Top Banner
page 1 The Finer Points of The Finer Points of Performing Pulmonary Performing Pulmonary Diagnostic Diagnostic Measurements Measurements James James P. Sullivan P. Sullivan, BA, RPFT , BA, RPFT Pulmonary Diagnostic Laboratories Pulmonary Diagnostic Laboratories Memorial Sloan Kettering Cancer Center Memorial Sloan Kettering Cancer Center New York, New York New York, New York sullivaj@mskcc.org sullivaj@mskcc.org If it moves air, If it moves air, we can get a we can get a we can get a we can get a number… number… Who Do We Learn From? Who Do We Learn From? ATS/ERS? ATS/ERS? Performance and equipment Performance and equipment standards. standards. AARC? AARC? Diagnostics Section. Diagnostics Section. Vendors? Vendors? Software and hardware only Software and hardware only Vendors? Vendors? Software and hardware only. Software and hardware only. All of these have their value and limitations. All of these have their value and limitations.
16

Finer Points of Performing Pulmonary Diagnostic ... · page 1 The Finer Points of Performing Pulmonary Diagnostic Measurements James James P. SullivanP. Sullivan, BA, RPFT, BA, RPFT

Jun 05, 2018

ReportDownload

Documents

vannga

  • page 1

    The Finer Points of The Finer Points of Performing Pulmonary Performing Pulmonary

    Diagnostic Diagnostic MeasurementsMeasurements

    James James P. SullivanP. Sullivan, BA, RPFT, BA, RPFTPulmonary Diagnostic LaboratoriesPulmonary Diagnostic Laboratories

    Memorial Sloan Kettering Cancer CenterMemorial Sloan Kettering Cancer CenterNew York, New YorkNew York, New York

    sullivaj@mskcc.orgsullivaj@mskcc.org

    If it moves air, If it moves air, we can get awe can get awe can get a we can get a numbernumber

    Who Do We Learn From?Who Do We Learn From?

    ATS/ERS?ATS/ERS? Performance and equipment Performance and equipment standards.standards.

    AARC?AARC? Diagnostics Section.Diagnostics Section.

    Vendors?Vendors? Software and hardware onlySoftware and hardware onlyVendors?Vendors? Software and hardware only.Software and hardware only.

    All of these have their value and limitations.All of these have their value and limitations.

  • page 2

    What are we looking for?What are we looking for?

    Spirometry:Spirometry: ObstructionObstruction

    Lung Volumes:Lung Volumes: RestrictionRestriction

    sbsbDDLLcoco:: RateRate of gas movement from of gas movement from alveoli into bloodalveoli into bloodalveoli into blood.alveoli into blood.

    MEP/MIP:MEP/MIP: ForceForce generated by ventilatory generated by ventilatory systemsystem

    We must instruct our patients to create the We must instruct our patients to create the physiologic physiologic conditionsconditions needed to best show needed to best show

    these.these.

    Standardized MeasurementsStandardized Measurements

    This is the real purpose of the ATS/ERS This is the real purpose of the ATS/ERS Guidelines and Statements.Guidelines and Statements.

    Equipment should be calibrated and Equipment should be calibrated and controlled to the same standards.controlled to the same standards.

    Testing procedures should follow the same Testing procedures should follow the same standards.standards.

    Reporting should include relevant date, Reporting should include relevant date, without unnecessary and outmoded values.without unnecessary and outmoded values.

  • page 3

    FVC: What is the BestFVC: What is the Best--Performed?Performed? The ATSThe ATS--Best vs. the BestBest vs. the Best--PerformedPerformed

    ATS defines best trial as the largest sum of ATS defines best trial as the largest sum of FVC and FEVFVC and FEV11; this generally works well ; this generally works well but can overstate these values in but can overstate these values in obstructive diseaseobstructive diseaseobstructive disease.obstructive disease.

    VVEXTEXT and PEFR are not included in bestand PEFR are not included in best--effort selection criteria.effort selection criteria.

    Some form of FVC, FEVSome form of FVC, FEV11, PEFR and V, PEFR and VEXTEXTshould be used to determine best effort.should be used to determine best effort.

    FVC: What is the BestFVC: What is the Best--Performed?Performed? VVEXTEXT: used to determine zero: used to determine zero--time for time for

    FEVFEV11 measurement; is a very good measurement; is a very good indicator of initial expiratory effort.indicator of initial expiratory effort.

    VVEXTEXT should be 5% of the FVC or 150 should be 5% of the FVC or 150 mL, whichever is greater.mL, whichever is greater., g, g

    The lower the VThe lower the VEXTEXT and the higher the and the higher the PEFR, the betterPEFR, the better--performed the effort is.performed the effort is.The The bestbest--performed effort is the most performed effort is the most

    accurate effort, even if the FVC and FEVaccurate effort, even if the FVC and FEV11are lower, especially in obstructive are lower, especially in obstructive

    patientspatients..

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

  • page 4

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

  • page 5

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

    BackBack--Extrapolated Volume (VExtrapolated Volume (VEXTEXT))

  • page 6

    FVC: FVC: Blow For How Blow For How LongLong?????? Adults: 6 s.Adults: 6 s. Children (

  • page 7

    Whenever Youre ReadyWhenever Youre Ready

    Give the patient as much control as Give the patient as much control as possible.possible. Some parts of breathing maneuver Some parts of breathing maneuver

    require exacting performance, directed require exacting performance, directed q g pq g pby the technologist.by the technologist. Other parts arent as crucial, and we may Other parts arent as crucial, and we may

    get better performance by saying, get better performance by saying, Whenever youre readyWhenever youre ready

    Tidal BreathingTidal Breathing

    Tidal Breathing must be treated as a Tidal Breathing must be treated as a maneuver.maneuver.

    It must be instructed, demonstrated and It must be instructed, demonstrated and observed, and if necessary, critiqued and observed, and if necessary, critiqued and

    corrected.corrected.

    What What Can The Can The Patient Teach Us?Patient Teach Us?

  • page 8

    Patient InstructionsPatient Instructions

    Our instructions should:Our instructions should: Include an accurate demonstration.Include an accurate demonstration. Create the measurement conditions Create the measurement conditions

    d d f t td d f t tneeded for accurate measurements.needed for accurate measurements. Exactly describe what the patient needs Exactly describe what the patient needs

    to do.to do.

    we cant assume that anyone who walks we cant assume that anyone who walks into your lab with or without a credential is into your lab with or without a credential is competent. The same applies to experience; competent. The same applies to experience; an individual may boast that they have 25 an individual may boast that they have 25 years of experience, but in reality years of experience, but in reality theyve theyve used those years to become really good atused those years to become really good atused those years to become really good at used those years to become really good at doing tests very poorlydoing tests very poorly..

    Quality Assurance of the Pulmonary Function TechnologistQuality Assurance of the Pulmonary Function TechnologistJeffrey M. Haynes, RRT, RPFTJeffrey M. Haynes, RRT, RPFT

    Respiratory Care, January 2012, Vol 57, No 1, pg 114Respiratory Care, January 2012, Vol 57, No 1, pg 114--126126

    DDLLco Performance Issuesco Performance Issues

    DDLLco Preco Pre--Inspiratory Maneuver Conditions:Inspiratory Maneuver Conditions:The 2005 Statement discouraged deep The 2005 Statement discouraged deep inspirations prior to the expiration to RV, but the inspirations prior to the expiration to RV, but the 2017 Statement no longer addresses this2017 Statement no longer addresses this2017 Statement no longer addresses this.2017 Statement no longer addresses this.

    -- ? ? ? ? ? ? --The references in the 2005 statement are still The references in the 2005 statement are still valid. I would still recommend for the expiration valid. I would still recommend for the expiration to RV begin at the end of a normal tidal to RV begin at the end of a normal tidal inspiration, and to NOT take a deep breath in.inspiration, and to NOT take a deep breath in.

  • page 9

    DDLLco IVC Greater than FVC or SVCco IVC Greater than FVC or SVC

    DDLLco IVC Greater than FVC or SVCco IVC Greater than FVC or SVC

    The start of the The start of the sbDsbDLLcoco is the same as the is the same as the European FVC maneuver, which is: European FVC maneuver, which is:

    VVTT RV TLC RV TLC

    Testing Order Makes a Difference!Testing Order Makes a Difference!

    1) Arterial Puncture2) Maximum Inspiratory and Expiratory Forces3) Pre-BD FVC4) Pre-BD MVV5) Pre-BD RAW/GAW6) Pre BD Lung Volumes (pleth or gas)6) Pre-BD Lung Volumes (pleth. or gas)7) Administer bronchodilator8) Post-BD DLco9) Post-BD FVC10) Post BD RAW/GAW11) Post-BD Lung Volumes (pleth. or gas)12) Simple Submaximal Exercise (6MWT, step

    tests)

  • page 10

    Testing Order Makes a Difference!Testing Order Makes a Difference!

    The DThe DLLco calculations assume an co calculations assume an ambient alveolar Oambient alveolar O22 concentration; Dconcentration; DLLco co should no be performed immediately should no be performed immediately after an Nafter an N22 Washout or when Washout or when supplemental Osupplemental O is being administeredis being administeredsupplemental Osupplemental O22 is being administeredis being administered..

    Theres always a compromiseTheres always a compromise

    Human Biologic Standard Quality AssuranceHuman Biologic Standard Quality Assurance

    Human Biologic Standard Quality AssuranceHuman Biologic Standard Quality Assurance

  • page 11

    About DAbout DLLco: What co: What Happens if the Happens if the IVC IVC < 85%?< 85%?

    About DAbout DLLco: What Happens if the IVC < 85%?co: What Happens if the IVC < 85%?

    About DAbout DLLco: What Happens if the IVC < 85%?co: What Happens if the IVC < 85%?

  • page 12

    Carbohydrates, RER and CPETCarbohydrates, RER and CPET

    Predominant Diet: RER:Fats/Lipids 0.70Proteins 0.80C b h d t 1 0Carbohydrates 1.0

    About DAbout DLLco: Anatomic Deadspace vs. co: Anatomic Deadspace vs. Washout VolumeWashout Volume

    Answer: Shedding of boundary layer gases.

    Poor Patient EffortPoor Patient Effort

  • page 13

    SixSix--Minute Walk TestMinute Walk Test

    What is Reported:What is Reported: DistanceDistance Any other added measurements can Any other added measurements can

    change the distance walked.change the distance walked.F f t l i t i tF f t l i t i t For safety, pulse oximetry is a must, For safety, pulse oximetry is a must, but the oximetry device must be as but the oximetry device must be as unobtrusive as possible.unobtrusive as possible.

    100 meter straight hallway is ideal.100 meter straight hallway is ideal.

    SixSix--Minute Walk TestMinute Walk Test

    SixSix--Minute Walk TestMinute Walk Test

  • page 14

    FVC > SVCFVC > SVC

    Theres really no physiologic reason Theres really no physiologic reason for this to happen.for this to happen.

    This is a coordination issue, not This is a coordination issue, not physiologyphysiologyphysiology.physiology.

    Errors of VC measurement are Errors of VC measurement are alwaysalwayserrors of understatement.errors of understatement.

    What is needed from an SVC?What is needed from an SVC? FRC baseline, IC and the largest possible FRC baseline, IC and the largest possible

    VCVC..

    FVC > SVCFVC > SVC Patients that consistently perform larger Patients that consistently perform larger

    FVCs than SVCs are telling you they can FVCs than SVCs are telling you they can perform this better when they blast it out.perform this better when they blast it out.

    Instruct and carefully measure the FRC Instruct and carefully measure the FRC baseline, have them inhale as deeply as baseline, have them inhale as deeply as they can, and then have them blast it out.they can, and then have them blast it out.

    Always ensure that the pneumotach is Always ensure that the pneumotach is correctly calibrated and is measuring correctly calibrated and is measuring accurately.accurately.

    Flow CalibrationFlow Calibration

    Current ATS/ERS calibration criteria Current ATS/ERS calibration criteria are to use a 3.0 L syringe with flows are to use a 3.0 L syringe with flows over a clinicallyover a clinically--relevant range, with all relevant range, with all flows returning volumes withinflows returning volumes within 3% of3% offlows returning volumes within flows returning volumes within 3% of 3% of the syringe volume, i.e., 2.91 the syringe volume, i.e., 2.91 3.09 L.3.09 L.

    Current standards do not address how Current standards do not address how close the inspiratory and expiratory close the inspiratory and expiratory volumes should be.volumes should be.

  • page 15

    Flow CalibrationFlow Calibration If a system returns average expiratory & If a system returns average expiratory &

    inspiratory volumes of 2.92 L and 3.08 inspiratory volumes of 2.92 L and 3.08 L, the system is technically within L, the system is technically within ATS/ERS limits.ATS/ERS limits.

    This system will drift towards the This system will drift towards the inspiratory side of the V/T tracing.inspiratory side of the V/T tracing.

    Expiratory and inspiratory flows & Expiratory and inspiratory flows & volumes will be under and overvolumes will be under and over--measured.measured.

    Inspiratory FVL will overshoot TLC.Inspiratory FVL will overshoot TLC.

    Infection ControlInfection Control Wash your hands in view of the patient.Wash your hands in view of the patient. Encourage your patients to gelEncourage your patients to gel--in and in and

    gelgel--out wherever they go throughout out wherever they go throughout your facility.your facility.

    Develop a hand hygiene workflow for allDevelop a hand hygiene workflow for all Develop a hand hygiene workflow for all Develop a hand hygiene workflow for all of the procedures performed by your of the procedures performed by your labs, and check for compliance every labs, and check for compliance every quarter.quarter.

    Infection ControlInfection Control

  • page 16

    Questions?Questions?

    Thank You!Thank You!James James P. SullivanP. Sullivan, BA, RPFT, BA, RPFT

    Supervisor, Pulmonary Diagnostic LaboratoriesSupervisor, Pulmonary Diagnostic LaboratoriesMemorial Sloan Kettering Cancer CenterMemorial Sloan Kettering Cancer Center

    New York, New YorkNew York, New Yorksullivaj@mskcc.orgsullivaj@mskcc.org

Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.