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Interpreting Spirometry

Article 2 to be placed under: Spirometer >> History >>

Even with the numerical precision that a spirometer can provide, determining pulmonary function relies on differentiating the abnormal from the normal. Measurements of lung function can vary both within and among groups of people, individuals, and spirometer devices. Lung capacity, for instance, may vary temporally, increasing and then decreasing in one person’s lifetime. As a result, ideas about what constitutes “normal” are based on one’s understanding about the sources of variabilities and can be left to interpretation.

Traditionally, sources of variation have been understood in discrete categories, such as age, height, weight, gender, geographical region (altitude), and race or ethnicity. Global efforts have been made in the early 20th century to standardize these sources to enable proper diagnosis and accurate evaluation of pulmonary function. However, rather than further aiming to understand the causes of such variations, the primary approach for dealing with observed differences in lung capacity has been to “correct for” them. Utilizing results from comparative population studies, attributes are empirically factored together into a “correction factor.” This number is then utilized to form a personalized ‘reference value’ that defines what is considered normal for one individual. Practitioners may thereby find the percent deviation from this predicted value, known as ‘percent of predicted,’ and determine whether someone’s lung function is abnormally poor or excellent.

In particular, ‘race correction’ or ‘ethnic adjustment’ has been effectively computer programmed into the modern-day spirometer. Preconceived notions that ‘white’ people have greater pulmonary function are embedded in spirometer measurement interpretation and have only been reinforced through this medical stereotyping. In the United States, spirometers use correction factors of 10-15% for those identified as ‘black’ and 4-6% for those identified as ‘Asian.’

Standard Guidelines

In 1960, the European Community for Coal and Steel (ECCS) first recommended guidelines for spirometry. The organization then published predicted values for parameters such as spirometric indices, residual volume, total lung capacity and functional residual capacity in 1971. The American Thoracic Society/European Respiratory Society also recommends race-specific reference values when available. Even today, the National Institute for Occupational Safety and Health’s Spirometry Training Guide that is linked to the Centers for Disease Control and Prevention’s website notes the use of race correction and a race-specific reference value in step four of “normal” spirometry.

Motivations

The use of reference values and discrete categorizations of sources of variability has been motivated by ideas of anthropometry and vital capacity. Studies have specifically looked at the relationship between anthropometric variables and lung function parameters.

Implications

The use of reference values has thus far not accounted for the social labelling of race and ethnicity. Determinations are often subjective or silently done by a practitioner. Another concern of utilizing reference values is misdiagnosis.

Evaluation of vital capacity has influenced other sectors of life other than medicine as well, including evaluation of life insurance applicants and diagnosis of tuberculosis.

Regarding gender, some population studies have indicated no difference based on gender. Notably, spirometers have been used to evaluate vital capacity in India since 1929, recording a statistically significant difference between males (21.8 mL/cm) and females (18 mL/cm).

Altering interpretations

Many have questioned whether the current standards are sufficient and accurate. As a multiethnic society develops, racial and ethnic origin as a factor becomes more and more problematic to utilize. Ideas connecting ethnicity to lack of nutrition and birthplace in a poor country become invalid as people immigrate and may be born in richer nations.

Article 1 to be placed under: John Harvey Kellogg >> Patents and Inventions >>

Medical patents

• 1896 Radiant-heat bath (US558394)
• 1906 Movement-cure apparatus (US835622)
• 1907 Exercising apparatus (US850938)
• 1908 Massage apparatus (US881321)

Medical inventions

Kellogg was not only a physician, surgeon, author, and administrator, but also an inventor. Although less discussed in comparison to his food creations, he designed and improved upon a number of medical devices that aided in his surgical operations and in treatment modalities falling under the term "physiotherapy" that were regularly used at the Battle Creek Sanitarium. Dr. Kellogg attempted to popularize these treatment methods, including electrotherapy, hydrotherapy, and motor therapy, in his work The Home Handbook of Domestic Hygiene and Rational Medicine first published in 1881.

As he specialized in certain gynecological surgeries (particularly hemorrhoidectomies and ovariotomies) and gastrointestinal surgeries, he developed various instruments for these operations including specialized hooks and retractors, a heated operating table, and an aseptic drainage tube used in abdominal surgery. Additionally, Kellogg took keen interest in devising instruments for light therapy, mechanical exercising, proper breathing, and pure water. His medical inventions spanned a wide range of applications and included a hot air bath, vibrating chair, oscillomanipulator, window tent for fresh air, pneumograph to graphically represent respiratory habits, loofah mitt, and apparatus for home sterilization of milk. Some of his inventions were even considered fashionable enough to be found in the first class gymnasium of the Titanic.

In the same way he refused to use his surgical skill or food manufacturing business for personal financial gain, Dr. Kellogg did not make concerted efforts to profit from his medical inventions. Kellogg’s statement in 1916 about his food company sheds light on his general motivations: “I desire to make clear … that the food business I have been carrying on is a part of my general scheme to propagate the ideas of health and biological living. Otherwise, I should not have engaged in it as a commercial enterprise, but I have carried it on as a part of the general philanthropic work in which I was engaged.”

Phototherapeutic inventions

Partly motivated by the overcast skies of Michigan, Kellogg experimented with and worked to develop light therapies, as he believed in the value of the electric light bulb to provide heat penetration for treating bodily disorders. He constructed his first incandescent light bath in 1891, utilizing it to treat a proclaimed thousands of patients at the Battle Creek Sanitarium before exhibiting the bath at the Chicago Exposition in 1893. The invention reportedly aroused little attention there but was brought back to Germany, where it began to be manufactured and sold; spread to Vienna by Kellogg's friend Dr. Wilhelm Winternitz; installed in royal palaces across Europe; and popularly replaced old Turkish steam baths at athletic clubs. Only after this popularization of cabinet baths in Europe did demand within the United States develop, as it was imported from Berlin to New York "as a therapeutic novelty". In 1896, Kellogg patented the radiant-heat bath in the United States (US558394).

In order “to make a record of his work and experience as a pioneer in this branch of physiotherapeutics,” Kellogg published his book Light Therapeutics: a practical manual of phototherapy for the student and the practitioner, with special reference to the incandescent electric-light bath in 1910. In the short work, Kellogg describes the application of the arc light to the spine, chest, abdominal region, loins, shoulders, hip and thigh, knees and other joints. Additionally, he goes into detail about combining electrotherapies with hydrotherapies, e.g. the electric light bath with shower and shampoo.

Electrotherapeutic inventions

Though Kellogg stated that "electricity is not capable of accomplishing half the marvels that are claimed for it by many enthusiastic electrotherapists," he still believed electric currents to be "an extremely valuable therapeutic agent, especially when utilized in connection with hydrotherapy, thermotherapy, and other physiologic methods." As a result, electrotherapy coils were used in the Static Electrical Department of the Battle Creek Sanitarium especially for cases of paresthesias of neurasthenia, insomnia, and certain forms of neuralgia. Devices were also utilized to administer electric shocks to various parts of a patient's body.

Vibrational therapy by way of sinusoidal (high-frequency oscillating) electric current was discovered by Kellogg in 1884 to have medical use for increasing blood circulation and passive exercise. In particular, Kellogg invented a vibrating chair used to stimulate vital organs in the lower abdomen. Even today one can visit the Kellogg Discovery Center in Battle Creek, Michigan, and sit on Kellogg's vibrating chair, which is equipped to mechanically oscillate 20 times per second. Furthermore, Kellogg devised an electrotherapy exercise bed in which a sinusoidal current that produced muscular contraction but no pain could be delivered for twenty minutes and reportedly achieve the stimulation of a brisk four-mile walk.

Mechanical massage devices

Massage devices included two- or four-person foot vibrators, a mechanical slapping massage device, and a kneading apparatus that was advertised in 1909 to sell for $150.00. Kellogg advocated mechanical massage, a branch of mechanotherapy, for cases of anemia, general debility, and muscular or nervous weakness.

Irrigator

In 1936, Kellogg filed a petition for his invention of improvements to an “irrigating apparatus particularly adaptable for colonic irrigating, but susceptible of use for other irrigation treatments.” The improved irrigator included features such as measuring the amount of liquid entering and exiting the colon as well as indicating and regulating the positive pressure of the pumped liquid.

At the Battle Creek Sanitarium, these colonic irrigators were often used to shoot gallons of water up a patient's rectum into their colon, sometimes followed by a half-pint yogurt enema to aid in further cleaning. It has been suggested that multiple people would get this treatment at one time.