The Benefits Of Enthusiastic Coaching In Spirometry Testing
Spirometry is a common physiological test used to measure the maximal volume of air that can be inspired and expired with maximal effort. This definition of spirometry is important as it instantly highlights how the test needs to be performed by the mention of ‘maximal effort’.
In occupational health, spirometry can be used in various areas as part of the health surveillance. The results can be obtained at the start of employment by obtaining a baseline value for the worker, or the spirometry results are obtained and observed annually, or at specific intervals depending on requirements of the employee, work environment or company. Spirometry results should be technically acceptable and repeatable as abnormal values may require referral to further intervention.
Obtaining technically acceptable results requires accurate equipment, an enthusiastic operator and subject cooperation and coordination. It is suggested that inconsistent effort can be due to inadequate instruction and coaching by the operator as well as other factors. This article will focus on the importance of good coaching and clear instructions before and during, the slow vital capacity (SVC) and forced vital capacity (FVC) measurements.
Preparing For A Spirometry Test
Achieving a technically acceptable spirometry session begins with the preparation of the test. Ensure height and weight measurements are taken accurately e.g. no shoes or heavy jackets to be worn. Once the person is sat down, check the relative contraindications, and ask about activities that should be avoided before the test according to the ATS/ERS 2019 Spirometry guidelines. Ensure the subject is sat on a comfortable chair with no wheels and arms on each side. Before testing begins, it is important to explain what the tests measures and what is required of the subject during the test. If the subject has a good understanding of the test, they are likely to perform the manoeuvres to a higher standard. In 2018, an online survey was conducted by the European Lung Foundation involving 1,760 patients from 52 countries. The aim of the survey was to improve spirometry testing by understanding the patient experience. The survey showed patients want clear information before, during and after the test. Operators should ensure they have fully explained the test in a clear and concise manner and provide feedback during the manoeuvres.
What Is The Correct Test Sequence?
Confidence in the test sequence used in spirometry is important to ensure technically acceptable and repeatable results are obtained. The steps recommended by the 2019 ATS/ERS guidelines are highlighted tables 1 and 2. The aim of this sequence is to allow the subject to breathe in as deeply as possible to total lung capacity and breathe out for as long as possible to reach residual volume. The operator should have a view of both the display screen and the subject throughout the test. Maximal inhalation is visible on the graph during testing however, it is mainly important to observe the subject not only for safety reasons, but because maximum inspiration will also be visible by looking at the subject as they may show raised shoulders and widened eyes.
Coaching during an SVC
Variation between coaching during an SVC and a FVC is important as they require different techniques. Good coaching involves focusing on each of the testing stages and making sure they are executed fully before progressing to the next step. The SVC measurement is obtained during a slow, gentle, maximal expiration after maximal inspiration. The subject should be instructed to breathe normally initially to obtain the stable tidal breathing trace, then they should be instructed to inhale until the lungs feel full, and then exhale gently until they feel empty. The air should not be released too slow as it could underestimate the VC. The manoeuvre should be a gentle, steady expiration alongside coaching to guide the subject to achieve a constant flow rate.
Coaching during an FVC
For an FVC manoeuvre the subject must first be instructed to breathe normally, the first maximum inhalation is important, and instruction should be given for the subject to “inhale as deeply as possible” (not just “take in a deep breath”). During the inspiration, the operator should coach the subject using phrases such as “more, more, more.“ and encouraging body language can also assist. Body language can be particularly useful where there may be a language barrier present. Indicators that show maximal inspiration has been achieved include eyebrows raising, eyes widening or raised shoulders. A subject who looks comfortable and hunched over is unlikely to be at full inhalation. The instruction should match the testing stages, if the focus is solely on instruction without matching the testing stages, then maximal inhalation might be missed which will underestimate the FVC.
The next step is the expiration. During the expiratory portion of the FVC manoeuvre, the subject should be instructed to blast the air out, not simply blow the air from the lungs. Continuous enthusiastic encouragement should be shown by the operator using body language and phrases such as “keep going”. It is important to note that although we want to achieve technically acceptable results, the safety of the subject should be a priority. The operator needs to be alert to any indications of discomfort where testing should stop and the manoeuvre be terminated if a subject is uncomfortable or approaching syncope.
Once the end of forced expiration criteria has been met the subject must take maximal breath back into total lung capacity, during which, use phrases such as “more, more, more” or “right to the top”.
What are the benefits of coaching?
Little research has been done in investigating the effects of encouragement in Spirometry There is one study carried out by (AL Zhranei et al., 2021) at a university in Saudi Arabia, they looked to determine whether general repetition or verbal encouragement influenced the vital capacity.136 healthy adults were split into two groups, both performing baseline spirometry and then repeated the spirometry test three times. On the second and third occasion one group received encouragement and the other group had repetition without encouragement. In the group who only repeated the test there was no difference in VC from baseline on the second and third attempt. In the group that had encouragement there was a difference in VC compared to baseline, based on statistical analysis of the data. This study highlights the important of verbal encouragement during spirometry testing.
Be a coach and a cheerleader
Enthusiastic coaching is beneficial in helping to achieve technically acceptable and repeatable results which may affect the workers job role. Good rapport with the subject and gaining their trust is crucial in obtaining maximal efforts. Finding the mid-ground between being a coach by providing feedback, and being a cheerleader by offering active encouragement, is vital. Operators should be open to adapting their approach as some subjects may require more assistance than others.
References:
AL Zhranei, R. et al. (2021) ‘The impact of verbal encouragement and repeating on the measurement of spirometry in healthy adult’, Cureus [Preprint]. doi:10.7759/cureus.18714.
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Cheung HJ, Cheung L. Coaching patients during pulmonary function testing: A practical guide. Can J Respir Ther. 2015 Summer;51(3):65-8. PMID: 26283871; PMCID: PMC4530837.
Graham, B.L. et al. (2019) ‘Standardization of spirometry 2019 update. an official American Thoracic Society and European Respiratory Society Technical Statement’, American Journal of Respiratory and Critical Care Medicine, 200(8). doi:10.1164/rccm.201908-1590st.
Enright PL. How to make sure your spirometry tests are of good quality. Respir Care. 2003 Aug;48(8):773-6. PMID: 12890297.
Johnson, B. et al. (2020) ‘Improving spirometry testing by understanding patient preferences’, ERJ Open Research, 7(1), pp. 00712–02020. doi:10.1183/23120541.00712-2020.5Imageaddexpandmore-dots
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