Predictors of spirometric test failure: a comparison of the 1983 and 1993 acceptability criteria from the European Community for Coal and Steel

Reduced lung function and cause-specific mortality: A population-based study of Norwegian men followed for 26 years

BACKGROUND AND AIM

Reduced lung function is associated with increased mortality, but it is unclear how different spirometric patterns are related to specific deaths. Aim of this study was to investigate these associations in a large general population cohort.

METHODS

The study population consisted of 26,091 men aged 30-46 years from the Pneumoconiosis Survey of Western Norway conducted in 1988-1990 with follow-up on date and cause of death for 26 years. Cox proportional hazard models were used to estimate the association between baseline FEV1, FVC, obstructive (OSP) and restrictive spirometric pattern (RSP) (z-scores calculated according to GLI-2012 equations) and mortality (European 2012 shortlist classification (E-2012)), after adjustment for age, body mass index, smoking habits, and education.

RESULTS

In total, 2462 (9%) subjects died. A predominant reduction of FEV1 (and OSP) were associated with respiratory non-cancer (E-8) (HR for one unit FEV1 z-score decrease 2.29 (95% CI 1.90, 2.77) and lung cancer mortality (E-2.1.8) (1.27(1.12, 1.44)). A similar reduction of FEV1 and FVC (and RSP) were associated with diabetes (E-4.1) (FEV1 2.21(1.67, 2.92), FVC 2.41(1.75, 3.32)), cerebrovascular (E-7.3) (1.52(1.21, 1.91), 1.54(1.19, 1.98)), ischemic heart disease (E-7.1) (1.22(1.10, 1.35), 1.21(1.08, 1.36)), neurological (E-6.3) (1.56(1.21, 2.01), 1.61(1.22, 2.13)), suicide (E-17.2) (1.37(1.13, 1.65), 1.29(1.04, 1.59)) and hematological cancer mortality (E-2.1.19-21) (1.29(1.05, 1.58), (1.26(1.00, 1.58)). No association was found between reduced lung function and mortality due to accidents, alcohol abuse, digestive and genitourinary cancer.

CONCLUSIONS

Spirometric obstruction was mainly related to pulmonary mortality. Spirometric restriction was mainly related to extra-pulmonary mortality.

Spirometry quality predictors in a large multistate prospective study

BACKGROUND

The Gulf Long-Term Follow-up (GuLF) Study is a prospective cohort study of health effects associated with oil spill response and clean-up following the 2010 Deepwater Horizon Disaster (DWH). As part of the study, spirometry testing of lung function was carried out in home visits across multiple states. Few studies have described factors associated with spirometry test failure in field-based settings.

OBJECTIVE

Our objective was to identify what factors, if any, predict test failure among GuLF Study participants who completed spirometry testing in a non-traditional setting.

METHODS

Trained examiners administered spirometry (May 2011-May 2013) to 10,019 participants living in US Gulf States (LA, MS, TX, AL, FL) using an Easy-on ultrasonic spirometer. We applied American Thoracic Society/European Respiratory Society quality criteria to determine quality test failure and identified factors predictive of failure using both a Stepwise and a LASSO model. We calculated odds ratios and 95% confidence intervals (CIs) for associations of selected factors with test failure.

RESULTS

Among GuLF Study participants who conducted spirometry, self-reported African American/Black participants (OR: 1.39, 95% CI: 1.23,1.56); men (OR:1.61, 95% CI: 1.41,1.83); and those making less than $20,000 per year (OR: 1.45, 95% CI: 1.26,1.67) were more likely to fail quality testing, while those who were obese were less likely to fail (OR: 0.61, 95% CI: 0.42,0.89).

CONCLUSION

Field-based studies involving spirometry should identify and account for participant factors that may influence test failure. Coaching that is tailored to those less likely to have experience with spirometry may help reduce test failure rates.

The use of a mobile spirometry with a feedback quality assessment in primary care setting - A nationwide cross-sectional feasibility study

OBJECTIVES

Mobile phone-linked portable spirometers are light-weight, easy to use and low cost, with new software to facilitate data collection. In this study we investigated the feasibility of the AioCare® mobile spirometry in primary care.

METHODS

In this nationwide, cross-sectional study, AioCare® spirometers (HealthUp, Poland) were distributed among primary healthcare centres across Poland. Operators (primary care professionals) received a 2-h training session, after which spirometry was performed in patients attending routine visits with respiratory symptoms or risk factors for obstructive airway diseases. Spirometry was considered technically correct when at least three manoeuvres met ERS/ATS acceptability and repeatability criteria. The most common spirometry errors were assessed and stepwise logistic regression was applied to identify factors associated with technically correct spirometry. Airway obstruction was defined as FEV₁/FVC below the lower limit of normal. A restrictive pattern was defined as FVC below the lower limit of normal.

RESULTS

Between 1 September 2018 and 1 September 2019, 10,936 spirometry examinations were performed in 9855 patients by 673 operators. 5347 (49%) spirometry examinations met both acceptability and repeatability criteria. The most common error was plateau error (17.7%). Operator age >40 years (OR 1.49, 95% CI 1.35-1.64) and repetition of the examination at the same visit (OR 1.90, 95% CI 1.66-2.16) increased the likelihood of a technically correct examination. Airway obstruction was found in 17% of correctly performed spirometry examinations.

CONCLUSIONS

Our nationwide study suggests that use of the AioCare® mobile spirometer in primary care could be feasible. More intensive and continual training should be implemented to improve the quality of spirometry examinations.

Quality assurance of spirometry in a population-based study -predictors of good outcome in spirometry testing

BACKGROUND

The assurance of high-quality spirometry testing remains a challenge.

METHODS

Spirometry training consisted of standardized coaching followed by certification for 35 spirometry-naïve and 9 spirometry-experienced research assistants. Spirometry was performed before and after bronchodilator (BD) in random population samples of 5176 people aged 40 years and older from 9 sites in Canada. using the hand-held EasyOne spirometer (ndd Medical Technologies Inc., Andover, MA, USA). Pulmonary function quality assurance with over reading was conducted centrally in Vancouver: spirograms were reviewed and graded according to ATS/ERS standards with prompt feedback to the technician at each site. Descriptive statistics were calculated for manoeuvre acceptability and repeatability variables. A logistic regression model was constructed for the predictors of spirometry quality success.

RESULTS

95% of test sessions achieved pre-determined quality standards for back extrapolated volume (BEV), time to peak flow (PEFT) and end of test volume (EOTV). The mean forced expiratory time (FET) was 11.2 seconds. Then, 90% and 95% of all manoeuvres had FEV1 and FVC that were repeatable within 150 ml and 200 ml respectively. Test quality was slightly better for post-BD test sessions compared with pre-BD for both groups of research assistants. Independent predictors of acceptable test quality included participant characteristics: female sex, younger age, greater BD responsiveness; but not study site or prior experience in completing spirometry by the technologist.

CONCLUSIONS

Good quality spirometry tests are attainable in large multicenter epidemiological studies by trained research assistants, irrespective of their prior experience in spirometry.

Reference values and repeatability of inspiratory capacity for men and women aged 65-85

The inspiratory capacity (IC) has recently gained importance because it may signal the occurrence of dynamic hyperinflation at rest or during exercise by reflecting changes in the end expiratory lung volume (EELV). However, reliable predicted values for IC are not currently available. The aim of the study was to generate predictive equations for reference values of IC in adults aged 65-85 living in Italy and to determine its limits of the within test-session repeatability. From the control group (n=429) of the SARA study data base, 241 (161 females) never smoked, non-obese (BMI<30 kg/m2) healthy subjects aged 65-85 who were able to correctly perform at least two manoeuvres of IC were selected. A model that incorporated age, height and body mass index as significant predictors in either sexes produced predicting equations for IC with a coefficient of determination of r2=.36 and .34 for females and males, respectively. Ninety per cent of all the subjects were able to keep the second highest IC within 200 ml (<9%) from the best IC. No significant gender difference was found for IC repeatability. We provided the equations for deriving reliable IC reference values that can be applied in the elderly people living in southern Europe. In this population IC showed limits of the within-session repeatability similar to those accepted for other spirometric indices such as FEV1 and FVC.

Factors determining performance of bronchodilator reversibility tests in middle-aged and elderly

Knowledge of the factors determining the performance of bronchodilator reversibility testing in a general population is lacking. Random samples of all adults aged 47-48 and 71-73 years living in Bergen, Norway, were invited to a cross-sectional study. Altogether 3506 subjects attended (69%). Test quality predictors were examined through multiple logistic regression analyses including gender, age, body mass, educational level, smoking history, respiratory symptoms, and in the elderly cohort cognitive level. Among the participants, 1.6% refused to inhale salbutamol, 2.5% failed the initial spirometry according to the ATS guidelines, and 1.3% failed the post-bronchodilator spirometry. Old age and body mass index > 30 kg/m2 were independent risk factors for an unsuccessful initial spirometry, and never smoking and respiratory symptoms were risk factors for failing the post-bronchodilator spirometry. Cognitive impairment in the elderly was a risk factor for failing both the initial- and post-bronchodilator spirometry. The median number of forced expirations was 7 in subjects obtaining an acceptable reversibility test. One third of these participants needed > or = 8 attempts, with independent predicting factors being old age, Little formal education and never smoking. Although reversibility testing becomes increasingly difficult with age, reliable data are obtained in a vast majority (94%) of subjects in our community study.

Repeatability of spirometry in 18,000 adult patients

The objective of this study was to determine the limits for repeatability of FEV1, FVC, and PEF during spirometry test sessions in adult outpatients. A retrospective chart review of 18,000 consecutive patients, aged 20 to 90 years, referred to a large outpatient pulmonary function laboratory for testing was performed. Measurements included the differences between the highest and second-highest FVC (dFVC), FEV1 (dFEV1), and PEF (dPEF), from prebronchodilator spirometry, and anthropometric factors. Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%). Patient characteristics, such as sex, age, height, smoking status, and FEV1 (% predicted), had very little effect on repeatability, explaining only 2 to 4% of the variation in repeatability (expressed in milliliters). We conclude that the ability of patients to meet or exceed spirometry repeatability goals does not depend on patient characteristics when testing is performed by experienced personnel. The current American Thoracic Society repeatability goal of 200 ml for FEV1 and FVC may be too lenient.

Feasibility of measuring lung function in preschool children

BACKGROUND

There have been difficulties in applying spirometric tests to children of preschool age.

METHODS

The feasibility of measuring lung function was examined in 652 children aged 3-6 years using dynamic spirometry with an animation programme and the guidelines approved by the European Respiratory Society.

RESULTS

Data from 603 (92%) children with at least two acceptable forced expiratory manoeuvres were analysed; 408 (68%) achieved at least three acceptable manoeuvres. Children with only two acceptable manoeuvres were younger, shorter, and weighed less (p<0.001). The lower levels of lung function in this group were partly explained by body size. 63% of those with three acceptable manoeuvres had a difference of </=5% between the highest and second highest forced expiratory volume in 1 second (FEV(1)); when a difference of </=10% was applied, 91% of the children were included. A similar trend was seen for forced vital capacity (FVC). The acceptability and reproducibility increased with increasing age, and levels of lung function increased linearly with age. The linear regression model showed that standing height was a satisfactory predictor of lung function; the explained fraction of variance (R(2)) was 59% for FEV(1). Most FVC manoeuvres in children older than 3 years were acceptable and reproducible.

CONCLUSIONS

Spirometric testing is feasible in preschool children and may be useful for both clinical practice and research. This study may fill the deficiency in reference values for European preschool children.

Quality of spirometry test performance in children and adolescents : experience in a large field study

STUDY OBJECTIVE

To determine the ability of children and adolescents to meet the American Thoracic Society (ATS) goals for spirometry quality that were based on results from adults.

DESIGN

Observational.

PARTICIPANTS

More than 4,000 public school students, ages 9 to 18 years.

MEASUREMENTS

Spirometry was performed annually for 3 years, with the recording of maneuver quality measures of forced expiratory time, end-of-test volume, back-extrapolated volume, and time to peak expiratory flow (PEFT), and the recording of differences between best and second-best FVC, FEV(1), and peak expiratory flow (PEF) values.

RESULTS

Regression analyses showed significant influences of participant age, gender, ethnicity, size, clinical status, and previous testing experience, as well as differences among individual test technicians. In general, these influences were small and explained little of the variance in performance. On average, children with a history of asthma or wheeze performed better quality spirometry than did others. Only PEFT improved significantly from year to year. Overall, only 15% of girls' tests and 32% of boys' tests met the PEFT criterion derived from adults in the Lung Health Study.

CONCLUSION

Most of the children met adult-based ATS goals for spirometry test performance. Age group-specific criteria are needed to ensure adequately fast PEFT and reproducible PEF values.

Association of years of occupational quartz exposure with spirometric airflow limitation in Norwegian men aged 30-46 years

BACKGROUND

The association between occupational quartz exposure and ventilatory function was investigated in men in a general population after adjusting for other potential determinants of outcome.

METHODS

All eligible men aged 30-46 years living in western Norway (n = 45,380) were invited to a cross sectional community survey. This included a self administered questionnaire (with respiratory symptoms, smoking habits and occupational exposures), spirometric recordings (using dry wedge below spirometers), and a chest radiograph (65% attendance). Measurements of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were obtained in 91% (n = 26,803) of those who participated, 26,106 of whom performed successful spirometric tests and had normal chest radiographs and remained for further analysis. Age, body mass index, and technician standardised residuals ((observed minus predicted value)/residual standard error) of maximum FEV1/height2 and FVC/height2 were used as outcome variables for adjusted lung function levels, respectively.

RESULTS

Occupational quartz exposure was reported by 13% (n = 3445) of those who participated in the survey, with a mean duration of seven years. Among those exposed to quartz, significant inverse linear relationships were observed between years of exposure and FEV1 level and the ratio of FEV1/FVC, independent of host characteristics. Multiple linear regression analyses showed that the difference in FEV1 associated with each year of quartz exposure was -4.3 ml (95% CI -1.1 to -7.5 ml; p = 0.01) compared with -6.9 ml (95% CI -4.7 to -9.1 ml; p < 0.01) from smoking 20 cigarettes/day for one year after adjusting for age, atopy, asthma, wheezing, marital status, and other occupational exposures.

CONCLUSION

In men aged 30-46 years with occupational quartz exposure and normal chest radiographs the duration of occupational quartz exposure was an independent predictor for spirometric airflow limitation.

Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) variability in asymptomatic never-smoking men

We examined the effects from subjects, technicians and spirometers on within-session variability in successful recordings of forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) in 4989 asymptomatic never-smoking men. All eligible men aged 30-46 years living in western Norway (n = 45,380) were invited to a cross-sectional community survey. Information on respiratory symptoms, smoking habits and occupational exposures was obtained from a self-administered questionnaire. Three successful FEV1 and FVC recordings were obtained in 26,368 attendants using three dry-wedge bellow spirometers operated by 10 different technicians. Within-subject standard deviation (SD) from three recordings of FEV1 and FVC was on average 102 and 106 ml, respectively, and increased with height (14 and 17 ml, respectively, per 10 cm) and body mass index (BMI) (11 and 14 ml, respectively, per 5 kg m-2). Between-subject SD of the mean of three FEV1 and FVC recordings was 591 and 754 ml, respectively, and increased in groups of increasing height (43 and 40 ml, respectively, per 10 cm). Small, but significant, differences were observed between technicians in within-subject SD and in levels of FEV1 and FVC. Homogeneity of between-subject variability, necessary for linear regression analysis, was obtained using FEV1 and FVC divided by height squared. In conclusion, within-subject variability in three successful spirometric recordings was small, but dependent on height and BMI of the subjects as well as technician performance. The observed heterogeneity in between-subject variation in FEV1 and FVC levels disappeared when each variable was divided by height squared. Novel multiple linear regression equations for FEV1/height2 and FVC/height2 were developed to be used in evaluating the effects from occupational airborne exposures in Nordic men aged 30-46 years.

The single-breath nitrogen test in coal miners: factors associated with failure to perform

The single-breath nitrogen washout (SBN2) test was used, along with spirometry, in the baseline examination of a longitudinal study in a cohort of active coal miners from North-eastern France. The procedure was computerized, allowing the technician to coach and encourage the subject, and excluding computation errors. While all miners performed satisfactory spirometry, a significant number were unable to meet the National Heart and Lung Institute recommendation concerning a 10% agreement of vital capacities. When the limits were set at +/-12%, 57 miners (24.2%) were still classified as failing to perform. When compared to those who succeeded, those failing proved to be significantly older, had more cumulated dust exposure, a higher prevalence of chronic cough and sputum, and a trend for more micronodulation on the chest radiographs. The ventilatory function did not differ between the two groups. These results confirm previous data on spirometric test failure concerning older age and respiratory symptoms, extending them to the SBN2 test. The present study further indicates that dust exposure and roentgenologic pneumoconiosis nodulation are associated with failure to perform the SBN2 test.