Pulmonary Evaluation
Pulmonary function testing is not routinely indicated for pre-operative evaluation.

However, spirometry has a little but an important role in assessing post
operative lung status and could guide as an pre operative risk indicator in
patients undergoing lung resection surgery or in surgery other than lung
resection (particularly thoracic or upper gastrointestinal surgery)
To note: Spirometry should only be done in those subjects if there is history of
tobacco smoking, or clinical or radiological findings suggestive of any pulmonary
abnormality.
Preoperative Evaluation in Lung Resection Surgery
Predicted postoperative (ppo) values should be calculated by deducting the

volume to be resected from the pre-operative (usually FEV1) values.
For this purpose "rule of five" can be used which assumes one-fifth function for
each lobe.
For example if the recorded preoperative FEV1 is 2.5 liters and one lobe
resection (lobectomy) is being considered, then one-fifth the recorded FEV1 has
to deducted to be calculate the ppo FEV1 in liters i.e.
2.5L - 0.5L = 2 L.
To note: FEV1 less than 40% predicted contraindicate any lung resection.
Preoperative Evaluation in Surgery other than Lung Resection

Pre-operative evaluation is done to assess the risk of postoperative pulmonary
complications and to minimize them by optimal treatment. Patients described as
high risk by spirometry can undergo surgery with an acceptable risk for
postoperative pulmonary complications. Risk is indirectly proportional to the
distance of surgical site from the thorax.
- 49 -
The Role of Spirometry in All Types of Airway Obstruction
Although classically the term obstructive abnormality implies obstruction of large

airways e.g. asthma and COPD, it is important to know the functional division of
the airways and the role of spirometry in obstruction of the upper and small
airways. Both are often missed in clinical practice and spirometry can be
extremely helpful in timely diagnosis and appropriate management of these
conditions
Functionally the airways can be divided as (Fig 11)
Upper airways: from the nose/mouth to carini
Large airways: from carini to 2mm diameter airways
Small airways: less than 2 mm diameter airways
Fig 11; Functional Classification of Airways
Upper airways
Carina
Large airways
Small airways<
2mm
Fig 11: Functional Anatomy of the airways
Types of Airway Obstruction
Upper Airway Obstruction (UAO) requires recording of flow volume loops.

Diagnosis of UAO can be made easily by inspecting the pattern of the FV loop
and calculation of certain indices with appropriate clinical and radiological
correlation.
Examples of UAO are tracheal stenosis, tracheal compression by goiter / mediastinal
masses and neoplasms of the larynx/trachea.
- 50 -
Large Airway Obstruction (LAO), the commonest cause for airway obstruction is
conclusively determined even by simple spirometry parameters defined by
reduced FEV1/FVC%, as obstructive abnormality
Small Airway Obstruction (SAO),

This is best diagnosed by high-resolution computed tomography (HRCT)
showing mosaic perfusion while spirometry is helpful only with clinical and
radiological correlation. Typically spirometry in SAO shows low FVC (due to air
trapping distal to the obstructed small airways), low FEV1 and flow rates. A
characteristic feature is false paradoxical fall in FEV1/FVC% due to greater
increase in FVC compared to FEV1 following bronchodilators.
Example of SAO is Obliterative bronchiolitis (OB) also called Constrictive

Bronchiolitis (CB). SAO is also seen associated with Bronchial Asthma, COPD
and Bronchiectasis.
Case History 6
A 27-year old male presented with stridor. to casualty of Sion Hospital He had
been on mechanical ventilation with a prolonged tracheostomy for 2 months
following a vehicular accident.
Clinical examination was unremarkable except stridor on auscultation.
CXR was clear. CT Thorax showed a 3cm narrowing of the trachea
Diagnosis: Post tracheostomy tracheal stenosis. (Fig 12)
The Flow Volume Loop (FVL) was as shown below
Interpretation: FVL showing variable fixed UAO due to tracheal stenosis.

Interesting case detected by Spirometry at CRF
Manish 45yr an area sales manager, smoking history since 22 yrs (10
cigarettes/day) came to CRF with complaints of Dyspnoea, cough with
expectoration , wheeze since 2days.
He gave past history of recurrent URTIs since past 15 yrs for which he was
regularly prescribed antibiotics on and off .He was referred to us as a case of
Chronic Bronchitis.
On History he was given a provisional Diagnosis of Chronic Bronchitis.
He was then asked to do spirometry .His results were as follows:
- 51 -
Baseline: Interpretation
FEV1=3.24(76%predicted) slightly reduced
FVC= 4.82(91%predicted) Normal
FEV1/ FVC ratio =0.67 slightly reduced
Post bronchodilator FEV1 = 4.17 (930ml and29%) Significant Reversibility
Interpretation
Obstructive lung disease with good bronchodilator response-Asthma, Severity
as per GINA guidelines is Mild persistent asthma.(pre-bronchodilator FEV1-76%
predicted)
Diagnosis : Mild Bronchial Asthma
Remark: Manish was diagnosed as Asthma which was confirmed on spirometry
.he was given advice on long term impact of smoking and the risk of developing
COPD.
With this information Manish has quit smoking.
Use of Spirometry in deciding what treatment to offer
Treatment of Asthma based on GINA Guidelines is based on spirometric values.
GOLD Guidelines too on which the management of COPD is based is too based
on spirometric
Management based on GOLD

Post-bronchodilator
FEV1
(% predicted)
- 52 -
Algorithm for the management of COPD
Mild Short acting bronchodilator as required

assess with symptoms and spirometry
Tiotropium Long acting beta agonist
Tiotropium+LABA LABA + tiotropium
Add
-Inhaled steroids
Severe -Theophylline
ADVANTAGE Spirometry
The spirometer should be one of the most useful instruments in clinical practice
today
Spirometry has a wide application throughout general medicine and
pulmonology.
The following are the benefits of spirometry.

Spirometry is an important database
Normal spirometry predicts a high likelihood of long-time survival; abnormal
spirometry indicates an adverse prognosis. Simple Spiro metric measures
provide an important database for the primary care physician and specialist. One
example is the patient who comes to the physician with cough and Dyspnoea
thought to be associated with a certain
occupation. Knowledge of prior spirometry will give a baseline for comparison.
Spirometry is key to diagnosis and patient monitoring
Spirometry is key to the identification of many disease states and to the objective
monitoring of responses to therapy for these heterogeneous conditions.
It should play a central role any time a physician prescribes potent bronchoactive
and anti inflammatory drugs.
A clinician would not treat hypertension without measurements of blood pressure,
give insulin or an oral hypoglycemic agent to a diabetic without measurements of
blood
- 53 -
sugar, treat cardiac arrhythmias without electrocardiogram monitoring, or use

warfarin anticoagulation without monitoring prothrombin times and international
normalized
ratio.
Nonetheless, spirometry is still not part of the primary care practice of most
physicians who regularly prescribe drugs designed to improve airflow, volume, or
both.
Spirometry is crucial in the detection of acute and chronic
airflow obstruction and in the monitoring of responses to therapy and disease
progress. Spirometry can distinguish asthma from COPD on the basis of
objective improvement in airflow, after use of bronchodilators, and, when
indicated, corticosteroids.
Spirometry is also key to the diagnosis and management all of the restrictive
pulmonary diseases.
Spirometry determines lung age
Spirometry is an aid in smoking cessation
To summarize
REALIZATION that Spirometry is an important diagnostic and management
tool in various lung disorders.
Spirometry is an important and invaluable office diagnostic device
It should be used by all primary care and most specialist physicians
Spirometry is recommended to measure the annual changes in lung functions
especially in high risk groups
Spirometry should be a part of the global health assessment programs
Spirometry is to dyspnea as the electrocardiogram is to chest pain
- 54 -
PEAK FLOW METER
Introduction
In the past the diagnosis and monitoring of severity of various diseases was based on
clinical examination but this involved a lot of judgment error. Now, we have objective
tools to measure severity of diseases accurately. A thermometer measures fever,
sphygmomanometer measures blood pressure and glucometer measures blood sugar.
Now peak flow meter is available to measure severity of diseases with airflow
obstruction such as Asthma and Chronic Obstructive Pulmonary Disease (COPD). Peak
flow meter measures peak expiratory flow rate which correlates closely with FEV1 in
measurements of airflow obstruction
PEAK EXPIRATORY FLOW METER = A THERMOMETER OF ASTHMA
Peak Expiratory Flow meter or commonly called Peak Flow Meter is an important aid
in the diagnosis and subsequent management of asthma. Peak flow meters are relatively
inexpensive, portable, robust and ideal for patients to use in home settings for day to day
objective monitoring of asthma. Peak Flow Meters are useful in the out-patient clinic and
primary health care settings to help in the diagnosis of asthma.
Why measure peak expiratory flow?
Lung function tests are essential for diagnosis and assessing the severity of asthma in
patients over 5 years of age (Global Initiative for Asthma Guidelines 2005). The
measurements provide an indirect assessment of airway hyper responsiveness, which
correlates closely with the degree of airway inflammation.
- 55 -
1. The peak expiratory flow rate is a reliable marker of airway obstruction, specially
the medium -sized & large-sized airways; and is therefore a useful screening tool
in the diagnosis of Obstructive Lung Diseases. When measured in an asthmatic
patient, it typically shows a wide variability between the morning and evening
values (reading are higher in the evening compared to morning). This enhanced
diurnal variability is strongly indicative of asthma.
2. Diagnosis of occupational asthma can be easily made.
3. One of the most useful roles of the peak flow meter is deciding the
pharmacotherapy of asthma and judging exacerbation episodes that might need
immediate attentions especially in those asthmatics, who are poor perceivers.
Asthma management can be made simple and tailored according to asthma severity as
assessed by the Peak flow Meter. You can give the patient a chart which compromises of
color codes, representing the severity of asthma
Green Zone: reading in green zone signify 80 -100%of personal best. This zone
suggests that treatment plan is working and one should continue this strategy.
Yellow Zone: PEFR values between 50-80% are in yellow zone. It is a zone of
caution and asthmatic patients with their PEFR in this zone should be cautious
and therefore make adjustments of daily activities and dose of the drugs.
Red zone: PEFR values below 50% of the personal best signify danger and
suggest immediate medical attention.
350
Peak expiratory flowrate (1/min)
300
250
200
150
100
50
0
6:00 AM 6:00 PM 6:00 AM
| Day 1 | Day 2 | Day 3 | Day 4 |
PEF chart of an asthmatic patient
Present view of pulmonologists is that regular use of peak flow meters help in improving
the control of asthma and reduction of hospitalizations and mortality.
- 56 -
Establishing Personal Best PEF Value:
Establishing personal best value and diurnal variability when the patient is under
effective treatment is very important. During a monitoring period of 2 to 3weeks, the
patient should record PEF measurements at least twice a day. On both occasions the
patient should measure the PEF at least three times and note the highest number. If the
patient takes a bronchodilator, the PEF should be measured before and after using the
bronchodilator.
The personal best is the highest PEF measurement achieved when the patients asthma is
under control. And this should be equal or more than 80% of predicted value of the
patient. A course of oral or inhalation corticosteroids in the initial evaluation period may
be needed to establish the personal best and minimum PEF daily variability.
600
After bd
500
PEF (1)
400
300
200
100 Before bd
0
0 1 2 3 4 5 6
Time (Days)
PEF chart of a patient with uncontrolled asthma showing diurnal variability

and reduced morning response to bronchodilator (bd)
Highest PEF Reading - Lowest PEF Reading

PEF variability = --------------------------------------------------------- X 100
(In %age) Highest PEF Reading
Example: Morning PEF=300; Evening PEF= 400
400 - 300
PEF Variability = ------------- X 100 = 25%
400
Types of Peak flow meters and Principle of working:
Various types of peak flow meters are available in the market e.g. Mini Wright and
Pink city flow meter. These are mechanical devises having springs and diaphragm.
Some devises use metal plate in place of a spring. The air flow entering into the flow
meter displaces the diaphragm and thereby compresses or stretches the spring or the
metal plate. This displacement is proportional to peak flow and the calibrated scale is
printed on it.
- 57 -
1. Wrights Peak Flow Meter 2. Health scan P F Meter 3.& 4. PFM (Patent pending)
How to measure peak expiratory flow?
For recording of peak expiratory flow rates a person

is asked to blow as hard as possible from a position
of maximal inspiration.
Pink city flow meter records both PIF and PEFR
While all other records PEFR.
PIF is approximately 2/3 of PEFR.
For recording of PIF a person inhales as fast as possible
from a position of maximal expiration
i.e. residual volume.
Procedure/ Technique: Whistle Watch 6001- PFM
1. Place the indicator at the base of the numbered scale and fix mouthpiece to PFM
2. Stand up
3. Take a deeeeep breath
4. Place the meter in your mouth and close your lips around the mouthpiece. Do not
put your tongue inside the hole.
5. Blow out as hard and fast as you can
6. Note down the number you get from the scale ( See zone also)
7. Repeat steps 1 to 6 two more times, because we require 3 readings
8. Note down the highest of the three values obtained.
- 58 -
Indications for Use of Peak Flow Meter in Clinical Practice
1. Diagnosis of Asthma: Asthma is a chronic inflammatory disease of airways

characterized by variable airflow obstruction. Since clinical examination lacks
sensitivity, therefore, a minimal requirement for diagnosis of asthma is
documentation of positive reversibility test and diurnal variability. Twenty
percent increase in PEFR values after administration of bronchodilators is
generally diagnostic of bronchial asthma.
2. Monitoring Severity of asthma: Asthma is a disease characterized by worsening

of breathing symptoms due to many triggers and in even in night times. The
reduction in best PEFR more than 30% suggests severity. Diurnal variability in
PEFR is an excellent index correlating closely with airway hyper responsiveness.
Once the best PEF values for a patient are known, these can then be used as a
reference value to judge asthma severity.
3. Identification of trigger factors: Regular PEFR recording can identify triggers

of asthma. Morning and evening PEFR are recorded and the finding of a reduced
PEFR is correlated with exposure to potential triggers in the preceding hours.
Repeated reduction following exposure to same trigger confirms the provocating
factor.
4. Therapy of Asthma: Treatment based on PEFR improves patient compliance,

reduces the chances of under and over treatment. Asthma is a progressive and
potentially fatal disease if untreated or under treated. PEFR values based
treatment guidelines are available in self management action plan ( See attached
adult asthma action plan)
400
Peak expiratory flow rate (1/min)
350
300
250
200
150
100
50
0
6:00 AM 6:00 PM 6:00 AM 6:00 PM 6:00 AM 6:00 PM
| Day 1 | Day2 | Day3 | Day4 |
PEF chart of a patient recovering from acute severe asthma.

5. To know asymptomatic airway obstruction: The current view is that airway
inflammation is present even if the patient is asymptomatic, hence emotion, stress
like triggers affect immediately. Therefore treat asymptomatic patients of asthma
on PEFR value as we treat persons suffering from hypertension or diabetes based
on criteria of blood pressure and blood sugar reading respectively.
- 59 -
6. Detection of COPD in Smokers: Routine measurement of PEFR in smokers

consulting for any problem can detect many asymptomatic patients of COPD.
7. Evaluation of Dyspnoea: A peak flow meter can help in differential diagnosis of

Dyspnoea. PEFR values more than 2.5 lit /sec. in a patient with severe Dyspnoea
exclude a bronchial cause. In upper airway obstruction mainly PIF is reduced.
8. Clinical and Epidemiological Research Studies: This is a simple and portable

tool for epidemiological and clinical studies in community.
Peak expiratory flow monitoring is recommended in asthma guidelines as a tool assessing

severity, monitoring response to treatment, detecting exacerbations, identifying triggers,
and providing objective justification for treatment to the patients.
Contraindications;
1. Facial paralysis ( Bells palsy)

2. Facial burn
3. Unable to hold firmly mouthpiece due to paresis and weakness.
Acceptability and repeatability
PEF measurement is effort dependent, patient need to be coached initially to give their
best effort. It is essential to use correct techniques and equipment.
Accuracy of Peak Flow meter
The earlier scale used on old version of Wrights peak flow meter (black letters on white
background). The air flow entering into the peak flow meter displaces the diaphragm and
thereby compresses or stretches the spring or the metal plate. This displacement is
proportional to peak flow was shown on this scale, which later on, through various
studied proved wrong. It had been reported that Wright scale Peak Flow Meters can over-
read in the midrange by up to 30%. The long linearity of the Wright scale Peak flow
meter had wrongly measured air flow changes in the midrange, and under represent
changes in the low and high ranges. Hence from 1st September 2004 onwards the Wright
scale peak flow meter became obsolete in the UK and other European Countries. From
this point onwards the new European (EU) scale became mandatory. And all peak flow
meters have to conform to the new European Standard EN 13836 since 2004.
How many blows are required?
The effort required to produce the measurement is a full inspiration to total lung capacity
followed by a short and fast maximal exhalation in a standing position. Such three
reading are taken in early morning and evening hence three blows are required.
Ideally PEF reading should be taken twice daily, immediately after arising and 12 hours
later, before and after using bronchodilator if a bronchodilator is needed. Any variation
more than 20% in PEFR indicates worsening of asthma.
- 60 -
What is the normal predicted peak flow rate?
There are no reliable studies in India that have generated normal predicted values for
peak expiratory flow rate. However, to get a rough idea about the normal predicted
values, the following predicted equations may be used.
Men:
New: In (PEF) = 0.755 In (age) 0.021 age -104.1 / ht + 5.16
Women:
New In (PEF) = 0.486 In (age) 0.016 age -76.8 / ht + 5.43
(Kindly Note: Age is in years and Height is in cm.)
These values depend on age, sex, and height of the patient. Since there is wide individual
variations in PEFR in general population, for self monitoring personal the best PEFR can
be used as a reference standard to judge asthma worsening. The personal best PEFR is
used as normal peak flow rate for that particular person.
Please see pages attached for predicted PEFR values varying from age 18 to 65 and
height 150 to 180 cm as per revised Nunn and Gregg equations.
Supervising home PEF monitoring:
The following guidelines should be used:

1. Educate the patient and family about the purpose and technique of home
monitoring. Education should include :
- How and when to use peak flow meter.
- How to record PEF measurement in a diary
- How to interpret the measurements
- How to respond to change
- What information to communicate to health care professional/s.
2. Explain how the health care professional use the home PEF data to choose and
evaluate treatment.
A decrease in peak flow of 20 to 30% of the patients personal best may mean the start
of an asthma episode. When this happen advice the patients to follow their asthma control
plan for treating an asthma episode.
Limitations of Peak Flow Meter:
1. The Peak flow Meter has no role in the day-to-day management of COPD, largely
because the peak flow values do not change, as in asthmatic patients.
2. Peak Flow Meter is a reliable marker of airway obstruction especially the
medium- sized and large- sized airways. Early asthma or early COPD which starts
predominately in the smaller airways cannot be picked up by Peak Flow Meter,
which shows normal peak flow readings.
3. PEF measurement is effort dependent hence its use in severe asthma / COPD
exacerbations is limited.
- 61 -
ASTHMA ACTION PLAN FOR YOUNG PEOPLE
Name Date
WHEN WELL
Preventer (if prescribed)

Use times a day
Use times a day
Reliever Use
(Take only when necessary for relief of wheeze or cough
Symptom controller (if prescribed)

Use
Before exercise take Use
WHEN NOT WELL
At first sign of a cold or a significant increase in wheeze or cough, take:

Reliever:
Use times a day
Preventer:
Use times a day
Use times a day
Symptom controller
Use times a day
When your symptoms get better, return to the doses you take when well.
IF SYMPTOMS GET WORSE, THIS IS AN ACUTE ATTACK
Extra steps to take
Emergency Medication Strength
Take
When your symptoms get better, gradually return to the doses you take when well.
- 62 -
ASTHMA ACTION PLAN FOR YOUNG PEOPLE
WHEN WELL
You will
be free of regular night-time wheeze or cough or chest tightness
have no regular wheeze or cough or chest tightness on waking or during the day
be able to take part in normal physical activity without getting asthma symptoms
need reliever medication less than 3 times a week (except if it is used before exercise)
WHEN NOT WELL
You will
have increasing night-time wheeze or cough or chest tightness
have symptoms regularly in the morning when you wake up
have a need for extra doses of reliever medication
have symptoms which interfere with exercise
(You may experience one or more of these)
IF SYMPTOMS GET WORSE, THIS IS AN ACUTE ATTACK
You will
have one or more of the following: wheeze, cough, chest tightness or shortness of
breath
need to use your reliever medication at least once every 3 hours or more often
DANGER SIGNS
your symptoms get worse very quickly
wheeze or chest tightness or shortness of breath continue after using reliever
medication or
return within minutes of taking reliever medication
severe shortness of breath, inability to speak comfortably, blueness of lips
IMMEDIATE ACTION IS NEEDED: CALL AN AMBULANCE
Take this Action Plan with you when you visit your doctor.
(Doctors name and stamp with Signature and date)
- 63 -
CRFs Predicted PEFR values for Males:

Predicted Equation: PEFR (Lt/min) Male = 69.259 2.229*Age + 2.888 * Height
Age (in Yrs)

Height
18.00 19.00 20.00 21.00 22.00 23.00 24.00 25.00
(in cm)
150 462 460 458 456 453 451 449 447
151 465 463 461 459 456 454 452 450
152 468 466 464 461 459 457 455 453
153 471 469 467 464 462 460 458 455
154 474 472 469 467 465 463 461 458
155 477 475 472 470 468 466 463 461
156 480 477 475 473 471 469 466 464
157 483 480 478 476 474 471 469 467
158 485 483 481 479 477 474 472 470
159 488 486 484 482 479 477 475 473
160 491 489 487 485 482 480 478 476
161 494 492 490 487 485 483 481 479
162 497 495 493 490 488 486 484 481
163 500 498 495 493 491 489 487 484
164 503 501 498 496 494 492 489 487
165 506 503 501 499 497 495 492 490
166 509 506 504 502 500 497 495 493
167 511 509 507 505 503 500 498 496
168 514 512 510 508 505 503 501 499
169 517 515 513 511 508 506 504 502
170 520 518 516 513 511 509 507 504
171 523 521 519 516 514 512 510 507
172 526 524 521 519 517 515 512 510
173 529 527 524 522 520 518 515 513
174 532 529 527 525 523 521 518 516
175 535 532 530 528 526 523 521 519
176 537 535 533 531 529 526 524 522
177 540 538 536 534 531 529 527 525
178 543 541 539 537 534 532 530 528
179 546 544 542 539 537 535 533 530
180 549 547 545 542 540 538 536 533
181 552 550 547 545 543 541 538 536
182 555 553 550 548 546 544 541 539
183 558 555 553 551 549 546 544 542
184 561 558 556 554 552 549 547 545
185 563 561 559 557 555 552 550 548
186 566 564 562 560 557 555 553 551
187 569 567 565 563 560 558 556 554
188 572 570 568 565 563 561 559 556
189 575 573 571 568 566 564 562 559
190 578 576 573 571 569 567 564 562
191 581 579 576 574 572 570 567 565
192 584 581 579 577 575 572 570 568
193 587 584 582 580 578 575 573 571
194 589 587 585 583 580 578 576 574
195 592 590 588 586 583 581 579 577
- 64 -
Age (in Yrs)

Height
26 27 28 29 30 31 32 33
(in cm)
150 445 442 440 438 436 433 431 429
151 447 445 443 441 438 436 434 432
152 450 448 446 444 441 439 437 435
153 453 451 449 446 444 442 440 438
154 456 454 452 449 447 445 443 440
155 459 457 454 452 450 448 446 443
156 462 460 457 455 453 451 448 446
157 465 462 460 458 456 454 451 449
158 468 465 463 461 459 456 454 452
159 470 468 466 464 462 459 457 455
160 473 471 469 467 464 462 460 458
161 476 474 472 470 467 465 463 461
162 479 477 475 472 470 468 466 464
163 482 480 478 475 473 471 469 466
164 485 483 480 478 476 474 472 469
165 488 486 483 481 479 477 474 472
166 491 488 486 484 482 480 477 475
167 494 491 489 487 485 482 480 478
168 496 494 492 490 488 485 483 481
169 499 497 495 493 490 488 486 484
170 502 500 498 496 493 491 489 487
171 505 503 501 498 496 494 492 490
172 508 506 504 501 499 497 495 492
173 511 509 506 504 502 500 498 495
174 514 512 509 507 505 503 500 498
175 517 514 512 510 508 506 503 501
176 520 517 515 513 511 508 506 504
177 522 520 518 516 514 511 509 507
178 525 523 521 519 516 514 512 510
179 528 526 524 522 519 517 515 513
180 531 529 527 524 522 520 518 516
181 534 532 530 527 525 523 521 518
182 537 535 532 530 528 526 524 521
183 540 538 535 533 531 529 526 524
184 543 540 538 536 534 532 529 527
185 546 543 541 539 537 534 532 530
186 548 546 544 542 540 537 535 533
187 551 549 547 545 542 540 538 536
188 554 552 550 548 545 543 541 539
189 557 555 553 550 548 546 544 542
190 560 558 556 553 551 549 547 544
191 563 561 558 556 554 552 550 547
192 566 564 561 559 557 555 552 550
193 569 566 564 562 560 558 555 553
194 572 569 567 565 563 560 558 556
195 574 572 570 568 566 563 561 559
- 65 -
Age (in Yrs)

Height (in cm) 34 35 36 37 38 39 40 41
150 427 424 422 420 418 416 413 411
151 430 427 425 423 421 418 416 414
152 432 430 428 426 424 421 419 417
153 435 433 431 429 426 424 422 420
154 438 436 434 432 429 427 425 423
155 441 439 437 434 432 430 428 426
156 444 442 440 437 435 433 431 428
157 447 445 442 440 438 436 434 431
158 450 448 445 443 441 439 436 434
159 453 450 448 446 444 442 439 437
160 456 453 451 449 447 444 442 440
161 458 456 454 452 450 447 445 443
162 461 459 457 455 452 450 448 446
163 464 462 460 458 455 453 451 449
164 467 465 463 460 458 456 454 452
165 470 468 466 463 461 459 457 454
166 473 471 468 466 464 462 460 457
167 476 474 471 469 467 465 462 460
168 479 476 474 472 470 468 465 463
169 482 479 477 475 473 470 468 466
170 484 482 480 478 476 473 471 469
171 487 485 483 481 478 476 474 472
172 490 488 486 484 481 479 477 475
173 493 491 489 486 484 482 480 477
174 496 494 492 489 487 485 483 480
175 499 497 494 492 490 488 485 483
176 502 500 497 495 493 491 488 486
177 505 502 500 498 496 494 491 489
178 508 505 503 501 499 496 494 492
179 510 508 506 504 502 499 497 495
180 513 511 509 507 504 502 500 498
181 516 514 512 510 507 505 503 501
182 519 517 515 512 510 508 506 503
183 522 520 518 515 513 511 509 506
184 525 523 520 518 516 514 511 509
185 528 526 523 521 519 517 514 512
186 531 528 526 524 522 519 517 515
187 534 531 529 527 525 522 520 518
188 536 534 532 530 528 525 523 521
189 539 537 535 533 530 528 526 524
190 542 540 538 536 533 531 529 527
191 545 543 541 538 536 534 532 529
192 548 546 544 541 539 537 535 532
193 551 549 546 544 542 540 537 535
194 554 552 549 547 545 543 540 538
195 557 554 552 550 548 545 543 541
- 66 -
Age (in Yrs)

Height
42 43 44 45 46 47 48 49
(in cm)
150 409 407 404 402 400 398 395 393
151 412 410 407 405 403 401 398 396
152 415 412 410 408 406 403 401 399
153 418 415 413 411 409 406 404 402
154 420 418 416 414 411 409 407 405
155 423 421 419 417 414 412 410 408
156 426 424 422 419 417 415 413 411
157 429 427 425 422 420 418 416 413
158 432 430 427 425 423 421 419 416
159 435 433 430 428 426 424 421 419
160 438 435 433 431 429 427 424 422
161 441 438 436 434 432 429 427 425
162 443 441 439 437 435 432 430 428
163 446 444 442 440 437 435 433 431
164 449 447 445 443 440 438 436 434
165 452 450 448 445 443 441 439 437
166 455 453 451 448 446 444 442 439
167 458 456 453 451 449 447 445 442
168 461 459 456 454 452 450 447 445
169 464 461 459 457 455 453 450 448
170 467 464 462 460 458 455 453 451
171 469 467 465 463 461 458 456 454
172 472 470 468 466 463 461 459 457
173 475 473 471 469 466 464 462 460
174 478 476 474 471 469 467 465 463
175 481 479 477 474 472 470 468 465
176 484 482 479 477 475 473 471 468
177 487 485 482 480 478 476 473 471
178 490 487 485 483 481 479 476 474
179 493 490 488 486 484 481 479 477
180 495 493 491 489 487 484 482 480
181 498 496 494 492 489 487 485 483
182 501 499 497 495 492 490 488 486
183 504 502 500 497 495 493 491 489
184 507 505 503 500 498 496 494 491
185 510 508 505 503 501 499 497 494
186 513 511 508 506 504 502 499 497
187 516 513 511 509 507 505 502 500
188 519 516 514 512 510 507 505 503
189 521 519 517 515 513 510 508 506
190 524 522 520 518 515 513 511 509
191 527 525 523 521 518 516 514 512
192 530 528 526 523 521 519 517 515
193 533 531 529 526 524 522 520 517
194 536 534 531 529 527 525 523 520
195 539 537 534 532 530 528 525 523
- 67 -
Age (in Yrs)

Height
50 51 52 53 54 55 56 57
(in cm)
150 391 389 387 384 382 380 378 375
151 394 392 389 387 385 383 381 378
152 397 395 392 390 388 386 383 381
153 400 397 395 393 391 389 386 384
154 403 400 398 396 394 391 389 387
155 405 403 401 399 397 394 392 390
156 408 406 404 402 399 397 395 393
157 411 409 407 405 402 400 398 396
158 414 412 410 407 405 403 401 399
159 417 415 413 410 408 406 404 401
160 420 418 415 413 411 409 407 404
161 423 421 418 416 414 412 409 407
162 426 423 421 419 417 415 412 410
163 429 426 424 422 420 417 415 413
164 431 429 427 425 423 420 418 416
165 434 432 430 428 425 423 421 419
166 437 435 433 431 428 426 424 422
167 440 438 436 433 431 429 427 425
168 443 441 439 436 434 432 430 427
169 446 444 441 439 437 435 433 430
170 449 447 444 442 440 438 435 433
171 452 449 447 445 443 441 438 436
172 455 452 450 448 446 443 441 439
173 457 455 453 451 449 446 444 442
174 460 458 456 454 451 449 447 445
175 463 461 459 457 454 452 450 448
176 466 464 462 459 457 455 453 450
177 469 467 465 462 460 458 456 453
178 472 470 467 465 463 461 458 456
179 475 473 470 468 466 464 461 459
180 478 475 473 471 469 467 464 462
181 481 478 476 474 472 469 467 465
182 483 481 479 477 475 472 470 468
183 486 484 482 480 477 475 473 471
184 489 487 485 483 480 478 476 474
185 492 490 488 485 483 481 479 476
186 495 493 491 488 486 484 482 479
187 498 496 493 491 489 487 484 482
188 501 499 496 494 492 490 487 485
189 504 501 499 497 495 492 490 488
190 507 504 502 500 498 495 493 491
191 509 507 505 503 501 498 496 494
192 512 510 508 506 503 501 499 497
193 515 513 511 509 506 504 502 500
194 518 516 514 511 509 507 505 502
195 521 519 517 514 512 510 508 505
- 68 -
Age (in Yrs)

Height
58 59 60 61 62 63 64 65
(in cm)
150 373 371 369 366 364 362 360 358
151 376 374 372 369 367 365 363 360
152 379 377 374 372 370 368 366 363
153 382 380 377 375 373 371 368 366
154 385 383 380 378 376 374 371 369
155 388 385 383 381 379 376 374 372
156 391 388 386 384 382 379 377 375
157 393 391 389 387 384 382 380 378
158 396 394 392 390 387 385 383 381
159 399 397 395 392 390 388 386 384
160 402 400 398 395 393 391 389 386
161 405 403 400 398 396 394 392 389
162 408 406 403 401 399 397 394 392
163 411 408 406 404 402 400 397 395
164 414 411 409 407 405 402 400 398
165 416 414 412 410 408 405 403 401
166 419 417 415 413 410 408 406 404
167 422 420 418 416 413 411 409 407
168 425 423 421 418 416 414 412 410
169 428 426 424 421 419 417 415 412
170 431 429 426 424 422 420 418 415
171 434 432 429 427 425 423 420 418
172 437 434 432 430 428 426 423 421
173 440 437 435 433 431 428 426 424
174 442 440 438 436 434 431 429 427
175 445 443 441 439 436 434 432 430
176 448 446 444 442 439 437 435 433
177 451 449 447 444 442 440 438 436
178 454 452 450 447 445 443 441 438
179 457 455 452 450 448 446 444 441
180 460 458 455 453 451 449 446 444
181 463 460 458 456 454 452 449 447
182 466 463 461 459 457 454 452 450
183 468 466 464 462 460 457 455 453
184 471 469 467 465 462 460 458 456
185 474 472 470 468 465 463 461 459
186 477 475 473 470 468 466 464 462
187 480 478 476 473 471 469 467 464
188 483 481 478 476 474 472 470 467
189 486 484 481 479 477 475 472 470
190 489 486 484 482 480 478 475 473
191 492 489 487 485 483 480 478 476
192 494 492 490 488 486 483 481 479
193 497 495 493 491 488 486 484 482
194 500 498 496 494 491 489 487 485
195 503 501 499 496 494 492 490 488
- 69 -
Age (in Yrs)

Height
66 67 68 69 70 71 72 73
(in cm)
150 355 353 351 349 346 344 342 340
151 358 356 354 352 349 347 345 343
152 361 359 357 354 352 350 348 346
153 364 362 360 357 355 353 351 348
154 367 365 362 360 358 356 354 351
155 370 368 365 363 361 359 356 354
156 373 370 368 366 364 362 359 357
157 376 373 371 369 367 364 362 360
158 378 376 374 372 370 367 365 363
159 381 379 377 375 372 370 368 366
160 384 382 380 378 375 373 371 369
161 387 385 383 380 378 376 374 372
162 390 388 386 383 381 379 377 374
163 393 391 388 386 384 382 380 377
164 396 394 391 389 387 385 382 380
165 399 396 394 392 390 388 385 383
166 402 399 397 395 393 390 388 386
167 404 402 400 398 396 393 391 389
168 407 405 403 401 398 396 394 392
169 410 408 406 404 401 399 397 395
170 413 411 409 406 404 402 400 398
171 416 414 412 409 407 405 403 400
172 419 417 414 412 410 408 406 403
173 422 420 417 415 413 411 408 406
174 425 422 420 418 416 414 411 409
175 428 425 423 421 419 416 414 412
176 430 428 426 424 422 419 417 415
177 433 431 429 427 424 422 420 418
178 436 434 432 430 427 425 423 421
179 439 437 435 432 430 428 426 423
180 442 440 438 435 433 431 429 426
181 445 443 440 438 436 434 431 429
182 448 446 443 441 439 437 434 432
183 451 448 446 444 442 440 437 435
184 454 451 449 447 445 442 440 438
185 456 454 452 450 448 445 443 441
186 459 457 455 453 450 448 446 444
187 462 460 458 456 453 451 449 447
188 465 463 461 458 456 454 452 449
189 468 466 464 461 459 457 455 452
190 471 469 466 464 462 460 457 455
191 474 472 469 467 465 463 460 458
192 477 474 472 470 468 465 463 461
193 480 477 475 473 471 468 466 464
194 482 480 478 476 474 471 469 467
195 485 483 481 479 476 474 472 470
- 70 -
Age (in Yrs)

Height
74 75 76 77 78 79 80 81
(in cm)
150 338 335 333 331 329 326 324 322
151 340 338 336 334 331 329 327 325
152 343 341 339 337 334 332 330 328
153 346 344 342 339 337 335 333 331
154 349 347 345 342 340 338 336 333
155 352 350 347 345 343 341 339 336
156 355 353 350 348 346 344 341 339
157 358 356 353 351 349 347 344 342
158 361 358 356 354 352 349 347 345
159 364 361 359 357 355 352 350 348
160 366 364 362 360 357 355 353 351
161 369 367 365 363 360 358 356 354
162 372 370 368 365 363 361 359 357
163 375 373 371 368 366 364 362 359
164 378 376 373 371 369 367 365 362
165 381 379 376 374 372 370 367 365
166 384 381 379 377 375 373 370 368
167 387 384 382 380 378 375 373 371
168 389 387 385 383 381 378 376 374
169 392 390 388 386 383 381 379 377
170 395 393 391 389 386 384 382 380
171 398 396 394 391 389 387 385 383
172 401 399 397 394 392 390 388 385
173 404 402 399 397 395 393 391 388
174 407 405 402 400 398 396 393 391
175 410 407 405 403 401 399 396 394
176 413 410 408 406 404 401 399 397
177 415 413 411 409 407 404 402 400
178 418 416 414 412 409 407 405 403
179 421 419 417 415 412 410 408 406
180 424 422 420 417 415 413 411 409
181 427 425 423 420 418 416 414 411
182 430 428 425 423 421 419 417 414
183 433 431 428 426 424 422 419 417
184 436 433 431 429 427 425 422 420
185 439 436 434 432 430 427 425 423
186 441 439 437 435 433 430 428 426
187 444 442 440 438 435 433 431 429
188 447 445 443 441 438 436 434 432
189 450 448 446 443 441 439 437 435
190 453 451 449 446 444 442 440 437
191 456 454 451 449 447 445 443 440
192 459 457 454 452 450 448 445 443
193 462 459 457 455 453 451 448 446
194 465 462 460 458 456 453 451 449
195 467 465 463 461 459 456 454 452
- 71 -
CRFs Predicted PEFR values for Females:

Predicted Equation: PEFR (Lt/min) Female = 168.551 1.776*Age + 1.354 * Height
Height
18 19 20 21 22 23 24 25
(in cm)
150 340 338 336 334 333 331 329 327
151 341 339 337 336 334 332 330 329
152 342 341 339 337 335 334 332 330
153 344 342 340 338 337 335 333 331
154 345 343 342 340 338 336 334 333
155 346 345 343 341 339 338 336 334
156 348 346 344 342 341 339 337 335
157 349 347 346 344 342 340 339 337
158 351 349 347 345 343 342 340 338
159 352 350 348 347 345 343 341 339
160 353 351 350 348 346 344 343 341
161 355 353 351 349 347 346 344 342
162 356 354 352 351 349 347 345 343
163 357 356 354 352 350 348 347 345
164 359 357 355 353 352 350 348 346
165 360 358 356 355 353 351 349 348
166 361 360 358 356 354 352 351 349
167 363 361 359 357 356 354 352 350
168 364 362 361 359 357 355 353 352
169 365 364 362 360 358 357 355 353
170 367 365 363 361 360 358 356 354
171 368 366 365 363 361 359 357 356
172 369 368 366 364 362 361 359 357
173 371 369 367 365 364 362 360 358
174 372 370 369 367 365 363 362 360
175 374 372 370 368 366 365 363 361
176 375 373 371 370 368 366 364 362
177 376 374 373 371 369 367 366 364
178 378 376 374 372 370 369 367 365
179 379 377 375 374 372 370 368 367
180 380 379 377 375 373 371 370 368
181 382 380 378 376 375 373 371 369
182 383 381 379 378 376 374 372 371
183 384 383 381 379 377 375 374 372
184 386 384 382 380 379 377 375 373
185 387 385 384 382 380 378 376 375
186 388 387 385 383 381 380 378 376
187 390 388 386 384 383 381 379 377
188 391 389 388 386 384 382 380 379
189 392 391 389 387 385 384 382 380
190 394 392 390 389 387 385 383 381
191 395 393 392 390 388 386 385 383
192 397 395 393 391 389 388 386 384
193 398 396 394 393 391 389 387 385
194 399 397 396 394 392 390 389 387
195 401 399 397 395 394 392 390 388
- 72 -
Height
26 27 28 29 30 31 32 33
(in cm)
150 325 324 322 320 318 317 315 313
151 327 325 323 322 320 318 316 314
152 328 326 325 323 321 319 318 316
153 330 328 326 324 322 321 319 317
154 331 329 327 326 324 322 320 318
155 332 330 329 327 325 323 322 320
156 334 332 330 328 326 325 323 321
157 335 333 331 330 328 326 324 323
158 336 335 333 331 329 327 326 324
159 338 336 334 332 331 329 327 325
160 339 337 335 334 332 330 328 327
161 340 339 337 335 333 331 330 328
162 342 340 338 336 335 333 331 329
163 343 341 340 338 336 334 332 331
164 344 343 341 339 337 336 334 332
165 346 344 342 340 339 337 335 333
166 347 345 344 342 340 338 336 335
167 348 347 345 343 341 340 338 336
168 350 348 346 345 343 341 339 337
169 351 349 348 346 344 342 341 339
170 353 351 349 347 345 344 342 340
171 354 352 350 349 347 345 343 341
172 355 353 352 350 348 346 345 343
173 357 355 353 351 350 348 346 344
174 358 356 354 353 351 349 347 346
175 359 358 356 354 352 350 349 347
176 361 359 357 355 354 352 350 348
177 362 360 358 357 355 353 351 350
178 363 362 360 358 356 355 353 351
179 365 363 361 359 358 356 354 352
180 366 364 363 361 359 357 355 354
181 367 366 364 362 360 359 357 355
182 369 367 365 363 362 360 358 356
183 370 368 367 365 363 361 360 358
184 372 370 368 366 364 363 361 359
185 373 371 369 368 366 364 362 360
186 374 372 371 369 367 365 364 362
187 376 374 372 370 368 367 365 363
188 377 375 373 372 370 368 366 364
189 378 377 375 373 371 369 368 366
190 380 378 376 374 373 371 369 367
191 381 379 377 376 374 372 370 369
192 382 381 379 377 375 373 372 370
193 384 382 380 378 377 375 373 371
194 385 383 381 380 378 376 374 373
195 386 385 383 381 379 378 376 374
Height
34 35 36 37 38 39 40 41
(in cm)
150 311 309 308 306 304 302 301 299
151 313 311 309 307 306 304 302 300
- 73 -
152 314 312 310 309 307 305 303 302

153 315 314 312 310 308 306 305 303
154 317 315 313 311 310 308 306 304
155 318 316 314 313 311 309 307 306
156 319 318 316 314 312 311 309 307
157 321 319 317 315 314 312 310 308
158 322 320 319 317 315 313 311 310
159 323 322 320 318 316 315 313 311
160 325 323 321 319 318 316 314 312
161 326 324 323 321 319 317 316 314
162 328 326 324 322 320 319 317 315
163 329 327 325 324 322 320 318 316
164 330 328 327 325 323 321 320 318
165 332 330 328 326 324 323 321 319
166 333 331 329 328 326 324 322 320
167 334 333 331 329 327 325 324 322
168 336 334 332 330 329 327 325 323
169 337 335 333 332 330 328 326 325
170 338 337 335 333 331 329 328 326
171 340 338 336 334 333 331 329 327
172 341 339 338 336 334 332 330 329
173 342 341 339 337 335 334 332 330
174 344 342 340 338 337 335 333 331
175 345 343 342 340 338 336 334 333
176 346 345 343 341 339 338 336 334
177 348 346 344 342 341 339 337 335
178 349 347 346 344 342 340 339 337
179 351 349 347 345 343 342 340 338
180 352 350 348 347 345 343 341 339
181 353 351 350 348 346 344 343 341
182 355 353 351 349 347 346 344 342
183 356 354 352 351 349 347 345 344
184 357 356 354 352 350 348 347 345
185 359 357 355 353 352 350 348 346
186 360 358 356 355 353 351 349 348
187 361 360 358 356 354 352 351 349
188 363 361 359 357 356 354 352 350
189 364 362 361 359 357 355 353 352
190 365 364 362 360 358 357 355 353
191 367 365 363 361 360 358 356 354
192 368 366 365 363 361 359 357 356
193 369 368 366 364 362 361 359 357
194 371 369 367 366 364 362 360 358
195 372 370 369 367 365 363 362 360
Height
42 43 44 45 46 47 48 49
(in cm)
150 297 295 294 292 290 288 286 285
151 298 297 295 293 291 290 288 286
152 300 298 296 294 293 291 289 287
153 301 299 298 296 294 292 290 289
154 302 301 299 297 295 294 292 290
- 74 -
155 304 302 300 299 297 295 293 291

156 305 303 302 300 298 296 295 293
157 307 305 303 301 299 298 296 294
158 308 306 304 303 301 299 297 295
159 309 307 306 304 302 300 299 297
160 311 309 307 305 303 302 300 298
161 312 310 308 307 305 303 301 300
162 313 312 310 308 306 304 303 301
163 315 313 311 309 308 306 304 302
164 316 314 312 311 309 307 305 304
165 317 316 314 312 310 308 307 305
166 319 317 315 313 312 310 308 306
167 320 318 317 315 313 311 309 308
168 321 320 318 316 314 313 311 309
169 323 321 319 317 316 314 312 310
170 324 322 321 319 317 315 313 312
171 325 324 322 320 318 317 315 313
172 327 325 323 322 320 318 316 314
173 328 326 325 323 321 319 318 316
174 330 328 326 324 322 321 319 317
175 331 329 327 326 324 322 320 318
176 332 330 329 327 325 323 322 320
177 334 332 330 328 327 325 323 321
178 335 333 331 330 328 326 324 323
179 336 335 333 331 329 327 326 324
180 338 336 334 332 331 329 327 325
181 339 337 335 334 332 330 328 327
182 340 339 337 335 333 332 330 328
183 342 340 338 336 335 333 331 329
184 343 341 340 338 336 334 332 331
185 344 343 341 339 337 336 334 332
186 346 344 342 340 339 337 335 333
187 347 345 344 342 340 338 337 335
188 349 347 345 343 341 340 338 336
189 350 348 346 345 343 341 339 337
190 351 349 348 346 344 342 341 339
191 353 351 349 347 345 344 342 340
192 354 352 350 349 347 345 343 341
193 355 354 352 350 348 346 345 343
194 357 355 353 351 350 348 346 344
195 358 356 354 353 351 349 347 346
- 75 -
Height
50 51 52 53 54 55 56 57
(in cm)
150 283 281 279 278 276 274 272 270
151 284 282 281 279 277 275 274 272
152 286 284 282 280 278 277 275 273
153 287 285 283 282 280 278 276 274
154 288 286 285 283 281 279 278 276
155 290 288 286 284 283 281 279 277
156 291 289 287 286 284 282 280 279
157 292 291 289 287 285 283 282 280
158 294 292 290 288 287 285 283 281
159 295 293 291 290 288 286 284 283
160 296 295 293 291 289 288 286 284
161 298 296 294 292 291 289 287 285
162 299 297 296 294 292 290 288 287
163 300 299 297 295 293 292 290 288
164 302 300 298 296 295 293 291 289
165 303 301 300 298 296 294 293 291
166 305 303 301 299 297 296 294 292
167 306 304 302 301 299 297 295 293
168 307 305 304 302 300 298 297 295
169 309 307 305 303 301 300 298 296
170 310 308 306 305 303 301 299 297
171 311 310 308 306 304 302 301 299
172 313 311 309 307 306 304 302 300
173 314 312 310 309 307 305 303 302
174 315 314 312 310 308 306 305 303
175 317 315 313 311 310 308 306 304
176 318 316 315 313 311 309 307 306
177 319 318 316 314 312 311 309 307
178 321 319 317 315 314 312 310 308
179 322 320 319 317 315 313 311 310
180 323 322 320 318 316 315 313 311
181 325 323 321 319 318 316 314 312
182 326 324 323 321 319 317 316 314
183 328 326 324 322 320 319 317 315
184 329 327 325 324 322 320 318 316
185 330 328 327 325 323 321 320 318
186 332 330 328 326 324 323 321 319
187 333 331 329 328 326 324 322 321
188 334 333 331 329 327 325 324 322
189 336 334 332 330 329 327 325 323
190 337 335 333 332 330 328 326 325
191 338 337 335 333 331 329 328 326
192 340 338 336 334 333 331 329 327
193 341 339 338 336 334 332 330 329
194 342 341 339 337 335 334 332 330
195 344 342 340 338 337 335 333 331
- 76 -
Height
58 59 60 61 62 63 64 65
(in cm)
150 269 267 265 263 262 260 258 256
151 270 268 266 265 263 261 259 258
152 271 270 268 266 264 262 261 259
153 273 271 269 267 266 264 262 260
154 274 272 271 269 267 265 263 262
155 275 274 272 270 268 267 265 263
156 277 275 273 271 270 268 266 264
157 278 276 275 273 271 269 267 266
158 279 278 276 274 272 271 269 267
159 281 279 277 276 274 272 270 268
160 282 280 279 277 275 273 272 270
161 284 282 280 278 276 275 273 271
162 285 283 281 280 278 276 274 272
163 286 284 283 281 279 277 276 274
164 288 286 284 282 280 279 277 275
165 289 287 285 284 282 280 278 277
166 290 289 287 285 283 281 280 278
167 292 290 288 286 285 283 281 279
168 293 291 289 288 286 284 282 281
169 294 293 291 289 287 285 284 282
170 296 294 292 290 289 287 285 283
171 297 295 294 292 290 288 286 285
172 298 297 295 293 291 290 288 286
173 300 298 296 294 293 291 289 287
174 301 299 298 296 294 292 290 289
175 302 301 299 297 295 294 292 290
176 304 302 300 299 297 295 293 291
177 305 303 302 300 298 296 295 293
178 307 305 303 301 299 298 296 294
179 308 306 304 303 301 299 297 295
180 309 307 306 304 302 300 299 297
181 311 309 307 305 304 302 300 298
182 312 310 308 307 305 303 301 300
183 313 312 310 308 306 304 303 301
184 315 313 311 309 308 306 304 302
185 316 314 312 311 309 307 305 304
186 317 316 314 312 310 309 307 305
187 319 317 315 313 312 310 308 306
188 320 318 317 315 313 311 309 308
189 321 320 318 316 314 313 311 309
190 323 321 319 317 316 314 312 310
191 324 322 321 319 317 315 314 312
192 326 324 322 320 318 317 315 313
193 327 325 323 322 320 318 316 314
194 328 326 325 323 321 319 318 316
195 330 328 326 324 322 321 319 317
- 77 -
Height
66 67 68 69 70 71 72 73
(in cm)
150 254 253 251 249 247 246 244 242
151 256 254 252 250 249 247 245 243
152 257 255 254 252 250 248 246 245
153 258 257 255 253 251 250 248 246
154 260 258 256 255 253 251 249 247
155 261 259 258 256 254 252 251 249
156 263 261 259 257 255 254 252 250
157 264 262 260 259 257 255 253 251
158 265 263 262 260 258 256 255 253
159 267 265 263 261 260 258 256 254
160 268 266 264 263 261 259 257 256
161 269 268 266 264 262 260 259 257
162 271 269 267 265 264 262 260 258
163 272 270 268 267 265 263 261 260
164 273 272 270 268 266 265 263 261
165 275 273 271 269 268 266 264 262
166 276 274 273 271 269 267 265 264
167 277 276 274 272 270 269 267 265
168 279 277 275 273 272 270 268 266
169 280 278 277 275 273 271 270 268
170 282 280 278 276 274 273 271 269
171 283 281 279 278 276 274 272 270
172 284 282 281 279 277 275 274 272
173 286 284 282 280 278 277 275 273
174 287 285 283 282 280 278 276 274
175 288 287 285 283 281 279 278 276
176 290 288 286 284 283 281 279 277
177 291 289 287 286 284 282 280 279
178 292 291 289 287 285 283 282 280
179 294 292 290 288 287 285 283 281
180 295 293 292 290 288 286 284 283
181 296 295 293 291 289 288 286 284
182 298 296 294 292 291 289 287 285
183 299 297 296 294 292 290 288 287
184 300 299 297 295 293 292 290 288
185 302 300 298 296 295 293 291 289
186 303 301 300 298 296 294 293 291
187 305 303 301 299 297 296 294 292
188 306 304 302 301 299 297 295 293
189 307 305 304 302 300 298 297 295
190 309 307 305 303 301 300 298 296
191 310 308 306 305 303 301 299 298
192 311 310 308 306 304 302 301 299
193 313 311 309 307 306 304 302 300
194 314 312 310 309 307 305 303 302
195 315 314 312 310 308 306 305 303
- 78 -
Height
74 75 76 77 78 79 80 81
(in cm)
150 240 238 237 235 233 231 230 228
151 242 240 238 236 234 233 231 229
152 243 241 239 238 236 234 232 231
153 244 243 241 239 237 235 234 232
154 246 244 242 240 239 237 235 233
155 247 245 243 242 240 238 236 235
156 248 247 245 243 241 239 238 236
157 250 248 246 244 243 241 239 237
158 251 249 248 246 244 242 240 239
159 252 251 249 247 245 244 242 240
160 254 252 250 248 247 245 243 241
161 255 253 252 250 248 246 244 243
162 256 255 253 251 249 248 246 244
163 258 256 254 253 251 249 247 245
164 259 257 256 254 252 250 249 247
165 261 259 257 255 253 252 250 248
166 262 260 258 257 255 253 251 249
167 263 261 260 258 256 254 253 251
168 265 263 261 259 257 256 254 252
169 266 264 262 261 259 257 255 254
170 267 266 264 262 260 258 257 255
171 269 267 265 263 262 260 258 256
172 270 268 266 265 263 261 259 258
173 271 270 268 266 264 262 261 259
174 273 271 269 267 266 264 262 260
175 274 272 271 269 267 265 263 262
176 275 274 272 270 268 267 265 263
177 277 275 273 271 270 268 266 264
178 278 276 275 273 271 269 267 266
179 279 278 276 274 272 271 269 267
180 281 279 277 276 274 272 270 268
181 282 280 279 277 275 273 272 270
182 284 282 280 278 276 275 273 271
183 285 283 281 280 278 276 274 272
184 286 284 283 281 279 277 276 274
185 288 286 284 282 281 279 277 275
186 289 287 285 284 282 280 278 277
187 290 289 287 285 283 281 280 278
188 292 290 288 286 285 283 281 279
189 293 291 289 288 286 284 282 281
190 294 293 291 289 287 286 284 282
191 296 294 292 290 289 287 285 283
192 297 295 294 292 290 288 286 285
193 298 297 295 293 291 290 288 286
194 300 298 296 294 293 291 289 287
195 301 299 298 296 294 292 291 289
- 79 -
APPENDICES:
1. ATS / ERS Task Force: Standardization of Lung Function Testing.

General Considerations of Lung Function Testing
Eur Respir J 2005; 26: 153-161
2. ATS / ERS Task Force: Standardization of Lung Function Testing.

Standardization of Spirometry
Eur Respir J 2005; 26: 319-338
3. How to make sure your Spirometry Tests are of good quality. Enright P. Respir
Care 2003; 48: 773-776.
4. Office Spirometry for Lung Health Assessment in Adults: Consensus Status from
National Lung Health Education Program. Ferguson G et al, Respir Care 2000;
45: 513-530
5. Technique and Equipment Pitfalls in Spirometry testing
- 80 -

1 - Spirometry Simplified With CRF's PEFR PDF

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Chest Research Foundation

COURSE MATERIAL FOR

CHEST RESEARCH FOUNDATION

E-mail: programmes@crfindia.com OR drmonica@crfindia.com

Dr Sundeep Salvi MD, DNB, PhD (UK)

Chest Research Foundation

(Commonly used terminology in the Spirometry Manual)

ATS American Thoracic Society

BTPS Body Temperature Pressure Saturation

COPD Chronic Obstructive Pulmonary Disease

ERS European Respiratory Society

GINA Global initiative for Asthma

MAV Maximal Attained Value (also called Personal Best Value)

PEF Peak Expiratory Flow

SAO Small Airways Obstruction

TLC Total Lung Capacity

UAO Upper Airway Obstruction

According to National Center for Macroeconomics and Health, Government of

Medical curriculum has rather been step-motherly towards spirometry with

Unfortunately, the role of Spirometry was not appreciated by the medical

What are the indications for Spirometry?

The most important indication for spirometry in clinical practice is to diagnose

Smoking cessation can be quite a challenge in clinical practice. No matter how

Non-smoking causes of COPD are becoming increasingly common in India. In

Spirometry can easily help one differentiate between breathlessness due to a

conducted by Chest Research Foundation reported that, in contrast to the

Management guidelines of COPD (Global Initiative for Obstructive Lung Disease)

Spirometry is therefore a very valuable diagnostic, therapeutic and management

To summarise the indications of spirometry in clinical practice:

Rapid and objective assessment of airflow obstruction and restrictive

Incorporate guideline recommendations for therapy based on COPD and

There are essentially two different types of spirometers Volume-displacement

The flow-sensor based spirometers utilize a sensor that measures flow as a

HOW TO PERFORM SPIROMETRY?

Spirometry should be performed only by well-trained personnel.

Remember Right Equipment, Right Technique and Right Interpretation are

How to perform the test?

Preparing the equipment:

The important steps in performing spirometry are:

Prepare the Equipment

Prepare the Subject

Position the Subject

Demonstrate the Test

Coach the Subject, Perform the Test

Look for Acceptability and Repeatability

Record the Values

Interpret Wisely. Take clinical findings

Prepare the Equipment:

1. Check that the equipment has been properly cleaned.

3. Perform Calibration check daily and keep a log.

Why is it important to calibrate daily?

5. Measure Room Temperature. Most modern spirometers will have an inbuilt

It is recommended that ambient temperature should be accurately recorded to

Why is it important to measure temperature accurately?

7. Have a chair without wheels for subjects.

Prepare the Subject:

1. Explain the purpose of the spirometry.

2. Check whether the test should be carried out or postponed

Contraindications for Spirometry:

Check if the patient is on a -blocker.

Positioning the Subject:

Demonstrate the Test:

Do a practical demonstration using a mouth piece. A visual impression is a lot better