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Spirometry Testing Standards in Spinal Cord Injury^*

Alyson Kelley, BS; Eric Garshick, MD, MOH, FCCP; Erica R. Gross, BS; Steven L. Lieberman, MD; Carlos G. Tun, MD and Robert Brown, MD

^* From the Pulmonary and Critical Care Medicine Section, Medical Service, and Rehabilitation Medicine Service, VA Boston Healthcare System; Harvard Medical School, Boston, MA. Currently at Massachusetts General Hospital.

Correspondence to: Eric Garshick, MD, MOH, FCCP, Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132; e-mail: eric.garshick{at}med.va.gov

Study objectives: Because muscle paralysis makes it uncertain whether subjects with spinal cord injury (SCI) can perform spirometry in accordance with American Thoracic Society (ATS) standards, determinants of test failure were examined.

Design: Cross-sectional study.

Setting: Veterans Affairs (VA) medical center.

Participants: Veterans with SCI at VA Boston Healthcare System and nonveterans recruited by mail and advertisement.

Measurements and results: Two hundred thirty of 278 subjects (83%) were able to produce three expiratory efforts lasting 6 s and without excessive back-extrapolated volume (EBEV). In 217 of 230 subjects (94%), FVC and FEV₁ were each reproducible in accordance with 1994 ATS standards. In the remaining 48 subjects, efforts with smooth and continuous volume-time tracings and acceptable flow-volume loops were identified. These subjects had a lower percentage of predicted FVC, FEV₁, and maximum expiratory and inspiratory pressures compared to the others, and a greater proportion had neurologically complete cervical injury (42% compared to 16%). In 19 subjects (40%), some expiratory efforts were not sustained maximally for 6 s but had at least a 0.5-s plateau at residual volume (short efforts). In eight subjects (17%), some efforts were not short but had EBEV. In the remaining 21 subjects (44%), some efforts were short, some had EBEV, and some had both. If these efforts were not rejected, 262 of 278 subjects (94%) would have produced three acceptable efforts, and in 257 subjects (92%), the efforts were reproducible.

Conclusions: Subjects with SCI with the most impaired respiratory muscles and abnormal pulmonary function are able to perform spirometry reproducibly despite not meeting usual ATS acceptability standards. Exclusion of these subjects would lead to bias in studies of respiratory function in SCI. The modification of spirometry testing standards to include efforts with EBEV and with a 0.5-s plateau if < 6 s would reduce the potential for bias.

Key Words: reference standards • spinal cord injury • spirometry

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