SPIROMETRY IMPLEMENTATION QUICK GLANCE GUIDE
Spirometry: A measure of airflow (how fast) and volume (how much)
Forced Vital Capacity (FVC): The volume delivered during an expiration made
as forcefully and completely as possible starting from full inspiration. Examples of Unacceptable Spirometry Tests:
Forced Expiratory Volume in the first second (FEV1): The volume delivered in Slow start Rounded Early Cough in
the first second of a FVC maneuver. of test peak termination first second
Obstruction is defined as FEV1/FVC ratio below the lower limits of normal. The
rule of thumb is if FEV1/FVC is down 10 or more from the predicted value.
Restriction: Spirometrywith a low FVC (less than the LLN) suggests
restriction. Further testing is needed to confirm.
Spirometry must establish a solid baseline meeting the American Thoracic
Society (ATS) criteria for acceptability and repeatability. Use Global Lung Repeatability Criteria from ATS: ATS requires three acceptable maneuvers
Initiative (GLI-2012) predictive ranges when available. GLI-2012 has a grading where the FEV1 is within 100 ml of each other.
system range of A-F, spectrometry tests with grades of A-C are clinically useful.
Contraindications of spirometry:
Recent surgery
Coaching Patients through Spirometry:
Within one month of myocardial infarction
Instruct patient to breathe normally. When the patient is ready, have them
Recent pneumothorax
take their deepest breath and blow as heard as they can, for as long as they
Unable to understand directions
can. There is a learning curve for spirometry. Use positive reinforcement to
Inability to seal mouthpiece
build on the patient's successes. For example, "that was good. This time,
take an even deeper breath." Demonstrating the maneuver can assist.
Refer to a specialist, if patient:
1. Has severe obstruction
2. Shows a restrictive pattern Testing for Bronchodilator Responsiveness (Formerly Reversibility): Give
3. Does not respond to medications patient 4 puffs of bronchodilator with a valved-holding chamber or a standard
nebulized dose. Wait 10-15 minutes after last dose to perform post-
Examples of obstructed and restricted flow loops bronchodilator maneuver. If the patient cannot perform acceptable baseline
maneuversor there is no evidence of airflow obstruction, do NOTgive a
bronchodilator.
Interstitial pulmonary fibrosis flow
Peak flow loop (restrictive lung disease)
Normal flow loop References:
1. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive
Mildly obstructed flow loop Pulmonary Disease. Updated 2024. https://goldcopd.org/2024-gold-report/
FVC 2. National Heart, Lung and Blood Institute National Asthma Education and Prevention
Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of
Asthma. Asthma Management Guidelines: Focused Updates 2020. https://
Moderately obstructed flow loop www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates
3. Quanjer, PH, et al. 2012. Multi Ethnic Reference Values for Spirometry for the 3-95
Severely obstructed flow loop Year Age Range: the global lung function 2012 equations. Eur Respir J 40(6):
1324-1343.
4. Graham BL. 2019. Standardization of Spirometry 2019 Update. An official American
Thoracic Society and European Respiratory Society Technical Statement. https://
doi.org/10.1164/rccm.201908-1590ST
May 2024
SPIROMETRY INTERPRETATION
ASTHMA COPD
Is this a good test?
Are acceptability and repeatability
criteria met?
Check FVC. If greater than the lower limits of normal (LLN),
restriction can be ruled out. If less than LLN, further testing is needed
to differentiate restriction from obstruction with air-trapping.
PRE-BRONCH PRE-BRONCH
Observed Predicted % Predicted LLN Observed Predicted % Predicted LLN
FVC (L)
FEV1(L)
5.25
3.59
5.68
4.64
92
77 What is the observed ratio (FEV1/ FVC (L)
FEV1(L)
2.09
1.06
2.78
2.08
75
51
FEV1/FVC (%) 69 82 FVC) compared to predicted? FEV1/FVC (%) 50 75
If below LLN = airflow obstruction
Rule of thumb, down 10 or greater =
airflow obstruction
ATS/ERS* Degree of severity of obstruction
based on FEV1 % predicted
Degree of severity FEV1 % predicted
Mild >70
Moderate 60-69
Moderately severe 50-59
PRE-BRONCH POST-BRONCH Severe 35-49 PRE-BRONCH POST-BRONCH
FVC (L)
Observed Predicted
5.25 5.68
% Predicted
92 FVC (L)
Observed % Predicted Post %
5.35 94
Change 2 Very severe <35 FVC (L)
Observed Predicted % Predicted
2.09 2.78 75 FVC (L)
Observed % Predicted Post %
2.03 Change -3
FEV1 (L) 3.59 4.64 77 FEV1 (L) 4.14 89 15 FEV1 (L) 1.06 2.08 51 FEV1 (L) 1.07 73 2
FEV1/FVC (%) 68 82 FEV1/FVC (%) 77 13 FEV1/FVC (%) 50 75 FEV1/FVC (%) 53 5
52
Airflow obstruction that is not significantly
Is there a bronchodilator response (BDR)? reversible does NOT rule out asthma. To help
As of 2022, BDR is defined as differential COPD from asthma with airflow
Consistent with asthma diagnosis? Yes Actual Post FEV1 - Actual Pre FEV1 x 100 No remodeling/fixed obstruction, further testing
Predicted FEV1 options include DL1CO1, chest x-ray, chest CT.
A change of >10% is considered a significant BDR
response
Asthma Severity
Persistent
COPD Severity
Intermittent Mild Moderate Severe
Stage I: mild Stage II: moderate Stage III: severe Stage IV: very severe
Normal FEV1 between
FEV1/FVC< 70% FEV1/FVC< 70% FEV1/FVC< 70% FEV1/FVC< 70%
5-11 years exacerbations FEV1 > 80% predicted FEV1 = 60-80% predicted FEV1 < 60% predicted
FEV1 ˝ 80% predicted FEV1 50-80% predicted FEV1 30-50% predicted FEV1 < 30% predicted or
FEV1 > 80% predicted FEV1 /FVC> 80% FEV1/FVC = 75-80% FEV1/FVC< 75% FEV1 < 50% predicted plus
FEV1 /FVC> 85%
chronic respiratory failure
Normal FEV1/FVC: Normal FEV1 between
8-19 yr 85% exacerbations FEV1 ˝ 80% predicted FEV1 60-80% predicted FEV1 < 60% predicted
12 + years
20-39 yr 80% FEV1 > 80% predicted
FEV1/FVCnormal
FEV1/FVCnormal FEV1/FVC reduced 5% FEV1/FVC reduced > Sample COPD Interpretation: The FEV1/FVC ratio being below the lower limits of
40-59 yr 75% 5%
60-80 yr 70% normal is consistent with airflow obstruction. A post bronchodilator FEV1/FVC ratio
below 70% is consistent with COPD. The FEV1 of 51% of predicted suggests a
moderately-severe airflow obstruction (based on the 2024 GOLD guidelines for
Sample asthma interpretation: The FEV1/FVC ratio below the lower limits of normal is severity of obstruction). There was no significant BDR to albuterol. Further testing
consistent with air flow obstruction. The FEV1 being 77% of predicted suggests a mild airflow revealed a diffusion capacity of 50% of predicted. The lateral chest x-ray showed
obstruction (based on the 2005 ATS/ERS guide for severity of obstruction). The post signs of hyperinflation and flattened diaphragm and the chest CThad classic changes
bronchodilator study reveals a significant BDR with the FEV1 increasing 15% and 550cc. This seen in emphysema. Based on GOLD , this 74 year old female has Stage II moderate
finding is consistent with diagnosis of asthma although clinical correlation is needed to confirm. COPD.Treatment should be based on the CAT score, mMRC score and
(Based on the 2020 Focused Guidelines Update for asthma severity), this 28 year old male with exacerbation history.
a baseline FEV1 of 77% has moderate persistent asthma. Treatment should begin with Step 3
or 4 therapy.
