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In this chapter, we will cover indications and contraindications, complications, informed consent, patient preparation, lung function tests, test phases, and when to terminate a test.
Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by a limitation in airflow that is not fully reversible. It includes chronic bronchitis and emphysema. Smoking is the most common risk factor for COPD. However, exposures to biofuels, air pollution and other chemical irritants are common factors in certain areas of the world. It leads to alveolar damage, increased mucus production, air trapping, hyperinflation and airflow obstruction.
1. Lung function testing is important in the diagnosis, severity assessment and monitoring of lung diseases.
2. Spirometry measures forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and FEV1/FVC ratio. Its uses include: screening for airflow limitation, assessing disease progression and diagnostic purposes (in combination with further lung function testing).
3. Lung volume measurements provide additional information to help differentiate restrictive, obstructive and mixed lung diseases.
4. Transfer factor for carbon monoxide (TLCO) (diffusion capacity of carbon monoxide (DLCO)) measures the ability of the lungs to transfer inhaled gas from the alveoli to red blood cells in the pulmonary capillaries. It can be used alongside the carbon monoxide transfer coefficient (KCO) for diagnostic purposes and to monitor disease progression.
5. Lung function testing is subject to a number of limitations and, as such, should be interpreted with flow–volume loops and clinical context.
Carbon dioxide laser posterior transverse cordotomy is a common option for bilateral vocal fold paralysis. This study prospectively evaluated aerodynamic and acoustic effects of unilateral carbon dioxide laser posterior transverse cordotomy in bilateral vocal fold paralysis patients.
Methods:
The study comprised 11 bilateral vocal fold paralysis patients (9 females, 2 males), with a mean age of 46.6 ± 14.1 years. All patients were treated by laser posterior transverse cordotomy. Pre-operative and two-month post-operative assessments were conducted, including: dyspnoea scales, maximum phonation time measurement, spirometry and bicycle ergometry.
Results:
All subjective and objective aerodynamic parameters showed statistically significant improvements between the pre- and post-operative period. Objective spirometric and ergometric parameters showed a significant increase post-operatively. The changes in objective voice parameters (fundamental frequency (f0), jitter, shimmer, soft phonation index and noise-to-harmonic ratio) were statistically non-significant; however, there was a significant improvement in subjective voice parameters post-operatively, as assessed by the voice handicap index and grade-roughness-breathiness-asthenia-strain scale (p = 0.026 and p = 0.018 respectively).
Conclusion:
Unilateral carbon dioxide laser posterior transverse cordotomy is an effective procedure that results in improved dyspnoea and aerodynamic performance with some worsening of voice parameters.
A subjective feeling of nasal airflow obstruction is a common symptom. An objective method for quantitative measurement of nasal airflow has long been desired. Rhinomanometry and acoustic rhinometry have been developed for anatomical and physiological evaluation of nasal obstruction. This study was designed to determine the usefulness of a portable spirometer in assessing upper airway obstruction.
Methods:
One hundred and ninety-six patients were assessed with nasal inspiratory spirometry to determine nasal airflow. All patients also underwent paranasal sinus computed tomography to determine anatomical abnormalities. Spirometry was performed on each nostril separately.
Results:
Sensitivity and specificity levels were high. This portable and easy to use device may be useful in respiratory assessment. Correlation between anatomical obstructions and subjects' complaints was statistically significant (p < 0.001), but no definite correlation between septal deviation severity and spirometric values was found.
Conclusion:
Portable spirometry is an objective and useful method of evaluating nasal obstruction, but needs more investigation to establish a standardised test.
We evaluated the effect of feedback after opportunistic spirometry in general practice on motivation for smoking cessation using stage change in the transtheoretical model. A total of 328 smokers aged over 35 years were given immediate feedback on the presence or absence of lung damage due to smoking, plus brief standard cessation advice. At 3 months, 99 (30.2%) smokers reported making an attempt to quit and 17 (5.2%) smokers reported moving into action stage for cessation. Of 297 (80.5%) successfully followed up, 81 (27.3%) smokers demonstrated forward shift and 35 (11.8%) smokers demonstrated backward shift. Feedback on the presence of lung damage was not significantly associated with reporting a quit attempt (p = .31) or moving into action stage for cessation (p = .30). Odds of forward or backward shift were not independently associated with either feedback on the presence of lung damage or normal lung function. Odds of backward shift with feedback on lung damage depended on participants' assessments of quit benefits, which were correlated with their prior self-assessment of lung damage. Our findings suggest that feedback to smokers after spirometry about the absence of lung damage is not harmful. However, eliciting personal health attitudes is also important so cessation advice can be tailored especially for smokers who believe they already have lung damage from smoking.
Thoracic surgery ranges from small low-risk procedures to major surgery, and for malignant and non-malignant disease. Assessment of the thoracic patient for surgery comprises two distinct areas. The first is the resectability of the lesion if malignant and the second is the fitness to withstand the morbidity it inevitably involves, referred to as operability by most surgeons. Lung function tests described in the chapter include spirometry, gas transfer capacity, functional tests, and arterial blood gas analysis. Sensitivity for detecting small lesions is reasonable but not as high as computerized tomography (CT) scans but the radiation exposure is very low and the investigation is widely available. In general, the resolution of the magnetic resonance imaging (MRI) scan is not superior to the CT scan and it is no better at confirming the presence or absence of invasion than CT scanning.
To define the predictive value of clinical diagnosis of chronic obstructive pulmonary disease (COPD) or suspected COPD in primary care patients with spirometric criteria for diagnosis.
Background
The diagnosis of COPD is usually made clinically but often not confirmed by diagnostic testing. Recent initiatives have called for universal spirometry testing in primary care to diagnose and monitor such patients the implications of this policy on diagnostic accuracy are not as yet known.
Methods
Retrospective comparative analysis of 677 consecutive primary care referrals to a district general hospital lung function laboratory for spirometry, March 1998 to December 2006.
Findings
Five hundred and three of 677 patients referred for open access spirometry had a primary care clinical diagnosis or suspected diagnosis of COPD. When compared with NICE spirometric criteria for diagnosis of COPD, 141 patients (28%) had normal spirometry, 46 (9%) had reversible airflow obstruction and 14 (3%) a restrictive pattern of spirometry. The positive predictive value of a primary care clinical diagnosis of COPD was 0.62 for patients referred for assessment of severity and 0.56 for those referred for diagnostic testing. Clinical suspicion of COPD in this sample was not confirmed by spirometry in a high proportion of referred patients. The introduction of the widespread use of spirometry for confirmation of primary care clinician made COPD diagnosis have important implications for both individual patients and primary care service planning.
Background: We investigated the aerobic capacity of 168 adult patients who had undergone successful surgical repair of tetralogy of Fallot at the University of Toronto Congenital Cardiac Centre for Adults. Methods: We compared values of peak uptake of oxygen, peak heart rate, forced vital capacity, and forced expiratory volume in 1 second to predicted values for their age groups. Results: The patients who had undergone surgical repair of tetralogy of Fallot demonstrated an overall diminished peak uptake of oxygen, at 51%, and peak heart rate, at 79%, compared to predicted values. No difference in peak aerobic capacity was found according to the initial surgical strategy of palliation or repair. Conclusions: Adult patients who have undergone surgical repair of tetralogy of Fallot have lower peak uptake of oxygen, and peak heart rate, compared to predicted values. The reduction in the peak heart rate may affect their exercise capacity. The peak uptake of oxygen also decreased with increasing age at the time of testing, and the age at surgical repair.
Studies in psychophysiology and behavioral medicine have uncovered
associations among psychological processes, behavior, and lung
function. However, methodological issues specific to the
measurement of mechanical lung function have rarely been discussed.
This report presents an overview of the physiology, techniques,
and experimental methods of mechanical lung function measurements
relevant to this research context. Techniques to measure lung
volumes, airflow, airway resistance, respiratory resistance,
and airflow perception are introduced and discussed. Confounding
factors such as ventilation, medication, environmental factors,
physical activity, and instructional and experimenter effects
are outlined, and issues specific to children and clinical groups
are discussed. Recommendations are presented to increase the
degree of standardization in the research application and
publication of mechanical lung function measurements in
psychophysiology.
Obstructing tumours of the upper airways have been demonstrated to alter the flow volume loop of pulmonary function testing. These alterations could be clues to the nature and location of the obstruction. This report describes a case of a pedunculated squamous cell carcinoma arising in the pharynx whose flow volume loop showed a saw tooth pattern which reflected the location and structure of the tumour.
Introduction: A case is presented in which a 43-year-old man suffering from a severe asthma attack, had ventilatory arrest during a hoisting procedure. Based on this experience, the influence of three hoisting techniques on lung function was tested.
Methods: The ventilatory capacity of 12 healthy volunteers was tested during three commonly used hoisting techniques: 1) single sling; 2) double sling; or 3) strapped to a stretcher.
Results: The vital capacity (VC) and the one-second, forced expiratory volume (FEV1) were reduced significantly during all hoisting techniques compared to the standing position. The reduction was significantly more pronounced on a stretcher than in either sling position. There were no differences in the FEV1 to VC ratio between the positions.
Conclusion: The small reduction in ventilatory capacity during hoisting procedures is tolerated easily by healthy individuals, but should be taken into account when planning such procedures on patients with severe pulmonary disease.
Pulmonary impairment is more frequent after cardiac surgery than after other major surgical procedures. The present study investigates whether, by using standard respiratory monitoring, i.e. side-stream spirometry and blood gas analysis, it is possible to detect changes in pulmonary function secondary to cardiopulmonary bypass. We investigated 18 patients undergoing elective coronary bypass surgery or aortic valve replacement. Cardiopulmonary bypass resulted in a nonsignificant increase in alveolar-arterial oxygen difference from 33.0 ± 10.6 kPa to 36.1 ± 12.5 kPa and arterial to end-tidal CO2 tension difference from 0.67±0.39 kPa to 0.79±0.54 kPa. Respiratory system resistance was unaltered. In contrast, dynamic compliance decreased significantly after cardiopulmonary bypass from 78.6 ± 22.9 to 65.4 ± 22.4 mL cmH2O−1 with open chest and from 61.0 ± 10.2 to 51.1 ± 17.2 mL cmH2O−1 with closed chest, compared with corresponding values before cardiopulmonary bypass. In conclusion, pulmonary gas exchange was not compromised after cardiopulmonary bypass, but a diminished respiratory compliance was a consistent finding, even in uncomplicated cardiac surgery using routine respiratory monitoring.
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