Module 1.0 Indications for PFT

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)


Spirometry Forced Vital Capacity (FVC)


Spirometry Flow – Volume Loop (FVL)

AKA; MEFV Curve


FVC and/or FVL

Pre/Post Bronchodilator

Pre/Post Bronchochallenge Methacholine Histamine Exercise


Spirometry Maximum Voluntary Ventilation (MVV)


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)


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


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 Gas Analysis and Oximetry Shunt Study


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


Evaluate adequacy of arterial oxygenation oxyhemoglobin saturation

Assess preoperative risk Lung resection or reduction


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”


Chronic Obstructive Pulmonary Disease (COPD)

Long-standing airway obstruction caused by:

Cystic Fibrosis Bronchitis Asthma Bronchiectasis Emphysema

“CBABE”


COPD

Characterized by:

Dyspnea at rest or with exertion Productive cough


Emphysema “air trapping”

Primarily caused by cigarette smoking! Genetic defect; absence of

α-antitrypsin Chronic exposure to environmental

pollutants


Emphysema

Dyspnea at rest or with exertion Productive cough Under weight Barrel-chested Use of accessory muscles


Emphysema

Purse-lip breathing Breath sounds are distant or absent Chest X-Ray

Flattened diaphragms Increased air spaces


Emphysema

Airway obstruction Spirometry

FEV1 is reduced

Air trapping Lung Volumes

Hyperinflation of FRC


Emphysema (cont)

Gas exchange abnormalities Diffusing Capacity (DLco)

Reduced Blood Gases

Hypoxemia/Hypercapnia

Possible O2 Desaturation with Exertion Exercise Testing


Chronic Bronchitis

“Excessive mucus production, with a productive cough on most days, for at least 3 months for 2 years or more.”


Chronic Bronchitis

Primarily caused by cigarette smoking!

Chronic exposure to environmental pollutants


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


Chronic Bronchitis (cont)


FEV1 is reduced

May have preserved DLco DLco to differentiate from emphysema


Chronic Bronchitis (cont)

Gas exchange abnormalities Blood Gases

Hypoxemia, Hypercapnia in advanced cases Polycythemia Cyanosis


Bronchiectasis

Pathologic dilatation of the bronchi, resulting from destruction of the bronchial wall by severe, repeated infections.


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.


Bronchiectasis

Dyspnea Very productive cough Purulent, foul smelling sputum Hemoptysis is common


Bronchiectasis

Frequent pulmonary infections Right-sided heart failure when

advanced Appear chronically ill - under weight Chest X-Ray / CT Scan

Airway Dilation


Bronchiectasis (cont)


FEV1 is reduced

Lung Volumes Hyperinflation


Hypoxemia, Hypercapnia in advanced cases


Asthma (Hypereactive Airway Disease)

Reversible airway obstruction. Obstruction is characterized by inflammation of the mucosal lining of the airways, bronchospasm, and increased airway secretions.


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


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


Cystic Fibrosis

An inherited disease that primarily affects the mucus-producing apparatus of the lungs and pancreas.


Cystic Fibrosis


FEV1 used to monitor the progression of the disease

Pulmonary function studies are routinely used to assess lung function following transplantation


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.


Any process that interferes with the bellows action of the lungs or chest wall can cause restriction.


Idiopathic Pulmonary Fibrosis

Characterized by alveolar wall inflammation resulting in fibrosis. Vascular changes are usually associated with pulmonary hypertension.



IPF often follows Treatment with bleomycin,

cyclophosphamide, methotrexate or amiodarone

Autoimmune diseases Rheumatoid arthritis, systemic lupus

erythematousus (SLE), scleroderma



Increasing exertional dyspnea Pulmonary hypertension

Vascular changes Chest X-Ray

Infiltrates are visible Honeycombing pattern when advanced



Spirometry Reduced VC

Lung Volumes Reduced TLC



Gas exchange abnormalities Reduced DLco Blood Gases

Hypoxemia; worsens with exertion

Lung compliance Reduced


Pneumoconiosis

Lung impairment caused by inhalation of dusts.

Silicosis – Silica dust Asbestosis – Asbestos fibers Coal Worker’s Pneumoconiosis – Coal

dust


Pneumoconiosis (cont)



Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases

Hypoxemia


Sarcoidosis

Granulomatous disease that affects multiple organ systems. The granuloma found in sarcoidosis is composed of macrophages, epithelioid cells, and other inflammatory cells.


Sarcoidosis

Fatigue Muscle weakness Fever Weight loss Dyspnea and cough Chest X-Ray

Enlargement of hilar and mediastinal lymph nodes

Interstitial infiltrates


Sarcoidosis

Spirometry Reduced VC Normal Flow Rates


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.


Kyphoscoliosis

Abnormal curvature of the spine both anteriorly (kyphosis) and lateraly (scoliosis).


Kyphoscoliosis



Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases (Hypoxemia / Hypercapnia)


Obesity

Increased mass of the thorax and abdomen interferes with the bellows action of the chest wall, as well as excursion of the diaphragm.


Obesity

Spirometry Reduced VC Normal Flow Rates



Obesity

Gas exchange abnormalities Decreased Diffusing Capacity (DLco) Blood Gases

Hypoxemia / Hypercapnia Polycythemia Pulmonary Hypertension Cor pulmonale


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.



Plural effusion is an abnormal accumulation of fluid in the pleural space.



Spirometry Reduced VC because of volume loss Difficulty performing because of pain

Lung Volumes Reduced TLC because of volume loss



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.


Diaphragmatic paralysis

Amyotrophic Lateral Sclerosis(ALS, Lou Gehrig’s disease)

Guillain – Barre’ syndrome

Myasthenia gravis



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.


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


Physical Measurements

Age Height (arm span if unable to stand) Weight Gender Race or Ethnic Origin


Physical Assessment

Breathing Patterns

Breath Sounds

Respiratory Symptoms


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


Pulmonary History

Personal History Tuberculosis Emphysema Chronic Bronchitis Asthma Recurrent lung infection Pneumonia or pleurisy Allergies or hay fever Chest injury Chest surgery


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?


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?


Cough

Do you ever cough? In the morning? At night? Blood? Phlegm? (when, color, volume)


Dyspnea

Do you get short of breath at the following times:

At rest? On exertion? At night?


Patient Disposition

Dyspneic Wheezing Coughing Cyanotic Apprehensive Cooperative


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

Module 1.0 Indications for PFT

Health & Medicine

Transcript of Module 1.0 Indications for PFT