Understanding the Problem with Pulmonary Function Testing

One great way to assist physicians with diagnosis and monitoring patient’s progress is Pulmonary Function Testing (PFT). But, the test doesn't come without limitations. For one thing, the results are not definitive, conclusive nor diagnostic. They are merely one of many chips in the process of differential diagnosis and monitoring.

I believe there are a few physicians, however, who think the PFT is the fail safe test to diagnose pulmonary disease. Yet this is not true and it cannot be true. Surely a PFT can be a great tool to help with the process of diagnosis and treatment, but it is not fail safe, and it's definitely not definitive.

Consider the following limitations of the Pulmonary Function Testing:

1. The results are based on patient effort.
2. Some practitioners misunderstand the results.
3. It is a test that is underutilized.
4. Chronic illness cannot be treated by PFT results obtained during an acute attack.

Two Basic Tests

Allow me to expound on all of the above. First, however, we have to describe the two basic and most important PFT tests:

1. Forced Vital Capacity (FVC): This is the "measurement of the patient's volume of air that they can exhale after a full inspiration with maximum speed and effort. A normal adult has a vital capacity of 3-5 LPM. The test basically determines how much air your chest can hold, and is determined by:

• Configuration of the chest cage
   
• Physical fitness of the patient - patients in good physical shape can inhale more air
   
• Posture of the patient - when slopped over you have less room for your lungs to expand)
   
• Gender - males can typically inhale more air than females
   
• Health of the patient - a variety of disease processes can decrease the amount of air you can inhale, such as COPD, asthma, cancer, pneumonia, scoliosis, tumors, neuromuscular disease, chest deformity, ascites, etc.

2. Forced Expiratory Capacity (FEV1): This is the amount of air exhaled in the first second of the FVC. It is one of the best PFT tests and cannot be faked. However, with poor effort, can be effected. This PFT test can help with diagnosis:

• 80% or better indicates normal
   
• 60-79% indicates mild obstruction
   
• 40-59% indicates moderate obstruction
   
• 40% or less indicates severe obstruction

So while your FEV1 might look like it can diagnose obstruction, and severity of obstruction, you are completely dependent on the effort of the patient. If the patient generated a poor effort and this wasn't reported by the technician, your diagnosis will be wrong.

For example, one study showed that poor effort inversely affected FEV1, as the worse effort by the patient the better the FEV1 looked. The best way to see if a patient had a good effort is to make sure the FVC loops are repeatable, and for this the physician is at the whim of the technician performing the test. The lazy technician may only perform one loop and say, "That's good enough."

Finding the Right Solution

Likewise, some practitioners do not understand that these results only fit guidelines, and are not definitive. Some physicians don't utilize it enough, as it can be used to monitor severity of disease, and show how it is getting better with treatment.

Although, if you have a patient do the PFT during an acute attack of, say, asthma or COPD, you cannot use that as a basis for your treatment long term. I say this because if a patient is sick in the hospital with asthma, he may be so sick, able to generate so little flow, the PFT may indicate an FEV1 of 30%. Surely this may be accurate for that patient visit, but the physician better have that patient on bronchodilators and systemic steroids to help the patient get through the crisis. Or, in other words, this is a poor time to be ordering a PFT.

If the clinician truly wants to know how bad the patient's lungs are during the normal course of a patient's life, the PFT must be done during a normal day, not a sick day. Unless, that is, the patient is sick every day, because then you'll have no choice.

PFTs are also underutilized to determine effectiveness of breathing treatments. One of the best tests to determine if albuterol works is to do a pre- and post-PFT, yet I find that most doctors order breathing treatments for their patients, sometimes QID, just because that patient has Cystic Fibrosis or COPD, even though the doctor has never seen any evidence those treatments work. If the patient doesn't have reversible airway obstruction (asthma as a first or secondary condition), albuterol will not work.

Technically speaking, any patient with home nebs should have had a Pulmonary Function Testing done at some point to determine if they do any good. Because, as we all know, 50% of patients receiving a placebo also said they felt the treatment made them feel better, even when it had no effect whatsoever.

Reference:

Frey, Michael V., "Spirometry: A Primer," February, 2013, www.rtmagazine.com

About the Author: Rick Frea is a licensed and Registered Respiratory Therapist and author of the Respiratory Therapy Cave.

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