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Pulmonary function testing interpretation, “bringing it all together”

Interpretation algorithm

Summary

Case studies

Self-assessment questions

Entry-level

Advanced

Appendix A: Answers to Self-Assessment Questions

Chapter 1, Indications for pulmonary function testing

Chapter 2, Spirometry

Chapter 3, Diffusing capacity tests

Chapter 4, Lung volumes, airway resistance, and gas distribution tests

Chapter 5, Ventilation and ventilatory control tests

Chapter 6, Blood gases and related tests

Chapter 7, Cardiopulmonary exercise testing and field tests

Chapter 8, Pediatric pulmonary function testing

Chapter 9, Bronchoprovocation challenge testing

Chapter 10, Specialized test regimens

Chapter 11, Pulmonary function testing equipment

Chapter 12, Quality systems in the pulmonary function laboratory

Chapter 13, Reference values and interpretation strategies

Glossary

Back Cover

Dead space ventilation per minute (BTPS)

fb, f Respiratory rate per minute, breathing frequency

VD/VT Dead space to tidal volume ratio

P100, P0.1 Pressure in the first 100 msec of an occluded breath, occlusion pressure

Spirometry

FVC Forced vital capacity with maximal expiratory effort

FIVC Forced inspiratory vital capacity with maximal inspiratory effort

FEVT Forced expiratory volume for a specific interval T

FEVT/FVC%, FEVT% Forced expiratory volume to forced vital capacity ratio expressed as a percentage

FEFx Forced expiratory flow related to some specific portion of the FVC, denoted as subscript X, referring to the volume of FVC already exhaled at the time of measurement

FEF25%–75% Forced expiratory flow during the middle half of the FVC (formerly the MMF)

FEF50%/FIF50% Forced expiratory flow to forced inspiratory flow at 50% of VC expressed as a ratio or a percentage

FET Forced expiratory time

PEF Peak expiratory flow

MEFV Maximal expiratory flow-volume curve

MIFV Maximal inspiratory flow-volume curve

PEFV Partial expiratory flow-volume curve

Forced expiratory flow related to the actual volume of the lungs denoted by subscript X, referring to the lung volume remaining when measurement is made

MVVX Maximal voluntary ventilation as the volume of air expired in a specified interval, denoted by subscript X (formerly MBC)

Pulmonary Mechanics

C Compliance, volume change per unit of pressure change

Cdyn Dynamic compliance, measured during breathing

* Where two symbols are given, both are commonly used

testing / Gregg L. Ruppel. 10th ed. c2013. | Includes bibliographical references and index.

Identifiers: LCCN 2016048605 | ISBN 9780323356251 (pbk.)

Subjects: LCSH: Pulmonary function tests–Handbooks, manuals, etc.

Classification: LCC RC734.P84 R86 2017 | DDC 616.2/40754–dc23

LC record available at https://lccn.loc.gov/2016048605

Content Strategist: Yvonne Alexopoulos

Content Development Manager: Billie Sharp

Publishing Service Manager: Deepthi Unni

Project Manager: Andrea Lynn Villamero

Design Direction: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors/Reviewers

Contributors

Susan Blonshine, BS, RRT, RPFT, FAARC, AEC President/CEO, TechEd Consultants, Technical Director, Michigan State University Pulmonary Function, Laboratory Mason, Michigan

Katrina M. Hynes, MHA, RRT, RPFT Supervisor Pulmonary Function Laboratory, Mayo Clinic Rochester, Minnesota

David A. Kaminsky, MD Professor of Medicine, Pulmonary and Critical Care, University of Vermont, Attending Physician Medicine, Pulmonary, and Critical Care, Fletcher Allen Health Care, Burlington, Vermont Reviewers

Ellen A. Becker, PhD, RRT-NPS, RPFT, AE-C, FAARC Professor, Respiratory Care, Cardiopulmonary Sciences, Rush University, Chicago, Illinois

Sarah Gabua, DNP, RN, CNE Nursing and Allied Health Consultant, Adjunct Faculty, Nursing and Allied Health, School of Nursing, 2nd Act Consulting, LLC, Ferris State University, Las Vegas, Nevada, and Big Rapids, Michigan

Janet Czermak Russell, MA, MS, APN-BC Associate Professor of Nursing, Essex County College Newark, New Jersey

respiratory physiology and the clinical skills to deal with symptomatic patients in the testing environment. Well-prepared technologists are more likely to avoid misclassification of disease states and to relate the results of pulmonary function tests to important patient outcomes. This edition of the Manual aspires to contribute to that preparation.

Carl D. Mottram, RRT, RPFT, FAARC, took responsibility as the author/editor beginning with the tenth edition. He has continued in this role to significantly expand and improve the eleventh edition. There is no one better qualified to continue improving the content and the format of the text. The Manual should continue to be a useful resource for students of lung function testing, whether they are therapists, technologists, or physicians.

Gregg L. Ruppel, MEd, RRT, RPFT, FAARC, Division of Pulmonary, Critical Care and Sleep Medicine, Saint Louis University School of Medicine, St Louis, Missouri

Preface

The primary functions of the lung are oxygenation of mixed venous blood and removal of carbon dioxide. Gas exchange depends on the integrity of the entire cardiopulmonary system, including airways, pulmonary blood vessels, alveoli, respiratory muscles, and respiratory control mechanisms. A few pulmonary function tests assess individual parts of the cardiopulmonary system. However, most lung function tests measure the status of the lungs’ components in an overlapping way.

This eleventh edition describes the most common pulmonary function tests, their techniques, and the pathophysiology that may be evaluated by each test. Topics covered include the following:

• Basic tests of lung function, including spirometry, lung volume measurements (i.e., body plethysmography, nitrogen washout and helium dilution), diffusing capacity, and blood gas analysis

• Ventilation and ventilatory control, cardiopulmonary exercise tests, and pediatric and infant pulmonary function testing

• Specialized test regimens that focus on exhaled nitric oxide measurements, forced oscillation techniques, metabolic studies, disability determination, and preoperative evaluation

• Bronchial challenge tests that assist the clinician in characterizing the hyperreactivity of the airways

• Pulmonary function testing equipment, quality assurance, and reference values and interpretation

Distinctive features

The eleventh edition includes many of the features from the

• Practice Tests to help students apply the knowledge learned within the text

• Conversion and Correction Factors

• Helpful Equations

• Reference Tables

• Sample Calculations

For the instructor, our Evolve Learning Resources include:

• PowerPoint presentations of Case Studies and Clinical Scenarios

• Test Bank containing approximately 600 questions

• Electronic image collection consisting of images from the textbook Instructors may use Evolve to provide an Internet-based course component that reinforces and expands the concepts presented in class. Evolve may be used to publish the class syllabus, outlines, and lecture notes; set up virtual office hours and e-mail communication; share important dates and information through the online class calendar; and encourage student participation through chat rooms and discussion boards. Evolve allows instructors to post examinations and manage their grade books online. For more information, visit http://evolve.elsevier.com or contact an Elsevier sales representative.

Acknowledgments

Carl D. Mottram, RRT, RPFT, FAARC

I would like to acknowledge a few key colleagues and friends who have contributed to my professional success. First, I had the honor of being educated and mentored by Drs. Fred Helmholtz and Robert (Bob) Hyatt, both of whom have passed since the tenth edition. Dr. Helmholtz, along with colleagues, assisted in the development of the G-suit during World War II and the nitrogen washout test for measuring lung volumes. After retirement he continued to have a significant impact on pulmonary medicine through a variety of professional activities, including spending a month teaching the respiratory therapy students basic pulmonary physiology. Dr. Helmholtz was also very active in the NBRC and AARC, championing the field of respiratory care.

Dr. Hyatt hired me into the pulmonary function laboratory. He was a soft-spoken, very intelligent man with a commanding presence when I first met him. He was the first to describe the flowvolume curve, a discovery that revolutionized the interpretation of spirometry and had a profound impact on patient care, yet he was very humble about this fact. I was told the story of a colleague describing his first encounter of meeting Dr. Hyatt. He queried, “So you invented the flow-volume curve?” Dr. Hyatt replied, “No, it was there. I just found it.”

Both these gentlemen were giants in the field of pulmonary diagnostic testing who shared their passion and knowledge about respiratory physiology with me during my early and mid-career development, and contemporary mentors Drs. Paul Scanlon, David Driscoll, Bruce Staats, and Ken Beck treated me as an equal and

CHAPTER 1

Indications for Pulmonary Function Testing

CHAPTER OUTLINE

Pulmonary Function Tests

Airway Function Tests

Lung Volume and Ventilation Tests

Diffusing Capacity Tests

Blood Gases and Gas Exchange Tests

Cardiopulmonary Exercise Tests

Metabolic Measurements

Indications for Pulmonary Function Testing

Spirometry

Lung Volumes

Diffusing Capacity

Blood Gases

Exercise Tests

Patterns of Impaired Pulmonary Function

Obstructive Airway Diseases

Restrictive Lung Disease

Diseases of the Chest Wall and Pleura

Neuromuscular Disorders

Congestive Heart Failure

Lung Transplantation

Preliminaries to Patient Testing

Before Patient Testing

Patient Preparation (Pre-Test Instructions)

Withholding Medications

Smoking Cessation

Other Patient Preparation Issues

Anthropometric Measurements

Physical Assessment

Pulmonary History

Test Performance and Sequence

Technologist-Driven Protocols

Patient Instruction

LEARNING OBJECTIVES

After studying the chapter and reviewing the figures, tables, and case studies, you should be able to do the following:

Entry-level

1. Categorize pulmonary function tests according to specific purposes.

2. List indications for spirometry, lung volumes, and diffusing capacity.

3. Identify at least one obstructive and one restrictive pulmonary disorder.

4. Relate pulmonary history to indications for performing pulmonary function tests.

Advanced