Post on 07-May-2015
Indications for PFT
RET 2414Pulmonary Function TestingModule 1.0
Indications For PFT
Learning Objectives
Categorize PFTs according to specific purposes Identify at least one indication for spirometry,
lung volumes, and diffusing capacity List one obstructive and one restrictive
pulmonary disorder Name at least two disease in which air trapping
may occur Relate pulmonary history to indications for
performing pulmonary function tests
Pulmonary Function Testing
Purpose for PFT
Identify and quantify pulmonary impairments
Pulmonary Function Testing
Tests can be divided into categories
Airway Function Lung Volumes and Gas Distribution Diffusing Capacity Blood Gas and Exchange Tests Cardiopulmonary Exercise Tests
Airway Function Tests
Spirometry Vital Capacity (VC)
Airway Function Tests
Spirometry Forced Vital Capacity (FVC)
Airway Function Tests
Spirometry Flow – Volume Loop (FVL)
AKA; MEFV Curve
Airway Function Tests
Spirometry Flow – Volume Loop (FVL)
AKA; MEFV Curve
Airway Function Tests
FVC and/or FVL
Pre/Post Bronchodilator
Pre/Post Bronchochallenge Methacholine Histamine Exercise
Airway Function Tests
Spirometry Maximum Voluntary Ventilation (MVV)
Airway Function Tests
Maximal Inspiratory (MIP)
Expiratory Pressure (MEP)
Airway Resistance (Raw)
Compliance (CL)
Indications for Spirometry
Detect the presence of lung disease
Spirometry is recommended as the “Gold Standard” for diagnosis of obstructive lung disease by:
National Lung Health Education Program (NLHEP)
National Heart, Lung and Blood Institute (NHLBI)
World Health Organization (WHO)
Indications for Spirometry
BOX 1-2
Diagnose the presence or absence of lung disease
Quantify the extent of known disease on lung function
Measure the effects of occupational or environmental exposure
Determine beneficial or negative effects of therapy
Indications for Spirometry
BOX 1-2
Assess risk for surgical procedures
Evaluate disability or impairment
Epidemiologic or clinical research involving lung health or disease
Lung Volumes
Includes the VC and its subdivisions, along with the FRC
Lung Volumes
Functional Residual Capacity (FRC) Nitrogen Washout
Lung Volumes
FRC Helium Dilution
Lung Volumes
FRC Thoracic Gas
Volumes
Ventilation
Minute Ventilation
Alveolar Ventilation
Dead Space
Distribution of Ventilation
Multiple – Breath N2
He Equilibration
Single – Breath Techniques
Indications for Lung Volume Tests Box 1-3
Diagnose or assess the severity of restrictive lung disease
Differentiate between obstructive and restrictive disease patterns
Assess the response to therapy
Make preoperative assessment of patients with compromised lung function
Indications for Lung Volume Tests Box 1-3
Determine or evaluate disability
Assess gas trapping by comparison of plethysmographic lung volumes with gas dilution lung volumes
Standardize other lung functions (i.e., specific conductance)
Diffusing Capacity (DLco)
Diffusing Capacity (DLco)
Single – Breath (Breath Hold)
Steady – State
Other Techniques
Indications for Diffusing CapacityBox 1-4
Evaluate or follow the progress of parenchymal lung disease
Evaluate pulmonary involvement in systemic disease
Evaluate obstructive lung disease
Evaluate cardiovascular diseases
Quantify disability associated with interstitial lung disease
Evaluate pulmonary hemorrhage, polycythemia, or left-to-right shunts
Indications for Diffusing CapacityBox 1-4
Blood Gases and Gas Exchange
Blood Gases and Gas Exchange
Blood Gas Analysis and Oximetry Shunt Study
Blood Gases and Gas Exchange
Pulse Oximetry and Capnography
Indications for Blood Gas AnalysisBox 1-5
Evaluate the adequacy of lung function
Determine the need for supplemental oxygen
Monitor ventilatory support
Indications for Blood Gas AnalysisBox 1-5
Document the severity or progression of know pulmonary disease
Provide data to correct or corroborate other pulmonary function measurement
Cardiopulmonary Exercise Test
Indications for Exercise TestingBox 1-6
Determine the level of cardiorespiratory fitness
Document or diagnose exercise limitations as a result of fatigue, dyspnea, or pain,
Cardiovascular / Pulmonary Disease
Indications for Exercise TestingBox 1-6
Evaluate adequacy of arterial oxygenation oxyhemoglobin saturation
Assess preoperative risk Lung resection or reduction
Indications for Exercise TestingBox 1-6
Assess disability Occupational lung disease
Evaluate therapeutic interventions such as heart or lung transplant
Patterns of Impaired Pulmonary Function
Sometimes, patients display patterns during testing that are consistent with a specific diagnosis
Obstructive Airway Diseases
Simple definition:
“Airflow into and out of the lungs is reduced”
Obstructive Airway Diseases
Chronic Obstructive Pulmonary Disease (COPD)
Long-standing airway obstruction caused by:
Cystic Fibrosis Bronchitis Asthma Bronchiectasis Emphysema
“CBABE”
Obstructive Airway Diseases
COPD
Characterized by:
Dyspnea at rest or with exertion Productive cough
Obstructive Airway Diseases
Emphysema “air trapping”
Primarily caused by cigarette smoking! Genetic defect; absence of
α-antitrypsin Chronic exposure to environmental
pollutants
Obstructive Airway Diseases
Emphysema
Dyspnea at rest or with exertion Productive cough Under weight Barrel-chested Use of accessory muscles
Obstructive Airway Diseases
Emphysema
Purse-lip breathing Breath sounds are distant or absent Chest X-Ray
Flattened diaphragms Increased air spaces
Obstructive Airway Diseases
Emphysema
Airway obstruction Spirometry
FEV1 is reduced
Air trapping Lung Volumes
Hyperinflation of FRC
Obstructive Airway Diseases
Emphysema (cont)
Gas exchange abnormalities Diffusing Capacity (DLco)
Reduced Blood Gases
Hypoxemia/Hypercapnia
Possible O2 Desaturation with Exertion Exercise Testing
Obstructive Airway Diseases
Chronic Bronchitis
“Excessive mucus production, with a productive cough on most days, for at least 3 months for 2 years or more.”
Obstructive Airway Diseases
Chronic Bronchitis
Primarily caused by cigarette smoking!
Chronic exposure to environmental pollutants
Obstructive Airway Diseases
Chronic Bronchitis
Chronic cough – “smoker’s cough” Dyspnea, particularly with exertion Chest X-Ray
Congested airways Enlarged heart w/prominent pulmonary
vessels Diaphragms normal or flattened
Edema of lower extremities
Obstructive Airway Diseases
Chronic Bronchitis (cont)
Airway obstruction Spirometry
FEV1 is reduced
May have preserved DLco DLco to differentiate from emphysema
Obstructive Airway Diseases
Chronic Bronchitis (cont)
Gas exchange abnormalities Blood Gases
Hypoxemia, Hypercapnia in advanced cases Polycythemia Cyanosis
Obstructive Airway Diseases
Bronchiectasis
Pathologic dilatation of the bronchi, resulting from destruction of the bronchial wall by severe, repeated infections.
Obstructive Airway Diseases
Bronchiectasis
Common in Cystic Fibrosis (CF), as well as following bronchial obstruction by a tumor or foreign body. When entire bronchial tree is involved, it is assumed that the disease is inherited.
Obstructive Airway Diseases
Bronchiectasis
Dyspnea Very productive cough Purulent, foul smelling sputum Hemoptysis is common
Obstructive Airway Diseases
Bronchiectasis
Frequent pulmonary infections Right-sided heart failure when
advanced Appear chronically ill - under weight Chest X-Ray / CT Scan
Airway Dilation
Obstructive Airway Diseases
Bronchiectasis (cont)
Airway obstruction Spirometry
FEV1 is reduced
Lung Volumes Hyperinflation
Gas exchange abnormalities Blood Gases
Hypoxemia, Hypercapnia in advanced cases
Obstructive Airway Diseases
Asthma (Hypereactive Airway Disease)
Reversible airway obstruction. Obstruction is characterized by inflammation of the mucosal lining of the airways, bronchospasm, and increased airway secretions.
Obstructive Airway Diseases
Asthma (Hypereactive Airway Disease)
Triggers; agents or events that cause an asthmatic episode
Allergic agents Pollens, animal dander, house dust mites,
molds Nonallergic agents
Viral infections, exercise, cold air, air pollutants, drugs, food additives, emotional upset
Occupational exposure Toluene 2,4-diisocyanate (TDI), cotton or wood
dusts, grain, metal salts, insecticides
Obstructive Airway Diseases
Asthma (cont)
Airway obstruction During Attacks
Peak Flow (PEF) is reduced, also used to track response to bronchodilators
Blood Gases Hypoxemia
During Diagnosis Airway Resistance (Raw) Spirometry, Pre/Post Bronchodilator Bronchial Provocation if airways appear normal
Obstructive Airway Diseases
Cystic Fibrosis
An inherited disease that primarily affects the mucus-producing apparatus of the lungs and pancreas.
Obstructive Airway Diseases
Cystic Fibrosis
Airway obstruction Spirometry
FEV1 used to monitor the progression of the disease
Pulmonary function studies are routinely used to assess lung function following transplantation
Obstructive Airway Diseases
Upper or Large Airway Obstruction(Upper: nose, mouth, pharynx)(Large: Trachea, mainstem bronchi)
Increased work of breathing Spirometry
Flow-Volume Loop
Restrictive Lung Disease
Characterized by:
Reduction in lung volumes
(Vital Capacity (VC) and Total Lung Capacity (TLC) are both reduced below the lower limits of normal.
Restrictive Lung Disease
Any process that interferes with the bellows action of the lungs or chest wall can cause restriction.
Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
Characterized by alveolar wall inflammation resulting in fibrosis. Vascular changes are usually associated with pulmonary hypertension.
Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
IPF often follows Treatment with bleomycin,
cyclophosphamide, methotrexate or amiodarone
Autoimmune diseases Rheumatoid arthritis, systemic lupus
erythematousus (SLE), scleroderma
Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
Increasing exertional dyspnea Pulmonary hypertension
Vascular changes Chest X-Ray
Infiltrates are visible Honeycombing pattern when advanced
Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
Spirometry Reduced VC
Lung Volumes Reduced TLC
Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
Gas exchange abnormalities Reduced DLco Blood Gases
Hypoxemia; worsens with exertion
Lung compliance Reduced
Restrictive Lung Disease
Pneumoconiosis
Lung impairment caused by inhalation of dusts.
Silicosis – Silica dust Asbestosis – Asbestos fibers Coal Worker’s Pneumoconiosis – Coal
dust
Restrictive Lung Disease
Pneumoconiosis (cont)
Spirometry Reduced VC
Lung Volumes Reduced TLC
Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases
Hypoxemia
Restrictive Lung Disease
Sarcoidosis
Granulomatous disease that affects multiple organ systems. The granuloma found in sarcoidosis is composed of macrophages, epithelioid cells, and other inflammatory cells.
Restrictive Lung Disease
Sarcoidosis
Fatigue Muscle weakness Fever Weight loss Dyspnea and cough Chest X-Ray
Enlargement of hilar and mediastinal lymph nodes
Interstitial infiltrates
Restrictive Lung Disease
Sarcoidosis
Spirometry Reduced VC Normal Flow Rates
Lung Volumes Reduced TLC
Gas exchange abnormalities Decreased Diffusing Capacity (DLco) when
advanced Blood Gases
Normal or hypoxemia
Diseases of Chest Wall and Pleura
Disorders involving the chest wall or pleura of the lungs result in restrictive patterns on pulmonary function testing.
Diseases of Chest Wall and Pleura
Kyphoscoliosis
Abnormal curvature of the spine both anteriorly (kyphosis) and lateraly (scoliosis).
Diseases of Chest Wall and Pleura
Kyphoscoliosis
Spirometry Reduced VC
Lung Volumes Reduced TLC
Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases (Hypoxemia / Hypercapnia)
Diseases of Chest Wall and Pleura
Obesity
Increased mass of the thorax and abdomen interferes with the bellows action of the chest wall, as well as excursion of the diaphragm.
Diseases of Chest Wall and Pleura
Obesity
Spirometry Reduced VC Normal Flow Rates
Lung Volumes Reduced TLC
Diseases of Chest Wall and Pleura
Obesity
Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases
Hypoxemia / Hypercapnia Polycythemia Pulmonary Hypertension Cor pulmonale
Diseases of Chest Wall and Pleura
Pleurisy and Pleural Effusion
Pleurisy is characterized by deposition of a fibrous exudate on the pleural surface – often associated with pneumonia or cancer. May precede the development of pleural effusion.
Diseases of Chest Wall and Pleura
Pleurisy and Pleural Effusion
Plural effusion is an abnormal accumulation of fluid in the pleural space.
Diseases of Chest Wall and Pleura
Pleurisy and Pleural Effusion
Spirometry Reduced VC because of volume loss Difficulty performing because of pain
Lung Volumes Reduced TLC because of volume loss
Diseases of Chest Wall and Pleura
Pleurisy and Pleural Effusion
Gas exchange abnormalities DLco – Difficulty performing due to pain Blood Gases
Large effusions may cause changes
Neuromuscular Disorders
Disease that affect the spinal cord, peripheral nerves, neuromuscular junctions, and the respiratory muscles can all cause a restrictive pattern of pulmonary function.
Neuromuscular Disorders
Diaphragmatic paralysis
Amyotrophic Lateral Sclerosis(ALS, Lou Gehrig’s disease)
Guillain – Barre’ syndrome
Myasthenia gravis
Neuromuscular Disorders
Spirometry Reduced VC
Lung Volumes Reduced TLC
Neuromuscular Disorders
Gas exchange abnormalities Blood Gases
Hypoxemia if involvement is severe Respiratory alkalosis from hyperventilation
Inspiratory Pressures MIP - Reduced
Congestive Heart Failure
Often caused by left ventricular failure, but may also be associated with cardiomyopathy, congenital heart defects, or left-to-right shunts. In each case, fluid backs up in the lungs.
Congestive Heart Failure
Spirometry Reduced VC
Lung Volumes Reduced TLC
Congestive Heart Failure
Gas exchange abnormalities DLco is reduced Blood Gases
Hypoxemia
Lung Compliance Reduced
Lung Transplantation
Lung transplantation has been used for patients with CF, primary pulmonary hypertension, and COPD.
Lung Transplantation
Pulmonary function testing is used to both assess potential transplant candidates and follow them postoperatively.
Preliminaries to Patient Testing
Patient Preparation
Withholding Medications Bronchodilator held 4-6 hours prior to test
Smoking Cessation Should be ceased 24 hours prior to test
Eating should be limited
Preliminaries to Patient Testing
Physical Measurements
Age Height (arm span if unable to stand) Weight Gender Race or Ethnic Origin
Preliminaries to Patient Testing
Physical Assessment
Breathing Patterns
Breath Sounds
Respiratory Symptoms
Preliminaries to Patient Testing
Pulmonary History
Age, gender, height, weight, race Current Dx. or reason for test Family History (immediate family: mother,
father, brother, or sister) Tuberculosis Emphysema Chronic Bronchitis Asthma Hay fever or allergies Cancer Other lung disorders
Preliminaries to Patient Testing
Pulmonary History
Personal History Tuberculosis Emphysema Chronic Bronchitis Asthma Recurrent lung infection Pneumonia or pleurisy Allergies or hay fever Chest injury Chest surgery
Preliminaries to Patient Testing
Occupation
What was your occupation? How long did you work there? Have you ever worked in …
Mine, quarry, foundry? Near gases or fumes? Dusty environment?
Preliminaries to Patient Testing
Smoking Habits
Have you ever smoked the following:
Cigarettes (how many per day?) Cigars (how many per day?) Pipe (how many bowls per day?) How many years? Do you still smoke? Do you live with a smoker?
Preliminaries to Patient Testing
Cough
Do you ever cough? In the morning? At night? Blood? Phlegm? (when, color, volume)
Preliminaries to Patient Testing
Dyspnea
Do you get short of breath at the following times:
At rest? On exertion? At night?
Preliminaries to Patient Testing
Patient Disposition
Dyspneic Wheezing Coughing Cyanotic Apprehensive Cooperative
Preliminaries to Patient Testing
Current Medications
Heart, lung, or blood pressure?
Last taken?
Test Performance
Patient Instruction
Many tests are effort dependent
Instruction & coaching very important
Demonstration a must
Test Performance
Patient Instruction
Encouragement during test
Suboptimal effort results in poor reproducibility
Documentation of effort important
Practice / Review
Which of the following are indications for performing spirometry?
I. Assess the risk of lung resectionII. Determine the response to
bronchodilator therapyIII. Assess the severity of restrictive lung
diseaseIV. Quantify the extent of COPD
a. I and IV b. II and III c. I, II, and IVd. II, III, and IV
Practice / Review
Which of the following symptoms is an indication for performing spirometry?
A. HeadacheB. Shortness of breathC. Chest painD. Daytime sleepiness
Practice / Review
Which of the following tests would be indicated to assess the severity of a restrictive lung disease?
A. Blood gas analysisB. Simple spirometryC. Lung volume determinationD. Cardiopulmonary exercise test
Practice / Review
Which of the following tests would be indicated in the evaluation of a patient exposed to dust including asbestos?
A. Shunt studyB. DLcoC. Methacholine challengeD. Airway Resistance
Practice / Review
A 17-year old female complains of chest tightness and cough after soccer practice. These symptoms are most consistent with which of the following?
A. EmphysemaB. Congestive heart failureC. AsthmaD. Cystic fibrosis
Practice / Review
Which of the following diseases often results in an obstructive pattern when simple spirometry is performed?
A. SarcoidosisB. Idiopathic pulmonary fibrosisC. PleurisyD. Chronic bronchitis
Practice / Review
Lung volumes measured by closed –circuit He dilution may be expected to show a reduced FRC in which of the following?
A. EmphysemaB. AsthmaC. Pulmonary fibrosisD. Upper airway obstruction
Practice / Review
Which of the following should a pulmonary function technologist do before performing spirometry?
a. Limit feedback to the patient to limit placebo effect
b. Explain the physiologic basis of the test c. Demonstrate how to correctly perform the test
maneuverd. Explain the exact number of efforts that will be
required for the test
Practice / Review
Pulmonary function testing is usually contraindicated in which of the following conditions?
A. Untreated pneumothoraxB. Congestive heart failureC. CyanosisD. Tuberculosis
Practice / Review
In which of the following diseases is air-trapping likely to occur?
A. Acute exacerbation of asthmaB. SarcoidosisC. AsbestosisD. EmphysemaE. B & CF. A & D
Practice / Review
Which of the following correctly describes appropriate physical measurements before pulmonary function testing?
I. Actual body weight should be used to calculate predicted values
II. Standing height should be measured when the patient is barefoot
III. Arm span should be used instead of height for a patient with kyphosis
IV. Age should be recorded to the nearest decade (10 years)
a. I onlyb. II and III c. I, II, and IVd. I, II, III, and IV