Spirometry (Paediatric) Guideline
Contents
1. best test The best test is defined as the manoeuvre with the largest sum of FVC and FEV e Ifa single volume time tracing or flow volume curve is to be included in a final report it should be the spirogram from the effort with the largest sum of FVC and FEV e Expiratory and inspiratory flow volume curves from different acceptable efforts may be combined to produce a flow volume loop e Amedical officer may request the reporting of other measurements see section 5 Definition of Terms in which case the largest value for all these measurements should be reported e The final report should include scientist s comments regarding acceptability and repeatability of the data software version if applicable date time and results of most recent calibration identification of reference values used 4 8 Note Test results that do not meet acceptability and repeatability criteria may still provide useful clinical information It is important to make note of the reasons in the report and advise to interpret with care Quality Control Procedures Quality control procedures specific to spirometry testing are detailed in Appendix 4 Quality Control Procedures Daily validation calibration checks weekly biological control testing and data analysis are the minimum quality control requirements 5 Definition of Terms Definitions of key terms are provided below Abbreviation Term Definiti2. Abbreviation Term Definition Explanation Details VC Vital capacity litres L The volume change between the position of full inspiration and complete expiration FVC Forced vital capacity The maximal volume of air exhaled with litres L maximally forced effort from a position of maximal inspiration FEV Forced expiratory volume The maximal volume of air exhaled in the first in one second litres L second of a forced expiration from a position of full inspiration PEF Peak expiratory flow litres The maximum expiratory flow achieved from per second L s or litres a maximum forced expiration starting without per minute L min hesitation from a point of maximal lung inflation BPTS Body pressure and Body temperature i e 37 C ambient temperature saturated pressure saturated with water vapour E REE Version No 1 0 Effective from 26 November 2012 Page 5 of 36 Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric e amp CCL Standard units L Litres Ls Litres per second L min Litres per minute 4 7 2 Preparing equipment and ensuring quality control See Appendix 4 Quality Control Procedures Preparing a spirometer as outlined in the ATS Pulmonary Function Laboratory Management Manual e Assemble the components according to the manufacturer s instructions
3. Displacement of the piston is translated to movement of a mechanical recording device Flow sensing Spirometer The flow sensing spirometer measures air flow rate directly The volume is then derived electronically from the flow signal There are several different types 1 The pneumotachometer measures flow by using a differential pressure flow sensor which consists of a tube containing a resistive element The resistive element allows gas to flow through it but causes a pressure drop The pressure drop across the resistive element is measured by means of a sensitive pressure transducer with pressure taps on either side of the element and is proportional to the flow rate of gas as long as the flow is laminar not turbulent In some systems the resistive element is heated which prevents accumulation of moisture from exhaled gas on the element 2 The ultrasonic flow sensor measures flow using ultrasonic pulses travelling in opposite directions at an angle to the air flow The speed at which the pulses travel is dependent on the air flow rate and direction and can be determined from the time the pulses take to travel from one side to the other The flow rate is thus determined from the pulse transit times 3 The hot wire flow sensor anemometer mass flow sensor contains a heated wire or wires As air flows past the wire it is cooled with the degree of cooling dependent on the air flow rate The air flow rate is proportional to the amoun
4. i e tubing connectors flow sensors valves and adapters e Putin place a new in line bacterial filter if used disposable mouthpiece or disinfected reusable mouthpiece for each patient e Turnonthe system to ensure adequate warm up refer to manufacturer s guidelines Allow time for equilibration to room temperature for portable systems e Perform a validation check calibration check For detailed procedures on performing validation and calibration see Appendix 4 Quality Control Procedures e Only perform spirometry at temperatures recommended by the equipment manufacturers e Document the environmental data from an accurate source representative of the laboratory prior to calibration Note Environmental data includes internal spirometer temperature or ambient temperature relative humidity if applicable and barometric pressure e Check for leaks daily when using volume displacement spirometers Leaks can be detected by applying constant pressure 23 0 cmH20 0 3kPa with the spirometer outlet occluded at or including the mouthpiece A volume loss of gt 30ml after 1 min indicates a leak and needs correcting Refer to manufacturer s guidelines if a problem is detected e Check the flow sensors for holes clogging channel plugging or excess moisture daily Refer to manufacturer s guidelines if a problem is detected Validating the calibration of the spirometer e A validation is the procedure used to check that t
5. disinfection procedure However Queensland Health infection control requirements supersede the manufacturer s recommendations so long as the equipment will not be damaged by these procedures All materials must be cleaned of debris before undergoing the disinfection process There are four main categories of sterilization and disinfection These are described below e ARE Version No 1 0 Effective from 26 November 2012 Page 21 of 36 a Queensland T Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric iaaa O eee Heat Heat is the universally employed and most reliable form of sterilization and is listed below in order of efficiency Steam under pressure autoclave Steam at atmospheric pressure Boiling water Dry heat under pressure Dry heat at atmospheric pressure Water below boiling point pasteurization Cold liquid Glutaraldehydes disinfect by interrupting metabolism and reproduction in microorganisms by binding to amino groups of proteins These agents are bactericidal tuberculocidal fungicidal and viracidal in 10 30 minutes and sporicidal in 10 hours Many of these agents require special precautions Comply with the material safety data of the product Gas Ethylene oxide ETO is the alkylating agent used extensively in gas sterilisation However this agent is unsafe for the environment and requires stringent material preparation and monitoring Other liquid disinf
6. showing premature termination e The patient cannot or should not continue to exhale How to ensure repeatability between individual spirograms After three acceptable spirograms have been obtained the following checks are used to assess for repeatability e The two largest values of FVC or VC must be within 0 150L of each other e The two largest values of FEV must be within 0 150L of each other e For patients with an FVC of lt 1 0L and preschool aged children the two elas FVC and FEVt values are within 0 100L of each other or 10 of the highest value e Aminimum of three acceptable manoeuvres should be saved and utilised for analysis interpretation mo EK Version No 1 0 Effective from 26 November 2012 Page 12 of 36 Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric LESSEE Eee e f between manoeuvre criteria are not achieved report results with explanatory comments Peak expiratory flow PEF During spirometry testing PEF is measured in conjunction with FEV and FVC and can be used to indicate maximal patient effort Note PEF can also be measured independently using a Peak Flow Meter Refer to ATS ERS guidelines 2005 4 7 6 Assessing bronchodilator reversibility Assessing bronchodilator reversibility is often performed as part of Spirometry The choice of drug dose and mode of delivery is a clinical decision made by the medical officer reques
7. 12 Page 35 of 36 a Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric e e A TE ee 12 Gauld LM Kappers J Carlin JB Robertson CF Prediction of childhood pulmonary function using ulna length American Journal of Respiratory amp Critical Care Medicine 2003 Oct 1 168 7 804 9 13 Hibbert ME Lanigan A Raven J Phelan PD Relation of armspan to height and the prediction of lung function Thorax 1988 Aug 43 8 657 9 14 Pesant C Santschi M Praud J P Geoffroy M Niyonsenga T Vlachos Mayer H Spirometric pulmonary function in 3 to 5 year old children Pediatr Pulmonol Multicenter Study Research Support Non U S Gov t 2007 Mar 42 3 263 71 15 Enright PL Linn WS Avol EL Margolis HG Gong H Jr Peters JM Quality of spirometry test performance in children and adolescents experience in a large field study Chest Comparative Study Research Support Non U S Gov t Research Support U S Gov t Non P H S Research Support U S Gov t P H S 2000 Sep 118 3 665 71 16 Neve V Edme J L Devos P Deschildre A Thumerelle C Santos C et al Spirometry in 3 5 year old children with asthma Pediatr Pulmonol 2006 Aug 41 8 735 43 17 Wanger J Clausen JL Coates A Pedersen OF Brusasco V Burgos F et al Standardisation of the measurement of lung volumes Eur Respir J Review 2005 Sep 26 3 511 22 18 Pellegrino R Viegi G Brusasco V Crapo RO Burgos F C
8. 212 in FEV is usually taken as positive however this criteria is not well defined in pre school children 4 7 7 Reporting results Note Reporting results as outlined below is as stated in the Queensland Health Guideline Spirometry Adult with the following exception e In addition to the below information if FEVo 5 or FEVo 75 are measured then report the highest values from the acceptable trials Note Test results that do not meet acceptability and repeatability criteria may still provide useful clinical information It is important to make note of the reasons in the report and advise to interpret with care e All volumes and flows are to be reported at BTPS conditions e FEV and FVC should be reported in litres L to two decimal places e Peak flow should be reported in litres per second L s to two decimal places or in litres per minute L min with no decimal places n eee RENE Version No 1 0 Effective from 26 November 2012 Page 14 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric L gt E_ __ gt E_ SS Eee e The largest VC from at least two acceptable and repeatable manoeuvres is reported e The largest FVC and largest FEV from acceptable and repeatable manoeuvres are reported even though the values may not come from the same manoeuvre e All other flows if required by the requesting medical officer are reported from the
9. Health and Medical Research Council 2010 cited 2012 12 09 12 CD33 Available from http www nhmrc gov au node 30290 5 Miller MR Crapo R Hankinson J Brusasco V Burgos F Casaburi R et al General considerations for lung function testing Eur Respir J 2005 Jul 26 1 153 61 6 Queensland Health Queensland Health Guideline Spirometry Adult 2013 Available from http www health qld gov au qhpolicy docs gdl qh gdl 386 pdf 7 American Association for Respiratory Care AARC Clinical Practice Guideline Spirometry 1996 Update Respiratory Care 1996 41 7 629 36 8 Swanney MP Eckert B Johns DP Burton D Crockett AJ Guy P et al Spirometry Training Courses A Position Paper of the Australian and New Zealand Society of Respiratory Science and the Thoracic Society of Australia and New Zealand 2004 Available from http www anzsrs org au spirotrainingposition pdf 9 American Thoracic Society Pulmonary Function Laboratory Management and Procedure Manual 2nd ed Wanger J Crapo R Irvin C editors American Thoracic Society 2005 10 Queensland Health Queensland Health Language Services Policy2000 Available from http Awww communities qld gov au resources multicultural media lanquage services policy a multicultural pdf 11 Cotes JE Chinn DJ Miller MR Lung Function Physiology Measurement and Application in Medicine 6th ed Blackwell Publishing 2006 E VEE Version No 1 0 Effective from 26 November 20
10. Journal of Respiratory amp bronchodilator flow volume loop peak Critical Care Medicine 175 12 1304 1345 flow e Miller M R J Hankinson et al 2005 Standardisation of spirometry European Respiratory Journal 26 2 319 338 References from alternate sources of information have been identified in this document Supersedes New document Accreditation References EQuIP and other criteria and standards RE Version No 1 0 Effective From 26 November 2012 Page 1 of 36 W Queensland AN ASA Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric EEE E Policy and Standard s e Informed Decision making in Healthcare QH POL 346 2011 Procedures Guidelines Protocols e Australian Guidelines for the prevention and control of infection in healthcare CD33 2010 e 2005 American Thoracic Society and European Respiratory Society ATS ERS guidelines 5 e Queensland Health Guideline Spirometry Adult Forms and templates e Nil 4 Guideline for performing paediatric spirometry 4 1 Emergency Protocol e Follow relevant Hospital and Health Service protocols or procedures in the event of an emergency 4 2 Infection Control Procedures e Testing patients with confirmed or suspected communicable diseases may pose a risk to staff and other patients due to potential cross infection See Appendix 1 for detailed infection control procedures e Adhere to relevant Hosp
11. Queensland health e care e people Health Guideline Document Number QH GDL 393 2013 Spirometry Paediatric Respiratory Science Custodian Review Officer 1 Pu rpose Chief Allied Health Officer oo This guideline provides recommendations regarding best practice to support high quality paediatric spirometry versiono 10 practice throughout Queensland Health facilities Applicable To 2 Sco pe All Health Practitioners performing g p g g paediatric spirometry This guideline provides information for all health practitioners who perform paediatric spirometry as part of Approval Date DD MM YYYY their clinical duties It covers the age range from pre schoolers children 2 to 6 years of age to young adults Effective Date 26 11 2012 18 years of age This guideline provides the minimum mandatory Next Review Date 26 11 2013 requirements for obtaining acceptable and repeatable pre and post bronchodilator reversibility spirometric data Rae using both volume and flow measuring devices uthority Chair State wide Clinical Measurements This document emphasises the differences when testing Nenon children Approving Officer 3 Related documents o This guideline is primarily based on the following documents e Beydon N S D Davis et al 2007 An official American Thoracic Society European Respiratory l l Society statement pulmonary function testing in a og preschool children American
12. Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric ie a eee Spirometer There are two general types of spirometers volume displacement and flow sensing spirometers see Appendix 3 General description of volume and flow sensing spirometers for details O O O When purchasing spirometers ensure that the spirometers meet the minimum ATS ERS recommendations the spirometers are capable of accumulating volume for 2 15s and measuring volumes 2 8L BTPS with an accuracy of 3 of reading or 0 050L whichever is greater with flows between 0 and 14 L s the total resistance to air flow at 14 L s is lt 1 5cmH20L 0 15kPa L s Note For more detailed requirements refer to the ATS ERS guidelines Ensure spirometers meet the minimum ATS ERS recommendations Ensure the spirometer s graphic display permits visual inspection of the flow volume and volume time curves essential for quality control Preschool children are more likely to produce technically inadequate expirations than older children and are likely to become bored or tired if the test session is prolonged unnecessarily It is therefore advantageous if the operator is able to visualize these curves onscreen or at least before the next effort Set the display to include FVC FEV time to PEF PEFT VBE back extrapolation volume and the point at which flow ceases presented as a proportio
13. ame method same observer RENE Version No 1 0 Effective from 26 November 2012 ex Queensland Government Page 16 of 36 Printed copies are uncontrolled Queensland Health Spirometry Paediatric ese Ee same instrument same location same conditions of use and repeated over a short space of time 6 Consultation Key stakeholders position and business area who reviewed this version are e Respiratory Working Party o Michael Brown Director of Respiratory amp Sleep Sciences Royal Brisbane and Women s Hospital o Andrew Coates Chief Respiratory Scientist Mater Health Services o Annette Dent Scientific Director Respiratory Science The Prince Charles Hospital o Janine Ferns Director Clinical Measurements Cairns Base Hospital o Leanne Rodwell Respiratory Scientist Royal Children s Hospital o Irene Schneider Respiratory Sciences Clinical Educator Respiratory Working Party Chair The Prince Charles Hospital Jessica Wilson Respiratory Scientist Respiratory Working Party Assistant Chair o Leanne Gauld Respiratory Paediatrician Mater Children s Hospital o Margaret McElrea Respiratory Scientist Queensland Children s Respiratory Centre Royal Children s Hospital e Primary stakeholders as identified in the Stakeholder analysis o QH Respiratory Laboratory Clinical Directors o QH Respiratory Laboratory Managers o Paediatric Respiratory Specialists Ch
14. ard testing is the correct value for the biological control the standard deviation SD can now be used to set the control limits where mean 1 96 x SD gives a confidence interval of 95 this means that approximately 95 of the values will be between 2SD of the mean The biological control results collected on a regular basis can be plotted on a Levy Jennings plot see Graph 1 and interpreted using the Westgard rules Westgard rules can be used to define specific limits for biological control results when compared with the gold standard testing results and to help determine if quality assurance responses need to be enacted as follows When one control observation exceeds the mean 2 SD a warning condition exists When one control observation exceeds the mean 3 SD an out of control condition exists When two consecutive control observations exceed 2 SD an out of control condition exists When four consecutive control observations exceed the mean 1 SD in the same direction an out of control condition exists When 10 consecutive control observations fall on the same side of the mean an out of control condition exists Generally the following rules apply the 2 SD limits are considered warning limits values between 2 and 3 SD limits indicate an error and the procedure should be repeated values beyond 3 SD are considered unacceptable and the testing system sho
15. asaburi R et al Interpretative strategies for lung function tests Eur Respir J Practice Guideline 2005 Nov 26 5 948 68 19 Johns D Pierce R Pocket Guide to Spirometry 2nd ed McGraw Hill Australia 2007 20 American Thoracic Society Pulmonary Function Laboratory Management and Procedures Manual 1st ed American Thoracic Society 1994 21 Cooper BG An update on contraindications for lung function testing2010 Available from http www ncbi nIm nih gov pubmed 20671309 22 Quanjer P Become an Expert in Spirometry cited 2012 14 12 2012 Available from http Awww spirxpert com indices7 htm 23 Queensland Health Queensland Health Spirometry Training Program 2012 ed Queensland Health 2012 eT O VEE Version No 1 0 Effective from 26 November 2012 Page 36 of 36 a Queensland P Government Printed copies are uncontrolled
16. ce Both methods are described below 1 Perform validation of the machine see Appendix 4 Quality Control Procedures for details 2 Introduce yourself to the patient including your name and position title and establish rapport 3 Verify the following information check for completed and signed doctor s request form including indications and contraindications identify patient by name date of birth and hospital identification number check for any contraindications to spirometry testing see section 4 4 Indications and Contraindications for performing spirometry record current medication that may alter lung function and a brief history as outlined in section 4 7 6 Assessing bronchodilator reversibility record height cm and weight kg measurements record gender and ethnic origin record testing position if not sitting and justification why test is performed in a non sitting position Performing the FVC and FEV manoeuvre 4 Explain and demonstrate the test manoeuvre to the patient including Correct use of the mouthpiece and nose clip Correct posture with head slightly elevated Position of the mouthpiece including tight mouth seal over the mouthpiece Complete inhalation prior to FVC and FEV Rapid and complete exhalation with maximal force for FVC and FEV 5 Have the patient assume the correct sitting position i e upright posture legs uncrossed and both feet flat on th
17. ce of droplet nuclei The breathing tube or mouthpiece should be decontaminated or changed between patients Open circuit If the patient or subject only exhales into the spirometer only the portion of the circuit through which re breathing occurs must be decontaminated between patients Alternatively a disposable sensor may be used and decontamination of sensors and mouthpieces can be avoided A low resistance disposable one way valve mouthpiece may be used to prevent inhalation from an open circuit This mouthpiece needs to be disposed of between patients Se ARES Version No 1 0 Effective from 26 November 2012 Page 20 of 36 a Queensland T Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric a e a e Eee Common transmissible infectious diseases often seen in the Respiratory Laboratory include Hepatitis B Hepatitis C Tuberculosis TB Human Immunodeficiency Virus HIV Pseudomonas cepacia Cytomegalovirus CMV Varicella Zoster Virus VZV The ATS ERS recommends extra precautions are taken for patients with known transmissible infectious diseases e Reserve equipment for the sole purpose of testing infected patients e Test infected patients at the end of the day allowing time for the equipment to be disassembled and disinfected e Test patients in their own rooms with adequate ventilation and appropriate protection for the technician A negative air conditioned room is ideal for
18. clip 3 Activate the spirometer SSS SSS eee RENE Version No 1 0 Effective from 26 November 2012 Page 10 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric gt _ a ee a When using the open circuit method Instruct the patient to inhale completely and rapidly until their lungs are full place the mouthpiece in the mouth and close lips tightly around the mouthpiece while holding their lungs full Instruct patient to exhale slowly and completely until their lungs are empty b When using the closed circuit method Attach nose clip place mouthpiece in mouth or assist patient in positioning themselves on the mouthpiece and instruct patient to close lips tightly around the mouthpiece and breathe quietly for no more than five breaths i e relaxed normal tidal breathing Instruct the patient to inhale completely until their lungs are full and exhale slowly and completely until their lungs are empty This provides a measure of expiratory vital capacity EVC Alternatively instruct the patient to exhale completely from end inspiration on a tidal breath until their lungs are empty This provides a measure of inspiratory vital capacity IVC 4 Encourage the patient to keep going until there is no volume change observed see section 4 7 5 Determining acceptability and repeatability 5 Observe the patient at all times during t
19. d If standing is preferred when performing the spirometry test then document the standing position in the report e Clearly instruct the child in the procedure prior to the commencement of each test and ensure they understand all requirements of the test Give ample opportunity for the patient or care giver to ask questions or receive clarification on the test and its requirements Actively coach the child before and during each trial Young children may not fully understand the requirements for the test but should be encouraged enthusiastically 4 7 4 Performing test procedure Note The test procedure below is as stated in the Queensland Health Guideline Spirometry Adult with the following exceptions e The Vital Capacity VC manoeuvre is not usually performed e Correct posture with head slightly elevated for older children and in the neutral position for younger children eT O REE Version No 1 0 Effective from 26 November 2012 Page 8 of 36 Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric LL Eee Note There are two methods for testing spirometry Open circuit and Closed circuit In the open circuit method the patient approaches the mouth piece after a complete inhalation to total lung capacity TLC whereas in the closed circuit method the patient inhales to TLC whilst firmly on the mouth piece and after several tidal volume TV breaths on the mouthpie
20. daily with a 3L syringe Check manufacturer s guidelines for details A8Lsyringe should be injected at three different flow rates between 2 and 12 L s with 3L injection times of 6sec and lt 0 5 sec minimum volume accuracy should be within 3 5 at all flows For spirometers that use disposable flow sensors a new unused sensor should be tested daily A flow linearity check of pneumotachs weekly ensures that minimum volume accuracy is met for the entire range of flows measured low mid high flows If the spirometer meets volume accuracy requirements of 3 5 ml for all flow rates tested then it meets the requirements for linearity Quality Control Analysis Data from calibrations and other quality control procedures must be analysed regularly in order to be useful and contribute to quality assurance procedures The results analysed must be obtained in a stable laboratory environment using the same calibration syringe calibration procedure biological standard or control material eg 3L syringe Biological Control is a healthy non smoking individual usually a staff member that is regularly tested and becomes the reference standard for the quality control program Biological control characterisation Biological controls must initially be characterised according to the gold standard testing procedures before the data becomes the reference standard The biological control s lung function must be measu
21. e If the manoeuvre has an obviously hesitant start then the trial should be terminated early to avoid unnecessary prolonged effort e for preschool children if the VBE is greater than 80 ml or 10 to 12 5 of FVC then the curve should be reinspected but need not necessarily be excluded e the time to reach the peak expiratory flow PEFT in the flow volume curve is lt 0 16sec for children and adolescents and lt 0 120sec to 0 130sec for pre school children 3 5 year olds 1 Middle of Test Criteria e No obstruction hesitation or artefact impeding the blow see Appendix 7 Examples of volume time and flow volume spirograms including Cough during the first second of exhalation Glottic closure that influences the measurement Early termination or cut off Effort that is not maximal throughout Air leaks at mouth Obstructed mouthpiece due to tongue or teeth in front of the mouthpiece or mouthpiece deformation due to biting End of Test Criteria e Continuous maximal expiratory blow for 26 sec in duration for children older than 10 years and 23 sec for children less than 10 years 929 5 p e A plateau in the volume time curve i e no change in volume lt 0 025L for a 1 second period Note A plateau is defined as no volume change lt 0 025L for a 1 second period In preschool aged children if expiratory flow stops at greater than 10 of the peak flow PEF then the manoeuvre should be classified as
22. e floor 6 Activate the spirometer a When using the open circuit method Attach the nose clip and instruct patient to inhale completely and rapidly until their lungs are full place mouthpiece in mouth and close lips tightly around the mouthpiece while holding their lungs full E RENE Version No 1 0 Effective from 26 November 2012 Page 9 of 36 Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric Cee a TE ee Instruct patient to exhale forcefully until no more air can be expelled b When using the closed circuit method Attach nose clip place mouthpiece in mouth or assist patient in positioning themselves on the mouthpiece and instruct patient to close lips tightly around the mouthpiece and breathe quietly for no more than 5 breaths i e relaxed normal tidal breathing Instruct patient to inhale completely and rapidly until their lungs are full With little or no pause at TLC lt 1sec instruct patient to exhale forcefully until no more air can be expired 7 Encourage the patient to maintain an upright posture i e no bending forwards during the manoeuvre 8 If a flow volume loop is being performed to measure forced inspiratory vital capacity the patient will exhale rapidly and forcefully until end of test criteria are achieved and then inhale as rapidly as possible back to TLC 9 Observe the patient at all times dur
23. e measure for arm span and Harpenden Callipers for measurement of ulna length when standing height cannot be measured see Appendix 6 Measurement of Ulna Length e paediatric chairs e computer recorder supplies depending on the type of spirometer used e barometer thermometer and hygrometer if not integrated into the equipment used This equipment is used for correcting volumes to body temperature i e 37 C ambient pressure air saturated with water vapour BTPS e validated 3L volume calibration syringe e for reversibility test metered dose inhaler MDI and spacer or small volume nebuliser with compressed gas source and disposable nebuliser mask mouthpiece 4 6 Training requirements All health professionals performing spirometry should as a minimum complete the Queensland Health Spirometry Training Program or another spirometry training to an equivalent standard 8 In addition when performing spirometry on a child a Blue Card is required by staff whoare not Registered Health Practitioners For further clarification on specific requirements see the Commission for Children and Young People and Child Guardian website www ccypcg qlid gov au For spirometry testing in preschool children it is essential that the health practitioner has the ability to establish rapport with the child and that he or she is able to obtain measurements without causing distress 4 7 Test Procedure 4 7 1 Key measures and terminology
24. ectants Other disinfectant liquids include alcohol quaternary ammonium compounds acetic acid formaldehyde phenols iodine chlorine and hydrogen peroxide 1 Acetic acid solutions quaternary ammonium compounds and household bleach may be used for disinfecting respiratory equipment However studies have not been performed to verify the usefulness of these agents 2 Alcohol and hydrogen peroxide may be used for skin cleaning and disinfection E eee EAE Version No 1 0 Effective from 26 November 2012 Page 22 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric TG Eee Appendix 2 Purposes for performing spirometry Diagnostic indications e evaluate symptoms signs or abnormal laboratory tests abnormal lab tests e measure the effect of disease on pulmonary function pulmonary dysfunction e screen individuals at risk of having pulmonary disease risk stratification e assess pre operative risk pre operative assessment e assess prognosis prognostic indicator Monitoring indications e assess therapeutic intervention e describe the course of diseases that affect lung function e monitor people exposed to injurious agents e monitor for adverse reactions to drugs with known pulmonary toxicity Disability Impairment Evaluations e assess patients as part of a rehabilitation program e assess risks as part of an insurance evaluation e assess individuals
25. ed is 3L SSS a SSS eee RENE Version No 1 0 Effective from 26 November 2012 Page 25 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric Cee SET ee e A calibration syringe should be validated yearly to ensure accuracy For specific details refer to the manufacturer s recommendations e A calibration syringe should be checked monthly for leaks by attempting to empty it with the outlet occluded This should be performed at more than one volume e Perform inspection of adjustable or variable stops if they exist especially if the syringe has been dropped or damaged e Use of the syringe on a large number of machines distinguishes between instrument problems and problems with the syringe Procedure for validation calibration checks e Volume validation ensures that the spirometer is within calibration limits 3 of the true volume usually 3L where a 3L syringe is used e Volume validation should be performed at least daily or after every 10 patients ina busy service e Recalibration may be indicated and BTPS correction factors updated if the temperature changes more than 50 C e In line bacterial viral respiratory filters must be in place during the validation if they are used during testing e For volume based spirometers Check spirometer for leaks daily by applying a constant positive pressure of 23 0cmH20 0 3 kPa with the spirome
26. for legal reasons Public Health e epidemiological surveys e derivation of reference equations e clinical research hs Version No 1 0 Effective from 26 November 2012 Page 23 of 36 a Queensland i XT Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric LEE E Appendix 3 General description of volume and flow sensing spirometers For detailed information about specific models refer to the instruction and service manual for each spirometer Refer to your local Hospital and Health Service protocols and procedures for details Volume displacement Spirometer e g wedge rolling seal The volume displacement spirometer collects and directly measures the volume of expired air There are two main types 1 The wedge bellows spirometer Vitalograph contains a collapsible bellows that unfolds in response to air being expired into it It expands and contracts like a fan One side of the bellows remains stationary the other side moves with a pivotal motion around an axis through the fixed side Displacement of the bellows by a volume of gas is translated to movement of a mechanical recording device The chart paper moves at a fixed speed under the pen while a spirogram is traced 2 The dry rolling seal spirometer consists of a chamber containing a piston which is attached to the inside of the chamber by a flexible seal As air moves in and out of the spirometer the piston moves back and forwards
27. he device is within calibration limits e g 3 of true e Conduct daily validation checks according to manufacturer s instructions see Appendix 4 Quality Control for details Note More frequent checks may be required where there is high patient throughput E PERE Version No 1 0 Effective from 26 November 2012 Page 6 of 36 Zx Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric EEE Sa eC 4 7 3 Preparing the patient e Carry out infection control measures prior to testing particularly hand washing for both patient and personnel performing spirometry e Document if the patient has withheld bronchodilator medications prior to testing Note The use of bronchodilator medications is at the patient s discretion despite the recommendation to withhold before the test e Refer to section 4 7 6 Assessing Bronchodilator Reversibility for detailed instructions regarding withholding times e Confirm that the patient has ceased smoking at least 1hr before testing ceased alcohol consumption at least 4 hrs before testing refrained from performing vigorous exercise within 30min of testing refrained from eating a large meal within 2hrs of testing e Ensure the patient is wearing clothing that enables full chest and abdominal expansion if possible loosen clothing e Assess patient for physical and developmental status to determine their ability t
28. he manoeuvre in case they experience light headedness or any other adverse reactions 6 Terminate the manoeuvre using keyboard mouse or special function keys as specified by the manufacturer once the end of test criteria have been met see section 4 7 5 Determining acceptability and repeatability 7 Repeat instructions and manoeuvres for a minimum of three manoeuvres coaching vigorously until end of test criteria are met with a maximum of four attempts and a rest period of gt 1 minute between each manoeuvre 8 Terminate test once acceptability and repeatability criteria are met see section 4 7 5 Determining acceptability and repeatability 4 7 5 Determining acceptability and repeatability of FEV FVC and VC measurements Clinically useful spirograms must be acceptable i e meet the criteria that comprises a good quality manoeuvre and repeatable i e the two highest FEV FVC and VC from three acceptable manoeuvres are in close agreement A spirogram is acceptable if the following are met Start of Test Criteria e begins from full inspiration e has arapid start of test that is the back extrapolated volume VBE is lt 5 of FVC or 0 15L whichever is greater see Appendix 8 Determination of back extrapolation SSS eee REE Version No 1 0 Effective from 26 November 2012 Page 11 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric Cee a E volum
29. ildren s Health Services Queensland Paediatric Respiratory Specialists Mater Children s Hospital Brisbane Statewide Respiratory Clinical Network SRCN State wide Clinical Measurements Network SWCMN Clinical Measurements Advisory Group CMAG for Clinical Education and Training District Directors of Allied Health Allied Health Workforce Advice and Coordination Unit AHWACU Allied Health Clinical Education amp Training AHCETU Clinical Education Queensland ClinEdQ Australia and New Zealand Society of Respiratory Science ANZSRS O O 0 Oo 0O 00o e Queensland Health Respiratory Laboratory Managers o Chris Brown Respiratory and Sleep Scientist Advanced The Townsville Hospital o Barry Dean Respiratory Scientist Royal Brisbane Children s Hospital o Brenton Eckert Scientific Director Princess Alexandra Hospital o Ryan Harle Respiratory Scientist Laboratory Manager Logan Hospital o Andrew Southwell Senior Clinical Measurement Scientist Respiratory Redcliffe Caboolture ARES Version No 1 0 Effective from 26 November 2012 Page 17 of 36 Cay Queensland ge Government lt lt Printed copies are uncontrolled Queensland Health Spirometry Paediatric Eee Joanne Wex Manager Clinical Measurements Rockhampton Base Hospital Debbie Zagami Respiratory Scientist Laboratory Manager Gold Coast Hospital e Queensland Health Respiratory Laboratory Clinical Directors Q Scott Bel
30. ildren s Hospital Herston QLD 4029 Version No 1 0 Effective from 26 November 2012 Page 30 of 36 gt Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric eee Appendix 6 Measurement of Ulna Length and its use in predicting lung function To measure the length of the ulna bone it is necessary to use a measurement instrument such as Harpenden Callipers Ulna length typically ranges from 15 to 30 cm in children The ulna length is obtained by seating the child with the forearm resting comfortably on a flat surface Place the palm downwards with the fingers extended and together The elbow is bent at 90 to 110 The proximal end of the ulna is found by palpating along its length The tip of the styloid process is felt at the wrist by palpating down the length of the bone distally until its end is felt The tips of the anthropometer Harpenden Calliper are placed adjacent to both end points and the ulna length U is measured in cm to two decimal places Triquetrum Radial styloid 2 process Ulna styloid process Dorsal tubercle hs Version No 1 0 Effective from 26 November 2012 Page 31 of 36 a Queensland V YY Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric ea ee Having measured the ulna length U a prediction of FEV FVC and FEF2s5 75 can be based on the published reference values of Gauld They are as foll
31. ing the manoeuvre in case they become unsteady due to light headedness or experience other adverse reactions such as chest pain 10 Terminate the manoeuvre using keyboard mouse or special function keys as specified by the manufacturer once the end of test criteria has been met see section 4 7 5 Determining acceptability and repeatability 11 Repeat the instructions and manoeuvres for a minimum of three manoeuvres more if necessary coaching vigorously until end of test criteria are met no more than eight manoeuvres are usually required however more than 8 attempts are permitted with pre school children 12 Terminate the test once the acceptability and repeatability criteria have been met see section 4 7 5 Determining acceptability and repeatability Performing the VC testing 1 Explain and demonstrate the test manoeuvre to the patient including a Correct use of the mouthpiece and nose clip b Position of the mouthpiece including tight mouth seal over the mouthpiece c Correct posture with head slightly elevated d Slow complete and relatively constant flow inhalation for VC e Slow complete and relatively constant flow exhalation for VC f Emphasis on complete filling and emptying of the lungs Note lf requested by the medical officer it is recommended that the VC is performed before the FVC because of the potential for muscular fatigue and volume history effects 2 Have the patient assume correct posture and attach nose
32. ital and Health Service infection control protocols or procedures at all times and in all facets of spirometry testing Specific infection control procedures pertaining to spirometry testing are outlined in Appendix 1 Infection Control Procedures e Australian Guidelines for the prevention and control of infection in healthcare CD33 2010 4 3 Gaining Consent e Gain consent in accordance with Queensland Health s Informed Decision making In Healthcare Policy 4 4 Identifying Indications and Contraindications for performing spirometry Indications for performing spirometry Spirometry has a variety of uses including e assisting with diagnostic evaluations e monitoring of pulmonary function e evaluating disability or impairment eC BER Version No 1 0 Effective from 26 November 2012 Page 2 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric L EE_ _EE eee e providing public health information For further indications refer to Appendix 2 Purposes for performing spirometry Contraindications for performing spirometry Some conditions may pose a relative danger to a patient or affect the validity of spirometry performance and results These include but are not limited to the following e unstable cardiovascular status unstable angina recent myocardial infarction within one month or pulmonary embolism e haemoptysis of un
33. known origin e recent pneumothorax e thoracic abdominal or cerebral aneurysms e recent thoracic abdominal or eye surgery e acute disorders such as nausea or vomiting e severe respiratory distress e physical limitations e cognitive impairment dementia e inability to adequately understand and follow instructions except when familiarising child with spirometry 4 5 Facilities and equipment Testing Facilities e Ensure clearly defined rooms are available for spirometry testing particularly for patients with confirmed or suspected communicable diseases and immuno compromised patients Specific infection control procedures pertaining to spirometry testing are outlined in Appendix 1 Infection Control Procedures e A child friendly pulmonary function laboratory is of the utmost importance Young children need to feel comfortable in the laboratory environment if they are to perform the measurements accurately Designated paediatric rooms may help to prevent distraction in children during testing e The operator has a significant impact on the comfort level of the child This type of environment may be achieved through a combination of friendly conversation songs or through distraction with a videotape book interactive computer game toy or puzzle e Allow adequate space for chairs wheel chairs and prams for the child and accompanying adult s TT PERE Version No 1 0 Effective from 26 November 2012 Page 3 of 36
34. l Thoracic Program Medical Director The Prince Charles Hospital Anthony Matthiesson Director Respiratory and Sleep Unit The Townsville Hospital Stephen Morrison Director of Thoracic Medicine Royal Brisbane and Women s Hospital Brent Masters Director Queensland s Children s Respiratory Centre Graham Simpson Director of Thoracic Medicine Cairns Base Hospital David Serisier Director Respiratory Medicine Mater Health Service Pathmanathan Sivakumaran Director Respiratory Services Gold Coast Hospital Khao Tran Respiratory Physician Logan Hospital Dr Craig Hukins Director Department of Respiratory and Sleep Medicine Princess Alexandra Hospital e State wide Respiratory Clinical Network SRCN O Deb C Hill Network Coordinator State wide Respiratory Clinical Network amp Principal Project Officer Clinical Networks Team Patient Safety amp Quality Improvement Service Centre for Healthcare Improvement 7 Guideline Revision and Approval History Version Modified Amendments Approved by No by authorised by 1 0 Dane Enkera Chair State wide Clinical Measurements Network Brett Duce Chair Clinical Measurements Advisory Group for clinical education va Queensland gt Government Version No 1 0 Effective from 26 November 2012 Page 18 of 36 Printed copies are uncontrolled Queensland Health Spirometry Paediatric EEE Eee 8 Appendices Appendix 1 I
35. land gt Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric c M Eoo A 9 Suggested Readings and References 9 1 Suggested readings e Cooper BG 2010 An update on contraindications for lung function testing Available from http www ncbi nim nih gov pubmed 20671309 e Johns DP and Pierce RP 2007 Pocket Guide to Spirometry 2nd edition McGraw Hill Australia e Quanjer PH Become an Expert in Spirometry Lung function indices Available from http www spirxpert com indices7 htm _ENREF 16 e Queensland Health Spirometry Training Program Available from https ilearn health qld gov au login index php _ENREF 23 9 2 References 1 Beydon N Davis SD Lombardi E Allen JL Arets HGM Aurora P et al An official American Thoracic Society European Respiratory Society statement pulmonary function testing in preschool children American Journal of Respiratory amp Critical Care Medicine Practice Guideline Review 2007 Jun 15 175 12 1304 45 2 Miller MR Hankinson J Brusasco V Burgos F Casaburi R Coates A et al Standardisation of spirometry Eur Respir J Practice Guideline 2005 Aug 26 2 319 38 3 Queensland Health Informed decision making in health care2012 Available from http www health qld gov au consent default asp 4 National Health and Medical Research Council Australian Guidelines for the Prevention and Control of Infection in Healthcare National
36. n glottic closure Version No 1 0 Effective from 26 November 2012 Page 33 of 36 a Queensland eu Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric Appendix 8 Determination of back extrapolation volume To determine the back extrapolation volume a line is constructed through the steepest part of the volume time curve Figure 3 Where this line crosses the time axis is the new time zero from which all time timed volumes such as FEV are measured The back extrapolation volume is the volume on the spirogram at the new time zero To render a spirogram acceptable the back extrapolation volume must be less than 5 of the FVC or 0 150 L whichever is greater Back extrapolation line ae 0 8 0 6 Volume L 0 4 0 2 jhe ye Time s 0 25 0 50 New time zero Figure 1 shows an expanded version of the early part of a volume time spirogram with a back extrapolation line through the steepest part of the curve to determine the new time zero at 0 21sec The back extrapolation volume is 0 09 L determined by volume expired at new time zero If the FVC is 4 18 L then EV is 2 1 FVC Most computerised systems provide immediate feedback on back extrapolation volume and should be used by the operator to determine if this acceptability criterion has been met RE Version No 1 0 Effective from 26 November 2012 Page 34 of 36 Queens
37. n of PEF Timed volumes displayed should include FEVo5 or FEVo75 and FEV This is because in preschoolers FEV1 often approximates the FVC Review these measurements before the next effort and encourage the child to alter his or her technique if necessary Paediatric spirometry equipment may include animated incentives in software intended for both pre schoolers and older children These incentives are designed to encourage rapid and prolonged expiration Incentives that encourage tidal breathing and maximal inspiration may also be helpful Use these visual incentives discretionally as they may distract some children Spirometers for use in preschool patients must be capable of measuring instantaneous flows with an accuracy of at least 5 Dead space should be minimized where possible although this requirement does not preclude the use of bacterial filters Otherwise recommendations for equipment for use in adult subjects apply Other supplies Assemble the following supplies va 9 Queensland disposable reusable supplies mouthpieces nose clips flow sensors pneumotachometers infection control supplies disposable in line bacteria filters gloves gowns masks protective eyewear Version No 1 0 Effective from 26 November 2012 Page 4 of 36 gt Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric T e aa a E eee e stadiometer for measuring height scales for weight tap
38. nfection Control Procedures The aim of infection control is to provide a better understanding of infections and their modes of transmission to staff It is also important in maintaining a safe working environment for staff and patients to help prevent disease transmission during pulmonary function testing General Hygiene guidelines Poor hygiene practice not only increases patient morbidity but also increases patient mortality Lung function testing equipment has the ability to spread or transmit blood borne and airborne pathogens droplets and other particles containing microbes being released in the air e g tuberculosis TB chicken pox respiratory syncytial virus RSV human immunodeficiency virus HIV and hepatitis The majority of the patient population would not be affected but individuals who are immune compromised are far more likely to develop complications If an active respiratory infection has been identified in a patient then the test request should be confirmed with the requesting medical officer Transmission of pathogens mo Transmission of pathogens can occur via a number of different routes including patient staff staff patient patient patient staff staff patient equipment and staff equipment ATS ERS guidelines define direct and indirect contact with regards to pulmonary function testing and transmission of pathogens as follows Direct contact From person to person There is the po
39. nt Printed copies are uncontrolled Queensland Health Spirometry Paediatric EE ee Appendix 5 Measurement of Stature The measurement is made using a stadiometer leaving both hands free to position the subject whilst measuring height Instruct patient to place heels together and stand as tall as possible with the heels calf buttocks and back preferably touching the stadiometer Once the patient is in this position cup the angles of the mandible in both hands tilt the patient s face so that the lower orbital margin eye socket is level with the external auditory meatus Ear canal This is the Frankfort Plane solid horizontal line in Figure 1 Apply gentle upward traction to the head If measuring a child instruct the child to inhale deeply Measure and record the height to the nearest centimetre in adults and 1 millimetre in children Note Compared with subjects who are standing erect but unsupported this procedure can increase the apparent height by up to 5cm It can also eliminate diurnal variation and improve the reproducibility which is then less than 2mm yale 9 Queensland Figure1 Measurement of stature showing the effects of moving the head into the Frankfort plane short dashed line at eye level and then applying traction The same method is also used for accurate height measurement in adults Diagram supplied courtesy of Barry Dean Queensland Children s Respiratory Centre Royal Ch
40. nt SSS Sa SSS eee RENE Version No 1 0 Effective from 26 November 2012 Page 13 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric r a are een ee Administration of Bronchodilators e Regardless of which method is used consideration of pulmonary deposition characteristics of the devices must be made so that appropriate and standardised dosages are delivered e Consult local Hospital and Health Service standing orders for bronchodilator administration for further guidelines Test Procedure e Perform spirometry according to 4 7 4 Performing Test Procedure This will provide a pre bronchodilator result e Administer the bronchodilator medication in the dose and method indicated for the test and according to hospital guidelines e Perform spirometry according to section 4 7 4 Performing Test Procedure 10 to 15 minutes following administration for short acting B agonists and 30 minutes for short acting anti cholinergic agents This will provide the post bronchodilator result Acceptability and repeatability Ensure test acceptability and repeatability according to section 4 7 5 Determining acceptability and repeatability Interpretation of results e The interpretation of reversibility in children is subjective The medical officer may look at the shape of the flow volume curve combined with the magnitude of improvement of FEV An increase
41. nt spirometers for leaks and linearity e checking tubing for tears e electrical safety Corrective measures include unscheduled action required to correct the instrument failure and can be performed by the manufacturer hospital bioengineer or the operating staff Maintenance logs must be kept and include dates and types of tasks conducted along with instructions on what action is to be taken if a problem is identified and needs to be rectified At a minimum the following record should be kept e problem or troubleshooting log e preventative maintenance list log e calibration log e quality control log New Instrumentation verification and validation must be performed on all new equipment before patient testing begins Instrument Calibration To have confidence in the data that is generated during spirometry testing the spirometer must be regularly calibrated for volume linearity and timing Depending on the type of spirometer used some or all of these parameters need regular validation Calibration syringe e The calibration syringe should be stored at the same temperature and humidity as the testing site away from direct sunlight and heat sources This is best achieved by storing the syringe close to the spirometer e A calibration syringe should be used to check the volume calibration of spirometers and must have an accuracy of 15mL or 0 5 of the full scale whichever is greater For most spirometers the syringe volume requir
42. nts Source Isolation precautions with testing patients with open sores or haemoptysis isolation of susceptible patients Protective Isolation Hands should be washed between patients and immediately after direct handling of mouthpieces tubing breathing valves or the interior surfaces of equipment Gloves should be worn at all times when handling contaminated equipment or where surfaces are suspected of holding pathogens which could be potentially transmitted Gloves also offer another barrier of defence for staff with open cuts or sores which need to be covered to prevent contamination and or transmission of disease pathogens Volume and flow based spirometers Disposable in line filters are an effective and less expensive method of preventing equipment contamination In line filters have been shown to remove microorganisms from the expiratory air stream and thus prevent their deposition as aerosol nuclei on spirometer surfaces The use of in line filters does not eliminate the need for regular cleaning and decontamination of lung function equipment When using equipment with inspiratory and expiratory manoeuvres in line bacterial viral filters should be used and disposed of after every patient single patient use Closed circuit A volume based spirometer in which a closed circuit technique has been used should be flushed between subjects with room air at least five times over the entire volume range of the spirometer to enhance clearan
43. o perform the test and or if special arrangements are required e g if the patient has a tracheostomy Engage an interpreter if required as per Queensland Health Language Services Policy e Record relevant medical history that may assist in the interpretation reporting of the spirometry This may include the following Breathlessness Cough Sputum Wheeze Symptoms of asthma Smoking history years packs day current status Known lung disease chest injuries operations Work history Occupational exposure to dust and respiratory irritants e Record the type dosage and time taken of any inhaled or oral medication that may alter lung function e Measure and record the patient s height barefoot in centimetres cm to one decimal place with feet together heels against the wall standing as tall and straight as possible and with the head in the Frankfort horizontal plane eyes level and looking ahead for detailed explanation see Appendix 5 Measurement of Stature Measure the ______ eee RENE Version No 1 0 Effective from 26 November 2012 Page 7 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric L _ gt EE__aE_E EEESE TE ee patient s height using an accurate measuring device such as a stadiometer Gently apply lifting pressure to the mastoid processes to elongate the vertebral column Heigh
44. ommon FEV FVC Forced expiratory volume The ratio of FEV to FVC or VC expressed as a Or in t seconds to forced vital percentage FEV is the most commonly used or vital capacity ratio measure FEV VC FEFx Forced expiratory flow The flow measured during a forceful expiration litres per second L s when x of the FVC has been exhaled FEF 25 FEFs59 and FEF75 are commonly reported FEF25 75 Forced mid expiratory flow The average flow measured over the middle litres per second L s 50 of an FVC manoeuvre Also known as mid expiratory flow PEF Peak expiratory flow litres The maximum expiratory flow achieved from a per second L s or litres maximum forced expiration starting without per minute L min hesitation from a point of maximal lung inflation TLC Total lung capacity litres The volume of gas in the lungs after maximal L inspiration or the sum of all volume compartments TV Tidal volume litres L The volume of gas inhaled or exhaled during the respiratory cycle also known as VT BTPS Body temperature and Body temperature i e 37 C ambient pressure pressure saturated air saturated with water vapour Acceptability Criteria Satisfactory start middle and end of test conditions Repeatability Criteria Closeness of agreement between the results of successive measurements of the same item carried out subject to all of the following conditions s
45. on Explanation Details VC Vital capacity litres L The volume change between the position of full inspiration and complete expiration IVC Inspiratory vital capacity The maximal volume of air inhaled slowly from litres L the point of maximal exhalation achieved by a slow expiration from end tidal inspiration EVC Expiratory vital capacity The maximal volume of air exhaled slowly from litres L the point of maximal inhalation FVC Forced vital capacity litres The maximal volume of air exhaled with O BER Version No 1 0 Effective from 26 November 2012 Page 15 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric EE Eee L maximally forced effort from a position of maximal inspiration FIVC Forced Inspiratory Vital The maximal volume of air inhaled with Capacity litres L maximally forced effort from a position of maximal expiration FIFX Forced Inspiratory Flow The flow measured during a forceful inspiration litres per second L s when x of the FIVC has been inspired FEV Forced expiratory volume The maximal volume of air exhaled in the first in one second litres L second of a forced expiration from a position of full inspiration FEV Forced expiratory volume The maximal volume of air exhaled with litres L maximally forced effort in t seconds 1 and 6 seconds are the most c
46. ows Male lt 20 years old FVC 2 718282 0 077 U 0 041 A 1 285 Cl 0 26 2 7182824 0 077 U 0 041 A 1 285 FEV 2 718282 0 071 U 0 046 A 1 269 Cl 0 25 2 7182824 0 071 U 0 046 A 1 269 FEF 25 75 2 718282 0 060 U 0 053 A 1 013 Cl 0 37 2 718282 0 060 U 0 053 A 1 013 Female lt 20 years old FVC 2 718282 0 078 U 0 037 A 1 315 Cl 0 22 2 7182824 0 078 U 0 037 A 1 315 FEV 2 718282 0 072 U 0 041 A 1 272 Cl 0 22 2 7182824 0 072 U 0 041 A 1 272 FEF 25 75 2 718282 0 053 U 0 054 A 0 806 Cl 0 37 2 7182824 0 053 U 0 054 A 0 806 A Age of subject Cl the 95 confidence Interval REIS Version No 1 0 Effective from 26 November 2012 Page 32 of 36 Cay Queensland ge Government lt lt Printed copies are uncontrolled Queensland Health Spirometry Paediatric LEE eee Appendix 7 Examples of volume time and flow volume spirograms Figure 1 Examples of unacceptable volume time spirometry results compared with a good effort Volume Good effort Submaximal effort poena Poor start Not at TLC prior to blow Premature termination or glottic closure Figure 2 Examples of unacceptable flow volume spirometry loops compared with an acceptable effort Acceptable 1N Submaximal A Not at TLC Cough efforts effort N z 2 ps prematurely or Submaximal Tongue inspiration N occlusio
47. red as accurately as possible under ideal conditions to determine a baseline value All subsequent testing of the biological control is compared to this baseline value Characterisation determines the variability of the biological control under the most ideal conditions Characterisation requires that e FEV VC FVC volumes are measured according to ATS ERS guidelines for acceptability and repeatability e The subject is free of symptoms or known respiratory disease that may cause variability in lung function results e Data is collected at least 10 times over a 1 2 week period under the above conditions to assess variability of the individual s data e The mean for each measured parameter becomes the reference standard or the correct value Biological control data analysis Day to day variations in physiological function of the biological control occur even under ideal testing conditions The variability is used to set the control limits for the test and e PAE Version No 1 0 Effective from 26 November 2012 Page 27 of 36 a Queensland T Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric LLL eee allows identification of data that is out of control and is determined by the following steps record FEV FVC VC for the 10 or more test manoeuvres performed for each parameter measured calculate mean and standard deviation SD the mean value during gold stand
48. t of electrical current required to keep the wire heated which depends on the mass of air flowing over the wire 4 The rotating vane flow sensor turbine type has a very light vane which spins when air flows past The rotating vane interrupts the light path between a light source and photocell causing pulses at the photocell The air flow rate is proportional to frequency of these pulses SSS SSS eee REE Version No 1 0 Effective from 26 November 2012 Page 24 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric EE Appendix 4 Quality Control Procedures Quality control must be conducted to ensure the precision and accuracy of the test equipment test procedure and the results collected It includes the regular maintenance and calibration of equipment and the regular testing of biological controls to validate testing equipment and test procedures All results of quality control testing should be recorded and analysed so that any problems can be identified and rectified as soon as they arise Quality control processes that conform to a best practice model are outlined below Instrument maintenance Regular preventative maintenance must be performed by the operator to anticipate problems with the equipment before they occur These should be done daily weekly monthly or yearly depending on the recommendation of the manufacturer e checking volume displaceme
49. t shall be measured and recorded at each visit using an accurate measuring device such as a stadiometer e When patients are unable to stand or accurate height measurements are impeded by deformity e g scoliosis then the ulna length should be measured using Harpenden callipers and the ulna length used in pulmonary function prediction equations Refer to Appendix 6 Measurement of ulna length for further instruction e f the measure of ulna length is not possible then the measurement of arm span can be used as it closely approximates standing height in children Have the patient stretch their arms in opposite directions to attain the maximal distance between the tips of the middle fingers e Measure the patient s weight in kilograms kg to the nearest 0 1kg with indoor clothing and without shoes e Verify the patient s identity full name and date of birth and the procedure to be performed e Document the patient s ethnic origin gender date of birth and hospital identification UR number e Leave the patient s dentures in place unless they interfere with the testing procedure or the patient s ability to perform the procedure as required E e For safety reasons perform the test with the patient sitting comfortably in a chair with arms and without wheels e Request the patient to sit upright legs uncrossed and both feet on the floor gt 7 ENREF 7 To achieve this posture it is suggested that paediatric chairs are use
50. tential for transmission of upper respiratory disease enteric infections and blood borne infections through direct contact Although hepatitis and HIV transmission are unlikely via saliva disease transmission is a possibility when there are open sores on the oral mucosa bleeding gums or haemoptysis The most likely surfaces for contact are mouthpieces and the immediate proximal surfaces of valves or tubing Indirect contact Via animate and inanimate objects There is potential for transmission of TB various viral infections and possibly opportunistic infections and nosocomial pneumonia through aerosol droplets The most likely surfaces for possible contamination by this route are mouthpieces and proximal valves and tubing BSS eee RENE Version No 1 0 Effective from 26 November 2012 Page 19 of 36 Exa Queensland Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric EEE Saas ee Prevention and Precautions Standard precautions should be followed at all times Disease prevention or cross contamination can be prevented by addressing the following issues regarding the source and the transmission of pathogens ensuring a clean environment proper hand washing techniques sterilisation and disinfection of equipment including valves and tubing use of in line bacterial viral filters safety mouthpieces personal protective equipment e g gloves gown masks etc isolation of infected patie
51. ter outlet occluded at the mouthpiece preferably with the mouthpiece in place A volume loss of 30ml after 1min indicates a leak and needs addressing Perform validation at least daily with a calibration syringe the volume of the syringe will depend on the type of spirometer being used Check manufacturer s guidelines for details A volume linearity check should be performed quarterly 1L increments with a calibrating syringe over entire volume range The procedure is detailed in the ATS ERS guidelines The check is considered accurate if the minimum volume accuracy requirements are met for all volumes tested i e measured volume should be within 3 5 this value includes the 0 5 syringe accuracy limit of the reading or 65ml whichever is greater The following method can be used to check the linearity for each volume tested Error Expected Volume Measured Volume X 100 Expected Volume Where Expected volume the actual volume of the syringe Measured volume the result recorded for the test Perform timer checks quarterly for spirometers with mechanical recorder time scale Using a stopwatch an accuracy of 2 must be achieved O ARA Version No 1 0 Effective from 26 November 2012 Page 26 of 36 a Queensland P Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric L gt _L___ TEE A e For flow based spirometers Perform validation at least
52. this situation and aids in the prevention of cross contamination Place patients in a separate area apart from other patients not in open waiting areas Provide patients with surgical masks and instruct them to wear the masks Provide patients with tissues and instructions on covering their mouth and nose when coughing or sneezing Environmental engineering controls such as ventilation air filtration or ultraviolet decontamination of air should be used to help prevent disease transmission where spread is by droplet nuclei as seen in tuberculosis Cleaning and Disinfecting Procedures Mouthpieces nose clips and any other equipment coming into direct contact with mucosal surfaces should be disinfected sterilized or if disposable discarded after each use Although the optimal frequency for disinfection or sterilization of tubing valves or manifolds has not been established any equipment surface showing visible condensation from expired air should be disinfected or sterilised before reuse whenever the potential for cross contamination exists Manufacturer s recommendations regarding the cleaning and disinfection of equipment must be consulted in order not to cause damage with the wrong cleaning procedure Heat sterilisation or cold sterilisation chemicals can damage flow sensors tubes and or seals Manufacturers should describe the recommended chemicals and concentrations as well as the PPE required by the staff undertaking the cleaning and
53. ting the test and dependent on the clinical question and clinical judgement Note The reversibility test procedure below is as stated in the Queensland Health Guideline Spirometry Adult with the following exceptions e Administer the salbutamol Ventolin using metered dose inhalation of 400 600ug salbutamol 4 6x100ug metered doses at 30 second intervals via a valved spacer device e Shake the metered dose inhalers before each actuation Recommendation for administration of bronchodilators in children is as follows e for young children via the tidal normal breathing method of 5 breathes for every actuation e for school age children via the breathe hold method of 5 10 seconds breath hold following the actuation from the start of a rapid inhalation Patient Preparation e Bronchodilator medications should be withheld prior to testing if evidence of the presence or absence of reversible airflow limitation is required Short acting bronchodilators B agonists or anticholinergics should be withheld for 4 hrs Long acting B agonist bronchodilators oral therapy with Aminophylline or slow release B agonist should be withheld for 12hrs e Ifthe aim of the test is to determine whether the patient s lung function can be improved with therapy in addition to their regular treatment then regular medication as prescribed can be continued e All other preparation steps are outlined in section 4 7 3 Preparing the patie
54. uld be evaluated Biological control testing procedure Routine biological control testing is performed weekly Routine biological control testing is performed under the same condition as routine patient testing according to ATS ERS guidelines Graph the biological control result on a Levy Jennings Plot see Graph 1 which has horizontal lines running across it to indicate the mean as well as one two and sometimes three standard deviations either side of the mean derived from the characterisation of the biological control These provide visual feedback of whether control values are in or out of control ARES Version No 1 0 Effective from 26 November 2012 Page 28 of 36 ay Queensland Y Government Printed copies are uncontrolled Queensland Health Spirometry Paediatric Cn e a E e Westgard rules are then used to determine if any quality assurance procedures need to be enacted PAARE ene Graph 1 Example of a Levy 3 28 Jennings plot showing the mean and one and two standard deviations derived from biological control characterisation The observation points are VC results 3 26 3 24 3 22 32 3 obtained from a biological control ao In this example no quality So assurance procedures need to be 3 14 enacted 3 12 3 1 3 08 T T 7 7 T Observation number DS BER E Version No 1 0 Effective from 26 November 2012 Page 29 of 36 Queensland T Governme
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