Spirometry

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  • High quality standard operating procedures (SOPs) are the cornerstone of mitigating risk and reducing cross infection between staff and patients undergoing spirometry
  • There is a clinical need to re-introduce spirometry to the community setting to facilitate accurate diagnosis of airways diseases
  • The exact number of patients in the backlog for diagnostic spirometry is unknown, it is estimated to be around 200–250 patients per 500,000 population (PCRS 2021)
  • Groups of patients for whom diagnostic spirometry will potentially impact their treatment pathway or determine their onward care should be prioritised (PCRS 2021)
  • Consider spirometry for those patients with a provisional diagnosis but poor response to treatment (PCRS 2021)
  • Routine spirometry is of low priority and evidence shows little clinical value (PCRS 2021)
  • Spirometry should be performed by an appropriately trained health care professional who is competent (NES 2021)
  • Current guidance from Antimicrobial Resistance and Healthcare Associated Infection Scotland (ARHAI) in collaboration with New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) and Public Health England (PHE) (https://hpspubsrepo.blob.core.windows.net/hps-website/nss/3055/documents/1_agp-sbar.pdf) lists the procedures currently designated as aerosol generating: spirometry is not considered to be an aerosol generating procedure (AGP).
  • British Thoracic Society (BTS), Association of Respiratory Nurse Specialists (ARNS), Primary Care Respiratory Society (PCRS) and the Association for Respiratory Technology and Physiology (ARTP) (https://www.pcrs-uk.org/sites/pcrs-uk.org/files/ReinstatingSpirometry270421.pdf) outline a pragmatic approach to the return of spirometry services in community settings.

Scope:

  • This document contains guidance on the prioritisation of spirometry, and appropriate measures to mitigate against potential infection. Although spirometry is considered to be non-AGP, spirometry associated cough has the potential to generate aerosol droplets so mitigating measures are recommended.
  • The operating method and re-introduction of spirometry is in compliance with: A guide to performing diagnostic spirometry (PCC 2013); ATS/ERS Standardisation of Spirometry 2019 update An Official American Thoracic Society and European Respiratory Society (ATS/ERS 2019); Risk Minimisation in Spirometry Re-start (BTS/ARTP 2021).
  • This document will standardise the procedure for re-introducing quality assured spirometry to meet quality assurance and infection prevention and control measures
  • This document will prioritise patient safety in compliance with professional organisation standards and governance requirements.

For more information on Spirometry, see PCRS website 

Operating step - Prepare room

Due consideration needs to be given to room air changes; however, it is not currently possible to monitor room changes in primary care, therefore pragmatic advice is to consider:

  1. Good air circulation e.g., testing in a room with an opening window / exterior door; ensuring interior door is closed during testing.
  2. The use of extraction fans placed in windows to exhaust room air to the outdoors may be considered. This will help draw fresh air into room via other open windows and doors without generating strong room air currents. Care must be taken to avoid causing contaminated air to flow directly from one person over.
  3. A Perspex screen between patient and operator offers an additional physical barrier for protection. These may not be widely available in general practice and are for consideration only.
  4. Consider portable high-efficiency particulate air (HEPA) fan/filtration systems
  5. Consider the positioning of the patient and performer of spirometry. The patient facing the open window during the procedure; performer to stand out of the direct line of exhaled breath

The Primary Care Respiratory Society (PCRS (2021)

https://www.pcrs-uk.org/news/new-update-spirometry-guidance

Prepare Operator

  1. Operators will need Personal Protective Equipment (PPE) consisting of gloves, apron, visor and Type IIR (surgical) mask but may be modified in line with local IPC policy (ARTP 2021)
  2. In most cases, staff undertaking spirometry will have been vaccinated. Individuals deemed to be at heightened risk of developing severe COVID-19 infection should receive an individual risk assessment in conjunction with the local Occupational Health team before undertaking frontline clinical measurements (ARTP 2021)

Association for Respiratory Technology and Physiology (ARTP 2021)

https://www.artp.org.uk/COVID19

Prepare Equipment

  1. Spirometry should be performed with a single use bacterial/viral filter in the circuit that meets ATS/ERS standards https://www.wms.co.uk/wms/en/GBP/Spirometers%2C-Nebulisers-and-Respiratory/Spirometer-Accessories-and-Consumables/MicroGard-Pulmonary-Bacterial-Viral-Filters-x50/p/D630
  2. Ensure spirometer has been cleaned as per manufacturers instructions; date and time recorded in IPC Logbook.
  3. Ensure spirometer has been calibrated as per PCC; ATS/ERS standards; date and time recorded in Calibration logbook.
  4. Record any problems encountered in Spirometry logbook and patient records.
  5. Report any breach of IPC, calibration/verification or problems encountered through appropriate channels as per local protocol.

Prioritisation of Patients

Prioritise groups of patients for whom diagnostic spirometry will potentially impact their treatment pathway or determine their onward care. Consider spirometry for those patients with a provisional diagnosis but poor response to treatment.

Spirometry to confirm diagnosis is valuable but not an immediate priority. If a patient’s history and clinical picture fits with the provisional diagnosis and they respond well to treatment it is important to confirm diagnosis but not at the expense of patients in whom spirometry might alter the diagnosis or treatment.

Routine spirometry is of low priority. Annual spirometry is no longer a Quality Outcomes Framework (QOF) requirement and the evidence shows little clinical value; if you still regularly perform spirometry on stable patients these should be at the back of the queue

https://www.artp.org.uk/News/risk-minimisation-in-spirometry-re-start-task-and-finish-group-document

Prepare Patient

  1. Pre-screening questionnaire: patients who have been triaged and meet the criteria – asymptomatic and no known contact with a COVID-19 case
  2. Spirometry should not be performed if
    1. the patient has any symptoms of COVID-19 infection at the time of the test
    2. if they are known to have recently been in  contact (within previous 10 days) with a confirmed case (PCRS 2021)
  3. Patients with profound immune vulnerability, procedures to protect them should be discussed with local clinical leads; testing at the start of a day or using a ‘cold’ testing room if possible.
  4. Allow for fallow time between patients to facilitate air changes between patients. A pragmatic approach is 1 hour between each patient.
  5. Staff performing spirometry should be aware of and utilize strategies to reduce cough and thus transmission of particles. These include but are not limited to
    1. Prior to testing, ensuring that patients are pre-counselled about what actions to take if they start to cough
    2. Try to stay on the mouthpiece if possible and cough into the filter
    3. If they feel they need to come off the device to cough, they should have a surgical facemask in immediate proximity that is placed over the mouth immediately following completion of the manoeuvre (e.g., simple surgical mask is lowered to the chin to allow a mouthpiece to be used and then replaced at end of procedure (PCRS 2021)
    4. Local services may wish to adapt the approach used in this context and in some cases use of a face shield that is lifted during the manoeuvre may be appropriate / easier for the patient.

Performing the test – Vital Capacity vs. Forced Vital Capacity

  1. Coughing associated with spirometry occurs predominantly following a forced and prolonged expiratory manoeuvre. In individuals where clinicians are concerned there is likely to be a heightened risk of infective cough:
    1. undertake a relaxed VC manoeuvre
    2. undertake a 1-2 second FVC manoeuvre to obtain FEV1 (PCRS 2021)

Record and Record Keeping

Good record keeping is a vital part of effective communication in primary care and integral to promoting safety and continuity of care for patients and clients. Staff need to be clear about their responsibilities for record keeping in whatever format records are kept.

Keep clear and accurate records relevant to your practice.

RCN (2015); NMC (2018); ARTP (2018)

Community based Spirometry

Click here for Community based Spirometry letter

Glossary

Abbreviation Meaning
ARHAI Antimicrobial Resistance and Healthcare Associated Infection Scotland 
AGP Aerosol generating procedure 
ARNS Association of Respiratory Nurse Specialists 
ARTP Association for Respiratory Technology and Physiology 
ATS/ERS
American Thoracic Society and European Respiratory Society
BTS
British Thoracic Society
HEPA
High-efficiency particulate air
IPC
Infection Prevention Control
PCRS 
Primary Care Respiratory Society
PPE Personal Protective Equipment
VC
Vital Capacity

Last reviewed: 31 December 2021

Next review: 30 June 2022

Author(s): Lead Clinical Respiratory Physiologist

Version: 1

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Senior Respiratory Physiologist

Document Id: TAM371