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Spirometry in Primary Care Setting
| Article Date: 5/31/2007 |
Spirometry in Primary Care Setting
Spirometry is the “gold standard” for diagnosing airway obstruction. The National Lung Health Education Program (NLHEP) has recommended the use of spirometry in the primary care office. NLHEP recommends that spirometry should be performed on all patients 45 years or older who currently smoke cigarettes, have quit within the last six months, or patients who have systematic lung disease.
Lung disease can be detected with the use of spirometry in a pre-systematic phase and successful smoking cessation will prevent additional disease progression. The Lung Health Study (LHS) has demonstrated prospectively that early identification and intervention of smokers could alter disease progression. Spirometry with its ability to recognize early airflow changes can help identify patients at risk, and prompt individuals to obtain medical attention.
The office spirometry test is a simple non-invasive procedure that takes only a few minutes of the patient’s and clinician’s time. The patient performs multiple breathing maneuvers with the guidance of the clinician. The patient may perform other breathing maneuvers like post-bronchodilator tests that give the clinician more information, but this takes more time and skill to perform. Office spirometers can be purchased at a lower cost than diagnostic acute care spirometers and some products can be useful in both settings.
The American Thoracic Society (ATS) and other professional organizations have set standards to certify the accuracy and the reproducibility of each spirometer. When examining a spirometer for purchase, look for these validations from various organizations, and make sure the manufacturer’s product meets these standards.
Spirometers measure the volume and speed at which air is moved in and out of the patient’s lungs. The amount of air that is forced out of the lungs after a maximal inhalation is called the Forced Vital Capacity or FVC. The Forced Expiratory Volume (FEV1) is the amount of volume expired in the first second. These two measurements are placed on a flow/volume/time graphic curve to examine patient effort and technique. This curve is known as a Flow Volume Loop. Other measurements are obtained within the FVC maneuver and gives additional information that assists in the evaluation of the type of pulmonary disease process.
A patient with abnormal airflow can generally be classified into obstructive, restrictive, or combined respiratory disorders. The FVC, FEV1, and their ratio are compared against predicated values. The standard definition for diagnosis of airflow obstruction is a FEV1/FVC ratio of <0.7. All modern spirometers have software that give predicted values, and assist in the evaluation of patient technique. ATS standards require that multiple measurements be performed to obtain satisfactory results. The FVC maneuver is sometimes difficult for the patient to perform, and the results may be affected by poor technique, inadequate patient effort, or poor patient education. Health care professionals performing the test should have basic training in pulmonary function studies.
All spirometers must correct for body temperature, ambient temperature, and water vapor saturation (BTPS) in order to obtain accurate flow and volume measurements. Spirometers must be setup to correct for this BTPS factor. Some spirometers need to be calibrated before use with 3-liter syringes sold by each manufacturer to correct for BTPS. Other manufacturers have a product design that allows for a fixed BTPS correction factor that eliminates the need for daily calibration. These fixed BTPS spirometers may be useful in the primary care setting because of the decreased amount of training needed to operate the device. Spirometer manufacturers must list the temperature and altitude ranges wherein each of their products will remain accurate.
The National Lung Health Education Program (NLHEP) has provided recommendations for the use of spirometry in primary care offices. As mentioned previously, Primary Care physicians should perform a spirometry test on all patients who are 45 years or older and report smoking cigarettes within the last year. This criteria is used whether the patient is symptomatic or not, and is an important tool in the detection of COPD. Spirometry also should be preformed on any patient with respiratory symptoms such as wheezing, chronic cough, sputum production, or dyspnea on exertion as a screening tool to detect asthma or COPD. Any patient that has symptoms that would suggest asthma should have a spirometry test. The early identification of abnormal lung function provides the patient, clinician, and physician with a teachable moment.
The NLHEP recommends that spirometers in primary care settings be used as screening tools, and that a basic spirometer with only three measurements FEV1, FEV6, and FEV1/FEV6 ratio be utilized. An office spirometer can have a setting that only measures these three parameters or that has additional settings for use by more advance operators. The patient performs a FVC maneuver, but the forced expiratory phase is discontinued after six seconds. The FEV1/FEV6 ratio is calculated as a fraction with only two decimal places measured. These modifications to the FVC maneuver make it easier for the patient and the clinician to perform. The FEV6 makes it easier for a patient with airway obstruction to complete a test maneuver due to the shortened expiratory time of the test. The ATS standards for satisfactory repeatability of results and maneuvers do not change with the NLHEP recommendations.
Spirometry can be reimbursed in the primary care setting in addition to normal Evaluation and Management (E&M) codes. There are three CPT codes that can be used for spirometry and are fully reimbursable whether the FVC or FEV6 maneuvers are performed, and can be billed under CPT 94010. Additional breathing tests can be billed under other CPT codes for each individual test preformed. Most of these additional tests require a FVC maneuver to be performed, and each test will require additional training for correct operation of the device.
In evaluating a spirometer for office use simplicity and ease of use of the device are primary points to consider. Spirometers that assist the operator in avoiding cross-contamination and that automatically correct for BTPS have the highest advantage over models without these features. An office spirometer that performs the FEV6 calculations, and also performs other diagnostic tests such as a FVC can be an adaptable alternative. Some spirometers have built-in pulse oximetry and USB computer connections for software or printing applications. When examining a spirometer for purchase, carefully review the company’s educational materials to make sure the device’s operation is explained in simple and understandable terms.
The spirometer is a valuable tool for the primary care physician, providing important information in the evaluation and management of patients. Spirometry can assist the primary care physician in diagnosing and treating lung disease. It can be a powerful tool to help patients quit smoking. Most spirometers are inexpensive and can pay for themselves in a very short time. An office spirometer is an easy to use and dependable device that has become a valuable tool for the primary care physician.
Spirometry is the “gold standard” for diagnosing airway obstruction. The National Lung Health Education Program (NLHEP) has recommended the use of spirometry in the primary care office. NLHEP recommends that spirometry should be performed on all patients 45 years or older who currently smoke cigarettes, have quit within the last six months, or patients who have systematic lung disease.
Lung disease can be detected with the use of spirometry in a pre-systematic phase and successful smoking cessation will prevent additional disease progression. The Lung Health Study (LHS) has demonstrated prospectively that early identification and intervention of smokers could alter disease progression. Spirometry with its ability to recognize early airflow changes can help identify patients at risk, and prompt individuals to obtain medical attention.
The office spirometry test is a simple non-invasive procedure that takes only a few minutes of the patient’s and clinician’s time. The patient performs multiple breathing maneuvers with the guidance of the clinician. The patient may perform other breathing maneuvers like post-bronchodilator tests that give the clinician more information, but this takes more time and skill to perform. Office spirometers can be purchased at a lower cost than diagnostic acute care spirometers and some products can be useful in both settings.
The American Thoracic Society (ATS) and other professional organizations have set standards to certify the accuracy and the reproducibility of each spirometer. When examining a spirometer for purchase, look for these validations from various organizations, and make sure the manufacturer’s product meets these standards.
Spirometers measure the volume and speed at which air is moved in and out of the patient’s lungs. The amount of air that is forced out of the lungs after a maximal inhalation is called the Forced Vital Capacity or FVC. The Forced Expiratory Volume (FEV1) is the amount of volume expired in the first second. These two measurements are placed on a flow/volume/time graphic curve to examine patient effort and technique. This curve is known as a Flow Volume Loop. Other measurements are obtained within the FVC maneuver and gives additional information that assists in the evaluation of the type of pulmonary disease process.
A patient with abnormal airflow can generally be classified into obstructive, restrictive, or combined respiratory disorders. The FVC, FEV1, and their ratio are compared against predicated values. The standard definition for diagnosis of airflow obstruction is a FEV1/FVC ratio of <0.7. All modern spirometers have software that give predicted values, and assist in the evaluation of patient technique. ATS standards require that multiple measurements be performed to obtain satisfactory results. The FVC maneuver is sometimes difficult for the patient to perform, and the results may be affected by poor technique, inadequate patient effort, or poor patient education. Health care professionals performing the test should have basic training in pulmonary function studies.
All spirometers must correct for body temperature, ambient temperature, and water vapor saturation (BTPS) in order to obtain accurate flow and volume measurements. Spirometers must be setup to correct for this BTPS factor. Some spirometers need to be calibrated before use with 3-liter syringes sold by each manufacturer to correct for BTPS. Other manufacturers have a product design that allows for a fixed BTPS correction factor that eliminates the need for daily calibration. These fixed BTPS spirometers may be useful in the primary care setting because of the decreased amount of training needed to operate the device. Spirometer manufacturers must list the temperature and altitude ranges wherein each of their products will remain accurate.
The National Lung Health Education Program (NLHEP) has provided recommendations for the use of spirometry in primary care offices. As mentioned previously, Primary Care physicians should perform a spirometry test on all patients who are 45 years or older and report smoking cigarettes within the last year. This criteria is used whether the patient is symptomatic or not, and is an important tool in the detection of COPD. Spirometry also should be preformed on any patient with respiratory symptoms such as wheezing, chronic cough, sputum production, or dyspnea on exertion as a screening tool to detect asthma or COPD. Any patient that has symptoms that would suggest asthma should have a spirometry test. The early identification of abnormal lung function provides the patient, clinician, and physician with a teachable moment.
The NLHEP recommends that spirometers in primary care settings be used as screening tools, and that a basic spirometer with only three measurements FEV1, FEV6, and FEV1/FEV6 ratio be utilized. An office spirometer can have a setting that only measures these three parameters or that has additional settings for use by more advance operators. The patient performs a FVC maneuver, but the forced expiratory phase is discontinued after six seconds. The FEV1/FEV6 ratio is calculated as a fraction with only two decimal places measured. These modifications to the FVC maneuver make it easier for the patient and the clinician to perform. The FEV6 makes it easier for a patient with airway obstruction to complete a test maneuver due to the shortened expiratory time of the test. The ATS standards for satisfactory repeatability of results and maneuvers do not change with the NLHEP recommendations.
Spirometry can be reimbursed in the primary care setting in addition to normal Evaluation and Management (E&M) codes. There are three CPT codes that can be used for spirometry and are fully reimbursable whether the FVC or FEV6 maneuvers are performed, and can be billed under CPT 94010. Additional breathing tests can be billed under other CPT codes for each individual test preformed. Most of these additional tests require a FVC maneuver to be performed, and each test will require additional training for correct operation of the device.
In evaluating a spirometer for office use simplicity and ease of use of the device are primary points to consider. Spirometers that assist the operator in avoiding cross-contamination and that automatically correct for BTPS have the highest advantage over models without these features. An office spirometer that performs the FEV6 calculations, and also performs other diagnostic tests such as a FVC can be an adaptable alternative. Some spirometers have built-in pulse oximetry and USB computer connections for software or printing applications. When examining a spirometer for purchase, carefully review the company’s educational materials to make sure the device’s operation is explained in simple and understandable terms.
The spirometer is a valuable tool for the primary care physician, providing important information in the evaluation and management of patients. Spirometry can assist the primary care physician in diagnosing and treating lung disease. It can be a powerful tool to help patients quit smoking. Most spirometers are inexpensive and can pay for themselves in a very short time. An office spirometer is an easy to use and dependable device that has become a valuable tool for the primary care physician.