PFT H8395 Ebook PDF

H8395_ebooks https://www.westernschools.com/Portals/0/html/H8395/zKhXyy_files/...
Pulmonary Function Testing

Michael R. Carr, Helen Schaar Corning
previous page
PRINT ALL
Pulmonary Function Testing
By
Michael R. Carr, BA, RRT, RCP
Helen Schaar Corning, RRT, RCP
Upon successful completion of this course, continuing education hours

will be awarded as follows:
Respiratory Therapists: 4 Contact Hours
1 of 45 20-Oct-2016 9:40 AM
Respiratory Therapy Planner: David Chang, EdD, RRT
The planner who worked on this continuing education activity has

disclosed that he has no significant financial or other conflicts of interest
pertaining to this course book.
Western Schools courses are designed to provide healthcare professionals with

the educational information they need to enhance their career development as well
as to work collaboratively on improving patient care. The information provided
within these course materials is the result of research and consultation with
prominent healthcare authorities and is, to the best of our knowledge, current and
accurate at the time of printing. However, course materials are provided with the
understanding that Western Schools is not engaged in offering legal, medical, or
other professional advice.
Western Schools courses and course materials are not meant to act as a
substitute for seeking professional advice or conducting individual research. When
the information provided in course materials is applied to individual cases, all
recommendations must be considered in light of each cases unique
circumstances.
Western Schools course materials are intended solely for your use and not for the
purpose of providing advice or recommendations to third parties. Western Schools
absolves itself of any responsibility for adverse consequences resulting from the
failure to seek medical, or other professional advice. Western Schools further
absolves itself of any responsibility for updating or revising any programs or
publications presented, published, distributed, or sponsored by Western Schools
unless otherwise agreed to as part of an individual purchase contract.
Products (including brand names) mentioned or pictured in Western Schools
courses are not endorsed by Western Schools, any of its accrediting organizations,
or any state licensing board.
COPYRIGHT 2006Western Schools. All Rights Reserved. No part(s)

of this material may be reprinted, reproduced, transmitted, stored in a
retrieval system, or otherwise utilized, in any form or by any means
electronic or mechanical, including photocopying or recording, now
existing or hereinafter invented, nor may any part of this course be used
for teaching without written permission from the publisher.
2 of 45 20-Oct-2016 9:40 AM
INTRODUCTION
COURSE OBJECTIVES
After completing this course, the learner will be able to:
1. List the primary indications for pulmonary function tests (PFTs) and
special procedures used.
2. Explain ATPS/BTPS and ATS standards.
3. Differentiate between lung volumes and lung capacities and the volumes
contained therein.
4. Explain what spirometry is and the volumes and flow rates that can be
determined by spirometry as well as the lung volumes that cannot be
measured by spirometry.
5. Summarize the DLCO procedure.
6. Explain body plethysmography.
7. List the purpose of performing the helium dilution and nitrogen washout.
8. Describe the pulmonary angiogram or arteriogram.
9. List the main purpose of a V/Q scan.
10. Differentiate obstructive and restrictive disorders based on PFT results.
11. Explain the normal and abnormal range in percent of predicted values.
12. Specify the formula for ideal body weight (IBW) and calculating the
oxygen index as well as how to calculate the P/F ratio.
espiratory therapists are often asked to perform pulmonary function tests
R (PF or PFT) in different areas of hospitals and oversee pulmonary function

laboratories. Pulmonary function testing offers many opportunities for a
respiratory therapist because there are numerous indications for testing, and the
tests are currently under-used by most physicians.
The pulmonary function technician (respiratory therapist) is responsible for
explaining the testing procedure to the patient and coaching the patient in order to
obtain the best possible results. The results are then documented and given to the
attending physician for interpretation and follow-up treatment, if needed.
Evaluation of pulmonary function benefits many types of patients. Pulmonary
disease may frequently be detected by PF years before the onset of signs or
symptoms. Early detection of pulmonary disease can be a strong influence in the
decision to quit smoking among patients, which reduces the risk of both
cardiovascular disease and worsening pulmonary disease. Test comparison helps
the physician to determine whether a specific therapeutic regimen is beneficial.
3 of 45 20-Oct-2016 9:40 AM
Shortness of breath is a common complaint for which PF tests can help

differentiate between a cardiac and a pulmonary cause. The PF tests performed
before planned surgery help to reduce the incidence of postoperative pulmonary
complications by identifying patients at increased risk. Finally, patients who feel that
their ability to work is limited by shortness of breath can be objectively evaluated by
PF tests.
This course describes the tests that respiratory therapists should be familiar
with even if they do not work in a pulmonary function laboratory. It is not uncommon
to see current charts of patients admitted to hospitals reporting previous PFTs. A
quick review of these results may be instrumental in decision making about current
treatment. In addition to defining the common pulmonary function tests performed,
a brief discussion of what may cause abnormalities in the results is included.
4 of 45 20-Oct-2016 9:40 AM
PULMONARY FUNCTION TESTING
PRIMARY INDICATIONS FOR PULMONARY FUNCTION

TESTS
Assessment of the respiratory system
Test for the presence of lung disease
Identify the type of lung disorder (obstructive vs. restrictive)
Aid in identifying location of disorder (small vs. large airways)
Evaluate the extent of pulmonary dysfunction
Assess progression of lung disease
Aid in establishing a therapeutic regimen for the dysfunction.
PFTs are used to assess the respiratory system, and can also aid in
differentiating between obstructive and restrictive lung diseases. Obstructive lung
diseases include asthma, bronchitis, bronchiectasis, emphysema, cystic fibrosis,
and bronchopulmonary dysplasia. Most other lung disorders are classified as
restrictive lung diseases. Some of the most common restrictive diseases and
disorders include pneumonia, pneumothorax, pulmonary edema, pleural effusion,
myasthenia gravis, obesity, and adult respiratory distress syndrome (ARDS).
PFT MEASUREMENT STANDARDS
ATPS / BTPS
Volumes measured by spirometry are at ambient temperature, pressure, and

saturated (ATPS) conditions.
These measurements are then adjusted for the temperature difference

between the spirometer and the patients body temperature, pressure, and
saturated conditions (BTPS).
ATS Standards
American Thoracic Society (ATS) standards are guidelines that safeguard

against procedural errors, and help assure accurate results. Important factors in
meeting ATS standards are to perform equipment calibration, maintenance, and
cleaning on a regular schedule.
Equipment can go out of calibration, on its own, whether frequently or rarely
used. Also, particulate matter can accumulate inside the machine causing it to go
out of calibration. It is important to calibrate PFT equipment on schedule to assure
results are valid. One must follow the manufacturers calibration, maintenance, and
cleaning schedules, as well as the employing institutions policies.
One example of calibrating spirometers involves injecting a known amount of air
into the spirometer, and testing for a readout result of the same value. A 3-liter
5 of 45 20-Oct-2016 9:40 AM
super syringe is often utilized for this calibration.

Another important point involving PFTs is that many tests are very effort-
dependent. The patient must be motivated to put forth the very best effort.
Additionally, the patient must be thoroughly instructed on the procedure before the
test, and given three attempts (when appropriate).
DESCRIPTIONS OF LUNG VOLUMES AND LUNG

CAPACITIES
n the field of pulmonary function testing (PFT), the air within the lungs is divided
I into segments called capacities and volumes. Each lung capacity contains two
or more lung volumes. The reason for assessing the air in segments is to more
accurately measure specific lung functions in different areas of the lungs. There are
many different pulmonary diseases, and a broad range of PFTs is required to
assess and diagnose them.
The total lung capacity (TLC) is a measurement of the total volume of air
contained in the lungs. The total lung capacity contains two segments: the vital
capacity (VC), and the residual volume (RV). Therefore VC plus RV equals TLC.
The vital capacity (VC) is a measurement of the maximum volume of air that
can be exhaled after a maximal inspiration. Forced vital capacity (FVC) is the same
in volume as the VC, but the patient is asked to exhale as quickly and forcefully as
possible. The FVC is performed when one wants to assess flow rates.
The residual volume (RV) is the volume of air remaining in the lungs after a
maximal exhalation. Measuring the RV requires special testing (discussed later in
the course), as this air cannot be measured by spirometry. Since residual volume is
a part of the total lung capacity, measurement of the TLC also requires special
testing.
The total lung capacity contains the inspiratory capacity (IC) and the functional
residual capacity (FRC). Therefore IC plus FRC equals TLC. The inspiratory
capacity is the maximum amount of air that can be inhaled after a normal tidal
6 of 45 20-Oct-2016 9:40 AM
volume exhalation. The functional residual capacity is the amount of air remaining
in the lungs after a normal tidal volume exhalation.
The inspiratory capacity is divided into two volumes: the inspiratory reserve
volume (IRV) and the tidal volume (VT). The IRV is the maximum volume of air
than can be inhaled after a normal tidal volume inspiration. The VT is the volume of
air that is inhaled and exhaled during normal quiet breathing.
The functional residual capacity is divided into two volumes called the expiratory
reserve volume (ERV), and the residual volume (RV). The ERV is the amount of air
than can be exhaled after a normal tidal volume exhalation.
PFT ABBREVIATIONS AND DESCRIPTIONS

ables 1 and 2 list the abbreviations and descriptions for lung capacities and
T volumes. Table 3 lists the calculations for normal values for each of the lung
capacities and volumes.
7 of 45 20-Oct-2016 9:40 AM
SPIROMETRY
pirometry is the most frequently performed pulmonary function test. It can
S be used as an initial screening or often in conjunction with other tests to

diagnose the presence or absence of lung disease, determine the extent of
disease on lung function, measure the effects of exposures to toxins, determine the
effects of therapy, evaluate surgical risk, and to evaluate impairment or disability.
Results are displayed in graphs called spirograms.
Spirometry can measure: VC/FVC, IC, IRV, VT, ERV, and flow rates.
Spirometry cannot measure: RV, FRC, and TLC. These require special
testing, covered later in this course.
FORCED VITAL CAPACITY MEASUREMENTS

he forced vital capacity (FVC) is a commonly utilized tool for assessing lung
T function. FVC aids in diagnosing both restrictive and obstructive lung

diseases. The FVC can also help pinpoint the location of the dysfunction in
the small or large airways, and provide flow rate results. Flow rates are calculations
of the amount of time it takes to exhale air. The patient inhales as deeply as
possible, then exhales as quickly and forcefully as possible. Patients are usually
given three attempts, and the best of the three results are used to calculate the flow
rates. The flow rates also aid in determining whether a small or large airway
dysfunction is present. (See Table 4.)
8 of 45 20-Oct-2016 9:40 AM
Table 5 lists the calculations for normal values for the flow rates listed above.
Forced Expiratory Volume Timed (FEVt)
The forced expiratory volume timed (FEVt) is the volume of air measured at
specific timed intervals during the FVC test. Measurements are taken at 0.5
seconds (FEV 0.5), at 1.0 seconds (FEV 1.0), at 2.0 seconds (FEV 2.0), and at 3.0
seconds (FEV 3.0). Another measurement of the FVC is given in a timed
percentage of the vital capacity (FEVt%). This is the percentage of air exhaled
during an FVC. The FEF 25%-75% (also called maximal mid- expiratory flow rate)
is a good spirometry test for detecting small airway disease. To assess the function
of the large airways, the forced expiratory flow-rate is measured between 200 mL
and 1200 mL of the total air exhaled during the FVC. This is called the FEF
200-1200, or the MEFR, which stands for the Maximum Expiratory Flow Rate.
SPECIAL PROCEDURES IN PULMONARY FUNCTION

TESTING
DLCO - Gas Diffusion Testing
9 of 45 20-Oct-2016 9:40 AM
This test measures the factors that affect the diffusion of air across the alveolar-
capillary (A/C) membrane. The test aids in diagnosing reduced surface area for
diffusion. The most common test used is the carbon monoxide diffusion capacity or
DLCO (Lung Diffusion for Carbon Monoxide). The most common technique for this
test is called the single breath technique. The patient inhales as deeply as possible,
breathing in a low concentration of carbon monoxide mixed with helium and air.
The patient must hold their breath for ten seconds, then exhale into a device that
analyzes the gas concentrations and calculates the diffusion capacity. The normal
value for a single breath DLCO is 25 mL/minute/mmHg.
A variation of this test is the steady state DLCO test, in which the patient
breathes normally for three minutes, inhaling a mixture of carbon monoxide,
helium, and air. The measurement is taken during the third minute. The normal
DLCO steady state value is 17 mL/minute/mmHg. The DLCO used in conjunction
with the FVC is the most useful PFT for detecting emphysema. The DLCO value is
reduced in emphysema and also in some restrictive diseases, including pulmonary
fibrosis and sarcoidosis.
Bronchial Provocation Tests
Some patients have normal spirograms with all the symptoms of asthma or an
undiagnosed cough. These people often have reactive airways disease (RADS).
Bronchial provocation is a method used to make a differential diagnosis.
Challenging the patient with inhaled histamine or methacholine is most commonly
used method. Important information regarding bronchial provocation tests is
summarized here:
A. Use of bronchial provocation test
1. To assess patients with normal PFTs and symptoms of bronchospasm.
2. To quantify severity of asthma and assess changes in airway reactivity.
3. Screening of those who may be at risk, or to document the effects of

environmental or occupational exposure to toxins.
B. Patients must be asymptomatic at baseline.

C. Bronchodilators and antihistamines must be withheld before the test. Inhaled
corticosteroids should not be withheld.
D. Appropriate emergency equipment and monitoring devices should be readily
available.
E. Baseline spirometry test are measured before the challenge and compared
with serial spirometry measurements taken at specified time intervals after
the challenge.
F. Methacholine challenge (adapted from the AARC Clinical Practice Guidelines)
1. Baseline FEV1 measurements are made before the administration of the

aerosolized drug and after each successive dose is administered.
2. The first dose of methacholine administered is 0.025 mg/ml. The dose used
for each subsequent administration is determined using a predetermined
dosing schedule. Dosing schedules commonly specify doubling the dose
each time, up to a maximum of 25 mg/ml.
10 of 45 20-Oct-2016 9:40 AM
3. The methacholine concentration that causes a 20% decrease in the FEV1

from baseline is referred to as the provocative dose or PD20%.
4. The test is stopped once PD20% is reached.
5. Normal, healthy subjects have a PD20% that is greater than the maximum
dose used for testing. These individuals do not show a 20% decrease in
FEV1 during a methacholine challenge.
6. A PD20% of 8 mg/ml is common in patients with hyperreactive airways.
Measuring Residual Volume, Functional Residual Capacity, and TLC
Measuring the residual volume requires special testing as it cannot be

measured by spirometry. Since the RV is a part of the FRC and the TLC, these
measurements also require special testing. The RV measurement includes air that
is trapped in the lungs after a maximal exhalation, and can help differentiate
between obstructive and restrictive lung disease. An increased FRC or an
increased RV/TLC ratio (more than 20%) can indicate an obstructive disorder. If the
TLC and the FRC are decreased, this indicates a restrictive disorder.
Body Plethysmograph
Also called the body box, this is the most accurate method for measuring the
FRC. This test can measure the total thoracic gas volume (TGV), including air
trapped in the smallest airways. The patient sits inside of the body plethysmograph
and pants against a closed shutter, at a rate of approximately 2 breaths per
second, while the pressures and volumes are obtained. The TGV is above normal
in obstructive disease, and below normal in restrictive disorder.
Helium Dilution Test (Closed Circuit)
Another method of measuring the FRC is the closed circuit helium dilution
method. The patient breathes a mixture of air with 10% helium. The helium is
diluted by the breathing until equilibrium takes place at approximately five to seven
minutes. A percentage of that helium is diluted by the patients FRC, and the
change in helium percentage is measured to determine the FRC. If equilibrium
takes longer (up to 20 min), it indicates obstructive disease. The FRC is above
normal in obstructive disease, and below normal in restrictive disorders. The helium
dilution test is fairly accurate, but if there is a large amount of air trapped in the
patients lungs, a small amount of air may be left undetected.
Nitrogen Washout Test (Open Circuit)
Another method of measuring the FRC that also aids in detecting a pulmonary
embolism is the nitrogen washout. In this test, the patient breathes 100% oxygen
for about 7 minutes exhaling all gas into an analyzer, and a breath-by-breath curve
is obtained. The patient then exhales completely. Fractional concentration of
alveolar nitrogen (FAN2) is noted, and the FRC is computed. The FRC is increased
in obstructive disease, and decreased in restrictive disorder.
11 of 45 20-Oct-2016 9:40 AM
After 7 minutes, the normal amount of nitrogen remaining in the lungs is less
than 2.5%. If greater than 2.5% nitrogen remains at 7 minutes, this indicates poor
distribution of ventilation, obstructive disorder, or possible pulmonary embolism.
Gas/Blood Flow Distribution Testing: Single Breath Nitrogen

Elimination (SBN2)
The single breath nitrogen elimination test measures the evenness of

distribution of inspired gases. This test is very sensitive for detecting early airway
closure, small airway obstructions, and pulmonary embolism. The patient exhales
maximally, then inhales 100% oxygen maximally, followed by slowly exhaling the
gas until the lungs feel empty. The exhaled gas passes through a nitrogen analyzer
that measures the change in the concentration of nitrogen. The first 750 mL of air
exhaled is mostly deadspace, and is discarded (phase I and II). The next 500 mL of
exhaled air (phase III) is used for measurement of nitrogen distribution. The rise of
nitrogen percentage in phase III should be less than 1.5%. A higher percentage
represents uneven distribution, and a possible pulmonary embolism. This test also
includes the closing volume test (CV) and closing capacity test (CC) as listed in the
following table.
Table 6 summarizes the special procedures used in PFT testing that were
discussed above. Additionally, this table includes the Flow-Volume Loop, Volume of
Isoflow, Pulmonary Angiogram or Arteriogram, and the Ventilation/Perfusion (V/Q)
scan.
12 of 45 20-Oct-2016 9:40 AM
13 of 45 20-Oct-2016 9:40 AM
14 of 45 20-Oct-2016 9:40 AM
Table 7 lists the normal values for the pulmonary mechanics discussed in detail
below.
DESCRIPTIONS OF MISCELLANEOUS PULMONARY

MECHANICS
Maximum Voluntary Ventilation (MVV) or Maximum Breathing

Capacity (MBC)
The maximum voluntary ventilation (MVV), also called the maximum breathing
capacity (MBC), gives information on the status of respiratory muscles, and
measures compliance and resistance. The patient is instructed to breathe as deep
and as fast as possible for 12-15 seconds into a spirometer with an accumulator
recording. The maneuver exaggerates air-trapping. The value is then converted
into minutes, with a normal value of 150 to 170 liters per minute for an average
adult. This test is very sensitive and can indicate an obstructive disease in the early
stages. Results are decreased in obstructive diseases in a severe restrictive
disease, but can be normal with a mild restrictive disease.
15 of 45 20-Oct-2016 9:40 AM
Peak Flow (PF) or Peak Expiratory Flow Rate (PEFR)
Peak Flow (PF) or Peak Expiratory Flow Rate (PEFR) is a test in which the
patient inhales as deeply as possible, then blows all the air out of their lungs as fast
as possible. (This procedure is basically the same as the FVC, but the PF or PEFR
only calculates one value instead of the many values calculated during an FVC
maneuver). For an average adult, the normal PEFR is approximately 400-600 liters
per minute. This test can be done with a simple and portable hand-held peak flow
meter. The test is typically used by patients with asthma and COPD to monitor their
respiratory status. The PEFR is also frequently utilized in emergency rooms to
quickly assess the pulmonary status of patients. PFTs are also used to assess a
patients response to bronchodilator therapy. Pre- and post-bronchodilator testing of
the FVC flow-rates, or the PEFR, give a reliable indication of the effectiveness of
the bronchodilator.
Maximal Expiratory Pressure (MEP)
The maximal expiratory pressure (MEP) is a test to assess respiratory muscle

strength. The patient inhales deeply, then blows all of their air into the device to
measure peak expiratory pressure. The normal value is greater than or equal to 80
cmH2O.
Maximal Inspiratory Pressure (MIP) and Negative Inspiratory Force

(NIF)
The maximal inspiratory pressure (MIP) and the negative inspiratory force (NIF)
are the same type of maneuver and can be performed using either a MIP or NIF
device. The MIP or NIF is done to assess respiratory muscle strength. The patient
inhales maximally with a short breath hold, and the peak inspiratory pressure is
measured. The normal MIP or NIF is -80 to -100 centimeters of water. A value of
-20 cmH2O or better is the minimal acceptable value at which ventilator weaning is
attempted.
The NIF is also commonly utilized to assess for impending respiratory failure as
seen in patients with myasthenia gravis and Guillain-Barr Syndrome. These
patients have neuromuscular disorders that can cause extreme weakness or
paralysis of the respiratory muscles. The VC and NIF are used in conjunction at set
time intervals to monitor these patients. When values decrease below the normal
range, they can indicate impending respiratory failure.
Incentive Spirometry (IS)
Incentive spirometry is used both as a lung exercise device and as a tool for
measuring inspiratory respiratory muscle strength. Incentive spirometry has proven
to improve lung aeration and prevent atelectasis. The normal values for IS are the
same as those for inspiratory capacity (IC), at 50 mL/Kg of ideal body weight. The
patients are instructed to exhale normally first, then to inhale on the device as
deeply as possible and perform a five second breath hold approximately ten times
every one to two hours while awake. The normal values are calculated, and
patients can then be instructed on how to monitor their own values.
16 of 45 20-Oct-2016 9:40 AM
INTERPRETING PFT RESULTS

bstructive pulmonary diseases include asthma, bronchitis, bronchiectasis,
O emphysema, cystic fibrosis, and bronchopulmonary dysplasia. Most other

lung dysfunctions are restrictive pulmonary disorders. (See Table 8.)
Interpreting PFT Results Based on Percent of Predicted Value
Normal: 80-120% of predicted.

Mild disorder: 65-79% of predicted.
Moderate disorder: 50-64% of predicted.
Severe disorder: Less than 50% of predicted.
Gold Expert Panel COPD Classification Stages
17 of 45 20-Oct-2016 9:40 AM
The Gold expert panel classified COPD into four stages, ranging from 0 to 3:
Stage 0: Patients at risk for COPD. Patients may have symptoms of chronic
cough and sputum production, but they have normal spirometry readings.
Stage 1: Mild COPD. Characterized by FEV1 > 80%, FEV1/FVC < 70%. Patients
may or may not have chronic cough and increased sputum production.
Stage 2: Moderate COPD. Characterized by a worsening of airflow beyond
stage 1. Stage 2 patients are often symptomatic, have shortness of breath
with exertion, and they seek medical attention to alleviate their symptoms.
Subcategories of stage 2 are IIA and IIB. Patients in stage IIA have a FEV1
between 50% and 80%. Patients in stage IIB have a FEV1 between 30%
and 50%. Patients with FEV1 below 50% are more prone to acute
exacerbations of COPD.
Stage 3: Severe COPD. Characterized by an FEV1 below 30%. Stage 3 also
includes patients with respiratory failure or right heart failure. Quality of life
is severely affected in these patients. Patients in stage 3 with acute
exacerbations often require hospitalization, as the exacerbations are
frequently life-threatening.
The diagnosis of COPD should be considered in any patient with a chronic
cough, sputum production, and recognized risk factors including tobacco use,
alpha-1 antitrypsin deficiency, or occupational exposure to dust and chemicals. In
patients with clinical signs of COPD, spirometry is used to aid in confirming the
diagnosis. All spirometry readings are conducted after bronchodilator treatment. To
establish the COPD diagnosis, the FEV1 is less than 80% of predicted value, and
the FEV1/FVC is less than 70%. These abnormal values indicate airflow limitation,
constituting the obstructive component of COPD. Many patients have the clinical
symptoms of COPD, like cough and sputum production before they develop
decreased lung function. However, they are at risk of progressing to more severe
disease.
Assessing Post Bronchodilator Percentage Improvement:
Non-significant improvement: Less than 15%

Significant improvement: 15% or greater.
(Very large improvements may be indicative of asthma.)
CALCULATIONS USED IN PFT MEASUREMENTS
Height and Weight Conversions
Height Inches (in) to Centimeters (cm) Conversion

Calculation:
Convert Inches to Centimeters: in 2.54 = cm
Convert Centimeters to Inches: cm 2.54 = in
(See Table 9.)
18 of 45 20-Oct-2016 9:40 AM
Ideal Body Weight (IBW)
Calculation:
Female: 105 + (5 height in inches over 60)
Example: 65 inch tall female has an IBW of 130 lb: 105 + (5 5)
Male: 106 + (6 height in inches over 60)
Example: 70 inch tall male has an IBW of 166 lb: 106 + (6 10)
Body Surface Area m2 (BSA)
Calculation:
Square root of: Height (in) Weight (lb) 3131
or
Square root of: Height (cm) Weight (kg) 3600
Body Mass Index (BMI)
Body Mass Index (BMI) is a screening used to measure body weight status. It is
calculated using the ratio of a persons body weight and height. Since obese
patients can be affected by restrictive lung disease, the BMI may help interpret
reduced lung volumes.
Calculation:
Weight in lb height in inches2 703
Example: Find the BMI of a 170 lb male who is 70 inches tall
170 lbs 70 inches2 (70 inches2 =70 70 =4900)
Weight in lb (170) height in inches2 (4900) = 0.0346
0.0346 703 = 24.38 BMI
BMI Values as Related to Weight Classification:
BMI < 18.5 Underweight
BMI 18.5-24.9 Normal weight
BMI 25-29 Overweight
BMI 30 or greater Obese
Basal Metabolic Rate (BMR) and Resting Energy Expenditure (REE)
19 of 45 20-Oct-2016 9:40 AM
BMR is a measure of an individuals energy requirements in calories per hour.

REE estimates the daily caloric requirements by the body at rest. This can be
obtained by indirect calorimetry that measures VO2 and VCO2, or by using
formulas. Listed here is one of the quicker calculations to estimate daily caloric
requirements:
BMR = IBW (in pounds) activity factor illness factor
Multiply desired weight or IBW (in pounds) by the activity factor as follows:
Activity factors:
12 for sedentary (most patients are in the sedentary range)
15 for moderately active (lots of walking, and moderate exercise for hour
or more 3-5 times/week)
18 for vigorously active (lots of daily activity and daily strenuous exercise
like jogging).
Next, multiply the result by the illness factor as follows:
1.0 for healthy person/no current illness
1.15 for mild illness
1.3 for moderate illness
1.5 for severe illness, pregnancy or lactation.
OXYGEN INDEX (OI)

etermination of OI is a good clinical tool that can be used to determine the
D
PaO2.
degree of hypoxemia, to monitor for improvement, and as a weaning tool.
OI takes into account the mean airway pressure (Mean Paw), FiO2, and
Formula:
Oxygen Index = (Mean Paw FiO2)
PaO2
Good oxygenation OI 5
Some degree of hypoxemia OI > 5
Severe hypoxemia OI 20
Since it is common knowledge that it is not good to be on a high FiO2 and have
low PaO2, the oxygen index formula helps by placing a number on the severity of
the hypoxemia.
Example #1
Given: Mean Paw 15, FiO2 1.0, PaO2 = 60 mmHg
Oxygen Index = (15 100) = 25
60
PaO2/FiO2 Ratio (P/F Ratio)
The P/F ratio is another tool used to assess the degree of hypoxemia. It can be
used for non-intubated patients, since the airway pressure is not included in the
calculation. The only factors are the PaO2 and FiO2.
20 of 45 20-Oct-2016 9:40 AM
Formula:
P/F Ratio = PaO2 divided by FiO2
Normal oxygenation P/F ratio > 200
Moderate hypoxemia P/F ratio between 100 and 200
Severe hypoxemia P/F ratio < 100
BRIEF REVIEW OF ARTERIAL BLOOD GASES (ABGS)

BGs are generally thought of as a category in itself, and are classified both
A as laboratory data and as PFTs. Because of the complexity of the subject,

an indepth review of ABG interpretation is beyond the scope of this course.
Below is a table of normal ABG values for reference (see Table 10), and a brief
review of how to quickly interpret ABGs (see Table 11 and Figure 2).
21 of 45 20-Oct-2016 9:40 AM
MOST COMMON CAUSES OF ABNORMAL

BLOOD GASES
Respiratory Acidosis:
Common causes: Insufficient alveolar ventilation: Pulmonary disease, CNS

depression, drugs causing respiratory depression, severe pneumonia,
respiratory muscle weakness (ie GuillainBarr syndrome); mechanical
hypoventilation
22 of 45 20-Oct-2016 9:40 AM
Pathophysiology: CO2 retention from hypoventilation
Laboratory: There is a gain in Hydrogen Ion Concentration (PaCO2) without

a comparable gain in base (HCO3-) resulting in a drop in pH. (See Figure 3.)
Respiratory Alkalosis:
Common causes: Alveolar hyperventilation: hypoxia, pulmonary emboli,

anxiety, fear, pain, exercise, fever; Stimulated respiratory center caused by:
brain injury, septicemia, encephalitis
Pathophysiology: Increased CO2 excretion from hyperventilation
Laboratory: There is a loss in Hydrogen Ion Concentration (PaCO2) without

a related loss in Base (HCO3-) which results in a rise in pH. (See Figure 4.)
23 of 45 20-Oct-2016 9:40 AM
Metabolic Acidosis:
Common causes: diabetic ketoacidosis, lactic acidosis, starvation, severe

diarrhea, renal failure, renal tubular acidosis, gastrointestinal fistulas, shock.
Pathophysiology: Gain of fixed acid, inability to excrete acid or loss of

base.
Laboratory: The decrease in Base (HCO3-) is not matched with a loss in

Hydrogen Ion Concentration (PaCO2) and therefore, the pH will decrease.
(See Figure 5.)
24 of 45 20-Oct-2016 9:40 AM
Metabolic Alkalosis:
Common causes: Potassium deficit (hypokalemia) is the most common

cause, high chloride, diuretics, corticosteroids, severe vomiting, excessive
gastric suctioning ie nasogastric tube, potassium deficit
Pathophysiology: Loss of strong acid or gain of base.
Laboratory: Decreases in cations (positive) and/or increases in anions

(negative) will increase pH without a parallel increase in Hydrogen Ion
Concentration (PaCO2). (See Figure 6.)
25 of 45 20-Oct-2016 9:40 AM
CONCLUSION
he use of spirometry in pulmonary function testing has a major role in
T determining the differential diagnosis of pulmonary and cardiac diseases. It

may also be used to rule out a restrictive or obstructive process in patients
that experience signs and symptoms of lung injury. The results from pulmonary
function studies are used to (1) evaluate pulmonary causes of dyspnea, (2) assess
severity of the pathophysiologic impairment, (3) follow the course of a particular
disease, (4) evaluate the effectiveness of bronchodilator therapy, and (5) assess
the patients preoperative status. Abnormal values require additional testing to
assess the lung impairment. Examples of such testing include lung volumes,
maximum voluntary ventilation, airway resistance, lung compliance, the nitrogen
washout gas distribution test, and CO2 response curve. Specialized test regimens,
such as cardiopulmonary stress testing and bronchoprovocation, help assess the
severity of lung disorders.
CLINICAL PRACTICE EXERCISE

Case # 1. The patient is a sixty-two-year-old male with a fifty-five pack/year
smoking history. The patient also worked as a sand blaster for forty years.
Recently, he has been complaining of increased shortness of breath. (See Table
12.)
26 of 45 20-Oct-2016 9:40 AM
Interpretation
Answer to Case # 1
Severe obstructive pattern (all flows decreased, FRC, RV increased),
unresponsive to bronchodilator. No restrictive pattern noted.
Case # 2. The patient is a thirty-six-year-old female with a history of systemic
lupus erythematosus. Currently, she is complaining of dyspnea and a persistent
cough. She has an eighteen pack/year smoking history and no apparent
occupational exposure to dust or other noxious materials. She is presently taking
prednisone. (See Table 13.)
Interpretation
27 of 45 20-Oct-2016 9:40 AM
Answer to Case # 2
Severe restrictive pattern with a mild obstructive component (all volumes
decreased, FEF25-75 decreased), FEF25-75 did not respond to bronchodilator,
PEFR did respond suggesting possible reversal of large airway obstruction.
28 of 45 20-Oct-2016 9:40 AM
EXAM QUESTIONS
PULMONARY FUNCTION TESTING
This is for your reference only. To complete the exam, login to your
account at http://www.westernschools.com
Questions 120
Note: Choose the one option that BEST answers each question.
1. What are the primary indications for PFTs?

a. Test for the presence of lung disease.
b. Identify if the patient has an obstructive or restrictive disorder.
c. Evaluate the extent of lung disease
d. All of the above
2. What are ATS standards?

a. Governmental regulations assuring conversion of BTPS conditions to
ATPS.
b. Guidelines that safeguard against procedural errors and ensure
accurate results.
c. Standards for outlining percentage
of predicted values.
d. Standards for assessing post bronchodilator improvement.
3. What is the difference between lung capacities and lung volumes as they
pertain to PFT terminology?
a. Each lung capacity contains 2 or more lung volumes.
b. Each lung volume contains 2 or more lung capacities.
c. Each lung volume contains more than
3 lung capacities.
d. There is no difference between lung volumes and lung capacities.
4. Which volumes are contained in the TLC?

a. IRV and ERV only.
b. VT and RV only.
29 of 45 20-Oct-2016 9:40 AM
c. IRV, VT, ERV, and RV.

d. IRV and RV only.
5. The calculation used to obtain the normal IC value for adults is

a. 50 mL/Kg of IBW.
b. 80 mL/Kg of IBW.
c. 30 mL/Kg of IBW.
d. 7 mL/Kg of IBW.
6. The calculation used to obtain the normal RV value for adults is

a. 50 mL/Kg of IBW.
b. 16 mL/Kg of IBW.
c. 50% of TLC.
d. 40% of TLC.
7. Spirometry can be used to measure

a. volumes only.
b. flow rates only.
c. flow rates and volumes (except for
the RV)
d. residual volume only.
8. The flow rate that best measures the function of the small and medium airways
is
a. inspiratory capacity.
b. functional residual capacity.
c. MEFR.
d. MMFR.
9. Which lung volumes and capacities cannot be measured by spirometry?

a. RV, FRC, and TLC.
b. VC, IC, and VT.
c. VC, IRV, and ERV
d. IC, IRV, and VT.
10. Which tests can be used to measure

residual volume?
30 of 45 20-Oct-2016 9:40 AM
a. Body box, Peak Flow, and V/Q scan.

b. Body box, DLCO, and arteriogram.
c. Body box, helium dilution, and
nitrogen washout.
d. TGV, angiogram, and bronchial provocation testing.
11. Which condition can cause the single breath DLCO test result to be less than
25 mL/min/mmHg?
a. Emphysema.
b. Pulmonary fibrosis.
c. Pulmonary embolism.
d. All of the above.
12. The body plethysmogram measures thoracic gas volume (TGV). The TGV is
increased in
a. restrictive disease.
b. obstructive disease.
c. pneumonia.
d. pneumothorax.
13. The helium dilution (closed circuit) and the nitrogen washout (open circuit)
tests are most useful for measuring
a. FRC.
b. peak flow rates.
c. FEV 2.0 seconds.
d. MEFR.
14. Which statement best describes the pulmonary angiogram (arteriogram)?

a. It measures volumes and flow rates of the VC displayed in a graphic loop.
b. The patient inhales a xenon gas while a study is done to detect any areas
of poor perfusion, or poor ventilation.
c. It is a radiographic study of the arteries useful for detecting pulmonary
embolism.
d. All of the above correctly describe the arteriogram.
15. A V/Q scan can detect

a. closing volume (CV) and closing capacity (CC).
b. poorly ventilated areas, unperfused blood vessels, and pulmonary
embolism.
31 of 45 20-Oct-2016 9:40 AM
c. the total volume of isoflow.

d. the Vmax50.
16. Which of the following statements are true?

I. The obstructive disease pattern reveals decreased flow rates.
II. The obstructive disease pattern reveals decreased residual volume.
III. The restrictive disease pattern reveals decreased volumes.
IV. The restrictive disease pattern reveals increased TLC.
a. I and II only.
b. I and III only.
c. II and III only.
d. I, II, III, and IV.
17. A patients PFT results on bedside spirometry are 85% of predicted values.
These results show
a. normal lung function.
b. a mild lung disorder.
c. a moderate lung disorder.
d. a severe lung disorder.
18. What is the formula for determining Ideal Body Weight (IBW) in pounds for
women?
a. (weight in pounds) / (height in inches2)
b. Height in inches 2.5
c. 106 + (6 height in inches over 60)
d. 105 + (5 height in inches over 60)
19. An oxygen index of 25 indicates

a. severe hypoxemia.
b. moderate hypoxemia.
c. mild hypoxemia.
d. good oxygenation.
20. What is the formula for the P/F ratio?

a. PaO2 / FiO2 5
b. PaCO2 / FiO2
c. PaO2 / FiO2
d. PaCO2 / FiO2 5
32 of 45 20-Oct-2016 9:40 AM
This concludes the final examination. To complete the exam, login to

your account at http://www.westernschools.com
33 of 45 20-Oct-2016 9:40 AM
APPENDIX
AARC CLINICAL PRACTICE

GUIDELINEN SPIROMETRY, 1996
UPDATE
(Reprinted from RESPIRATORY CARE (Respir Care 1996; 41(7):629-636))

S 1.0 PROCEDURE:
Spirometry (S): The first American Association for Respiratory Care
(AARC) Spirometry Clinical Practice Guideline, published in 1991, was
based largely on the American Thoracic Society (ATS) 1987
recommendations. Since that time, the ATS has published new
recommendations. This updated AARC Clinical Practice Guideline not only
reflects these new ATS recommendations but also contains additional
recommendations on the use of bronchodilators in conjunction with
spirometry.
S 2.0 DESCRIPTION/DEFINITION:
The objective of spirometry is to assess ventilatory function. Spirometry
includes but is not limited to the measurement of forced vital capacity
(FVC), the forced expiratory volume in the first second (FEV1), and other
forced expiratory flow measurements such as the FEF25-75%. In addition,
it sometimes includes the measurement of maximum voluntary ventilation
(MVV). A graphic representation (spirogram) of the maneuver should be a
part of the results. Either a volume-time or flow-volume display is
acceptable. Other parameters that may be obtained by spirometry include:
FEFmax (PEF), FEF75%, FEF50%, FEF25%, FIF50%, and FIFmax (PIF).
S 3.0 SETTING:
These guidelines should be applied to spirometry performed by trained
health-care professionals
3.1 in the pulmonary function or research laboratory;
3.2 at the bedside, in acute, subacute, extended care, and skilled nursing
facilities;
3.3 in the clinic, treatment facility, and physician/s office;
3.4 in the workplace or home;
3.5 for public screening.
S 4.0 INDICATIONS:
The indications for spirometry include the need to
4.1 detect the presence or absence of lung dysfunction suggested by
history or physical signs and symptoms (eg, age, smoking history, family
history of lung disease, cough, dyspnea, wheezing) and/or the presence of
34 of 45 20-Oct-2016 9:40 AM
other abnormal diagnostic tests (eg, chest radiograph, arterial blood gas
analysis);
4.2 quantify the severity of known lung disease;
4.3 assess the change in lung function over time or following
administration of or change in therapy;
4.4 assess the potential effects or response to environmental or
occupational exposure;
4.5 assess the risk for surgical procedures known to affect lung function;
4.6 assess impairment and/or disability (eg, for rehabilitation, legal
reasons, military).
S 5.0 CONTRAINDICATIONS:
The requesting physician should be made aware that the circumstances
listed in this section could affect the reliability of spirometry measurements.
In addition, forced expiratory maneuvers may aggravate these conditions,
which may make test postponement necessary until the medical
condition(s) resolve(s).
Relative contraindications to performing spirometry are:
5.1 hemoptysis of unknown origin (forced expiratory maneuver may
aggravate the underlying condition);
5.2 pneumothorax;
5.3 unstable cardiovascular status (forced expiratory maneuver may
worsen angina or cause changes in blood pressure) or recent myocardial
infarction or pulmonary embolus;
5.4 thoracic, abdominal, or cerebral aneurysms (danger of rupture due to
increased thoracic pressure);
5.5 recent eye surgery (eg, cataract);
5.6 presence of an acute disease process that might interfere with test
performance (eg, nausea, vomiting);
5.7 recent surgery of thorax or abdomen.
S 6.0 HAZARD/COMPLICATIONS:
Although spirometry is a safe procedure, untoward reactions may occur,
and the value of the information anticipated from spirometry should be
weighed against potential hazards. The following have been reported
anecdotally:
6.1 pneumothorax;
6.2 increased intracranial pressure;
6.3 syncope, dizziness, light-headedness;
6.4 chest pain;
6.5 paroxysmal coughing;
6.6 contraction of nosocomial infections;
6.7 oxygen desaturation due to interruption of oxygen therapy;
6.8 bronchospasm.
35 of 45 20-Oct-2016 9:40 AM
S 7.0 LIMITATIONS OF METHODOLOGY/ VALIDATION OF RESULTS:

7.1 Spirometry is an effort-dependent test that requires careful instruction
and the cooperation of the test subject. Inability to perform acceptable
maneuvers may be due to poor subject motivation or failure to understand
instructions. Physical impairment and young age (eg, children < 5 years of
age) may also limit the subjects ability to perform spirometric maneuvers.
These limitations do not preclude attempting spirometry but should be
noted and taken into consideration when the results are interpreted.
7.2 The results of spirometry should meet the following criteria for number
of trials, acceptability, and reproducibility. The acceptability criteria should
be applied before reproducibility is checked.
7.2.1 Number of trials: A minimum of 3 acceptable FVC maneuvers should
be performed. If a subject is unable to perform a single acceptable
maneuver after 8 attempts, testing may be discontinued. However, after
additional instruction and demonstration, more maneuvers may be
performed depending on the subjects clinical condition and tolerance.
7.2.2 Acceptability: A good start-of-test includes:
7.2.2.1 an extrapolated volume of < or = 5% of the FVC or 150 mL,
whichever is greater;
7.2.2.2 no hesitation or false start;
7.2.2.3 a rapid start to rise time.
7.2.3 Acceptability: no cough, especially during the first second of the
maneuver.
7.2.4 Acceptability: no early termination of exhalation.
7.2.4.1 A minimum exhalation time of 6 seconds is recommended, unless
there is an obvious plateau of reasonable duration (ie, no volume change
for at least 1 second) or the subject cannot or should not continue to
exhale further.
7.2.4.2 No maneuver should be eliminated solely because of early
termination. The FEV1 from such maneuvers may be valid, and the volume
expired may be an estimate of the true FVC, although the FEV1/FVC and
FEF25-75% may be overestimated.
7.2.5 Reproducibility:
7.2.5.1 The two largest FVCs from acceptable maneuvers should not vary
by more than 0.200 L, and the two largest FEV1s from acceptable
maneuvers should not vary by more than 0.200 L.
Note: The ATS has changed its recommendations from those made in the
1987 ATS guideline (a reproducibility criterion of 5% or 0.100 L, whichever
is larger). This change is based on evidence from Hankinson and Bang
suggesting that intrasubject variability is independent of body size and that
individuals of short stature are less likely to meet the older criterion than
are taller subjects. In addition, the 0.200-L criterion is simple to apply.
However, there are two concerns with this change. The first is whether the
0.200-L criterion is too permissive in shorter individuals (eg, children).
Enright and co-workers reported a failure rate of only 2.1% in 21,432
testing sessions on adults using the 5% or 100-mL criterion. In addition,
36 of 45 20-Oct-2016 9:40 AM
they found that only 0.4% of test sessions failed to meet relaxed criteria of
5% or 200 mL. These failure rates are much lower than the 5-15% failure
rates reported by Hankinson and Bang. Enright and co-workers did not
study children, but there was some height overlap in the two studies. Thus,
we are not convinced that the 5% rule is inappropriate when applied to
shorter individuals. Indeed, Hankinson and Bang stated in their report ...it
appears that the technician appropriately responded to the lack of a
reproducible or acceptable test result by obtaining more maneuvers from
these subjects. The second concern is that the 0.200-L criterion may be
too rigid for very tall individuals (eg, height > 75 inches). Hankinson and
Bang did not study subjects taller than 190 cm (ie, 75 inches). In order to
send a consistent message, we recommend the ATS reproducibility
criterion but urge practitioners: (a) to use this criterion as a goal during
data collection and not to reject a spirogram solely on the basis of its poor
reproducibility, (b) to exceed the reproducibility criterion whenever possible
because it will decrease inter- and intralaboratory variability, and (c) to
comment in the written report when reproducibility criteria cannot be met.
7.3 Maximum voluntary ventilation (MVV) is the volume of air exhaled in a
specified period during rapid, forced breathing. This measurement is
sometimes referred to as the maximum breathing capacity (MBC).
7.3.1 The period of time for performing this maneuver should be at least 12
seconds but no more than 15 seconds, with the data reported as L/min at
BTPS.
7.3.2 At least two trials should be obtained, and the two highest should
agree within 10%.
7.4 The use of a nose clip for all spirometric maneuvers is strongly
encouraged.
7.5 Subjects may be studied in either the sitting or standing position.
Occasionally, a subject may experience syncope or dizziness while
performing the forced expiratory maneuver. Thus, the sitting position may
be safer. If such a subject is standing, an appropriate chair (ie, with arms
and not on rollers) should be placed behind the subject in the event that he
or she needs to be seated quickly. When the maneuver is performed from
a seated position, the subject should sit erect with both feet on the floor,
and be positioned correctly in relation to the equipment. Test position
should be noted on the report.
7.6 Spirometry is often performed before and after inhalation of a
bronchodilator.
7.6.1 The drug, dose, and mode of delivery should be specifically ordered
by the managing physician or determined by the laboratory and should be
noted in the report.
7.6.2 The length of the interval between administration of the
bronchodilator and postbronchodilator testing varies among laboratories,
but there appears to be more support for a minimum interval of 15 minutes
for most short and intermediate-acting beta-2 agonists. This does not
guarantee that peak response will be determined, and underestimation of
peak bronchodilator response can occur.
7.6.3 Subjects who use inhaled short-acting bronchodilators should be
37 of 45 20-Oct-2016 9:40 AM
tested at least 4 to 6 hours after the last use of their inhaled bronchodilator
to allow proper assessment of acute bronchodilator response. Long-acting
inhaled bronchodilators may need to be withheld for a more extended
period. Subjects should understand that if they need to administer their
bronchodilator prior to the test because of breathing problems, they should
do so. Bronchodilators taken on the day of testing should be noted in the
report. Table 1 lists commonly used drugs that may confound assessment
of acute bronchodilator response and the recommended times for
withholding.
7.6.4 Interpretation of response to a bronchodilator should take into
account both magnitude and consistency of change in the pulmonary
function data. The recommended criterion for response to a bronchodilator
in adults for FEV1 and FVC is a 12% improvement from baseline and an
absolute change of 0.200 L. However, because the peak effect of the drug
may not always be determined, the inability to meet this response criterion
does not exclude a response. In addition, dynamic compression of the
airways during the forced expiratory maneuver may mask bronchodilator
response in some subjects, and the additional measurement of airway
resistance and calculation of specific conductance and resistance may
provide documentation of airway responsiveness.
7.7 Reporting of results:
7.7.1 The largest FVC and FEV1 (at BTPS) should be reported even if they
do not come from the same curve.
7.7.2 Other reported measures (eg, FEF25-75% and instantaneous
expiratory flowrates, such as FEFmax and FEF50%) should be obtained
from the single acceptable best-test curve (ie, largest sum of FVC and
FEV1) and reported at BTPS.
7.7.3 All values should be recorded and stored so that comparison for
reproducibility and the ability to detect spirometry-induced bronchospasm
(as evidenced by a worsening in spirometric values with successive
attempts-and not related to fatigue) are simplified.
7.7.4 The highest MVV trial should be reported.
7.8 Subject demographics and related information:
7.8.1 Age: The age on day of test should be used.
7.8.2 Height: The subject should stand fully erect with eyes looking straight
ahead and be measured with the feet together without shoes. An accurate
measuring device should be used. For subjects who cannot stand or who
have a spinal deformity (eg, kyphoscoliosis), the arm span from finger tip
to finger tip with arms stretched in opposite directions can be used as an
estimate of height. (20)
7.8.3 Weight: An accurate scale should be used to determine the subjects
weight while wearing indoor clothes but without shoes.
7.8.4 Race: The race or ethnic background of the subject should be
determined and reported to help ensure the use of appropriate reference
values and appropriate interpretation of data.
7.8.5 The time of day, equipment or instrumentation used, and name of the
technician administering the test should be recorded.
38 of 45 20-Oct-2016 9:40 AM
7.9 Open- and closed-circuit testing:

7.9.1 Open circuit: The subject takes a maximal inspiration from the room,
inserts the mouthpiece into the mouth, and then blows out either slowly
(SVC) or rapidly (FVC) until the end-of-test criterion is met. Although the
open-circuit technique works well for some subjects, others have difficulty
maintaining a maximum inspiration while trying to position the mouthpiece
correctly in the mouth. These subjects may lose some of their vital capacity
due to leakage prior to the expiratory maneuver.
7.9.2 Closed-circuit: The subject inserts the mouthpiece into the mouth and
breathes quietly for no more than 5 tidal breaths, takes a maximal
inspiration from the reservoir, and then blows out either slowly (SVC) or
rapidly (FVC) until the end-of-test criterion is met. This rebreathing
technique is preferred if the spirometer system permits because it (1)
allows the subject to obtain a tight seal with the mouthpiece prior to
inspiration and (2) allows evaluation of the volume inspired.
S 8.0 ASSESSMENT OF NEED:
Need is assessed by determining that valid indications are present.
S 9.0 ASSESSMENT OF TEST QUALITY:
Spirometry performed for the listed indications is valid only if the
spirometer functions acceptably and the subject is able to perform the
maneuvers in an acceptable and reproducible fashion. All reports should
contain a statement about the technicians assessment of test quality and
specify which acceptability criteria were not met.
9.1 Quality control:
9.1.1 Volume verification (ie, calibration): at least daily prior to testing, use
a calibrated known-volume syringe with a volume of at least 3 L to
ascertain that the spirometer reads a known volume accurately. The known
volume should be injected and/or withdrawn at least 3 times, at flows that
vary between 2 and 12 L/s (3-L injection times of approximately 1 second,
6 seconds, and somewhere between 1 and 6 seconds). The tolerance
limits for an acceptable calibration are 3% of the known volume. Thus,
for a 3-L calibration syringe, the acceptable recovered range is 2.91-3.09
L. We encourage the practitioner to exceed this guideline whenever
possible (ie, reduce the tolerance limits to < 3%)
9.1.2 Leak test: Volume-displacement spirometers must be evaluated for
leaks daily. One recommendation is that any volume change of more than
10 mL/min while the spirometer is under at least 3-cm-H2O pressure be
considered excessive.
9.1.3 A spirometry procedure manual should be maintained.
9.1.4 A log that documents daily instrument calibration, problems
encountered, corrective action required, and system hardware and/or
software changes should be maintained.
9.1.5 Computer software for measurement and computer calculations
should be checked against manual calculations if possible. In addition,
biologic laboratory standards (ie, healthy, nonsmoking individuals) can be
tested periodically to ensure historic reproducibility, to verify software
upgrades, and to evaluate new or replacement spirometers.
39 of 45 20-Oct-2016 9:40 AM
9.1.6 The known-volume syringe should be checked for accuracy at least

quarterly using a second known-volume syringe, with the spirometer in the
patient-test mode. This validates the calibration and ensures that the
patient-test mode operates properly.
9.1.7 For water-seal spirometers, water level and paper tracing speed
should be checked daily. The entire range of volume displacement should
be checked quarterly.
9.2 Quality Assurance: Each laboratory or testing site should develop,
establish, and implement quality assurance indicators for equipment
calibration and maintenance and patient preparation. In addition, methods
should be devised and implemented to monitor technician performance
(with appropriate feedback) while obtaining, recognizing, and documenting
acceptability criteria.
S 10.0 RESOURCES:
10.1 Equipment: The spirometer must meet or exceed the requirements
proposed by the ATS and must be calibrated appropriately. (3) Spirometers
should produce a paper record of volume-time and/or flow-volume
displays. Reference values should be appropriate for the population of
subjects tested and should be validated by testing a group of healthy,
nonsmoking subjects with the same mix of age, gender, and height used in
the reference study.
10.2 Personnel: Spirometry should be administered under the direction of
a doctor (MD, DO, or PhD) specifically trained in pulmonary function
testing. The value of spirometry results can be compromised by poor
patient instruction secondary to inadequate technician training. Thus,
technicians should have documented training, with continued competency
assessments in spirometry administration and recognition of causes for
errors encountered in the testing process and a sound understanding of
physiologic effects caused by bronchodilators. They should be trained in
basic life support and emergency procedures appropriate to the setting.
Spirometry can be administered by persons who meet criteria for either
Level I or Level II.
10.2.1 Level I: Persons trained in and with demonstrated ability to perform
spirometry. Minimum educational requirements for Level-I personnel
should be a high school diploma. One or more years of college or
equivalent training and strong mathematical skills are encouraged. We
recommend that Level-I personnel take an approved training course and
have at least 6 months of supervised training. Test quality should be
reviewed by Level-II personnel or a physician, with feedback on an
ongoing basis.
10.2.2 Level II: Persons with formal education (2 or more years of
college-level studies in biologic sciences and/or mathematics) and training
that includes 2 or more years of experience administering spirometry. One
of the following credentials is recommended: Certified Respiratory Therapy
Technician (CRTT), Registered Respiratory Therapist (RRT), Certified
Pulmonary Function Technologist (CPFT), Registered Pulmonary Function
Technologist (RPFT).
S 11.0 MONITORING:
40 of 45 20-Oct-2016 9:40 AM
The following should be evaluated during the performance of spirometric

measurements to ascertain the validity of the results:
11.1 acceptability of maneuver and reproducibility of FVC, FEV1.
11.2 level of effort and cooperation by the subject.
11.3 equipment function or malfunction (eg, calibration).
11.4 The final report should contain a statement about test quality.
11.5 Spirometry results should be subject to ongoing review by a
supervisor, with feedback to the technologist. Quality assurance and/or
quality improvement programs should be designed to monitor technician
competency, both initially and on an ongoing basis.
S 12.0 FREQUENCY:
The frequency with which spirometry is repeated should depend on the
clinical status of the subject and the indications for performing the test.
S 13.0 INFECTION CONTROL:
Spirometry is a relatively safe procedure, but the possibility of cross-
contamination exists, either from the patient-patient or the patient-
technologist interface. The following guidelines should be applied
whenever spirometry is performed.
13.1 Universal Precautions should be applied in all instances in which
there is the potential for exposure to blood and body fluids. The
appropriate use of barriers (eg, gloves) and handwashing are
recommended.
13.2 Due to the nature of forced expiratory maneuvers and the likelihood of
coughing when spirometry is performed by subjects who may have active
infection with M. tuberculosis or other airborne organisms, the following
precautions are recommended:
13.2.1 The room in which spirometry is performed should meet or exceed
the recommendations of U.S. Public Health Service for air changes and
ventilation. The ideal situation is an area in the testing department
specially ventilated for isolation patients and incorporating filtration or
ultraviolet decontamination of air. If this is not possible, the patient should
be returned to the isolation room as soon as possible or, alternatively,
tested at the bedside using an acceptable spirometer.
13.2.2 When procedures involve patients with suspected infectious
airborne diseases, barrier protection (eg, mask or personal respirator
meeting regulatory agency requirements) is required.
13.2.3 The use of gloves or other impermeable barriers is encouraged
when contaminated equipment is handled.
13.2.4 The air in a volume-displacement spirometer should be flushed out
at least 5 times between subjects.
13.2.5 Equipment can be reserved for the sole purpose of testing infected
patients (eg, those with M. tuberculosis or methicillin-resistant
Staphylococcus aureus).
13.2.6 Infected patients can be tested at the end of the day or week and
equipment can then be disassembled and disinfected.
41 of 45 20-Oct-2016 9:40 AM
13.2.7 Special precautions may need to be taken for immunocompromised

subjects.
13.3 The mouthpiece, tubing, and any parts of the spirometer that come
into direct contact with the subject should be disposable or be disinfected
between patients. It is unnecessary to routinely clean the interior surface of
volume-displacement spirometers.
13.3.1 The open-circuit technique (ie, no rebreathing on mouthpiece or
through breathing tube) reduces the risk of infection to the patient but not
to the technician. The mouthpiece should be changed between patients,
but it is not necessary to change breathing tube or hose, unless excessive
water condensation occurs.
13.3.2 If the closed-circuit technique (subject rebreathes on mouthpiece
and through the breathing tube and spirometer) is used, the breathing tube
and mouthpiece should be disposed of or disinfected between subjects.
13.3.3 For flow-sensing systems in which no breathing tube is interposed
between the subject and the device, inspiration from the device should be
avoided or the flow-sensing element and interior tubing should be
disinfected between subjects.
13.4 Bacteria filters are widely used in pulmonary function laboratories,
although the need for such filters and their effectiveness is not well
documented. These filters impose added resistance and have been
reported to have a statistical but not clinically meaningful effect on
pulmonary function test results. If in-line filters are used during spirometry,
we recommend that the equipment be calibrated with the filter installed and
that the filter be discarded after use on a single subject. The use of in-line
filters does not eliminate the need for regular cleaning and disinfection and
does not guarantee that transmission of disease(s) cannot occur.
Cardiopulmonary Diagnostics Focus Group:
Kevin Shrake, MA, RRT, Chairman, Springfield IL
Sue Blonshine, BS, RPF,T RRT, Lansing MI
Robert A Brown, BS, RPFT, RRT, Madison WI
Gregg L Ruppel, Med, RRT, St Louis MO
Jack Wanger, MBA, RPFT, RRT, Denver CO
42 of 45 20-Oct-2016 9:40 AM
REFERENCES
American Association for Respiratory Care: Clinical practice guideline:

spirometer Respir Care 1996; 41(7):629-636)
American Association for Respiratory Care. Clinical practice guideline:
assessing re-sponse to bronchodilator therapy at point of care. Respir
Care 1995;40: 1300-1307.
resuscitation in acute care hospitals. Respir Care 1993;38(11):1169-1200.
Spirometry. Respir Care 1991;136: 1414-1417.
American Thoracic Society. Standardization of spirometry 1994 update. Am J
Respir Crit Care Med 1995;152 (3):1107-1136.
American Thoracic Society Workshop on Lung Function Testing, Becklare M,
Crapo RO, co-chairpersons. Lung function testing: selection of reference
values and interpretative strategies. Am Rev Respir Dis 1991;144
(5):1202-1218.
American Thoracic Society. Standardization of spirometry-1987 update. Am Rev
Respir Dis 1987;136:1039-1060. Published concurrently in Respir Care
1987;32(11): 1039-1060.
American Thoracic Society. Evaluation of impairment / disability secondary to
respiratory disorders. Am Rev Respir Dis 1986;133(6):1205-1209.
Casaburi R, Adame D, Hong CK. Comparison of albuterol to isoproterenol as a
bronchodilator for use in pulmonary function testing. Chest
1991;100:1597-1600.
Centers for Disease Control and Prevention. Guidelines for preventing the
transmission of Mycobacterium tuberculosis in health care facilities, 1994.
MMWR 1994; 43:1-32.
Centers for Disease Control and Prevention. Guidelines for preventing the
transmission of Mycobacterium tuberculosis in health-care facilities, 1994.
MMWR 1994; 43:s1-132.
Centers for Disease Control. Update: universal precautions for prevention of
transmission of human immunodeficiency virus, hepatitis B virus, and other
blood borne pathogens in health care settings. MMWR 1988;37: 377-388.
Centers for Disease Control. Summary: recommendations for preventing
transmission of infection with human T-lymphotrophic virus type
III/lymphadenopathy-associated virus in the workplace. MMWR 1985;
34:681, 686, 691-695.
Crapo RO. Pulmonary function testing. N Engl J Med 1994;331: 25-30.
Czervinske, Banrhart, Sherry: Perinatal and Pediatric Respiratory Care. 2002.
WB Saunders Company.
Dales RE, Spitzer WO, Tousignant P, Schechter M, Suissa S. Clinical
interpretation of airway response to bronchodilator: epidemiologic
43 of 45 20-Oct-2016 9:40 AM
considerations. Am Rev Respir Dis 1988;138(2):317-320.

Enright PL, Johnson LR, Connett JE, Voelker H, Buist AS. Spirometry in the lung
health study: 1. Methods and quality control. Am Rev Respir Dis
1991;143(6): 1215-1223.
Ferris BG. Epidemiology standardization project. Am Rev Respir Dis
1979;118(Suppl):7-13).
Fuso L, Accardo D, Bevignani G, et al. Effects of a filter at the mouth on
pulmonary function tests. Eur Respir J 1995; 8:314-317.
Garner JS, Favero MS. CDC guidelines for the prevention and control of
nosocomial infections: guideline for hand washing and hospital
environmental control. Am J Infect Control 1986;14:110-129.
Giddens, Jean Foret, PhD, MSN, RN, CS, Langford, Rae W., EdD, RN: Nursing
PDQ. 2004. St Louis, Mosby.
Glindmeyer HW, Jones RN, Barkman HW, Weill H. Spirometry: quantitative test
criteria and test acceptability. Am Rev Respir Dis 1987;136(2):449-452.
Gold Expert Panel COPD Classification Stages: Online, 2009. Available from
medinfo.ufl.edu/~gec/coa2/COPDtable.html.
Gold, Warren M., Nadel, Jay A.: Atlas of Procedures in Respiratory Medicine.
2002. WB Saunders Company.
Hankinson JL. Pulmonary function testing in the screening of workers: guidelines
for instrumentation, performance, and interpretation. J Occup Med
1986;28:1081-1082.
Hankinson JL, Bang KM. Acceptability and reproducibility criteria of the
American Thoracic Society as observed in a sample of the general
population. Am Rev Respir Dis 1991;143(3):516-521.
Hepper NGG, Black LF, Fowler WS. Relationship of lung volume to height and
arm span in normal subjects and in patients with spinal deformity. Am Rev
Respir Dis 1965;91:356-362.
Johns DP, Ingram C, Booth H, Williams TJ, Walters EH. Effect of a microaerosol
barrier filter on the measurement of lung function. Chest
1995;107(4):1045-1048.
Lewis, Sharon, Dirksen, Shannon Ruff, Heitkemper, Margaret. Medical Surgical
Nursing. 2003. Elsevier Science.
Light RW, Conrad SA, George RB. Clinical significance of pulmonary function
tests-the one best test for evaluating the effects of bronchodilator therapy.
Chest 1977;72:512-516.
McKay RT, Lockey JE. Pulmonary function testing: Guidelines for medical
surveillance and epidemiological studies. Occup Med 1991;6:43-57.
Miller WF, Scacci R, Gast LR. Laboratory evaluation of pulmonary function.
Philadelphia: JB Lippincott Co, 1987.
Montenegro HD, Chester EH, Jones PK. Cardiac arrhythmias during routine
tests of pulmonary function in patients with chronic obstruction of airways.
Chest 1978;73:133-139.
Morris AH, Kanner RE, Crapo RO, Gardner RM. Clinical pulmonary function
44 of 45 20-Oct-2016 9:40 AM
testing: A manual of uniform laboratory procedures, 2nd ed. Intermountain

Thoracic Society, 1984, Salt Lake City.
Murray, John F., Nadel, Jay A.: Textbook of Respiratory Medicine. 3rd edition.
2001. Elsevier Science.
Myers, Ehren, Hopkins, Tracey: LPN Notes. 2004. Philadelphia, F.A. Davis.
Oaks, Dana, BA, RRT, NPS, Clinical Practitioners Pocket Guide to Respiratory
Care, 20th Anniversary Issue, 6th Edition 2004.
Robert E Hyatt, Robert, Scanlon, Paul, and Nakamura, M. Interpretation of
Pulmonary Function Tests, 3rd Edition, 2009. Philadelphia, Lippincott, Inc.
Rutala DR, Rutala WA, Weber DR, et al. Infection risks associated with
spirometry. Infection Control Hospital Epidemiol 1991;12:89-92.
Shigeoka JW. Calibration and quality control of spirometer systems. Respir Care
1983;28(6):747-753.
Shim C. Response to bronchodilators. Clin Chest Med 1989;10:155-164.
Tablan OC, Williams WW, Martone WJ. Infection control in pulmonary function
laboratories. Infect Control 1985;6:442-444.
U.S. Center for Disease Control And Prevention (CDC). Retrieved April 2005,
from www.cdc.gov
Waalkens HJ, Merkus PJE, can Essen-Zandvliet EEM, et al, Assessment of
bronchodilator response in children with asthma. Eur Respir J
1993;6:645-651.
WebMD Health, Retrieved May 2005, from www.webmd.com
Wilkins, Robert L., Scanlan, Craig L., Stoller, James K.: Egans Fundamentals of
Respiratory Care. 8th edition. 2003. Elsevier Science.
Wyka, Kenneth A., Mathews, Paul, Clark, William F., et al.: Foundations of Res-
piratory Care. 2001. Delmar Learning.
Zibrak JD, ODonnell CR, Marton K. Indications for pulmonary function testing.
Ann Intern Med 1990; 112:793-794.
previous page start
45 of 45 20-Oct-2016 9:40 AM

PFT H8395 Ebook PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PFT H8395 Ebook PDF

Uploaded by

Copyright:

Available Formats

H8395_ebooks https://www.westernschools.com/Portals/0/html/H8395/zKhXyy_files/...

Pulmonary Function Testing

Pulmonary Function Testing

Upon successful completion of this course, continuing education hours

Respiratory Therapy Planner: David Chang, EdD, RRT

The planner who worked on this continuing education activity has

Western Schools courses are designed to provide healthcare professionals with

COPYRIGHT 2006Western Schools. All Rights Reserved. No part(s)

2. Explain ATPS/BTPS and ATS standards.

5. Summarize the DLCO procedure.

6. Explain body plethysmography.

8. Describe the pulmonary angiogram or arteriogram.

9. List the main purpose of a V/Q scan.

10. Differentiate obstructive and restrictive disorders based on PFT results.

espiratory therapists are often asked to perform pulmonary function tests

R (PF or PFT) in different areas of hospitals and oversee pulmonary function

Shortness of breath is a common complaint for which PF tests can help

PULMONARY FUNCTION TESTING

PRIMARY INDICATIONS FOR PULMONARY FUNCTION

Test for the presence of lung disease

Identify the type of lung disorder (obstructive vs. restrictive)

Aid in identifying location of disorder (small vs. large airways)

Evaluate the extent of pulmonary dysfunction

Assess progression of lung disease

Aid in establishing a therapeutic regimen for the dysfunction.

PFT MEASUREMENT STANDARDS

Volumes measured by spirometry are at ambient temperature, pressure, and

These measurements are then adjusted for the temperature difference

American Thoracic Society (ATS) standards are guidelines that safeguard

super syringe is often utilized for this calibration.

DESCRIPTIONS OF LUNG VOLUMES AND LUNG

PFT ABBREVIATIONS AND DESCRIPTIONS

S be used as an initial screening or often in conjunction with other tests to

FORCED VITAL CAPACITY MEASUREMENTS

T function. FVC aids in diagnosing both restrictive and obstructive lung

Forced Expiratory Volume Timed (FEVt)

SPECIAL PROCEDURES IN PULMONARY FUNCTION

DLCO - Gas Diffusion Testing

Bronchial Provocation Tests

1. To assess patients with normal PFTs and symptoms of bronchospasm.

2. To quantify severity of asthma and assess changes in airway reactivity.

3. Screening of those who may be at risk, or to document the effects of

B. Patients must be asymptomatic at baseline.

1. Baseline FEV1 measurements are made before the administration of the

3. The methacholine concentration that causes a 20% decrease in the FEV1

4. The test is stopped once PD20% is reached.

6. A PD20% of 8 mg/ml is common in patients with hyperreactive airways.

Measuring Residual Volume, Functional Residual Capacity, and TLC

Measuring the residual volume requires special testing as it cannot be

Helium Dilution Test (Closed Circuit)

Nitrogen Washout Test (Open Circuit)

Gas/Blood Flow Distribution Testing: Single Breath Nitrogen

The single breath nitrogen elimination test measures the evenness of

DESCRIPTIONS OF MISCELLANEOUS PULMONARY

Maximum Voluntary Ventilation (MVV) or Maximum Breathing

Peak Flow (PF) or Peak Expiratory Flow Rate (PEFR)

Maximal Expiratory Pressure (MEP)

The maximal expiratory pressure (MEP) is a test to assess respiratory muscle

Maximal Inspiratory Pressure (MIP) and Negative Inspiratory Force

Incentive Spirometry (IS)

INTERPRETING PFT RESULTS

O emphysema, cystic fibrosis, and bronchopulmonary dysplasia. Most other

Interpreting PFT Results Based on Percent of Predicted Value