Pulmonary function tests

URL of this page: http://www.nlm.nih.gov/medlineplus/ency/article/003853.htm Pulmonary function tests are a group of tests that measure how well the lungs take in and release air and how well they move gases such as oxygen from the atmosphere into the body's circulation.

How the Test is Performed

In a spirometry test, you breathe into a mouthpiece that is connected to an instrument called a spirometer. The spirometer records the amount and the rate of air that you breathe in and out over a period of time. For some of the test measurements, you can breathe normally and quietly. Other tests require forced inhalation or exhalation after a deep breath. Lung volume measurement can be done in two ways:

The most accurate way is to sit in a sealed, clear box that looks like a telephone booth (body plethysmograph) while breathing in and out into a mouthpiece. Changes in pressure inside the box help determine the lung volume. Lung volume can also be measured when you breathe nitrogen or helium gas through a tube for a certain period of time. The concentration of the gas in a chamber attached to the tube is measured to estimate the lung volume.

To measure diffusion capacity, you breathe a harmless gas for a very short time, often one breath. The concentration of the gas in the air you breathe out is measured. The difference in the amount of gas inhaled and exhaled measures how effectively gas travels from the lungs into the blood.

How to Prepare for the Test

Do not eat a heavy meal before the test. Do not smoke for 4 - 6 hours before the test. You'll get specific instructions if you need to stop using bronchodilators or inhaler medications. You may have to breathe in medication before the test.

How the Test Will Feel

Since the test involves some forced breathing and rapid breathing, you may have some temporary shortness of breath or lightheadedness. You breathe through a tight-fitting mouthpiece, and you'll have nose clips.

Why the Test is Performed

Pulmonary function tests are done to:

Diagnose certain types of lung disease (especially asthma, bronchitis, and emphysema) Find the cause of shortness of breath Measure whether exposure to contaminants at work affects lung function Assess the effect of medication Measure progress in disease treatment

It also can be done to:

Spirometry measures airflow. By measuring how much air you exhale, and how quickly, spirometry can evaluate a broad range of lung diseases. Lung volume measures the amount of air in the lungs without forcibly blowing out. Some lung diseases (such as emphysema and chronic bronchitis) can make the lungs contain too much air. Other lung diseases (such as fibrosis of the lungs and asbestosis) make the lungs scarred and smaller so that they contain too little air. Testing the diffusion capacity (also called the DLCO) allows the doctor to estimate how well the lungs move oxygen from the air into the bloodstream.

Normal Results
Normal values are based upon your age, height, ethnicity, and sex. Normal results are expressed as a percentage. A value is usually considered abnormal if it is less than 80% of your predicted value. Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

What Abnormal Results Mean

Abnormal results usually mean that you may have some chest or lung disease.

Risks
The risk is minimal for most people. There is a small risk of collapsed lung in people with a certain type of lung disease. The test should not be given to a person who has experienced a recent heart attack, or who has certain other types of heart disease.

Considerations
Your cooperation while performing the test is crucial in order to get accurate results. A poor seal around the mouthpiece of the spirometer can give poor results that can't be interpreted. Do not smoke before the test.

Alternative Names
PFTs; Spirometry; Spirogram; Lung function tests

References
Mason RJ, Broaddus VC, Murray JF, Nadel JA. Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders; 2005.

Spirometry
Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs), measuring lung function, specifically the measurement of the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. Spirometry is an important tool used for generating pneumotachographs which are helpful in assessing conditions such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD.

Contents
[hide] 1 Spirometry testing 1.1 Procedure 1.2 Limitations of test 1.3 Related tests 2.1 Forced Vital Capacity (FVC) 2.2 Forced Expiratory Volume in 1 second (FEV1) 2.3 FEV1/FVC ratio (FEV1%) 2.4 Forced Expiratory Flow (FEF) 2.5 Forced Inspiratory Flow 2575% or 2550% 2.6 Peak Expiratory Flow (PEF) 2.7 Tidal volume (TV) 2.8 Total Lung Capacity (TLC) 2.9 Diffusion capacity (DLCO) 2.10 Maximum Voluntary Ventilation (MVV) 2.11 Static lung compliance (Cst) 2.12 Others

2 Parameters

3 Technologies used in spirometers 4 See also 5 References 6 Further reading 7 External links

[edit] Spirometry testing

Device for spirometry. The patient places his or her lips around the blue mouthpiece. The teeth go between the nubs and the shield, and the lips go over the shield. A noseclip guarantees that breath will flow only through the mouth.

A modern USB PC-based spirometer.

Screen for spirometry readouts at right. The chamber can also be used for body plethysmography.

The spirometry test is performed using a device called a spirometer, which comes in several different varieties. Most spirometers display the following graphs, called spirograms:

a volume-time curve, showing volume (liters) along the Y-axis and time (seconds) along the X-axis a flow-volume loop, which graphically depicts the rate of airflow on the Y-axis and the total volume inspired or expired on the X-axis

[edit] Procedure

The basic forced volume vital capacity (FVC) test varies slightly depending on the equipment used. Generally, the patient is asked to take the deepest breath they can, and then exhale into the sensor as hard as possible, for as long as possible, preferably at least 6 seconds. It is sometimes directly followed by a rapid inhalation (inspiration), in particular when assessing possible upper airway obstruction. Sometimes, the test will be preceded by a period of quiet breathing in and out from the sensor (tidal volume), or the rapid breath in (forced inspiratory part) will come before the forced exhalation. During the test, soft nose clips may be used to prevent air escaping through the nose. Filter mouthpieces may be used to prevent the spread of microorganisms.
[edit] Limitations of test

The maneuver is highly dependent on patient cooperation and effort, and is normally repeated at least three times to ensure reproducibility. Since results are dependent on patient cooperation, FVC can only be underestimated, never overestimated. FEV1 may sometimes be overestimated in people with some diseases - a softer blow can reduce the spasm or collapse of lung tissue to elevate the measure. Due to the patient cooperation required, spirometry can only be used on children old enough to comprehend and follow the instructions given (6 years old or more), and only on patients who are able to understand and follow instructions - thus, this test is not suitable for patients who are unconscious, heavily sedated, or have limitations that would interfere with vigorous respiratory efforts. Other types of lung function tests are available for infants and unconscious persons. Another major limitation is the fact that many intermittent or mild asthmatics have normal spirometry between acute exacerbation, limiting spirometry's usefulness as a diagnostic. It is more useful as a monitoring tool: a sudden decrease in FEV1 or other spirometric measure in the same patient can signal worsening control, even if the raw value is still normal. Patients are encouraged to record their personal best measures.
[edit] Related tests

Spirometry can also be part of a bronchial challenge test, used to determine bronchial hyperresponsiveness to either rigorous exercise, inhalation of cold/dry air, or with a pharmaceutical agent such as methacholine or histamine. Sometimes, to assess the reversibility of a particular condition, a bronchodilator is administered before performing another round of tests for comparison. This is commonly referred to as a reversibility test, or a post bronchodilator test (Post BD), and is an important part in diagnosing asthma versus COPD. Other complementary lung functions tests include plethysmography and nitrogen washout.

[edit] Parameters

Measurement Example of a modern PC based spirometer printout.

Approximate value Male Female

The most common parameters measured in spirometry are Vital capacity (VC), Forced vital capacity (FVC), Forced expiratory volume (FEV) at timed intervals of 0.5, 1.0 (FEV1), 2.0, and 3.0 seconds, Forced expiratory flow 2575% (FEF 2575) and Maximal voluntary ventilation (MVV),[1] also known as Maximum breathing capacity.[2] Other tests may be performed in certain situations.

Forced vital 4.8 L 3.7 L capacity (FVC) Tidal volume (Vt) 500mL 390mL Total lung capacity 6.0 L 4.7 L (TLC)

Results are usually given in both raw data (litres, litres per second) and percent predicted - the test result as a percent of the "predicted values" for the patients of similar characteristics (height, age, sex, and sometimes race and weight). The interpretation of the results can vary depending on the physician and the source of the predicted values. Generally speaking, results nearest to 100% predicted are the most normal, and results over 80% are often considered normal. Multiple publications of predicted values have been published and may be calculated online based on age, sex, weight and ethnicity. However, review by a doctor is necessary for accurate diagnosis of any individual situation.

A bronchodilator is also given in certain circumstances and a pre/post graph comparison is done to assess the effectiveness of the bronchodilator. See the example printout. Functional residual capacity (FRC) cannot be measured via spirometry, but it can be measured with a plethysmograph or dilution tests (for example, helium dilution test).

Average values for Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1) and Forced Expiratory Flow 25 75% (FEF2575%), according to a study in the United States 2007 of 3,600 subjects aged 480 years. [3] Y-axis is expressed in litres for FVC and FEV1, and in litres/second for FEF2575%.

[edit] Forced Vital Capacity (FVC)

Forced Vital Capacity (FVC) is the volume of air that can forcibly be blown out after full inspiration, measured in liters. FVC is the most basic maneuver in spirometry tests.
[edit] Forced Expiratory Volume in 1 second (FEV1)

Average values for FEV1 in healthy people depend mainly on sex and age, according to the diagram at left. Values of between 80% and 120% of the average value are considered normal.[4] Predicted normal values for FEV1 can be calculated online and depend on age, sex, height, weight and ethnicity as well as the research study that they are based upon.
[edit] FEV1/FVC ratio (FEV1%)

FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC. In healthy adults this should be approximately 7580%. In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV1 is diminished because of increased airway resistance to expiratory flow; the FVC may be decreased as well, due to the premature closure of airway in expiration, just not in the same proportion as FEV1 (for instance, both FEV1 and FVC are reduced, but the former is more affected because of the increased airway resistance). This generates a reduced value (<80%, often ~45%). In restrictive diseases (such as pulmonary fibrosis) the FEV1 and FVC are both reduced proportionally and the value may be normal or even increased as a result of decreased lung compliance. A derived value of FEV1% is FEV1% predicted, which is defined as FEV1% of the patient divided by the average FEV1% in the population for any person of similar age, sex and body composition.
[edit] Forced Expiratory Flow (FEF)

Forced Expiratory Flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration. It can be given at discrete times, generally defined by what fraction remains of the functional vital capacity (FVC). The usual intervals are 25%, 50% and 75% (FEF25, FEF50 and FEF75), or 25% and 50% of FVC. It can also be given as a mean of the flow during an interval, also generally delimited by when specific fractions remain of FVC, usually 2575% (FEF2575%). Average ranges in the healthy population depend mainly on sex and age, with FEF2575% shown in diagram at left. Values ranging from 50-60% and up to 130% of the average are considered normal. [4] Predicted normal values for FEF can be calculated online and depend on age, sex, height, weight and ethnicity as well as the research study that they are based upon.

MMEF or MEF stands for maximal (mid-)expiratory flow and is the peak of expiratory flow as taken from the flow-volume curve and measured in liters per second. It should theoretically be identical to peak expiratory flow (PEF), which is, however, generally measured by a peak flow meter and given in liters per minute.[5] Recent research suggests that FEF25-75% or FEF25-50% may be a more sensitive parameter than FEV1 in the detection of obstructive small airway disease.[6][7] However, in the absence of concomitant changes in the standard markers, discrepancies in mid-range expiratory flow may not be specific enough to be useful, and current practice guidelines recommend continuing to use FEV1, VC, and FEV1/VC as indicators of obstructive disease.[8][9] More rarely, forced expiratory flow may be given at intervals defined by how much remains of total lung capacity. In such cases, it is usually designated as e.g. FEF70%TLC, FEF60%TLC and FEF50%TLC.[5]
[edit] Forced Inspiratory Flow 2575% or 2550%

Forced Inspiratory Flow 2575% or 2550% (FIF 2575% or 2550%) is similar to FEF 2575% or 2550% except the measurement is taken during inspiration.
[edit] Peak Expiratory Flow (PEF)

Normal values for Peak Expiratory Flow (PEF), shown on EU scale.[10]

Peak Expiratory Flow (PEF) is the maximal flow (or speed) achieved during the maximally forced expiration initiated at full expiration, measured in liters per minute.
[edit] Tidal volume (TV)

Tidal volume (TV) is the volume of air inspired or expired in single breath at rest.

[edit] Total Lung Capacity (TLC)

Total Lung Capacity (TLC) is the maximum volume of air present in the lungs
[edit] Diffusion capacity (DLCO)

Diffusing Capacity (DLCO)is the carbon monoxide uptake from a single inspiration in a standard time (usually 10 sec). Since air consists of very minute or trace quantities of CO, 10 seconds is considered to be the standard time for inhalation, then rapidly blow it out (exhale). The exhaled gas is tested to determine how much of the tracer gas was absorbed during the breath. This will pick up diffusion impairments, for instance in pulmonary fibrosis.[11] This must be corrected for anemia (because rapid CO diffusion is dependent on hemoglobin in RBC's; a low hemoglobin concentration, anemia, will reduce DLCO) and pulmonary hemorrhage (excess RBC's in the interstitium or alveoli can absorb CO and artificially increase the DLCO capacity). Atmospheric pressure and/or altitude will also affect measured DLCO, and so a correction factor is needed to adjust for standard pressure. Online calculators are available to correct for hemoglobin levels and altitude and/or pressure where the measurement was taken.
[edit] Maximum Voluntary Ventilation (MVV)

Maximum Voluntary Ventilation (MVV) is a measure of the maximum amount of air that can be inhaled and exhaled within one minute. For the comfort of the patient this is done over a 15 second time period before being extrapolated to a value for one minute expressed as liters/minute. Average values for males and females are 140-180 and 80-120 liters per minute respectively.
[edit] Static lung compliance (Cst)

When estimating static lung compliance, volume measurements by the spirometer needs to be complemented by pressure transducers in order to simultaneously measure the transpulmonary pressure. When having drawn a curve with the relations between changes in volume to changes in transpulmonary pressure, Cst is the slope of the curve during any given volume, or, mathematically, V/P.[12] Static lung compliance is perhaps the most sensitive parameter for the detection of abnormal pulmonary mechanics.[13] It is considered normal if it is 60% to 140% of the average value in the population for any person of similar age, sex and body composition.[4] In those with acute respiratory failure on mechanical ventilation, "the static compliance of the total respiratory system is conventionally obtained by dividing the tidal volume by the difference between the "plateau" pressure measured at the airway opening (PaO) during an occlusion at endinspiration and positive end-expiratory pressure (PEEP) set by the ventilator".[14]
[edit] Others

Forced Expiratory Time (FET) Forced Expiratory Time (FET) measures the length of the expiration in seconds. Slow Vital capacity (SVC) Slow Vital capacity (SVC) is the maximum volume of air that can be exhaled slowly after slow maximum inhalation. Maximal pressure (Pmax and Pi) Pmax is the asymptotically maximal pressure that can be developed by the respiratory muscles at any lung volume and Pi is the maximum inspiratory pressure that can be developed at specific lung volumes.[15] This measurement also requires pressure transducers in addition. It is considered normal if it is 60% to 140% of the average value in the population for any person of similar age, sex and body composition.[4] A derived parameter is the coefficient of retraction (CR) which is Pmax/TLC .<hedenstrom2009/>

Mean transit time (MTT) Mean transit time is the area under the flow-volume curve divided by the forced vital capacity.[16]

Technologies used in spirometers

Volumetric Spirometers Water bell Bellows wedge Fleisch-pneumotach Lilly (screen) pneumotach Turbine (actually a rotating vane which spins because of the air flow generated by the subject. The revolutions of the vane are counted as they break a light beam) Pitot tube Hot-wire anemometer Ultrasound

Flow measuring Spirometers

To evaluate symptoms Chest pain Cough Dyspnea Orthopnea Phlegm production Wheezing Chest deformity Cyanosis Diminished breath sounds Expiratory slowing Overinflation Unexplained crackles

To evaluate signs

To evaluate abnormal laboratory tests

Abnormal chest radiographs Hypercapnia Hypoxemia Polycythemia Smokers Persons in occupations with exposures to injurious substances To assess preoperative risk To assess prognosis (lung transplant, etc.) To assess health status before enrollment in strenuous physical activity programs Bronchodilator therapy Steroid treatment for asthma, interstitial lung disease, etc. Management of congestive heart failure Other (antibiotics in cystic fibrosis, etc.) Pulmonary diseases Obstructive small airway diseases Interstitial lung diseases Cardiac diseases Congestive heart failure Neuromuscular diseases Guillain-Barr syndrome

To measure the effect of disease on pulmonary function To screen persons at risk for pulmonary diseases

Some routine physical examinations

Monitoring To assess therapeutic interventions

To describe the course of diseases affecting lung function

To monitor persons in occupations with exposure to injurious agents To monitor for adverse reactions to drugs with known pulmonary toxicity Evaluation of Disability or Impairment To assess patients as part of a rehabilitation program Medical Industrial Vocational

To assess risks as part of an insurance evaluation To assess persons for legal reasons Social Security or other government compensation programs Personal injury lawsuits Other Epidemiologic surveys Comparison of health status of populations living in different environments Validation of subjective complaints in occupational or environmental settings Derivation of reference equations

Public Health

Pulmonary Function Studies

http://www.unboundmedicine.com/nursingcentral/ub/view/Davis-Lab-and-Diagnostic-Tests/425095/all/Pulmonary_Function_Studies
General

Synonym/Acronym: Pulmonary function tests (PFTs). Common Use: To assess respiratory function to assist in evaluating obstructive versus restrictive lung disease and to monitor and assess the effectiveness of therapeutic interventions. Area of Application: Lungs, respiratory system. Contrast: None.
Description

Pulmonary function studies provide information about the volume, pattern, and rates of airflow involved in respiratory function. These studies may also include tests involving the diffusing capabilities of the lungs (i.e., volume of gases diffusing across a membrane). A complete pulmonary function study includes the determination of all lung volumes, spirometry, diffusing capacity, maximum voluntary ventilation, flow-

volume loop (see

), and maximum expiratory and inspiratory pressures. Other studies include small airway volumes. Pulmonary function studies are classified according to lung volumes and capacities, rates of flow, and gas exchange. The exception is the diffusion test, which records the movement of a gas during inspiration and expiration. Lung volumes and capacities constitute the amount of air inhaled or exhaled from the lungs; this value is compared to normal reference values specific for the patients age, height, and gender. The following are volumes and capacities measured by spirometry that do not require timed testing. Tidal volume Total amount of air inhaled and exhaled with one breath. Residual volume Amount of air remaining in the lungs after a maximum expiration effort (not measured by spirometry, but can be calculated from the functional residual capacity [FRC] minus the expiratory reserve volume [ERV]); this indirect type of measurement can be done by body plethysmography (see monograph titled Plethysmography) Inspiratory reserve volume Maximum amount of air inhaled after normal inspirations Expiratory reserve volume Maximum amount of air exhaled after a resting expiration (can be calculated by the vital capacity [VC] minus the inspiratory capacity [IC]) Vital capacity Maximum amount of air exhaled after a maximum inspiration (can be calculated by adding the IC and the ERV) Total lung capacity Total amount of air that the lungs can hold after maximal inspiration (can be calculated by adding the VC and the residual volume [RV])

Inspiratory capacity Maximum amount of air inspired after normal expiration (can be calculated by adding the inspiratory RV and tidal volume) Functional residual capacity Volume of air that remains in the lungs after normal expiration (can be calculated by adding the RV and ERV) The volumes, capacities, and rates of flow measured by spirometry that do require timed testing include the following: Forced vital capacity in 1 sec Maximum amount of air that can be forcefully exhaled after a full inspiration Forced expiratory volume Amount of air exhaled in the first second (can also be determined at 2 or 3 sec) of forced vital capacity (FVC, which is the amount of air exhaled in seconds, expressed as a percentage) Maximal midexpiratory flow Also known as forced expiratory flow rate (FEF2575), or the maximal rate of airflow during a forced expiration Forced inspiratory flow rate Volume inspired from the RV at a point of measurement (can be expressed as a percentage to identify the corresponding volume pressure and inspired volume) Peak inspiratory flow rate Maximum airflow during a forced maximal inspiration Peak expiratory flow rate Maximum airflow expired during FVC Flow-volume loops Flows and volumes recorded during forced expiratory volume and forced inspiratory VC procedures (see

) Maximal inspiratory-expiratory pressures Measures the strength of the respiratory muscles in neuromuscular disorders Maximal voluntary ventilation Maximal volume of air inspired and expired in 1 min (may be done for shorter periods and multiplied to equal 1 min) Other studies for gas-exchange capacity, small airway abnormalities, and allergic responses in hyperactive airway disorders can be performed during the conventional pulmonary function study. These include the following: Diffusing capacity of the lungs Rate of transfer of carbon monoxide through the alveolar and capillary membrane in 1 min Closing volume Measures the closure of small airways in the lower alveoli by monitoring volume and percentage of alveolar nitrogen after inhalation of 100% oxygen Isoflow volume Flow-volume loop test followed by inhalation of a mixture of helium and oxygen to determine small airway disease Body plethysmography Measures thoracic gas volume and airway resistance Bronchial provocation

Quantifies airway response after inhalation of methacholine Arterial blood gases Measure oxygen, pH, and carbon dioxide in arterial blood Values are expressed in units of mL, %, L, L/sec, and L/min, depending on the test performed.
Indications Detect chronic obstructive pulmonary disease (COPD) and/or restrictive pulmonary diseases that affect the chest wall (e.g., neuromuscular disorders, kyphosis, scoliosis) and lungs, as evidenced by abnormal airflows and volumes Determine airway response to inhalants in patients with an airway-reactive disorder Determine the diffusing capacity of the lungs (DCOL) Determine the effectiveness of therapy regimens, such as bronchodilators, for pulmonary disorders Determine the presence of lung disease when other studies, such as x-rays, do not provide a definitive diagnosis, or determine the progression and severity of known COPD and restrictive pulmonary disease Evaluate the cause of dyspnea occurring with or without exercise Evaluate lung compliance to determine changes in elasticity, as evidenced by changes in lung volumes (decreased in restrictive pulmonary disease, increased in COPD and in elderly patients) Evaluate pulmonary disability for legal or insurance claims Evaluate pulmonary function after surgical pneumonectomy, lobectomy, or segmental lobectomy Evaluate the respiratory system to determine the patient's ability to tolerate procedures such as surgery or diagnostic studies Screen high-risk populations for early detection of pulmonary conditions (e.g., patients with exposure to occupational or environmental hazards, smokers, patients with a hereditary predisposition)

Potential Diagnosis

Normal Findings:
Normal respiratory volume and capacities, gas diffusion, and distribution No evidence of COPD or restrictive pulmonary disease

Normal adult lung volumes, capacities, and flow rates are as follows: TV 500 mL at rest RV 1,200 mL (approximate) IRV 3,000 mL (approximate)

ERV 1,100 mL (approximate) VC 4,600 mL (approximate) TLC 5,800 mL (approximate) IC 3,500 mL (approximate) FRC 2,300 mL (approximate) FVC 3,0005,000 mL (approximate) FEV1/FVC 81%83% MMEF 25%75% FIF 25%75% MVV 25%35% or 170 L/min PIFR 300 L/min PEFR 450 L/min F-V loop Normal curve DCOL 25 mL/min per mm Hg (approximate) CV 10%20% of VC Viso Based on age formula Bronchial No change, or less than 20% provocation reduction in FEV1 Note: Normal values listed are estimated values for adults. Actual pediatric and adult values are based on age, height, and gender. These normal values are included on the patient's pulmonary function laboratory report.CV = closing volume; DCOL = diffusing capacity of the lungs; ERV = expiratory reserve volume; FEV1 = forced expiratory volume in 1 sec; FIF = forced inspiratory flow rate; FRC = functional residual capacity; FVC = forced vital capacity in 1 second; F-V loop = flow-volume loop; IC = inspiratory capacity; IRV = inspiratory reserve volume; MMEF = maximal midexpiratory flow (also known as FEF 25 75); MVV = maximal voluntary ventilation; PEFR = peak expiratory flow rate; PIFR = peak inspiratory flow rate; RV = residual volume; TLC = total lung capacity; TV = tidal volume; VC = vital capacity; Viso = isoflow volume. Abnormal Findings: Allergy Asbestosis Asthma Bronchiectasis Chest trauma Chronic bronchitis Curvature of the spine Emphysema

Myasthenia gravis Obesity Pulmonary fibrosis Pulmonary tumors Respiratory infections Sarcoidosis

Critical Findings

N/A
Interfering Factors The aging process can cause decreased values (FVC, DCOL) depending on the study done. Inability of the patient to put forth the necessary breathing effort affects the results. Medications such as bronchodilators can affect results. Improper placement of the nose clamp or mouthpiece that allows for leakage can affect volume results. Confusion or inability to understand instructions or cooperate during the study can cause inaccurate results. Testing is contraindicated in patients with cardiac insufficiency, recent myocardial infarction, and presence of chest pain that affects inspiration or expiration ability. Exercise caution with patients who have upper respiratory infections, such as a cold or acute bronchitis.

Nursing Implications and Procedures

Pretest:
Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Patient Teaching: Inform the patient this procedure can assist in assessing lung function. Obtain a history of the patients complaints or symptoms, including a list of known allergens, especially allergies or sensitivities to latex, iodine, seafood, anesthetics, or contrast mediums. Obtain a history of the patients cardiovascular and respiratory systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. Obtain a list of the patients current medications, including herbs, nutritional supplements, and nutraceuticals (see Appendix F: Effects of Natural Products on Laboratory Values). Review the procedure with the patient. Address concerns about pain related to the procedure and explain that no discomfort will be experienced during the test. Explain that the procedure is generally performed in a specially equipped room or in a health-care providers (HCPs) office by an HCP specializing in this procedure and usually lasts 1 hr.

Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. Record the patients height and weight. The patient should avoid bronchodilators (oral or inhalant) for at least 4 hr before the study, as directed by the HCP. Instruct the patient to refrain from smoking tobacco or eating a heavy meal for 4 to 6 hr prior to the study. Protocols may vary among facilities.

Intratest: Ensure the patient has complied with dietary and medication restrictions and pretesting preparations. Obtain an inhalant bronchodilator to treat any bronchospasms that may occur with testing. Instruct the patient to void and to loosen any restrictive clothing. Instruct the patient to cooperate fully and to follow directions. Observe standard precautions, and follow the general guidelines in Appendix A: Patient Preparation and Specimen Collection. Place the patient in a sitting position on a chair near the spirometry equipment. Place a soft clip on the patients nose to restrict nose breathing, and instruct the patient to breathe through the mouth. Place a mouthpiece in the mouth and instruct the patient to close his or her lips around it to form a seal. Tubing from the mouthpiece attaches to a cylinder that is connected to a computer that measures, records, and calculates the values for the tests done. Instruct the patient to inhale deeply and then to quickly exhale as much air as possible into the mouthpiece. Additional breathing maneuvers are performed on inspiration and expiration (normal, forced, and breath-holding).

Post-test: A report of the examination will be sent to the requesting HCP, who will discuss the results with the patient. Assess the patient for dizziness or weakness after the testing. Allow the patient to rest as long as needed to recover. Instruct the patient to resume usual diet and medications, as directed by the HCP. Recognize anxiety related to test results, and be supportive of perceived loss of independent function. Discuss the implications of abnormal test results on the patients lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Reinforce information given by the patients HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.

Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patients symptoms and other tests performed.

Related Monographs Related tests include 1-AT, anion gap, arterial/alveolar oxygen ratio, biopsy lung, blood gases, bronchoscopy, carboxyhemoglobin, chest x-ray, chloride sweat, CBC, CBC hemoglobin, CBC WBC count and differential, CT angiography, CT thoracic, culture and smear for mycobacteria, culture bacterial sputum, culture viral, cytology sputum, echocardiography, ECG, Gram stain, IgE, lactic acid, lung perfusion scan, lung ventilation scan, MR angiography, MRI chest, osmolality, phosphorus, plethysmography, pleural fluid analysis, potassium, PET chest, pulse oximetry, sodium, and TB skin test. Refer to the Cardiovascular and Respiratory systems tables at the end of the book for related tests by body system.

Procedure for the assessment of lung function with spirometry

10 June, 2003 VOL: 99, ISSUE: 23, PAGE NO: 57 Kath Cooper, SRN, is associate lecturer/short course manager and spirometry module coordinator, Respiratory Education and Training Centre, Aintree, and part-time practice nurse in Cheshire Pat Mitchell, a member of the Registration Council for Clinical Physiology, is chief technician, Respiratory Laboratory, University Hospital Aintree, and is executive member of the Association of Respiratory Technicians and Physiologists (ARTP) Spirometry records breath movements, inhalation and exhalation, and is integral to the management of lung disease, alongside good history taking and careful documentation. Tests can indicate a patient's optimal response to treatment or triggers, and the rate of decline in lung function. It is useful to detect the presence of lung disease, those susceptible to developing lung disease and to classify patients into severity classifications to optimise management. Spirometry records breath movements, inhalation and exhalation, and is integral to the management of lung disease, alongside good history taking and careful documentation. Tests can indicate a patient's optimal response to treatment or triggers, and the rate of decline in lung function. It is useful to detect the presence of lung disease, those susceptible to developing lung disease and to classify patients into severity classifications to optimise management. Measurements used in spirometry Forced expiratory volume (FEV) gives a measurement of the volume of air exhaled in a given time - often 0.5, 1, 2, 3, 4 or even 6 seconds. At 1s, this is referred to as FEV1. On average, a healthy person can exhale more than 80 per cent of the air in the first second. Readings of FEV1 can be used to classify lung disease when compared with predicted values for age, sex, height and ethnic origin (British Thoracic Society, 1997): - Mild: FEV1 = 60-79 per cent; - Moderate: FEV1 = 40-59 per cent;

- Severe: FEV1 < 40 per cent. Vital capacity (VC) is another useful measure in determining patients' lung status. Forced vital capacity (FVC) represents the total amount of air exhaled at force from a maximum inhalation (total lung capacity) to maximum exhalation (residual volume), measured against time. Relaxed Vital Capacity (VC) is the volume from maximal inspiration to maximal expiration performed slowly, and not measured against time. The ratio FEV1/FVC (the amount of air exhaled at one second compared with the total volume of either the FVC or VC, whichever is the greater) is often expressed as FEV1% and can be used to distinguish between restrictive disease, for example, pulmonary fibrosis; and obstructive disease, for example, asthma (Fig 1). A restrictive pattern affects lung expansion and is characterised by a low FEV1, a low FVC and a high FEV1/FVC ratio. An obstructive pattern is one which affects the rate at which air can be expelled from the lungs and is characterised by a reduced FEV1, normal FVC and a low FEV1/FVC ratio. Preparation of the patient for spirometry Nurses should be familiar with the type of spirometer they are using. Patients should be informed about spirometry to aid adequate preparation for the test and to enable the patient to give informed consent. Many variables may affect the test - before it, the patient should avoid: - Smoking for 24 hours; - Drinking alcohol for at least four hours; - Vigorous exercise for at least 30 minutes; - Wearing any tight clothing; - Eating a large meal for at least two hours; - Taking short-acting bronchodilators for four hours; - Taking long-acting beta-2-agonist inhalers for 12 hours; - Taking slow-release medicines that affect respiratory function, and theophylline-based drugs for 24 hours (ARTP/BTS, 1994). Procedure for spirometry The ARTP/BTS (1994) guidelines recommend the following steps:

- The patient should be seated in a chair with arms; - Two relaxed measurements of vital capacity should be performed first, (the patient should use nose clips for this procedure to prevent air leakage from the nose), followed by three forced vital capacity measurements; - A large breath to full inspiration is taken through mouth; - The mouthpiece is placed into the patient's mouth and the patient is asked to place his or her lips and teeth around the mouthpiece to form a tight seal; - For the relaxed VC, the patient breathes out at a comfortable speed, but for the FVC the patient should breathe out hard and quickly until all air is expelled; - The FVC should take 6s, but in some patients with obstructive breathing patterns it can take up to 15s; - At least 30s should be left between blows (exhalations using the spirometer) to enable the patient to recover; - A minimum of three and a maximum of eight blows should be attempted at any one time. It is vital that patients inhale completely, to total lung capacity, and continue to exhale until they have fully emptied their lungs (to residual volume) so that a low vital capacity is not recorded due to poor effort. It is vital to observe a patient's technique and the shape of the flow/volume or volume/time curves to detect poor effort. Reproducibility Spirometry equipment should be checked regularly, using the manufacturers' instructions, to ensure readings are accurate. A log should be kept to record any verification or calibration checks performed. The printout of each set of measurements recorded with a patient should be examined to ensure that the tests are consistent (reproducible). The following points should be assessed (ARTP/BTS, 1994): - At the start of the test (time = zero), there should be a steep rise in the curve (Fig 1); - The results of two FVC tests performed by the same patient should be within five per cent and 100ml of each other (to demonstrate consistency); - Equipment should be capable of recording up to 14s; up to a volume of 8l (litres); or up to a flow rate of 15l/s; - Calibration/verification of the machine should take place daily or at the start of a session;

- The end point of the test should be when less that 0.05l has been exhaled in a 2s period; if the test exceeds 15s; or if the operator has to end the test for clinical reasons. Reporting results Careful and accurate reporting is vital to ensure that patients are diagnosed and treated correctly. The best FEV1 and FVC results should be selected from three reproducible blows (these need not be from the same manoeuvre as long as results are within 100ml and five per cent of each other). The FEV1/FVC ratio should be calculated from the best VC reading, whether this is a relaxed or a forced manoeuvre. Reference values and ranges should be reported. Reversibility This refers to an improvement in FEV1 after an intervention such as a drug treatment. About 10-20 per cent of patients with COPD will respond to steroid therapy - the largest response is usually seen in patients who have a positive response to bronchodilators. The response of patients with COPD to steroids is under review and may point to a need for prolonged trials of inhaled steroid treatment for a period of 12 weeks (Global Initiative on Chronic Obstructive Lung Disease, 2001). A change in FEV1 of more than 200ml and 15 per cent compared with previous readings is suggestive of a positive response to a particular medication, for example a bronchodilator, and not a change in the airway size due to normal fluctuation (Sourk and Nugent, 1983). Patients who show improvements with bronchodilators should be considered for a steroid reversibility trial; the post-bronchodilator FEV1 and the post-steroid FEV1 should be assessed and compared (American Thoracic Society, 1991). Subsequent FEV1 recordings should be made after administration of bronchodilators to inform further treatment (Hansen et al, 1999). Many patients in the moderate and severe stages of COPD show a reduction in exacerbation rates even if they have had a negative steroid trial, and this should be considered in management strategies (BTS, 1997). The Gold guidelines from The Global Initiative for Chronic Obstructive Lung Disease (2001) advocate several changes to the interpretation and classification of spirometry. They suggest that many patients with COPD may be treated as patients with asthma because they have a degree of reversibility to their airway function. They also suggest that the FEV1/FVC ratio is a more sensitive test, to be considered when judging if reversibility is partial, as in COPD, or complete, as in asthma. Current guidelines may, therefore, underestimate the severity of the disease when only FEV1 is considered (BTS, 1997). Conclusion Spirometric investigations are not simple to perform, but they are valuable for assessing lung function and diagnosing lung disease. An increasing number of general practices are purchasing spirometers, so adequate training of staff is essential.