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Pulmonary function test and role in asthma diagnosis and monitoring

Pulmonary function test and role in asthma diagnosis and monitoring

Presented by Rapisa Nantanee, MD.

December 4, 2020

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Pulmonary function test and role in asthma diagnosis and monitoring

  1. 1. Pulmonary Function Test and Role in Asthma Diagnosis & Monitoring Topic Review December 4th, 2020 Rapisa Nantanee, M.D. Pediatric Allergy and Immunology Unit King Chulalongkorn Memorial Hospital
  2. 2. Outline • Pulmonary Function Test • Spirometry • Interpretation • Asthma diagnosis • Asthma monitoring • PFT in COVID-19 pandemic
  3. 3. Spirometry • Key Updates • A new list of relative contraindications was added. • Spirometers are now required to meet International Organization for Standardization (ISO) 26782 standards, but with a maximum permissible accuracy error of ± 2.5%. • Device quality assurance procedures were updated. • Operator training as well as attainment and maintenance of competency were addressed. • The list of activities that patients should avoid before testing was updated. • There is a focus on the use of devices that measure both expiration and inspiration. • Maneuver acceptability and repeatability criteria were updated. The end of forced expiration (EOFE) was redefined. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  4. 4. Spirometry • Key Updates (continued) • Requirements for spirometry systems to provide uniform cues and feedback to the operator were added. • New withholding times for bronchodilators before bronchodilator responsiveness testing were developed. • A new grading system for assessment of spirometry quality was developed. • Standardized operator feedback options that promote synoptic reporting were developed. • Preliminary findings derived from an international patient survey were presented. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  5. 5. Spirometry • A physiological test that measures the maximal volume of air that an individual can inspire and expire with maximal effort. • Volume or flow as a function of time • FVC: The volume delivered during an expiration made as forcefully and completely as possible starting from full inspiration • FEV1: The expiratory volume in the first second of an FVC maneuver. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  6. 6. Indications B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  7. 7. Relative Contraindications B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. • The forced expiratory maneuver used in spirometry increases intrathoracic, intraabdominal, and intracranial pressures. • The physical effort required can increase myocardial demand.
  8. 8. Relative Contraindications • Spirometry should be discontinued if the patient experiences pain during the maneuver. • Patients with potential contraindications may be tested in a pulmonary function laboratory where operators are more experienced and there may be access to emergency care if needed. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  9. 9. Laboratory Details • Record ambient temperature, barometric pressure, and time of day • Quiet and comfortable environment, separated from the waiting room and other patients being tested • The patient should be seated erect, with shoulders slightly back and chin slightly elevated. • A noseclip or manual occlusion of the nostrils should be used. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  10. 10. Hygiene and Infection Control • To prevent the transmission of infection to patients and staff during pulmonary function testing. • The operator must wash her or his hands or use an approved hand sanitizer before contact with each new patient. • The patient should be given an approved hand disinfectant gel or wipe upon first entry into the testing station. • Disposable, in-line filters for spirometers • All disposable items, including filters, mouthpieces, noseclips, and gloves, must be disposed of at the end of the testing session. • Infected patients • Reserving equipment for the sole purpose of testing infected patients • Testing at the end of the workday • Testing in their own rooms with adequate ventilation and appropriate protection for the operator. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  11. 11. https://www.wikiwand.com/en/Spirometry
  12. 12. Equipment • All spirometers meet the standards contained in the current update of ISO 26782. • Maximum permissible error of ± 2.5% • Standards for diffusing capacity specify a volume accuracy of ± 2%. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  13. 13. Display • For optimal quality control, both volume–time and flow–volume real-time displays are required, and operators must visually inspect the performance of each maneuver for quality assurance before proceeding with another maneuver. • Flow–volume graph • Expiratory flow must be plotted upward, and expiratory volume must be plotted toward the right. • A 2:1 aspect ratio must be maintained between the flow and volume scales. • Volume–time graph • Begin at the point of maximum inspiration or 1 second before Time 0, whichever occurs first. • The display of the maneuver should continue to the end of the plateau or the beginning of inspiration. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  14. 14. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  15. 15. BTPS Adjustment • All spirometry outcomes must be reported at BTPS (body temperature, ambient barometric pressure, saturated with water vapor). • Changes in spirometer or flow sensor temperature can be a source of variability. • Spirometer temperature should be measured and not assumed to be constant, even over the course of one testing session. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  16. 16. Operator Details • Observe and engage with the patient to achieve optimal results • Operator training and attainment and maintenance of competency must be integrated in any spirometry testing service. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  17. 17. Patient Details • The patient’s age, height, and weight (wearing indoor clothes and without shoes) are recorded. • Preferable to calculate age using the date of birth and the date of the test • Birth sex and ethnicity • Ethnicity categories for the Global Lung Function Initiative (GLI) reference values are white (i.e., European ancestry), African American, Northeast Asian, Southeast Asian, and other/mixed. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  18. 18. Patient Preparation • Patients should be as relaxed as possible before and during the tests. • Patients should be asked to loosen tight-fitting clothing. • Well-fitting dentures are usually left in place. • Withhold long- and short-acting bronchodilators before testing? • To diagnose an underlying lung condition, then withholding bronchodilators before testing is useful. • To determine a response to an existing therapeutic regimen, bronchodilator medications are generally not withheld. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  19. 19. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  20. 20. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  21. 21. FEV1 and FVC Maneuver • Test Procedure: 4 distinct phases of the FVC maneuver: • 1) maximal inspiration • 2) a “blast” of expiration • 3) continued complete expiration for a maximum of 15 seconds, and • 4) inspiration at maximal flow back to maximum lung volume • Most of the variability in results relates to • Inadequate and variable inspiration to TLC, ending the expiration prematurely, and variable effort. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  22. 22. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  23. 23. FEV1 and FVC Maneuver • Test Procedure: 4 distinct phases of the FVC maneuver: • 1) Maximal inspiration • The preceding inspiration be rapid and any pause at full inspiration be minimal (≤ 2 s). • “Inspire as deeply as possible” • Indicators of maximal inspiration include eyebrows raising or eyes widening, and sometimes the head begins to quiver. • 2) a “blast” of expiration • 3) continued complete expiration for a maximum of 15 seconds, and • 4) inspiration at maximal flow back to maximum lung volume B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  24. 24. FEV1 and FVC Maneuver • Test Procedure: 4 distinct phases of the FVC maneuver: • 1) Maximal inspiration • 2) Maximal expiration • At full inflation, without hesitation, the patient should be prompted to “blast,” not just “blow,” the air from their lungs, and then he or she should be encouraged to fully expire. • The spirometry system must signal the operator when a plateau has been reached or forced expiratory time (FET) reaches 15 seconds. • If the patient is able to see a volume–time trace still moving as they blow and/or a numeric or analog display of flow in mL/s, this might help motivate them to keep blowing. Children may benefit from incentive displays. • 3) continued complete expiration for a maximum of 15 seconds • 4) inspiration at maximal flow back to maximum lung volume B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  25. 25. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. Acceptable
  26. 26. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. Acceptable
  27. 27. FEV1 and FVC Maneuver • Test Procedure: 4 distinct phases of the FVC maneuver: • 1) Maximal inspiration • 2) Maximal expiration • 3) continued complete expiration for a maximum of 15 seconds • 4) Maximal inspiration after forced expiration • Upon completing the forced expiration, the patient should remain on the mouthpiece, and the operator should again coach the patient to rapidly inspire to full inflation. This will provide a measure of forced inspiratory VC (FIVC). • Comparison of the FIVC with the FVC will provide feedback to the operator on whether the patient began the forced expiration from full inflation. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  28. 28. FEV1 and FVC Maneuver • With appropriate coaching, children as young as 2.5 years old with normal cognitive and neuromotor function are able to perform acceptable spirometry. • Specifically trained operators, child-friendly environment, encouragement, detailed but simple instructions, lack of intimidation, and visual feedback in the teaching B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  29. 29. Within-Maneuver Evaluation • The following criteria were developed as objective measures to determine whether a maximal effort was achieved and acceptable FEV1 and/or FVC measurements were obtained. • However, in some cases, maneuvers that do not meet all of the criteria may be the best that the patient is able to do on that occasion, and although the FEV1 and/or FVC measurements are not technically acceptable, they may be clinically useful (i.e., “usable”). B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  30. 30. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  31. 31. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. Defines Time 0 The back-extrapolated volume (BEV) is the volume of gas that has already been expired from maximal lung volume to Time 0 and is included in the FEV1 and FVC measurements. BEV must be <5% of the FVC or 0.100 L, whichever is greater.
  32. 32. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. The hesitation time, defined as the time from the point of maximal inspiration to Time 0 should be 2 seconds or less. Acceptable maneuver with a hesitation time of 0.62 s. A hesitation time of 2.21 s which should generate a warning and a message to instruct the patient to blast out immediately when completely full.
  33. 33. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. - A large BEV will usually result in an erroneously high FEV1. - Patients with upper airway obstruction or neuromuscular disease are often unable to initiate a rapid increase in flow, and the BEV limit may be exceeded. - The operator must have the ability to override the BEV acceptability designation for such patients.
  34. 34. Within-Maneuver Evaluation • BEV must be <5% of the FVC or 0.100 L, whichever is greater. • The hesitation time should be 2 seconds or less. • The rise time from 10% to 90% of peak flow should be ≤150 ms. • But may be greater than this in a maneuver in a patient with upper airway obstruction. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  35. 35. End of forced expiration (EOFE) • To ensure that a true FVC has been achieved. • Achieving 1 of the following 3 recommended indicators of EOFE is required: 1. There is less than a 0.025-L change in volume for at least 1 second (a “plateau”). OR 2. The patient has achieved an forced expiratory time (FET) of 15 seconds. OR 3. The patient cannot expire long enough to achieve a plateau (e.g., children with high elastic recoil or patients with restrictive lung disease). - repeatedly achieve the same FVC. • The FVC must be greater than, or within the repeatability tolerance of, the largest FVC observed before this maneuver in the current testing set. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  36. 36. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  37. 37. End of forced expiration (EOFE) • Acceptable FEV1 measurement may be obtained from a maneuver with early termination after 1 second. • For children aged 6 years or younger, an acceptable FEV0.75 (the forced expiratory volume in the first 0.75 s) may be obtained from a maneuver with early termination after 0.75 seconds. • No requirement for a minimum FET. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  38. 38. End of forced expiration (EOFE) • FEV1 and FVC measurements from a maneuver with FIVC – FVC > 0.100 L or 5% of FVC, whichever is greater, are not acceptable. • If the volume of the maximal inspiration (i.e., FIVC) after EOFE is greater than FVC, then the patient did not start the maneuver from TLC. • A cough during the first second of the maneuver can affect the measured FEV1 value, and the FEV1 from such a maneuver is neither acceptable nor usable. • However, the FVC may be acceptable. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  39. 39. End of forced expiration (EOFE) • Glottic closure or early termination, such as inspiration or coming off the mouthpiece, renders FVC unacceptable. • If it occurs in the first 1 second, renders FEV1 unacceptable and unusable. • The first 0.75 seconds - FEV0.75 unacceptable and unusable. • Obstruction of the mouthpiece (e.g., by the tongue being placed in front of the mouthpiece, by teeth in front of the mouthpiece, or by distortion from biting) may affect the performance of either the device or the patient. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  40. 40. End of forced expiration (EOFE) • Maneuvers conducted with an erroneous zero-flow level will either under-or overestimate FEV1 and FVC. • Both FEV1 and FVC neither acceptable nor usable. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. Not acceptable/usable
  41. 41. Operator feedback • The spirometry system software must provide explicit feedback to the operator indicating FEV1 and FVC acceptability at the completion of each maneuver. • The operator must have the ability to override the acceptability designation. • Because the operator may note a leak, a cough, inadequate inspiration or expiration, or a faulty zero-flow level that was not detected by the software. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  42. 42. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  43. 43. Between-Maneuver Evaluation • The goal of each prebronchodilator testing set and post- bronchodilator testing set is to achieve a minimum of three acceptable FEV1 and three acceptable FVC measurements. • If these criteria are not met in three maneuvers, additional trials must be attempted, up to eight maneuvers in adults, although more may be done in children. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  44. 44. BEV must be <5% of the FVC or 0.100 L, whichever is greater. Repeatability criteria - Age > 6 yr: The difference between the largest and the next largest FVC and FEV1 is ≤ 0.150 L - Age ≤ 6 yr: The difference between the largest and the next largest FVC and FEV1 ≤ 0.100 L or 10% of largest FVC, whichever is greater.
  45. 45. Bronchodilator Responsiveness Testing • A determination of the degree of improvement of airflow in response to bronchodilator administration • If the aim of the test is to determine whether the patient’s spirometric lung function can be improved with therapy in addition to their regular treatment -- may continue with regular medication before the test. • If the test is used for diagnosis or to determine whether there is any change in spirometric lung function in response to bronchodilators -- withhold bronchodilators before baseline testing. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  46. 46. Bronchodilator Responsiveness Testing B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. Inhaled corticosteroids and leukotriene modifiers need not be withheld.
  47. 47. Bronchodilator Responsiveness Testing • Because normal baseline spirometry does not rule out a bronchodilator response, all initial spirometry done for diagnostic reasons should be performed before and after bronchodilator administration. • Thereafter the clinician may choose to perform spirometry without bronchodilator responsiveness testing, but it is important to consider baseline variability in lung function when making this decision. • Monitoring lung function by serial spirometry, especially in patients with obstructive lung disease, may be more useful by following postbronchodilator values. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  48. 48. Bronchodilator Responsiveness Testing 1. Performs prebronchodilator spirometry to achieve three acceptable FEV1 and FVC measurements. 2. Bronchodilator is administered. 3. Three or more additional post-bronchodilator acceptable FEV1 and FVC measurements B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  49. 49. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. When using an MDI in young children (< 5 years) the use of a facemask has been suggested during tidal breathing bronchodilator inhalation.
  50. 50. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. - 5 mg of albuterol sulfate inhalation solution is nominally equivalent to 400 μg by MDI, and 1 mg of ipratropium bromide inhalation solution is nominally equivalent to 80 μg by MDI (54, 55). - The driving gas should be air. Routine use of 100% oxygen as the driving gas for a jet nebulizer for bronchodilator responsiveness testing is not recommended.
  51. 51. Bronchodilator Responsiveness Testing • The 2005 ATS/ERS Spirometry Standards example used a dose of 400 μg albuterol or 160 μg ipratropium by MDI to ensure that the response was high on the dose–response curve. • A combination of ipratropium bromide and albuterol has demonstrated an increased response compared to either of the individual agents alone in identifying responsiveness in COPD patients. • When using ipratropium only, the recommended wait time is 30 minutes. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  52. 52. Reported Values • The largest FVC and the largest FEV1 • FEV1/FVC • The largest value from maneuvers meeting the acceptability criteria for FEV1. • FIVC, PEF. • FET from the maneuver with the largest FVC. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  53. 53. B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  54. 54. Reported Values B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88. • Children aged 6 years or younger have relatively large airways compared with their lung volume and may complete expiration in <1 second. • FEV0.75 should be reported and if FET is >1 second, then FEV1 should also be reported. • The mean forced expiratory flow, midexpiratory phase (FEF25- 75), may be reported from the maneuver with the largest sum of FEV1 and FVC.
  55. 55. Grading the Quality of the Test Session B. L. Graham, et al. Standardization of Spirometry 2019 Update. An Official ATS and ERS Technical Statement. Am J Respir Crit Care Med. 2019 Oct 15;200(8):e70-e88.
  56. 56. Classification of ventilatory function patterns • Obstructive defects • Restrictive defects • Mixed obstructive/restrictive defects • Non-specific ventilatory patterns Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell.
  57. 57. Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell. Spirometry parameters alone
  58. 58. Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell.
  59. 59. Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell.
  60. 60. Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell. Normal Restrictive ventilatory pattern Suboptimal effort Obstruction with gas trapping Gas trapping and hyperinflation
  61. 61. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  62. 62. Analysing the shape of the flow–volume curve Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell. Normal Normal Airway obstruction with almost complete reversibility Airflow obstruction Restriction Obstruction
  63. 63. Upper airway obstruction Borg BM, et al. Interpretation of Lung Lunction–A step by Step Guide. 2014 Oxford Wiley Blackwell. Normal Intrathoracic upper airway obstruction Fixed upper airway obstruction Extrathoracic upper airway obstruction.
  64. 64. D. Czovek. Kendig’s Disorders of the Respiratory Tract in Children, 9th ed. 2019. Chapter 11.
  65. 65. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  66. 66. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  67. 67. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  68. 68. B. Thompson, C. G. Irvin. Middleton’s 9th ed. Chapter 42.
  69. 69. M. Gallucci, et al. Front. Pediatr. (2019) 7:54.
  70. 70. M. Gallucci, et al. Front. Pediatr. (2019) 7:54.
  71. 71. Lung function testing during COVID-19 pandemic and beyond • Lung function tests (LFTs) often generate aerosols in the form of droplets due to patients coughing and testing often requires generation of high minute ventilation and flow rates. • LFTs therefore pose a considerable risk for the spread of infection to individuals and surrounding surfaces within and around the test areas even in asymptomatic patients. Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  72. 72. Lung function testing during COVID-19 pandemic and beyond Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  73. 73. Recommendations for Pandemic Phase - Level 1 safety • We do not recommend any patients with symptoms of COVID-19 or flu like symptoms are tested under any circumstances at this time. • Postpone all routine testing during the critical phase of this crisis. • COVID patients must not be tested for a minimum of 30 days post infection. • For highest risk patients requiring essential testing, lung function should be carried out in a negative pressure room and using equipment only for purpose of high risk or infected patients. • Exercise testing, nebulisation, bronchial challenge tests, and other aerosol generating procedures should be postponed at this time. Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  74. 74. Recommendations for Post Peak Phase - Level 2 safety • All testing procedures can be reintroduced with extra precautions (Full PPE and appropriate mask should be guided by local policy). • Exercise testing, nebulisation, bronchial challenge tests, and other aerosol generating procedures should be limited to specific equipment and testing rooms. • Use filters to minimise escape of aerosol from the exhalation ports when using nebulisers. Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  75. 75. Recommendations for Post Pandemic Phase - Level 3 safety • Return to Pre-COVID-19 standards for the delivery of lung function services. Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  76. 76. Recommendation from ERS Group 9.1 (Respiratory function technologists /Scientists) https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h
  77. 77. Thank you for your attention

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