ENRICHMENT 1: PULMONARY FUNCTION TEST

I. Topic Outline: Equipment for Volume & Flow Measurement

A. Volume/ Flow Measuring Instruments

VOLUME-DISPLACEMENT spirometers
 Water-Seal Spirometers
The patient inhales through the spirometer, causing the bell to rise during expiration and fall
during inspiration. Every spirometer bell has a "bell factor" that connects the vertical
movement to a particular volume (milliliters or liters). The movement of the bell was traced
with a pen using a rotating drum, or kymograph.

Using paper that had the spirometer bell factor built in, volumes were measured from the
kymograph trace. The volumes obtained using this method represent the gas in the
spirometer at ambient pressure, temperature, and saturation (ATPS). Vital capacity (VC), for
example, needs to be adjusted for the body's temperature, pressure, and saturation (BPTS).

 Dry Rolling Seal Spirometers

A typical unit is made with a lightweight piston made up of aluminum horizontally mounted
in a cylinder. The piston is held up by a rod that is supported by frictionless bearings. A
flexible plastic seal connects the piston to the cylinder wall. As the piston moves, the seal rolls
on itself rather than sliding.

A rolling seal of a similar type can also be used with a vertically mounted, lightweight piston
that rises and falls while breathing (as in the dry-seal Stead-Wells described in the preceding
section). The rolling seal together with the bearings reduces the mechanical resistance of the
piston. With the piston fully displaced, the maximum volume of the cylinder is usually 10-12 L.
Because the piston has a large diameter, small excursions of a few inches are sufficient to
record large volume changes.

 Bellows-Type Spirometers
These devices are made up of collapsible bellows that fold or unfold in response to
breathing irregularities. The traditional bellows design is a versatile accordion-style container.
One end is fixed, while the other is displaced proportionally to the volume inspired or expired.
The wedge bellows works in the same way, except it expands and contracts like a fan. One
side of the bellows remains stationary, while the other pivots around an axis through the fixed
side.

A potentiometer or a pen moving on graph paper are used to translate the displacement of
the bellows caused by a volume of gas. For mechanical recording, chart paper glides at a
constant speed under the pen while tracing a spirogram. A linear or rotary potentiometer
converts the displacement of the bellows into a DC voltage for automated testing. An A/D
converter receives the analog signal before sending it on to a computer.

 Flow-sensing spirometers
The term pneumotachometer describes a device that measures gas flow. Flow-sensing
spirometers use various physical principles to produce a signal proportional to gas flow. This
signal is then integrated to measure volume in addition to flow. Integration is a process in
which flow (volume per unit of time) is divided into a large number of small intervals (time).
The volume from each interval is summed (Figure 11-4). Integration can be performed easily
by an electronic circuit or by computer software. Accurate volume measurement by flow
integration requires an accurate flow signal, accurate timing, and sensitive detection of low
flow.
 B. Plethysmographs

Body plethysmography is performed inside a closed, airtight, transparent plastic container. A

sensor within the box tracks any changes in air pressure when you breathe into a mouthpiece.
A sensor included into the mouthpiece also measures the pressure and airflow in your mouth.

The sensor inside the box detects changes in the volume of air and air pressure inside the box
as your chest expands and contracts while you breathe. Changes in pressure are also
recorded by the mouthpiece's sensor.

 Pressure plethysmograph: A pressure plethysmograph measures your lung volumes

by measuring gas pressure changes in a clear, airtight plastic box. The box contains a
fixed amount of air. A special machine connected to the mouthpiece called a
spirometer measures volume in the area between your neck and abdomen (thorax). A
pressure plethysmograph is very sensitive and can measure small changes in volume.
Another name for a pressure plethysmograph is a closed-type plethysmograph.

 A volume plethysmograph measures changes in gas volume by monitoring gas

displacement in an airtight, transparent plastic box. The surrounding air in the box exits
through a hole in a wall attached to a spirometer when the gas volume in your thorax
changes. The airflow is measured by the spirometer. The volume plethysmograph is a
difficult test; thus, it is only used by medical researchers. An open-type
plethysmograph is another term for a volume plethysmograph.

 The pressure-volume plethysmograph is a test that combines aspects of the

pressure and volume plethysmographs. Any volume changes in your thorax when
breathing drive, the air in the box to pass through a hole in the wall and into a
spirometer. The readings for pressure change or volume displacement will then be
combined by your healthcare provider.

C. Directional Breathing Valves and Directional Control Valves

D. Display/ Recording Instruments

Answer the Practice Questions:

1. Discuss the importance and indications for PFT

- Spirometry is used to establish baseline lung function, assess dyspnea, assess respiratory
impairment or disability, discover pulmonary disease, monitor the effects of treatments used
to treat respiratory disease, assess surgical risk, and carry out surveillance for occupationally
related lung disease. Additionally, it can be applied to epidemiological studies, clinical trials,
and research.

2. Enumerate and describe the different types of equipment used in PFT

I. Spirometer
- a tool that gauges a patient's capacity for inhaling and exhaling air at different rates
and volumes. It aids in the diagnosis of both restrictive and obstructive lung conditions.
II. Peak flowmeter
- a portable instrument that gauges how quickly a patient can exhale air by blowing as
forcefully and quickly as they can.
III. Body plethysmograph
- It is a sizable enclosure into which the patient is placed and which is capable of
measuring both the volume of air taken in and the volume left in the lungs following an exhale.
IV. Pulmonary gas analyzer
- is a device that analyzes a patient's exhaled breath to determine its oxygen and
carbon dioxide content. You may evaluate how well the lungs are exchanging gases using this
information.
V. Gas-conditioning device
- used to control the air given to the patient during a pulmonary function test in terms of
temperature and humidity.
VI. Blood gas analyzer
- It is a device that assesses the levels of carbon dioxide and oxygen in a patient's
blood. This data can be used to determine whether the blood is storing too much CO2 and
how well the lungs are exchanging gases.
VII. Silverman pneumotachometer
- is a tool used to quantify the rate at which gases move through the body when
breathing. It helps to ensure laminar flow while acting as a resistive element by utilizing
several screens.
VIII. Pulse oximeter
- is a tool that gauges a patient's blood's oxygen saturation. This is useful for
determining how efficiently the lungs supply blood and body tissues with oxygen.
II. Topic Outline: Test for Pulmonary Volumes and Ventilation

A. Pulmonary Volumes and Ventilation

There are four standard lung volumes mentioned in the written publications, they are as
follows: Tidal (TV), Inspiratory Reserve (IRV), Expiratory Reserve (ERV), and Residual
Volumes (RV). Together with these are the standard lung capacities, which are the Inspiratory
(IC), Functional Residual (FRC), Vital (VC) and Total Lung Capacities (TLC).
B. Direct Spirometry and Impedance Plethysmography

Spirometry does not assess lung capacity overall or residual lung volume. Other
parameters measured by body plethysmography include the pressure difference between
your mouth and lungs (airway resistance) and the volume of gases in your thorax
(intrathoracic gas volume, or ITGV).

Lung plethysmography is more precise than spirometry, the commonly utilized method of
measuring lung volumes. Boyle's Law, a scientific principle that explains the relationship
between a gas's pressure and volume, is the foundation for the measurements from this test.

C. Indirect Spirometry/ Body Plethysmography/ Gas Dilution

Boyle's law, which states that the product of a gas's pressure and volume remains
constant at a fixed temperature, forms the foundation of body plethysmography, sometimes
referred to as the "body box" method, for calculating lung volumes. An airtight box with a
pressure transducer and a pneumotachograph to measure airflow is used to contain the
patient. A pneumotach shutter is closed at the conclusion of silent expiration, and the patient
is instructed to pant against the closed circuit. It is measured how much the pressure
changes in the box and at the mouth, which in a closed system equals alveolar pressure. The
initial lung volume (FRC) can be determined using observations of changes in pressure and
volume.

Each of the three techniques—body plethysmography, nitrogen washout, and helium

dilution—has benefits and drawbacks. In patients with extensive airway blockage, the two
approaches based on gas equilibration may underestimate lung volumes since equilibration
can take a while. Plethysmography is a simple procedure that enables repeated
measurements to examine the reproducibility of results quickly. The results are unaffected by
the degree of underlying airway blockage. Large bullae or hiatal hernias may, however, be
taken into account in estimates of lung volume because plethysmography results are based
on all gas in the chest. Plethysmography is also expensive, and some patients find it
uncomfortable due to claustrophobia, body size, or bone deformities.

D. Radiologic Estimation of Lung Volume

According to tomographic studies, the accuracy of the radiography technique used to

measure lung displacement volumes is +/- 210 ml. With intra- and inter-observer variabilities
of less than 1% and less than 5%, respectively, the approach is quick and easy to apply.
 E. Interpretation of Pulmonary Volumes and Ventilation

Answer the Practice Questions:

1. Describe the measurements that indicate pulmonary volumes and ventilation.

I. Tidal Volume (TV)

It refers to how much air may be inhaled or expelled in a single respiratory cycle. This
illustrates how the respiratory centers, respiratory muscles, and mechanics of the chest
wall and lungs all work. The average adult value is 10% of vital capacity (VC), or roughly
300–500 ml (6–8 ml/kg), although exercise can boost this value up to 50% of VC.

II. Inspiratory Reserve Volume (IRV)

IRV is often kept in reserve but is employed during deep breathing. It is the volume of air
that can be forcibly inhaled following a normal tidal volume. 1900-3300 ml is the typical
adult value.

III. Expiratory Reserve Volume (ERV)

It is the amount of air that can be forcefully exhaled after a normal tidal volume has been
exhaled. The typical value for an adult is 700–1200 ml. With obesity, ascites, or with upper
abdominal surgery, ERV is decreased.

IV Residual Volume (RV)

It is the amount of air in the lungs that is still present after a maximum exhale. The
average normal adult value is 1200 ml (20–25 ml/kg). It is calculated indirectly from the
sum of FRC and ERV and cannot be determined by spirometry.

2. Describe the pathophysiologic patterns associated with obstructive and

restrictive lung disease.
Shortness of breath is a symptom of
Obstructive lung disease and occurs when it is
difficult to completely expel all the air from the
lungs. Exhaled air comes out more slowly than
usual due to injury to the lungs or restriction of the
airways within the lungs. An excessively large
amount of air may remain in the lungs after a
thorough expiration. People with restricted lung
disease are unable to breathe all the way through.
They are unable to fully inflate their lungs.

Most frequently, a condition that makes the lungs

stiff leads to Restrictive lung disease. Other times,
the restriction in lung expansion may be brought on
by the chest wall's stiffness, the muscles' weakness,
or the nerves' injury.
III. Topic Outline: Test for Pulmonary Mechanics

A. Forced Vital Capacity Maneuver

Inhalation, the first "blast" phase of exhalation, and final exhalation are the three phases
of the FVC maneuver. The patient is told to inhale as much as possible and then instantly
expel by "blasting" the breath out. The patient is instructed to keep exhaling until airflow is no
longer measured and at least six seconds have passed since the test started. It is advised to
apply a nose clip or manually close the nostrils.

B. Low-Density Gas Spirometry

-

C. Maximum Voluntary Ventilation

The maximum amount of air that may be moved voluntarily in one minute is known as the
maximal voluntary ventilation (MVV) measurement. The maximum volume attained over a
period of 15 consecutive seconds is stated in liters per minute. Subjects are told to breathe
rapidly and deeply for 15 to 30 seconds. Ventilatory volumes are monitored during this time.

The subject's cooperation and effort are crucial for the success of this test. The test is
nonspecific because factors other than ventilatory problems such as loss of coordination of
the respiratory muscles, musculoskeletal disease of the chest wall, neurologic disease, and
deconditioning from any chronic illness decrease MVV. Patients with airway obstruction
experience a drop in the MVV, but this effect is less pronounced in those with mild to
moderate restrictive abnormalities because quick, shallow breathing can effectively make up
for the reduced lung volume.

D. Airway Resistance/ Conductance

The amount of resistance to airflow through the respiratory tract during inspiration and
expiration is referred to as airway resistance. The size of the airway and whether the flow is
laminar or turbulent are two important parameters that affect resistance. We shall discuss the
physiology and significance of surfactant as alveolar expansion also depends on it.

The specific airway conductance (sGaw), also known as the gradient of the line depicting
conductance as a function of lung volume, is the airway conductance in relation to lung
volume. Lung volume is linearly correlated with the airway conductance (Gaw), which is the
reciprocal of the Raw. The specific airway conductance (sGaw), which is the conductance
expressed per unit of lung volume, is hence what is typically determined in practice. By using
the body plethysmographic approach, where lung volume and airway resistance can
essentially be evaluated simultaneously, this may be computed rather easily.

E. Compliance
Pulmonary compliance, an assessment of lung expandability is crucial to the proper
operation of the respiratory system. It speaks to the lungs' capacity to stretch and enlarge.
Volume and pressure can be divided to determine lung compliance (C = V/P).

Lung compliance is influenced by elastin, a protein found in connective tissue, and surface
tension, which is reduced by the creation of surfactants. By resisting the outward pull of chest
wall compliance, lung compliance participates in the lung-chest wall system. The lungs can
reach the proper functional residual capacity—the volume still in the lungs following passive
expiration—thanks to the net compliance (lung-chest wall system).

The lung's compliance refers to the relationship between the transmural pressure—that is,
pressure that passes through a wall or hollow structure—across the organ and its volume.
Alveoli and the intrapleural space are separated by a pressure difference known as
 transmural pressure. Greater alveolar pressures than intrapleural pressures are indicated by
positive transmural pressures.

Compliance of the respiratory system describes the expandability of the lungs and
chest wall. There are two types of compliance: dynamic and static.

Dynamic compliance describes the lung compliance and airway resistance together with
the compliance measured while breathing. This is referred to as the change in lung volume
caused by a change in pressure when flow is present.

Static compliance explains pulmonary compliance during periods of reduced airflow, such
as an inspiratory stop. In the absence of flow, this is described as the change in lung volume
caused by a change in pressure.

F. Maximum Inspiratory/ Expiratory Pressures

It is common practice to gauge the strength of the respiratory muscles using maximum
inspiratory pressure (MIP) and maximal expiratory pressure (MEP), which are known to
reflect respiratory muscle weakness more accurately than forced vital capacity evaluated
using a spirometer.

Answer the Practice Questions:

1. Describe the measurements that indicate pulmonary mechanics.
Measurements of transpulmonary pressure (pressure at airway opening minus pleural
pressure) and variations in flow and volume during the respiratory cycle are used to compute
pulmonary mechanics.

Pneumotachographs measures airflow and volume. Pleural pressure can be calculated using
esophageal pressure obtained with a micro transducer-tipped catheter, an air- or fluid-filled
balloon linked to a pressure transducer, or both. An occlusion test can assess the precision of
the esophageal pressure measurement.

Based on the presumption of a linear model, compliance and resistance are calculated. The
driving pressure is therefore always the result of adding the elastic and resistive pressures.
The conventional "chord" analysis can be used to complete the computations. or by any of
several computational methods, like the least mean squares method of analysis.

IV. Topic Outline: Test for Pulmonary Gas Distribution and Matching with Perfusion

A. Dead-space Ventilation
The amount of vented air that is not involved in gas exchange is known as dead
space. Anatomical dead space and physiologic dead space are the two different types
of dead space. The amount of air that occupies the conducting zone of respiration, which is
made up of the nose, trachea, and bronchi, serves as a proxy for anatomical dead space. The
value of anatomic dead space is 150 mL since this amount is 30% of the typical tidal volume
(500 mL). The amount of respiratory zone air that is not involved in gas exchange, known as
physiologic or total dead space, is equal to anatomic plus alveolar dead space.

The respiratory bronchioles, alveolar duct, alveolar sac, and alveoli make up the respiratory
zone. Alveolar dead space in an adult in good health is minimal. As a result, anatomical dead
space is similar to physiological dead space. In lung illness conditions where the alveolar
diffusion membrane is dysfunctional or when there are ventilation/perfusion mismatch
problems, one can see an increase in the value of physiologic dead space.
 B.
Distribution of Ventilation

Ventilation, or breathing, consists of the flow of air through the conducting channels that
connect the atmosphere with the lungs. Pressure gradients created by the diaphragm and
thoracic muscles contracting cause the air to travel through the channels.

Pulmonary ventilation

Breathing is the general name for pulmonary ventilation. It is the process through which air
moves into and out of the lungs during inspiration (inhalation) and expiration (expiration).
Pressure differences between the atmosphere and the gases in the lungs cause air to flow.

Like other gases, air also moves from an area of higher pressure to one of lower
pressure. The variations in pressure that lead to ventilation are produced by muscular
breathing motions and the recoil of elastic tissues. During pulmonary breathing, three
pressures are used:

 Atmospheric pressure
 Intraalveolar (intrapulmonary) pressure
 Intrapleural pressure

The air pressure outside of the body is known as atmospheric pressure. The pressure inside
the lungs' alveoli is known as interalveolar pressure. The pressure inside the pleural cavity is
known as intrapleural pressure. As a result of these three pressures, the lungs are ventilated.

Inspiration

The act of bringing air into the lungs is known as inspiration (inhalation). As a result of the
contraction of muscles, it is the active phase of breathing. The thoracic cavity expands and the
diaphragm contracts during inspiration. As a result, the interalveolar pressure is reduced,
allowing air to enter the lungs. The breath of inspiration fills the lungs.

Expiration

Expiration (exhalation) is the practice of exhaling air from the lungs while breathing. The
diaphragm relaxing and tissue recoiling elastically cause the thoracic volume to decrease and
the interalveolar pressure to rise during expiration. The act of exhaling forces air out of the
lungs.
 Answer the Practice Questions:
1. Describe the principles behind pulmonary distribution and perfusion
Diffusion is the method used to exchange gases between the pulmonary capillary
blood and alveoli, as will be covered in the following chapter. Oxygen and carbon dioxide
diffuse passively over the alveolar-capillary barrier based on the variations in their
concentrations. Alveolar ventilation and pulmonary capillary perfusion are required to maintain
these concentration variances.

Alveolar ventilation brings oxygen into the lung and removes carbon dioxide from it. Similarly,
the mixed venous blood brings carbon dioxide into the lung and takes up alveolar oxygen. The
alveolar and are thus determined by the relationship between alveolar ventilation and
pulmonary capillary perfusion. Alterations in the ratio of ventilation to perfusion, called the
, will result in changes in the alveolar and , as well as in gas delivery to or
removal from the lung.

Alveolar ventilation is normally about 4 to 6 L/min and pulmonary blood flow (which is equal to
cardiac output) has a similar range, and so the

for the whole lung is in the range of 0.8 to 1.2.

However, ventilation and perfusion must be matched on the alveolar-capillary level, and the
for the whole lung is really of interest only as an approximation of the situation in all the
alveolar-capillary units of the lung. For instance, suppose that all 5 L/min of the cardiac output
went to the left lung and all 5 L/min of alveolar ventilation went to the right lung. The whole
lung
would be 1.0, but there would be no gas exchange because there could be no gas
diffusion between the ventilated alveoli and the perfused pulmonary capillaries.

V. Topic Outline: Test for Pulmonary Gas Diffusion

A. Test Description
One of the several pulmonary function tests that help measure how well the lungs are
functioning is a gas diffusion study. "Pulmonary" refers to something that has to do with the
lungs. In this context, "diffusion" refers to how efficiently the alveoli, or air sacs, in the
lungs, transport oxygen to and remove carbon dioxide from the blood in the capillaries (small
blood arteries), which surround them. The diffusing capacity of the lung for carbon monoxide
(DLCO) and lung diffusion testing are additional names for this test.

B. Techniques for Measurement

DLCO is measured using the following techniques:
I. Single breath method
In the single breath method, the patients are instructed to take a few typical resting
breaths before being instructed to fully exhale until they reach residual volume (RV). The
subject is then instructed to inhale the test gas quickly until reaching vital capacity (VC). The
test gas contains:
 0.3% CO
 0.3% tracer gas (helium, methane, or neon)
 21% oxygen
 Balance nitrogen
II. Intrabreath Method
The intrabreath method, which calculates DLCO while exhaling, is another way to do
so. In comparison to the gas that leaves during the later phases of exhalation, the gas that
leaves during the early phase of exhalation has less time to pass from alveoli to capillaries
and will contain a higher concentration of CO. DLCO can be calculated using the variation
between different samples of exhaled gas.
III. Rebreathing Technique
Less commonly employed, typically during activity investigations, is the rebreathing
approach. Rebreathing, on the other hand, is more in line with the physiology of the
respiratory system and may be a more accurate test for determining diffusing capacity than
the intrabreath approach, according to a study by Liu et al. Suzuki et al.'s intrabreath
technique for determining diffusion capacity is a trustworthy substitute for the single breath
technique, according to a different study they did.

C. Equipment Required
The single-breath DLCO equipment recommendations and standard testing practices
have been adopted by the American Thoracic Society (ATS). Testing equipment and
processes should be standardized to guarantee that tests are carried out consistently. These
standards enable comparison of data from various pulmonary function testing facilities. Most
of the variances might be attributed to procedural issues that, when fixed, diminish the
differences, according to numerous small studies that indicated that measurements taken
with the same person in other laboratories can differ by up to 50%

To measure DLCO, it is important to first understand that there are interactions between the
subject and the testing device (such as equipment put in front of the patient's face or
mouthpieces), the technician and the subject, and the testing instrument itself. The subject's
health is crucial to the test's outcome. Results may be impacted by several patient
characteristics. A meal within two hours of the test, recent vigorous exercise, an ongoing or
recent respiratory infection, and blood alcohol levels are all prohibited. To assess forced vital
capacity or slow vital capacity, the subject must already have spirometry. They must also be
seated for the test session, completely cooperative, and able to follow directions.

D. Test Administration

Typically, a gas diffusion study is carried out in a specialized lung function lab or clinic. The
patient will get instructions prior to arriving for the test:

• Inhaler medications and bronchodilators should be stopped temporarily before

the test if they are being used to treat breathing problems.

• Avoid a large meal before the test.

• Stop smoking four to six hours before the exam.

The procedure for taking the test is as follows:

• The patient will be asked to stand or sit close to a spirometer, a measurement

tool. In a variety of lung function tests, this little device measures the amount of
air that enters and leaves the lungs.
• A mouthpiece is fitted around the patient's mouth and a clip is placed on the
patient's nose so that the patient can only breathe through a tube attached to the
mouthpiece. During this examination, it's crucial to maintain a tight seal with the
mouth.
 • The patient inhales a combination of gases.
• After holding the breath for ten seconds, the breath is released into the
spirometer tube.
• The apparatus calculates the concentration of the tracer gas in the admixture of
air.

If the patient's physician advises it, another kind of pulmonary function test (PFT) could be
carried out either before or after the gas diffusion test. There is no barrier preventing more
than one PFT from being performed in a single session.

Spirometry and lung volume measurements (by dilution or body plethysmography) are two
other PFT types.

E. Interpretation of Test Results

Answer the Practice Questions:
1. Describe the purposes and techniques used to measure diffusion capacity.

DlCO is a measurement of the interaction between the alveolar surface area, alveolar-
capillary perfusion, alveolar-capillary interface physical characteristics, capillary volume,
hemoglobin concentration, and CO and hemoglobin reaction rate. The single-breath breath-
holding technique is the most common and extensively used technique. In order to "wash out"
mechanical and anatomic dead space, the patient must inhale a predetermined volume of test
gas (often helium), hold their breath for 10 seconds, and then let their breath out. The total
lung capacity, the amount of time spent holding one's breath, and the CO initial and final
alveolar concentrations are used to determine DlCO. The test gas dilution and the initial
alveolar CO concentration are used to estimate alveolar volume. The initial alveolar pressure
of CO is taken into account as the driving pressure.

Since the amount of hemoglobin in the blood and diffusing capacity are correlated, a
correction for anemic individuals is utilized to distinguish between DlCO being decreased due
to anemia and being limited by the parenchyma or the interface.

VI. Topic Outline: Predicted Normal Values for Pulmonary Function Tests
A. Factors Affecting Predicted Normal Values
Conclusion: In addition to age, it is recommended to take into account weight and height
when using spirometry as a diagnostic tool because they both significantly correlate with lung
volumes.
B. Sources of Predictive Equations for Normal PFT Values

C. Using Predictive Equations for Normal PFT Values

Answer the Practice Questions:

1. Explain and interpret Pulmonary Function Test results (give examples).

VII. Topic Outline: Computers in Pulmonary Function Testing

A. Hardware Term
E-prom program microprocessors are commonly found in small automated spirometric
devices. Other examples include the dedicated microprocessor with floopy disk stations, the
general-purpose personal computer, and the multi-user minicomputer system. All four types
provide online data gathering. However, there are currently no ADCs and accompanying
software commercially available for some of the most popular personal computers. In
general, programs written in assembly language are required for real-time data processing
on microprocessor-based systems. As soon as the interfaces are available, the superb and
now inexpensive graphic features available for personal computers can be exploited for PFT.

B. Data Terms

C. Software/ Programming Terms

D. General Operation of Computers

E. Computer Application to PFT

F. General Concerns

Answer the Practice Questions:

1. Evaluate and address issues surrounding equipment application and/or
operation

2. Identify and explain any hazards that may be associated with each
procedure and methods to minimize those hazards.

3. Demonstrate basic computer and electronic data management skills

VIII. Pulmonary Function Testing Regimens

A. Patient Assessment for PFT
Before beginning spirometry, it is important to verify the patient's identity, record their
age, sex, and race, as well as their height without shoes or boots, weight (if scales are
available), and race. Although these factors are not used in prediction equations, knowing
them is helpful because volume may be restricted in obese patients. The arm span might be
used as a rough approximation if the patient is unable to stand for the height measurement.

B. General Administration of PFT

C. Bronchodilator Benefit Studies

D. Pre-operative PFT Studies

E. Broncho-provocation Studies
Using a bronchial provocation test, you can gauge how sensitive your lungs are. Asthma
is frequently diagnosed or ruled out as the cause of symptoms using this method.
The test can take one of three forms:

 Irritant challenge. Your doctor tests your airways by exposing you to an asthma
trigger, such as smoke or a chemical.

 Exercise challenge. To see whether physical effort affects how the airways respond,
you exercise on a treadmill or stationary bike.

 Methacholine challenge. The chemical metacholine, which causes the airways to

constrict with low doses in persons with asthma and with large doses in people without
asthma, is inhaled at escalating dosages. Your doctor will explore for another source
of your symptoms if there is no reaction to the low doses.

F. Studies for Exercise-Induced Asthma

Exercise-induced asthma is a breathing problem (bronchoconstriction) associated with
histamine production that is brought on by aerobic exercise and lasts for a while. Medical
disorders, environmental circumstances, and drugs are some of the causes.

In most cases, exercise-induced asthma is diagnosed clinically. Laboratory testing is

typically used to clarify clinical ambiguities, diagnose therapy failures, and narrow the
differential diagnosis.

The following laboratory tests are used to check for allergies and infections:
• Complete blood count: To assess eosinophil numbers (for allergy) and the
possibility of infection.
• Immunoglobulin E levels, with or without eosinophil nasal swab: To assess
probability of allergic illness.
• Radioallergosorbent testing and skin allergen testing: To assist identify certain
allergens.
• C-reactive protein levels or erythrocyte sedimentation rate: To assess for
inflammatory and infectious disorders.
• Sputum analysis and culture: To detect infection and determine the best course of
action for treating strains of resistant organisms.
• Thyroid function tests: To check for thyroid malfunction if asthma symptoms are
thought to be mimicked by anxiety.
G. Studies to Document Impairment/ Disability

Answer the Practice Questions:

1. Discuss the appropriate monitoring techniques for each procedure and modifications per
patient assessment

A. Indications
• To recognize and measure alterations in pulmonary function.
• To assess the requirement for and quantify therapy efficacy.
• To conduct lung disease epidemiologic surveillance.
• To evaluate patients for pulmonary problems following surgery.
B. Equipment
Spirometers can occasionally be referred to as a collective noun for all volume- and flow-
measuring equipment. Spirometers are devices that measure volume and come in water-
sealed, bellows, and dry rolling seal varieties. As they fill with gas, these devices enlarge.
The expansion's size corresponds to the volume that was measured, and its speed
corresponds to the flow rate. Volume-measuring instruments can measure volumes with high
precision in the absence of leaks and at low momentum forces, and they can compute flow
rates with high precision at low inertia and friction forces.

Pneumotachometers are a widespread name for flow-measuring equipment, while some

professionals exclusively use it to refer to the Fleisch device. These instruments use a variety
of original ideas to measure flow. Pneumotachometers of the Fleisch type track changes in
pressure as gas passes past them. Another kind of flow-measuring gadget, called
thermistors or mass flowmeters, measures the temperature change brought on by gas
moving past it. Turbinometers are another option; they work by rotating a fan or a set of
blades that resemble a windmill. It is outside the purview of this chapter to provide
comprehensive explanations and examples of each sort of gadget.

No matter the device type or the measurement technique employed, all measuring devices
have a few significant traits. RTs can choose and employ these gadgets effectively by being
aware of these common traits. Each measuring device has different output, resolution,
linearity, capacity, accuracy, and error characteristics.

C. Contraindications
• Hemoptysis
• Pneumothorax
• Ischemia or acute myocardial infarction
• Acute lung embolism
• Severe abdomen or chest pain
• A recent cataract operation
• Failure to adhere to directions

D. Hazards and Complications

All procedures have some risks. The risks of this procedure may include:

• Unsteadiness throughout the test

• Experiencing breathlessness

• Coughing

• An asthma episode triggered by inhaling deeply

In some cases, you shouldn’t have PFTs. Reasons for this can include:

• Recent eye surgery, as a result of elevated intraocular pressure during the procedure

• Current abdominal or chest surgery

• Chest pain, a recent heart attack, or a cardiac condition that is unstable.

• An aneurysm, a ballooning blood artery, in the chest, abdomen, or brain

• Respiratory infections, such as a cold or the flu, or active tuberculosis (TB).

 • Depending on your general health and other variables, your risks may change.

• Find out from your doctor which dangers are most relevant to you. Any worries you
may have can be discussed with them.

Certain things can make PFTs less accurate. These include:

•
Failing to adhere to test-taking instructions.
•
Using bronchodilators, drugs that dilate the airways.
•
Taking painkillers
•
Pregnancy
•
Bloated stomach. Your capacity to inhale deeply may be impacted by this.
•
Extreme exhaustion or other health issues, including a head cold, that impair your
capacity to do the tests.
E. Monitoring during the Procedure

F. Assessment of the outcome

Quality Assurance for PFT

A. Components of Quality Assurance Process
B. Calibration and Quality Control for Spirometers and Plethysmographs

Answer the Practice Questions:

1. List down the rationale for the precautionary safety measures observed during PFT
procedures

PATIENT CONSIDERATIONS

Contraindications
 Performing lung function tests can be physically demanding for a minority of patients. It
is recommended that patients should not be tested within 1 month of a myocardial
infarction. Patients with any of the conditions are unlikely to achieve optimal or
repeatable results.

Position
 Testing may be performed either in the sitting or standing position, and the position
should be recorded on the report. Sitting is preferable for safety reasons in order to
avoid falling due to syncope. The chair should have arms and be without wheels. If a
wheelchair is used, the wheels should be locked. If the standing position is used, a
chair can be placed behind the patient/subject, so that they can be quickly and easily
moved into a sitting position if they become light-headed during the manoeuvre. Obese
subjects, or those with excessive weight at the mid-section, will frequently obtain a
deeper inspiration when tested in the standing position. Consequently, forced
expiratory volumes and flows may improve with the standing position in these
individuals. Normal-weight subjects typically have equivalent values when tested
sitting or standing, but, for longitudinal studies, the same test position should be used
each time.

PATIENT DETAILS
Age, height and weight
 The patient's age, height and weight (wearing indoor clothes without shoes) are
recorded for use in the calculation of reference values. The age should be expressed
in years. Height and weight should be expressed with the units in use in the country,
corresponding to the ones of the selected reference equation. Body mass index should
be calculated as kg·m−2. The height should be measured without shoes, with the feet
together, standing as tall as possible with the eyes level and looking straight ahead,
and using an accurate measuring device. For patients with a deformity of the thoracic
cage, such as kyphoscoliosis, the arm span from fingertip to fingertip can be used as
an estimate of height. Arm span should be measured with the subject standing against
a wall with the arms stretched to attain the maximal distance between the tips of the
middle fingers. A regression equation using arm span, race, sex and age has been
found to account for 87% of the variance in standing height 5, with the standard error
of the estimate for height ranging from 3.0 to 3.7 cm. Using fixed arm-span ratios (e.g.
height = arm span/1.06) estimated the standing height reasonably well, except at the
extremes, but was always inferior to the regression equation. Estimating height in this
way introduces a further level of uncertainty with regard to the predicted value of the
lung function index, and the use of fixed ratios has been shown to lead to
misclassification of disease. The use of knee height to predict height can also be used
for handicapped people where arm span may be difficult to measure.

Therapy
 The operator should record the type and dosage of any (inhaled or oral) medication
that may alter lung function and when the drugs were last administered.

Subject preparation
 Subjects should avoid the activities, and these requirements should be given to the
patient at the time of making the appointment. On arrival, all of these points should be
checked, and any deviations from them recorded.

 Subjects should be as relaxed as possible before and during the tests. The decision to
avoid long- and short-acting bronchodilators is a clinical one, dependent on the
question being asked. If the study is performed to diagnose an underlying lung
condition, then avoiding bronchodilators is useful. If the study is carried out to
determine a response to an existing therapeutic regimen, then one may choose not to
withhold bronchodilator medications.

 Patients should be asked to loosen tight-fitting clothing. Dentures should normally be

left in place; if they are loose, they may interfere with performance and are, therefore,
best removed.

LABORATORY DETAILS
 Ambient temperature, barometric pressure and time of day must be recorded.
Temperature is an important variable in most pulmonary function tests and is often
measured directly by the instrument. The way in which it is measured and used may
vary from instrument to instrument. For example, it may be measured with a simple
thermometer or an internal thermistor. Regardless of the method used, it is the
responsibility of the laboratory to confirm the accuracy of temperature measurements,
and it is the responsibility of the manufacturer to describe or provide a clear
mechanism for checking the accuracy of instrument temperature measurements. They
should also provide instructions on how to respond when acceptable temperature
performance cannot be confirmed. Ideally, when patients return for repeat testing (e.g.
at a clinic), the equipment and the operator should be the same, and the time of day
should be within 2 h of previous test times.

 There should be appropriate delays between tests, as indicated in the subsequent

sections of this series of documents. Other orders of testing are acceptable (e.g. static
lung volumes, diffusing capacity, dynamic studies, inhalation of bronchodilator agent
 and then repeat dynamic studies, as taken from table 3⇓), but the order should be kept
constant to avoid introducing unanticipated variability to test results. The choice of
order of testing should consider the potential effect of one test on the subsequent test.
For example, the measurement of carbon monoxide diffusing capacity of the lung
(DL,CO) immediately after a nitrogen washout measurement of the total lung capacity
(TLC) will be affected by the increased oxygen content in the lungs, unless enough
time has passed to allow the oxygen concentration to return to normal. Also, tidal
breathing manoeuvres may be disturbed by a recently performed maximal forced
expiratory manoeuvre. Bronchodilator administration may affect static lung volumes,
reducing hyperinflation by up to 0.5 L 9. While bronchodilators do not seem to affect
diffusing capacity when measured by the Jones–Meade method, they may allow ∼10%
of patients to obtain a measurement of diffusing capacity that was not possible pre-
bronchodilator.

HYGIENE AND INFECTION CONTROL

 The goal of infection control is to prevent the transmission of infection to
patients/subjects and staff during pulmonary function testing. The number of
documented cases of infection transmission is very small, but the potential is real (see
Level of infection risk section). This set of recommendations focuses on equipment
used to measure spirometry, diffusing capacity and lung volumes. Organisms may also
be transmitted via pulse oximeter probes and nebulizers used to administer
bronchodilators. Although infection risks increase with exposure to blood, this
document does not deal with the risks of arterial blood gases. Pulmonary laboratories
performing blood gas analysis should follow the same infection-control procedures
used by their clinical laboratory. Infection can be transmitted by direct contact or by
indirect means.

Transmission by direct contact

 There is potential for transmission of upper respiratory diseases, enteric infections and
blood-borne infections through direct contact. Although hepatitis and HIV contagion
are unlikely via saliva, transmission becomes a possibility with open sores on the oral
mucosa or bleeding gums. The most likely surfaces for contact are mouthpieces and
the immediate proximal surfaces of valves or tubing.

Transmission by indirect contact

 There is potential for transmission of tuberculosis (TB), various viral infections,
opportunistic infections and nosocomial pneumonia through aerosol droplets. The
most likely surfaces for possible contamination by this route are mouthpieces, proximal
valves and tubing.

Prevention
Transmission to technicians
 Prevention of infection transmission to technicians exposed to contaminated
spirometer surfaces can be accomplished through proper hand washing and use of
barrier devices, such as suitable gloves. To avoid technician exposure and cross-
contamination, hands should be washed immediately after direct handling of
mouthpieces, tubing, breathing valves or interior spirometer surfaces. Gloves should
be worn when handling potentially contaminated equipment if the technician has any
open cuts or sores on his/her hands. Hands should always be washed between
patients. Indications and techniques for hand washing during pulmonary function
testing have previously been reviewed

2. Evaluate the reliability of results

 It is recognized as the gold standard device for PFT devices. It can detect volumes up
to 12 L and has a flow rate range of 0.03-20 L/s. It has an accuracy of an error range
of ±3% when measuring 50 mL.
3. Evaluate clinical implications

 There is increasing recognition of the need for objective physiological measurements

of lung function during the preschool years in order to identify and treat early lung
disease before irreversible structural changes occur; monitor disease progression and
efficacy of therapeutic interventions and distinguish the various wheezing phenotypes
that occur in this age group, all of which require different management strategies.
While preschool pulmonary function tests are undoubtedly excellent research tools ,
their role in the clinical management of the individual young child remains more
controversial . In particular, further work is required to establish information on the
within -subject , between occasion variability and the relative sensitivity and specificity
of each technique, as well as developing more appropriate prediction equations for this
age group, before they can be used confidently in the clinical management of
individual child. This review examines the various challenges facing paediatricians who
are responsible for children with respiratory diseases such as asthma, wheezing,
cystic fibrosis and chronic lung disease following preterm delivery and summarises
recent recommendations from an ATS/ERS Task Force.

Requirements for submission:

1. Use short bond paper
2. Minimum of 10 pockets short refillable clear book/folder (blue) for 10 topics (tasks)
3. Date of submission, March 24 (Dean's ofc.)