4430 Class 1

What is the primary role of the pulmonary laboratory?

To perform diagnostic tests related to pulmonary function

What are the working hours typically for a pulmonary laboratory?

8-5 M-F or integrated 24/7

What are the qualifications of a MD in a pulmonary laboratory?

MD or DO

What are the titles for personnel in the pulmonary laboratory environment?

Medical Director

Technical Director

Supervisor

Manager

Team Leader

Technologists

What are the qualifications for technologists in the pulmonary laboratory environment?

CRT, RRT, CPFT, RPFT

What are the skills you need to work in the pulmonary laboratory environment?

Patience

ingenuity

skills

communication

persuasion

math

analysis

Describe the chance of infection control in the pulmonary lab environment

Low risk but there is potential to transmit infective microorganisms

How can transmission occur?

direct or indirect contact

What kind of equipment have to cleaned between patients?

mouthpiece, nose clips, tubing, any equipment surface showing visible condensation from exhaled air

How should you clean equipment in the pulmonary lab?

dispose, sterilize or disinfect before reuse. separate testing systems and filters used but not always necessary

What standard precautions should be applied for infection control?

gloves, hand washing, masks

Which patients pose the greatest potential hazard?

patients with oral lesions

Which patients are the greatest risk?

Patients with compromised immune systems (e.g. lung transplant patients)

Other than infection control, what are the other safety concerns?

high pressure gas cylinders, electrical devices, aerosol exposures

What are the categories of PFTs?

airway function

lung volumes and ventilation

diffusing capacity or DLCO tests

arterial blood gases and gas exchange tests

cardiopulmonary exercise testing

metabolic measurements

What are the 7 airway function tests?

Vital capacity (VC)

forced vital capacity (FVC)

peak expiratory flow (PEF)

bronchial challenge or bronchial provocation tests

maximal voluntary ventilation (MVV)

maximum inspiratory and expiratory pressure (MIP and MEP)

airway resistance (raw) and lung compliance (CL)

What is vital capacity test?

the most basic test of pulmonary function

What does vital capacity test measure?

the largest amount of air that can be moved into or out of the lungs

When and who first measured vital capacity?

mid 1800s by a surgeon named Hutchinson

What is the forced vital capacity test?

an enhancement of the simple VC

What does forced vital capacity detect?

Obstructive pulmonary diseases

How does forced vital capacity detect obstructive pulmonary diseases?

By timing FVCs. Healthy patients exhale 80% of their FVC in 1 second and almost all in 4-6 seconds. Patients with obstructive pulmonary diseases take much long, usually around 15 seconds

What is FEV 1?

The forced expired volume in the first second

What does FEV 1 assess?

A low FEV 1 value indicates airway obstruction

What does FEF 25-75 measure?

Forced expiratory flow (25%-75%) are tied to the radius of smaller airways and can detect obstruction in smaller airways

What is FVL?

Forced volume loop (smile at the bottom of graph)

What is peak expiratory flow?

The maximum speed at which patient is exhaling

What is peak expiratory flow measured with?

flow-sensing spirometer or a peak flow meter

What is peak expiratory flow for?

to monitor asthmatic patients

What is one benefit of PEF equipment?

portable to allow monitoring at home

What is bronchial challenge or bronchial provocation tests used for?

FVC, FEV1 and other flows like FVL are used to measure response to bronchodilator medications

What is EVH?

Eucapnic Voluntary Hyperventilation is a test used to mimic heavy breathing when exercising

What does EVH diagnose?

exercise-induced asthma

What is MVV?

maximal voluntary ventilation

What does MVV measure?

It measures the maximum volume of air a person can breathe in and out rapidly and deeply over a short, sustained period of 12 to 15 seconds, expressed in liters per minute. It estimates the peak ventilation available to meet physiological demands

What is MIP and MEP?

maximum inspiratory pressure and maximum expiratory pressures

What is MEP and MIP a measure of?

respiratory muscle strength

How is MEP and MIP measured?

With a pressure transducer or simple manometer

What is MEP and MIP usually analyzed together with?

Adjuncts to spirometry for monitoring respiratory muscle function in pulmonary and nonpulmonary diseases

What does airway resistance measure?

Provides estimates of alveolar pressure

How is airway resistance measured?

With a plethysmography that calculates pressure drop across the airways related to flow at the mouth

How is lung compliance measured?

By passing a small balloon into the esophagus to measure pleural pressure

What are the 3 lung volume and ventilation tests?

Helium dilution

nitrogen washout

plethysmography

What does helium dilution measure?

Functional Residual Capacity (FRC) using a closed circuit

How does helium dilution measure FRC?

It measures the time required for helium to equilibrate during rebreathing which indicates the efficiency of gas exchange and distribution of ventilation within the lungs

What are the disadvantages of helium dilution?

It provides limited information about the distribution of ventilation within the lungs

What does nitrogen washout measure?

Functional residual capacity (FRC) using an open circuit

How is nitrogen washout conducted?

Patients breathe 100% of O2 to wash nitrogen out of the lungs and collection and analysis of N2 allows FRC to be estimated

How can nitrogen washout be displayed?

Pattern of N2 washout can be displayed graphically where volume of N2 is plotted over time to measure lung capacity

What is the most commonly used method to measure lung volume and ventilation?

plethysmography (VTG)

What is plethysmography based on?

Boyle’s law

What does plethysmography measure?

thoracic gas volumes (same as FRC)

How is plethysmography conducted?

Patient sits in a booth or body box

What are the other methods to measure lung volume and ventilation tests

Chest radiographs and computerized tomography scans

What is one diffusion capacity test?

Single breathing diffusing capacity (DLCO)

What does DLCO assess?

small but measurable differences between inspired and expired gas containing carbon monoxide which is related to the uptake of gas across the lung

What is the most widely used and standardized test?

DLCO

How is cardiopulmonary exercise tests conducted?

using a treadmill or cycle ergometer

What is being measured in a cardiopulmonary exercise test?

heart rate (HR)

Electrocardiogram (ECG)

Blood Pressure (BP)

Respiratory rate (RR)

What does cardiopulmonary exercise test analyze?

exhaled gas

What is the difference between invasive and non-invasive cardiopulmonary exercise test?

Invasive involves inserting an arterial line in the patient to continuously measure blood pressure and lactate levels

What do metabolic measurements measure?

energy expenditure and caloric requirements using Basal Metabolic Rate (BMR) and Resting Energy Expenditure (REE)

How is BMR measured?

Using added oxygen and oxygen consumed estimates energy expenditure

What does BMR detect?

disorders that affect metabolism

How is REE measured?

Using O2 consumption and CO2 production which is related to metabolic needs

What is REE used for?

to manage critically ill patients whose caloric needs are difficult to estimate

What are the 7 indications for spirometry?

1. to diagnose the presence of absence of lung disease

2. quantify the extent of known disease on lung function

3. measure effects of occupational or environmental exposure

4. determine beneficial or negative effects on therapy

5. assess risk for surgical procedures

6. evaluate disability or impairment

7. epidemiologic or clinical research involving lung or health disease

What pulmonary symptoms might indicate a need for spirometry?

SOB or Dyspnea, wheezing, cough, sputum production, chest discomfort, orthopnea (SOB when lying down and disappears when sitting up)

What are the physical indicators for spirometry?

decreased breath sounds, chest wall abnormalities

What abnormal lab findings may indicate a need for spirometry?

CXR or CT studies, blood gas or pulse oximetry

What is one other indicator for the need for spirometry?

before beginning strenuous physical activities

Which pulmonary diseases can spirometry quantify the extent of damage on lung function?

Chronic Obstructive Pulmonary Disease (COPD), asthma, cystic fibrosis (CF), interstitial disease

Which cardiac diseases can spirometry quantify the extent of damage on lung function?

Congestive heart failure (CHF)

Which neuromuscular diseases can spirometry quantify the extent of damage on lung function?

Guillain-Barre Syndrome (GBS)

Which occupational or environmental exposure indicates a need for spirometry?

smoking or working in hazardous or dusty environments

Which therapies does spirometry determine the benefits or negative effects of?

bronchodilator or steroids

cardiac drugs (antiarrhythmics, diuretics)

lung resection, reduction, or transplant

pulmonary rehabilitation

Which surgical procedures indicates a need for spirometry?

lung resection (lobotomy, pneumonectomy), thoracic procedures (sternotomy), upper abdominal procedures

What is the purpose of spirometry to evaluate disability or impairment?

1. for social security or other compensation programs

2. legal or insurance evaluations

3. cardiopulmonary rehabilitation assessment

What are the 6 indications of the need for lung volume testing?

1. diagnose or assess the severity of restricted lung disease

2. differentiate between obstructive and restrictive diseases

3. assess response to therapeutic interventions

4. make preoperative assessments of patients with compromised lung function

5. determine the extent of hyperinflation

6. assess gas trapping by comparison of plethysmographic lung volumes with gas dilution lung volumes

Which therapeutic interventions need lung volume testing?

bronchodilators, steroid

lung transplantation, resection, reduction

radiation or chemotherapy

What are the 6 indicators for DLCO?

1. evaluate or follow the progress of parenchymal lung diseases

2. evaluate pulmonary involvement in systemic diseases

3. evaluate obstructive lung disease

4. evaluate cardiovascular diseases

5. quantify disability associated with interstitial lung disease

6. evaluate pulmonary hemorrhage, polycythemia, or left to right shunts (increased DLCO)

Which parenchymal lung diseases does DLCO evaluate?

1. dusts (asbestos, silica, metals)

2. organic agents (allergic alveolitis)

3. Drugs (amiodarone, bleomycin)

Which systemic diseases indicate a need for DLCO?

1. rheumatoid arthritis

2. sarcoidosis

3. systemic lupus erythematosus (SLE)

4. Systemic sclerosis

5. Mixed connective tissue disease

Which obstructive diseases does DLCO follow the progress of?

emphysema

cystic fibrosis

What obstructive diseases does DLCO differentiate?

emphysema

chronic bronchitis

asthma

What does DLCO predict for COPD?

arterial desaturation during exercise

Which cardiovascular disease does DLCO evaluate?

primary pulmonary hypertension

acute or recurrent pulmonary thromboembolism

pulmonary edema and congestive heart failure

What are 6 indications for exercise testing?

1. evaluate exercise intolerance or level of fitness

2. document or diagnose exercise limitations as a result of fatigue, dyspnea or pain

3. exercise evaluation for cardiac or pulmonary rehabilitation

4. assess preoperative risk, particularly lung resection or reduction

5. assess disability, particularly related to occupational lung disease

6. evaluate therapeutic interventions such as heart or lung transplantation

Which 4 groups of conditions does exercise testing diagnose exercise limitation?

cardiovascular diseases, pulmonary diseases, mixed cardiovascular and pulmonary etiologies, unexplained dyspnea

Which cardiovascular diseases does exercise testing test for limitations?

1. myocardial ischemia or dyspnea

2. cardiomyopathy

3. congestive heart failure

4. peripheral vascular disease

5. selection for heart transplantation

Which pulmonary diseases does exercise testing test for limitations?

1. airway obstruction

2. interstitial lung disease

3. pulmonary vascular disease

What can result in unexplained dyspnea?

deconditioning, upper airway abnormalities (VCD)

What does exercise testing evaluate for cardiac or pulmonary rehabilitation?

exercise desaturation/hypoxemia, oxygen prescription

What are obstructive lung diseases?

longstanding diseases that impair airflow into or out of the lungs

What is a common symptom of obstructive lung disease?

SOB at rest or exertion usually with a productive cough

Give 5 examples of obstructive lung diseases?

COPD: emphysema and chronic bronchitis, asthma, bronchiectasis, cystic fibrosis

Does obstructive lung diseases usually happen alone?

Can be alone or in combination

What is emphysema?

A lung disease where the alveoli are damaged which leads to air trapping

How is emphysema diagnosed?

Physical assessment, CXR or CT and PFTs primary diagnostic tools

What is emphysema caused by?

Primarily by smoking

can be genetic: alpha-1 antitrypsin deficiency

chronic exposure to environmental pollutants