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SPIROLA: A Solution for More Effective Use

Posted on by Eva Hnizdo, PhD, and Lu-Ann Beeckman-Wagner, PhD

While mortality rates for most chronic illnesses (heart disease, malignancy, stroke) have declined in the U.S., mortality from chronic obstructive pulmonary disease (COPD) has increased over the past 3 decades. COPD is the fourth-leading cause of death and the second leading cause of disability in the United States. Blue-collar workers have the highest prevalence of chronic obstructive pulmonary disease (COPD) in the country. The main cause of COPD is abnormal inflammatory response of the lung to inhalation of noxious particles and gases, with tobacco smoking being the most prevalent risk factor. Most cases of obstructive or restrictive respiratory diseases are preventable.

Evidence shows that in occupational settings with exposure to respiratory hazards, maintaining worker’s respiratory health is important not only for workers’ health but for reducing companies’ and individuals’ health-related costs.1-6 The National Institute for Occupational Safety and Health (NIOSH) new WorkLife initiative supports a new approach to reduce workplace hazards and promote worker safety, health, and well-being, which reflects the growing appreciation of the complexity of influences on worker health and the interactions between work-based and non-work factors. This kind of approach is particularly important in promoting workers’ respiratory health since the adverse effects of occupational and non-occupational hazards often cannot be discerned in respiratory disease. While the chronic effects of smoking and occupational exposure usually lead to a relatively small additional annual decrement in lung function during the early years of life, the lung function deterioration starts to escalate around 40 years of age in susceptible individuals. Additionally, abdominal obesity, prevalent in the U.S. workforce, usually causes restrictive pattern of impairment, and increased risk of metabolic syndrome and cardiovascular disease and diabetes.

Spirometry is a pulmonary function test measuring the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. Periodic spirometry can provide a valuable tool for early recognition and prevention of respiratory diseases and for maintaining workers’ respiratory health and general fitness. Spirometry can assist the health professional by determining if a worker demonstrates a specific pattern of respiratory impairment and can help to assess the effectiveness of measures implemented to prevent further lung function deterioration. In addition, results from defined groups of workers can be evaluated in relation to potential workplace hazards. When using periodic spirometry in the workplace, reliable baseline spirometry measurements must be established followed by good quality periodic spirometry and the evaluation of changes over time. The American College of Occupational and Environmental Medicine (ACOEM) provides guidelines on workplace periodic spirometry testing and interpretation. NIOSH approves courses in spirometry for instruction of those administering screening pulmonary function testing to employees exposed to occupational hazards. NIOSH also provides a list of course sponsors, course audit and sponsorship renewal dates, schedule of courses, and instructor resources, such as a training manual, available on the NIOSH Topic Page Spirometry in the Occupational Setting.

NIOSH recently developed computer software for Spirometry Longitudinal Data Analysis (SPIROLA) to enhance healthcare providers’ capacity in managing and interpreting periodic spirometry.7-11 SPIROLA is designed to assist healthcare providers in:

  1. monitoring spirometry data precision and quality;
  2. applying interpretative strategies to identifying individuals who may experiencing excessive loss of lung function (i.e., those at risk of developing disabling lung function impairment);
  3. integrating and evaluating longitudinal spirometry, questionnaire responses, and information on potential risk factors for decision-making;
  4. designing, recoding, and implementing intervention plans; and
  5. subsequent evaluation of the effect of intervention in individuals and a group.

The software can be downloaded for free from the NIOSH Topic Page Spirometry in the Occupational Setting for accomplishing (i to ii), and on request from to accomplish (iii-v). See an example of a SPIROLA chart below:

Screen capture of a SPIROLA chart 
If you conduct workplace periodic spirometry we invite you to share your experiences by posting on this blog. We would specifically be interested in posts addressing:

  • How periodic spirometry results are used in your setting including potential barriers to using spirometry results for prevention
  • How an individual’s spirometry measurement changes are evaluated over time for example by:
    • visual inspection of the longitudinal spirometry results,
    • calculating changes over time using a computer,
    • comparing results to ATS or ACOEM interpretation guidelines for annual or longer follow-up changes, or
    • if not evaluated, describe the barriers to evaluating changes in spirometry measurements over time.
  • Barriers to computerizing spirometry data
  • Your experiences, if any, with Spirometry Longitudinal Data Analysis (SPIROLA) software
  • Your thoughts about additional assistance that NIOSH could provide to promote use of periodic spirometry for respiratory disease prevention.

Dr. Hnizdo is a senior service fellow in the NIOSH Division of Respiratory Disease Studies. Her research focus is on epidemiological research into longitudinal spirometry and medical monitoring for occupational lung diseases.

Dr. Beeckman-Wagner is a Health Scientist in NIOSH’s Division of Respiratory Disease Studies and the program director for the NIOSH-Approved Spirometry Training Program.

See this entry’s references

Posted on by Eva Hnizdo, PhD, and Lu-Ann Beeckman-Wagner, PhD

9 comments on “SPIROLA: A Solution for More Effective Use”

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    You will be happy to know we are incorporating the Spirola data into our QI Plan this year. We will quarterly assess technician efficiency using the Spirola value system. My questions involve the beginning performance statement under #2. We will change that to read “Not more than 150ml…” The statement says that 500ml is ok, since it is greater than 150ml, so we will fix that. However, the standard we have used when testing patients is “no greater than 200ml between best test and next best test on both the FEV1 and FVC.” Is 150ml the newest standard under ATS Guidelines? I think this difference will affect the grade given under Spirola. How hard would it be to change our Spirola Database to 200ml instead of 150ml if 200ml’s is our pulmonologists preference?

    Indicator to measure improvement Beginning performance Goal
    1. Use of Spirola spirometry quality grades using QFEV!, QFVC, Q Test Grades A & B 90%
    2. Use of Spirola repeatability score using FEV1 and FVC values >150ml between 1st & 2nd best test 90%

    I am pleased that you are finding SPIROLA useful. The 2005 new ATS/ERS standards are for between maneuver criteria of 0.150 L for both FVC and FEV1. This is why SPIROLA uses 150 ml. If you for some reason cannot use the 150 ml standard, we could alter your version of SPIROLA, but then you would not be able to download a new version from the Internet.


    I am using the Vmax lung function equipment and would love to harness this database using Spirola. Is there anyway I can do this? Has anyone else had any success in using Spirola with Vmax lung function equipment?

    Your software looks really useful. I have a question and a comment. My question: is the software designed for use in all age groups or just adults?

    My comment: we have found the the Quality Check grades given by some office spirometers are grossly inaccurate as they are unable to detect errors within the wave formation (eg cough, variable flow) and thus gives the false report that a test is done well when it would not pass ATS/ERS standards if graded by a human. Thus your feedback about QC trends, although laudable, would repeat the same inaccurate information created by the QCs generated by the spirometers.

    The figures referenced are available here:
    Currently SPIROLA software analyzes and plots spirometry data for adults, ages 18 to 100 years. The new version, which we hope to put up soon, will start from 15 years of age. If there is a demand for it, we may be able to incorporate changes to allow monitoring of children from 6 years of age and add a set of reference equations for children.

    Although the Quality Grades provided by some spirometer manufacturers may not be entirely accurate in ascertaining test quality, we have found that monitoring of the Quality Grades over time can be helpful in evaluation of the relative performance of different technicians. In occupational settings, some technicians can have high frequency of certain errors and the Quality Grade function helps to identify technicians who may require additional training. For example, the figures below show performance of two technicians who conducted spirometry testing on the same population of workers using the same equipment. The figures show the percentage of Quality Grades that did not meet the ATS/ERS acceptability and repeatability criteria (green lines), as evaluated by the grades provided by the spirometer, and the repeatability criteria (blue lines). The first technician (Figure 1) had a high percentage of tests with FVC Quality Grades (green line with a square symbol) that do not meet the ATS/ERS criteria; in this case mainly lack of fulfillment of the end of test criteria (the flow volume curves decreases at the end). For the second technician (Figure 2) most tests had grades that meet the ATS/ERS criteria (except the first session which is based on one individual).

    However, I agree with your comment that the monitoring of Quality Grades is only as useful as the software that provides the Quality Grades. Some spirometers provide only Test Quality Grades rather than grades for FEV1 and FVC separately. In addition, Quality Grades may not be able to detect errors within the wave formation (e.g., cough, variable flow) and if these errors are systematically accepted by some technicians they may go undetected by the monitoring. However, if the software assessment is consistent, it is likely that a technician who makes systematically one kind of error will also make other errors that will be detected by the monitored Quality Grades and the need for additional training will become clear. In our experience, the continuous monitoring of the technicians performance helps to maintain technicians performance and identify those who may need additional training.

    The other SPIROLA software function that helps to evaluate longitudinal FEV1 data precision is the red line shown in the above figures. The red line monitors the relative within-person variation in FEV1 tests repeated over time (i.e., longitudinal data precision) and the value of 4% represents acceptable longitudinal FEV1 data precision. The within-person variation is useful for the evaluation of the performance of the spirometry testing protocol and of the performance of the spirometer itself. The figure below shows changes in the value of the within-person variation (relative and absolute) over time associated with a purchase of a new spirometer and possible associated procedural errors. The spirometry data collected during the period of high within-person variation were grossly inaccurate for any purposes. Replacement of the spirometer helped to improve the longitudinal FEV1 data precision.

    I concur with you that a human evaluation of spirometry quality using spirometry tracings is important and needs to be a part of any spirometry testing program. The functions provided by SPIROLA for the purposes of monitoring spirometry Quality Grades by technicians, and for monitoring of longitudinal data precision are additional tools helpful in maintaining acceptable and reliable spirometry data.

    I heard that there are at least three spirometry machines that interface with the SPIROLA software so that the data from the test is automatically stored in SPIROLA. I would like to know which spirometry machines have this interface capability.

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