Indications for PFT

1
Indications for PFT

• RET 2414
• Pulmonary Function Testing
• Module 1.0

2
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

3
Pulmonary Function Testing

• Purpose for PFT
• Identify and quantify pulmonary impairments

4
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

5
Airway Function Tests

• Spirometry
• (meaning the measuring of breath) is the most
  common of the Pulmonary Function Tests (PFTs).
  It measures lung function, specifically the
  direct measurement of the amount (volume) and/or
  speed (flow) of air that can be inhaled and
  exhaled.

6
Airway Function Tests

• Spirometry
• Vital Capacity (VC)

7
Airway Function Tests

• Spirometry
• Forced Vital Capacity (FVC)

8
Airway Function Tests

• Spirometry
• Flow Volume Loop (FVL)
• AKA MEFV Curve

9
Airway Function Tests

• Spirometry
• Flow Volume Loop (FVL)
• AKA MEFV Curve

10
Airway Function Tests

• FVC and/or FVL
• Pre/Post Bronchodilator
• Pre/Post Bronchochallenge
• Methacholine
• Histamine
• Exercise

11
Airway Function Tests

• Spirometry
• Maximum Voluntary Ventilation (MVV)

12
Airway Function Tests

• Maximal Inspiratory (MIP)
• Expiratory Pressure (MEP)
• Airway Resistance (Raw)
• Compliance (CL)

13
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)

14
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

15
Indications for Spirometry BOX 1-2

• Assess risk for surgical procedures
• Evaluate disability or impairment
• Epidemiologic or clinical research involving lung
  health or disease

16
Lung Volumes

• Determination of lung volume
• Includes the VC (spirometry) and its
  subdivisions, along with the FRC (indirect
  spirometry) from these TLC and other lung
  volumes can be determined

17
Lung Volumes

• Functional Residual Capacity (FRC)
• Nitrogen Washout
• Helium Dilution
• Thoracic Gas Volumes

18
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

19
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)

20
Ventilation

• Minute Ventilation
• Alveolar Ventilation
• Dead Space

21
Distribution of Ventilation

• Multiple Breath N2
• He Equilibration
• Single Breath Techniques

22
Diffusing Capacity (DLco)
23
Diffusing Capacity (DLco)

• Single Breath (Breath Hold)
• Steady State
• Other Techniques

24
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

25
Indications for Diffusing CapacityBox 1-4

• Evaluate cardiovascular diseases
• Quantify disability associated with interstitial
  lung disease
• Evaluate pulmonary hemorrhage, polycythemia, or
  left-to-right shunts

26
Blood Gases and Gas Exchange
27
Blood Gases and Gas Exchange

• Blood Gas Analysis and Oximetry
• Shunt Study

28
Blood Gases and Gas Exchange

• Pulse Oximetry and Capnography

29
Indications for Blood Gas AnalysisBox 1-5

• Evaluate the adequacy of lung function
• Determine the need for supplemental oxygen
• Monitor ventilatory support

30
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

31
Cardiopulmonary Exercise Test
32
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

33
Indications for Exercise TestingBox 1-6

• Evaluate adequacy of arterial oxygenation
  oxyhemoglobin saturation
• Assess preoperative risk
• Lung resection or reduction

34
Indications for Exercise TestingBox 1-6

• Assess disability
• Occupational lung disease
• Evaluate therapeutic interventions such as heart
  or lung transplant

35
Patterns of Impaired Pulmonary Function

• Sometimes, patients display patterns during
  pulmonary function testing that are consistent
  with a specific diagnosis

36
Obstructive Airway Diseases

• Simple definition
• Airflow into and out of the lungs is reduced

37
Obstructive Airway Diseases

• Chronic Obstructive Pulmonary Disease (COPD)
• Long-standing airway obstruction caused by
• Cystic Fibrosis
• Bronchitis
• Asthma
• Bronchiectasis
• Emphysema
• CBABE

38
Obstructive Airway Diseases

• COPD
• Characterized by
• Dyspnea at rest or with exertion
• Productive cough

39
Obstructive Airway Diseases

• Emphysema air trapping
• Primarily caused by cigarette smoking!
• Genetic defect absence of
• a-antitrypsin
• Chronic exposure to environmental pollutants

40
Obstructive Airway Diseases

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

41
Obstructive Airway Diseases

• Emphysema
• Purse-lip breathing
• Breath sounds are distant or absent
• Chest X-Ray
• Flattened diaphragms
• Increased air spaces

42
Obstructive Airway Diseases

• Emphysema
• Airway obstruction
• Spirometry
• FEV1 is reduced
• Air trapping
• Lung Volumes
• Hyperinflation of FRC

43
Obstructive Airway Diseases

• Emphysema (cont)
• Gas exchange abnormalities
• Diffusing Capacity (DLco)
• Reduced
• Blood Gases
• Hypoxemia/Hypercapnia
• Possible O2 Desaturation with Exertion
• Exercise Testing

44
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.

45
Obstructive Airway Diseases

• Chronic Bronchitis
• Primarily caused by cigarette smoking!
• Chronic exposure to environmental pollutants

46
Obstructive Airway Diseases

• Chronic Bronchitis
• Chronic cough smokers cough
• Dyspnea, particularly with exertion
• Chest X-Ray
• Congested airways
• Enlarged heart w/prominent pulmonary vessels
• Diaphragms normal or flattened
• Edema of lower extremities

47
Obstructive Airway Diseases

• Chronic Bronchitis (cont)
• Airway obstruction
• Spirometry
• FEV1 is reduced
• Dlco
• Usually reduced
• May have a preserved (normal) Dlco, which is
  helpful to distinguish it from emphysema

48
Obstructive Airway Diseases

• Chronic Bronchitis (cont)
• Gas exchange abnormalities
• Blood Gases
• Hypoxemia, Hypercapnia in advanced cases
• Polycythemia
• Cyanosis

49
Obstructive Airway Diseases

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

50
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.

51
Obstructive Airway Diseases

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

52
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

53
Obstructive Airway Diseases

• Bronchiectasis (cont)
• Airway obstruction
• Spirometry
• FEV1 is reduced
• Lung Volumes
• Hyperinflation
• Gas exchange abnormalities
• Blood Gases
• Hypoxemia, Hypercapnia in advanced cases

54
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.

55
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

56
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

57
Obstructive Airway Diseases

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

58
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

59
Obstructive Airway Diseases

• Upper or Large Airway Obstruction
• (Upper nose, mouth, pharynx)
• (Large Trachea, mainstem bronchi)
• Increased work of breathing
• Spirometry
• Flow-Volume Loop

60
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.

61
Restrictive Lung Disease

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

62
Restrictive Lung Disease

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

63
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

64
Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Increasing exertional dyspnea
• Pulmonary hypertension
• Vascular changes
• Chest X-Ray
• Infiltrates are visible
• Honeycombing pattern when advanced

65
Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Spirometry
• Reduced VC
• Lung Volumes
• Reduced TLC

66
Restrictive Lung Disease

• Idiopathic Pulmonary Fibrosis
• Gas exchange abnormalities
• Reduced DLco
• Blood Gases
• Hypoxemia worsens with exertion
• Lung compliance
• Reduced

67
Restrictive Lung Disease

• Pneumoconiosis
• Lung impairment caused by inhalation of dusts.
• Silicosis Silica dust
• Asbestosis Asbestos fibers
• Coal Workers Pneumoconiosis Coal dust

68
Restrictive Lung Disease

• Pneumoconiosis (cont)
• Spirometry
• Reduced VC
• Lung Volumes
• Reduced TLC
• Gas exchange abnormalities
• Decreased Diffusing Capacity (DLco)
• Blood Gases
• Hypoxemia

69
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.

70
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

71
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

72
Diseases of Chest Wall and Pleura

• Disorders involving the chest wall or pleura of
  the lungs result in restrictive patterns on
  pulmonary function testing.

73
Diseases of Chest Wall and Pleura

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

74
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)

75
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.

76
Diseases of Chest Wall and Pleura

• Obesity
• Spirometry
• Reduced VC
• Normal Flow Rates
• Lung Volumes
• Reduced TLC

77
Diseases of Chest Wall and Pleura

• Obesity
• Gas exchange abnormalities
• Decreased Diffusing Capacity (DLco)
• Blood Gases
• Hypoxemia / Hypercapnia
• Polycythemia
• Pulmonary Hypertension
• Cor pulmonale

78
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.

79
Diseases of Chest Wall and Pleura

• Pleurisy and Pleural Effusion
• Plural effusion is an abnormal accumulation of
  fluid in the pleural space.

80
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

81
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

82
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.

83
Neuromuscular Disorders

• Diaphragmatic paralysis
• Amyotrophic Lateral Sclerosis
• (ALS, Lou Gehrigs disease)
• Guillain Barre syndrome
• Myasthenia gravis

84
Neuromuscular Disorders

• Spirometry
• Reduced VC
• Lung Volumes
• Reduced TLC

85
Neuromuscular Disorders

• Gas exchange abnormalities
• Blood Gases
• Hypoxemia if involvement is severe
• Respiratory alkalosis from hyperventilation
• Inspiratory Pressures
• MIP - Reduced

86
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.

87
Congestive Heart Failure

• Spirometry
• Reduced VC
• Lung Volumes
• Reduced TLC

88
Congestive Heart Failure

• Gas exchange abnormalities
• DLco is reduced
• Blood Gases
• Hypoxemia
• Lung Compliance
• Reduced

89
Lung Transplantation

• Lung transplantation has been used for patients
  with CF, primary pulmonary hypertension, and
  COPD.

90
Lung Transplantation

• Pulmonary function testing is used to both
  assess potential transplant candidates and follow
  them postoperatively.

91
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

92
Preliminaries to Patient Testing

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

93
Preliminaries to Patient Testing

• Physical Assessment
• Breathing Patterns
• Breath Sounds
• Respiratory Symptoms

94
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

95
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

96
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?

97
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?

98
Preliminaries to Patient Testing

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

99
Preliminaries to Patient Testing

• Dyspnea
• Do you get short of breath at the following
  times
• At rest?
• On exertion?
• At night?

100
Preliminaries to Patient Testing

• Patient Disposition
• Dyspneic
• Wheezing
• Coughing
• Cyanotic
• Apprehensive
• Cooperative

101
Preliminaries to Patient Testing

• Current Medications
• Heart, lung, or blood pressure?
• Last taken?

102
Test Performance

• Patient Instruction
• Many tests are effort dependent
• Instruction coaching very important
• Demonstration a must

103
Test Performance

• Patient Instruction
• Encouragement during test
• Suboptimal effort results in poor reproducibility
• Documentation of effort important

104
Practice / Review

• Which of the following are indications for
  performing spirometry?
• I. Assess the risk of lung resection
• II. Determine the response to
• bronchodilator therapy
• III. Assess the severity of restrictive lung
• disease
• IV. Quantify the extent of COPD
• a. I and IV
• b. II and III
• c. I, II, and IV
• d. II, III, and IV

105
Practice / Review

• Which of the following symptoms is an indication
  for performing spirometry?
• A. Headache
• B. Shortness of breath
• C. Chest pain
• D. Daytime sleepiness

106
Practice / Review

• Which of the following tests would be indicated
  to assess the severity of a restrictive lung
  disease?
• A. Blood gas analysis
• B. Simple spirometry
• C. Lung volume determination
• D. Cardiopulmonary exercise test

107
Practice / Review

• Which of the following tests would be indicated
  in the evaluation of a patient exposed to dust
  including asbestos?
• A. Shunt study
• B. DLco
• C. Methacholine challenge
• D. Airway Resistance

108
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. Emphysema
• B. Congestive heart failure
• C. Asthma
• D. Cystic fibrosis

109
Practice / Review

• Which of the following diseases often results in
  an obstructive pattern when simple spirometry is
  performed?
• A. Sarcoidosis
• B. Idiopathic pulmonary fibrosis
• C. Pleurisy
• D. Chronic bronchitis

110
Practice / Review

• Lung volumes measured by closed circuit He
  dilution may be expected to show a reduced FRC in
  which of the following?
• A. Emphysema
• B. Asthma
• C. Pulmonary fibrosis
• D. Upper airway obstruction

111
Practice / Review

• Which of the following should a pulmonary
  function technologist do before performing
  spirometry?
• Limit feedback to the patient to limit placebo
  effect
• Explain the physiologic basis of the test
• Demonstrate how to correctly perform the test
  maneuver
• Explain the exact number of efforts that will be
  required for the test

112
Practice / Review

• Pulmonary function testing is usually
  contraindicated in which of the following
  conditions?
• A. Untreated pneumothorax
• B. Congestive heart failure
• C. Cyanosis
• D. Tuberculosis

113
Practice / Review

• In which of the following diseases is
  air-trapping likely to occur?
• A. Acute exacerbation of asthma
• B. Sarcoidosis
• C. Asbestosis
• D. Emphysema
• E. B C
• F. A D

114
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 only
• b. II and III
• c. I, II, and IV
• d. I, II, III, and IV