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Indications for PFT

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Title: 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
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