Spirometry

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

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

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.

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

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.

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)

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)

Click here for Community based Spirometry letter