Despite its efficacy, spirometry is often underutilized in the pediatric primary care setting.

By Dillon Stickle

Spirometry, a test used to assess how well our lungs work, is a staple tool for diagnosing conditions that affect our breathing. Particularly for pediatric patients, spirometry has built itself a reputation as the gold standard for diagnosing and managing asthma. Although the prevalence of asthma in children has improved in the last decade, it still remains one of the most common chronic lung diseases1—which makes clear that physicians still need to be knowledgeable on best practices in diagnosing and managing asthma in the pediatric population. Some studies have shown, however, that spirometry is often underutilized in the pediatric primary care setting overall.2

Understanding the Reasons

There are several factors that contribute to underutilization of spirometry, according to Daniel Weiner, MD, Associate Professor of Pediatrics, University of Pittsburgh School of Medicine.

“Many primary care settings do not have office staff that have been adequately trained to coach children to perform spirometry,” he said. “The physicians may not feel comfortable interpreting spirometry.” Additionally, Weiner noted, office visits in primary care are often as short as 10-15 minutes, and spirometry can easily take an additional 10-15 minutes. “This presents a challenge for patient flow through the office.”

Gregory S. Montgomery, MD, co-medical director, Pediatric Pulmonary Hypertension Program, Riley Hospital for Children at IU Health and associate professor of Clinical Pediatrics, Indiana University School of Medicine, has a couple of other ideas about why spirometry might fly under the radar in the pediatric primary care setting.

“There is a common misconception that most children simply cannot adequately perform a spirometry maneuver,” he said. “However, our experience has shown a persistent approach by a well-trained, enthusiastic spirometry technician can provide reproducible, clinically-helpful flow-volume curves in most children—even some cooperative toddlers.

“Second, many primary care facilities either do not have access to or do not feel investment in spirometry devices is worthwhile. I firmly believe spirometry data can greatly enhance the clinical picture in children with either suspected or known asthma, and in many cases, allows treatment decisions and/or specialty referral to be made much more confidently,” he adds.

Best Practices and More Training

Given these reasons, it is easy to understand why both Montgomery and Weiner say that the current use of spirometry in the pediatric primary care setting does not conform to current national guidelines. “I often will see children that have been given a ‘definitive’ asthma diagnosis made solely upon the presence of episodic wheezing or persistent cough,” said Montgomery. “As the guidelines clearly recommend, spirometry really should be a key facet to making the diagnosis of asthma in children over five years of age, rather than reliance on clinical symptoms, family history and peak flow measures.”

“National guidelines recommend spirometry at diagnosis, after initiating therapy, and then every 1-2 years after that,” added Weiner. “In our specialty setting, we obtain spirometry at every visit, not only for assisting in diagnosis but for monitoring response to therapies and/or disease progression. We try not to rely on clinical assessments alone, and seek to use objective measurements whenever possible. “

Consequences and Solutions

Identifying the reasons why spirometry is underutilized in pediatric primary care settings is only the first step in understanding the issue. Not using spirometry testing, or not using it enough, may have clinical implications that could otherwise have been avoided. According to Montgomery, one of the challenges that can arise is the misuse of certain medications because of an incorrect diagnosis.

“I have seen many children with a profound degree of airway obstruction on spirometry in my office, which belies a minimalist asthma medication regimen currently prescribed,” Montgomery said. “At other times, I have seen children given a simple clinical diagnosis of asthma without any previous spirometry testing. Upon referral to our practice, these same children will subsequently show absolutely no evidence of obstruction on routine spirometry despite persistent symptoms. For many of these kids, asthma is often not the correct diagnosis. Further investigation will usually lead to an alternative diagnosis, but during the preceding time period, many kids are unnecessarily exposed to multiple medications such as repeated doses of systemic corticosteroids.”

Montgomery adds that diagnoses like vocal cord dysfunction, functional dyspnea and even some anatomic abnormalities can be teased out with simple spirometry testing.

While it is possible for kids to go undiagnosed when spirometry is not implemented, Weiner’s concern is the severity of symptoms, and how that affects the type of treatment the patients receive. “It is possible that some children go undiagnosed,” he said, “but more commonly is a patient whose symptoms are felt to be only intermittent or mild and they have obvious obstruction on spirometry –signaling a need for more chronic therapy.”

Montgomery also emphasizes that spirometry results are not binary (ie normal or abnormal), but quantitative. “How we approach a patient with mild obstruction may be different than how we approach a patient with moderate or severe obstruction.” Weiner also said that, occasionally, spirometry testing will identify completely different problems, such as a patient with a restrictive pulmonary defect, that require additional testing.

So, what can be done to improve the overall utilization of spirometry in diagnosing and managing pediatric asthma? Montgomery and Weiner both agree that better education and training is a good start.

“I think greater physician education highlighting the important role spirometry plays in the national asthma treatment guidelines is key,” said Montgomery. “I believe this is often understated or simply overlooked.”

Weiner adds that physicians “need to be able to recognize whether the patient performed the maneuver properly and recognize a variety of artifacts that affect test quality,” and that they “should not rely on the computer to tell them whether the patient performed the test properly.”

Montgomery has a few other pointers as well. He said, “We should be reinforcing that physicians, myself included, are notoriously bad at predicting the true degree of airway obstruction simply based on history and exam. We need a source of objective data, and it can be obtained even in children. Physician groups should also know that simple spirometry can be easily and readily implemented within most busy office settings, and this does not mean placing a huge plethysmography body-box device in the middle of their clinic. Finally, deciding to use spirometry in the primary care setting does not in any way preclude specialty consultation in those patients where a diagnosis remains elusive.”

“I would say that the important parts of success in getting good quality spirometry are having an enthusiastic coach who is not afraid to engage with young patients, and practice, practice, practice for the technicians and the patients,” said Weiner. “Often a young patient doing spirometry for the first or second time is not able to perform the maneuver properly, but after doing it for the third or fourth time they finally get it.”

Products in Spirometry

There are plenty of spirometry products currently on the market that aim to give physicians the best possible tools when diagnosing and managing asthma in children. Here are some noteworthy products designed specifically for the pediatric population.

The latest spirometer from ndd Medical technologies is the EasyOne Air, which has unique features for pediatric patients. “During the development stage, ndd surveyed pediatric providers for input on the product’s design,” said Joy Tobin, spokesperson for ndd. “This helped shape the EasyOne Air which offers multiple incentives to assist children in achieving their best effort. The FlowTube is ndd’s patented mouthpiece, and was designed to fit comfortably in a child’s mouth.”

Rich Rosenthal, vice president of the company Vitalograph, said the company has two products out there that have a special application to pediatrics. “Our Micro, simply put, is the lowest priced full function spirometer offering complete flow/volume loops and well-defined pre-post bronchodilator (asthma reversibility) testing,” he said. “There often is a resistance by pediatricians to invest a lot into getting spirometry going in their practices. The Micro is a good choice for them. Our PC-based spirometer, Pneumotrac, along with its software package called Spirotrac V, features predicted sets for very young children and has about nine different animated incentive graphics, making boring spirometry tests into a game for the kids.”

Spirometry testing is clearly useful in diagnosing and managing asthma in children, and hopefully more pediatric primary care settings will be utilizing it more in the future. RT

References

  1. Zahran HS, Bailey CM, Damon SA, Garbe PL, Breysse PN. Vital Signs: Asthma in Children — United States, 2001–2016. MMWR Morb Mortal Wkly Rep 2018;67:149–155. DOI: http://dx.doi.org/10.15585/mmwr.mm6705e1
  2. Ayuk AC, Uwaezuoke SN, Ndukwu CI, Ndu IK, Iloh KK, Okoli CV. Spirometry in Asthma Care: A Review of the Trends and Challenges in Pediatric Practice. Clinical Medicine Insights Pediatrics. 2017;11:1179556517720675. doi:10.1177/1179556517720675.