Both the ATS and ACOEM stress the importance of Spirometry refresher training, since it has been observed that test performance by well trained technicians can decay over a period of time resulting in an increasing prevalence of poor quality data. Poor quality data invariably results in an increase in false positive and sometimes false negative interpretations. As stated in the ATS standardization of spirometry 2019 update: It is the responsibility of the operator to observe and engage with the patient to achieve optimal results, which requires a combination of training and experience. Training courses for conducting quality spirometry testing are available in many countries, which has led to operators following ATS/ERS standards (14, 15, 49-51), but short-term follow-up and supplementary training are important to maintain quality (52, 53). Operator training and attainment and maintenance of competency must be integrated in any spirometry testing service (54).

It would appear that the reason for this downward trend in technician performance can be related to one of the following reasons:

  1. Increased work pressure (not enough time allocated to the test procedure) thereby prompting technicians to take shortcuts in procedure to save time
  2. Boredom, resulting in careless work caused by having to perform too many tests each day

The need for periodic retraining of those conducting spirometry testing is supported by a paper written by Dr William Edmonson, writing in the Medical Journal ‘Chest’ (publication of the American College of Chest Physicians) where he reports on a study conducted to document the effects of periodic retraining of technicians and the resultant improvement in their performance by collecting a higher prevalence of valid data

Does Periodic Technician Training Affect Spirometry Quality?

William R. Edmonson MD, Anywhere University

PURPOSE:Pulmonary function testing is an integral part of clinical decision making. In order to accurately assess disease status, the physician must have a test that is both reproducible and interpretable. The American Thoracic Society (ATS) has published standards for spirometry, lung volumes, and diffusing capacity which give us guidance for having tests which are of acceptable quality. Our study examines the effect of technician education on the quality of spirometry.

METHODS:Using ATS guidelines, we retrospectively analyzed spirometric tests performed by 5 technicians in a large hospital affiliated with an academic institution throughout a 7 month period. Initial on-site training was performed prior to the beginning of the study with a repeat session given 6 months later. Tests were compared throughout the 7 month period for meeting ATS requirements. Tests were considered to meet ATS guidelines if the Forced Vital Capacity, Forced Expired Volume in 1 second, and the Peak Expired Flow were reproducible; in addition, the best test met the ATS criteria for individual trial as follows: 1) initial extrapolation of expiration < 5%; 2) end of test plateau; and 3) expiratory time 6 seconds or greater. _ square analysis was used to test whether there are differences among the three testing periods. Bonferroni correction was used for multiple comparisons. This study was approved by the Institutional Review Board.

RESULTS:After initial training, 71% of spirometry performed met ATS criteria. Two months later, without further training, the percentage of spirometry meeting ATS criteria dropped to 48% (p<0.01). The percentage of tests meeting ATS criteria for the next 4 months remained between 48-51% (p>0.99). Training was then reinitiated with an improvement to 67% of tests meeting ATS standards (p<0.01) which returned results to their previous quality (p>0.99).

CONCLUSION:Decline in quality was statistically significant after 2 months of the initial training session. This trend persisted until repeat training was performed. Periodic technician training improved the percentage of spirometry meeting ATS criteria and, thus, the quality of the tests performed. Periodic training should be considered at least every 2 months for all technicians performing spirometric testing.

CLINICAL IMPLICATIONS:Improved spirometry quality will assist clinicians in making more accurate assessments of their patients’ disease status. Cost of medical care may improve if additional testing can be avoided on patients with inaccurate or uninterpretable spirometric tests.

DISCLOSURE:W. R. Edmonson, None.