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Infant/Toddler Pulmonary Function Tests (2008)

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Infant/Toddler Pulmonary Function Tests (2008) AARC Clinical Practice Guideline Infant/Toddler Pulmonary Function Tests—2008 Revision & Update ITPFT 1.0 PROCEDURE: 2.4.3 Tidal breathing measures: RR; time Infant/toddler pulmonary function tests (ITPFTs) to reach peak tidal expiratory flow (tPTEF); 41, total expiratory time (tE); ratio of tPTEF/tE ITPFT 2.0 DESCRIPTION/DEFINITION: 42 2.4.4 Partial expiratory flow-volume 2.1 Infant/toddler pulmonary function tests curves: maximal flow at functional residual measure a variety of pulmonary variables in capacity (VmaxFRC) 49, 68 subjects who are generally too young to per- 2.4.5 Raised volume rapid thoracoabdomi- form, comprehend, or comply with necessary nal compression technique: forced vital ca- instructions for conventional pulmonary diag- pacity (FVC); forced expired volume at 0.5 nostic procedures and 0.75 seconds respectively (FEV0.5, 2.2 Subjects are typically tested under con- FEV0.75); forced expiratory flow at 25%, scious sedation or while sleeping and are spon- 50%, 75% and between 25% and 75% of taneously breathing. ITPFTs have also been FVC (FEF25, FEF50, FEF75, FEF25-75) performed in subjects who are mechanically 68, 73 ventilated. 2.4.6 Whole body plethysmography: 2.3 ITPFTs may include measurements of: plethysmographic functional residual ca- 2.3.1 Passive respiratory mechanics, 1-35 pacity (FRCpleth); airway resistance 2.3.2 Dynamic respiratory mechanics, 32, 33, (Raw) 97, 101 35-39 2.4.7 Gas dilution techniques: helium dilu- 2.3.3 Tidal breathing measurements, 1, 35, 40 -42 tion (FRCHe), nitrogen washout (FRCN2), 2.3.4 Partial expiratory flow-volume breath-by-breath inert gas washout or mul- curves, 2-7, 9, 12-14, 17, 35, 43-68 tiple breath washout (MBW) techniques 2.3.5 Raised volume rapid thoracoabdomi- measure lung clearance index (LCI) or nal compression technique, 12, 24, 35, 52-59, 68-89 mixing ratios (MR) 105, 109 2.3.6 Whole-body plethysmography, 9, 32, 35, 2.4.8 Forced deflation: FVC, maximum ex- 64, 84, 85, 90-101 piratory flows at 25 and 10% of FVC 2.3.7 Gas dilution techniques, 7, 10, 11, 14, 20, 26- (MEF25, MEF10) 111 29, 35, 43, 51, 90-92, 95, 99,100, 102-109 and 2.5 Although these procedures are intended pri- 2.3.8 Forced deflation technique in intubat- marily for neonates and infants, some older ed subjects. 110, 111 subjects may be successfully evaluated, if ap- 2.4 Common indices measured using these var- propriately sized equipment is employed and ious techniques includes: methodology limitations are well understood. 2.4.1 Passive respiratory mechanics: total 2.6 The maneuvers used during the raised vol- respiratory system compliance (Crs); total ume technique are being used to acquire motion respiratory system resistance (Rrs); and free images during chest CT at end inspiration time constant (Trs) 8, 33, 34 and end exhalation in infants and children. 112 2.4.2 Dynamic respiratory mechanics: lung 2.7 Investigational techniques in infants such as compliance (CL); lung resistance (RL); res- forced oscillation and interrupter resistance piratory rate (RR), and tidal volume 33, 38 have been described. 113-117 Consensus regard- RESPIRATORY CARE • JULY 2008 VOL 53 NO 7 929 AARC GUIDELINE: INFANT/TODDLER PULMONARY FUNCTION TESTS ing methodology for these techniques is not ITPFT 5.0 CONTRAINDICATIONS: available for infants; therefore, the techniques are It is absolutely critical that prior to initiating briefly described in section 8 of this document. ITPFTs the technologist and physician carefully 2.8 Hardware Considerations: evaluates the patient. Clinical judgment and/or cau- 2.8.1 Size appropriate measurement de- tion should be exercised due to the need for seda- vices, such as pneumotachometers tion and invasiveness of some of these techniques. with appropriate flow range are critical. 118 5.1. Absolute Contraindications (based on the 2.8.2 When setting up equipment, one recommendations of the writing committee): should use tubing sizes and connections 5.1.1 Active pulmonary bleeding, that create the minimum possible mechani- 5.1.2 Open chest wound, cal deadspace. It is important to remember 5.1.3 Untreated or tension pneumothorax, that modifying connections near pneumota- 5.1.4 Past history of intolerance to sedation, chometers or flowmeters may adversely af- 5.1.5 Significant upper airway obstruction, fect measurement accuracy. 118 5.1.6 Seizure disorder (if performing the raised volume technique; the multiple in- ITPFT 3.0 SETTING: flations may lead to a drop in carbon diox- 3.1. Testing may be performed, in a variety of ide levels, thus a drop in seizure threshold), settings including, but not limited to: hospital 5.1.7 Hemodynamically significant con- laboratories, intensive and intermediate care genital heart disease, units, and specialized clinics. It is critical to note 5.1.8 If patient has not remained without that the infants are often undergoing conscious food and/or drink based on the conscious sedation and must be appropriately monitored in sedation policy of the individual institution, the specific setting. When performing these 5.1.9 Naso-facial deformities that prevent tests, the top priority is the safety of the infant effective mask seal or increase risk of gas- and toddler. 118, 119 Please see sections 10 and 11 tric insufflation. for details regarding monitoring and personnel. 5.2 Relative Contraindications (based on the recommendations of the writing committee): ITPFT 4.0 INDICATIONS: 5.2.1 Medical conditions that could com- Indications for ITPFTs include the following: promise patient’s condition if ventilatory 4.1 To serve as an outcome measure in epidemi- support is temporarily interrupted when 1, 2, 3, 12, 17, 32, 47, 48, 50, 58, 63, 71, 75, 76, performing ITPFTs, ologic research 5.2.2 79, 93, 120 Central hypoventilation, 5.2.3 Pre-existing central nervous system 4.2 To improve one’s understanding of the natu- depression or neurologic impairment such ral history of lung growth, or diseases present- as hydrocephalus, ing in infancy (e.g., cystic fibrosis, bronchopul- 5.2.4. Severe gastroesophageal reflux, monary dysplasia, wheezing illnesses) 4, 9, 10, 11, esophagitis or gastritis, 13, 14, 15, 20, 21, 23, 25, 26, 31, 36, 40, 43, 44, 46, 51, 55, 56, 59, 65, 69, 5.2.5 Uncooperative or combative patient, 70, 74, 77, 83, 88, 89, 90, 92, 94, 99, 102, 108, 120 5.2.6 Patients with pacemakers (Thora- 4.3 To evaluate therapeutic responses (e.g., to coabdominal compression technique medication or respiratory interventions) 5, 6, 7, 27, (Hugs) may lead to possible dislodging of 28, 29, 30, 52, 61, 86,120 wires), 5.2.7 Febrile patients, or a recent history 4.4 To help in predicting the risk of subsequent URI, pneumonia or excessive coughing. pulmonary dysfunction based upon initial test- 63, 67, 70, 120 ing. ITPFT 6.0 PRECAUTIONS/HAZARDS 4.5 To provide physiologic measures of lung AND/OR COMPLICATIONS: function in a variety of diseases 4, 9, 10, 11, 13, 14, 15, 20, 25, 31, 36, 40, 43, 46, 50, 51, 52, 55, 65, 69, 70, 78, 85, 88, 89, 90, 91, Due to the need for sedation and the potential inva- 92, 94, 108, 120 siveness of the procedure, the technician performing 930 RESPIRATORY CARE • JULY 2008 VOL 53 NO 7 AARC GUIDELINE: INFANT/TODDLER PULMONARY FUNCTION TESTS the technique should be an expert in airway manage- the complexity of both performing and interpreting ment and monitoring of infants and toddlers. Al- the data. The ATS/ERS Working Group of Infant though ITPFTs are generally safe procedures, the Lung Function Testing has published guidelines to following untoward events may occur: 121-123 standardized performance and interpretation of 6.1 Vomiting with aspiration with consequent ITPFT results. 7.1 apnea and laryngospasm and/or bronchospasm Methodology and limitations for ITPFT (The forced deflation technique requires tra- techniques are: 7.1.1 Raised volume rapid cheal intubation), 111 thoracoabdominal compression technique 6.2 Pneumothorax, (RVRTC). 6.3 Loss of airway patency leading to increased 7.1.1.1 RVRTC Methodology: 35, 68, 73 121-123 upper airway obstruction (due to sedation), 7.1.1.1.1 Inflatable jacket is 6.4 Transmission of contagion via improperly wrapped around the thorax of the cleaned equipment or as a consequence of the sedated, supine infant. There inadvertent spread of droplet nuclei or body flu- should be a minimum of 3 finger ids (patient-to-patient or patient-to-technolo- breadths between the infant and the gist) Infection control is critical (see section jacket to prevent restriction of lung 13), 124-126 volumes. If the jacket is too tight, 6.5 Oxygen desaturation due to (a) worsening there is a restriction of lung vol- umes. If the jacket is too loose, of ventilation-to-perfusion mismatch and hy- there is a delay in the initiation of poventilation as a consequence of sedation the “hug.” 73 121-123 and/or positioning; (b) interruption of 7.1.1.1.2 A clear facemask secured oxygen therapy or failure to preoxygenate the to the face with therapeutic putty is patient prior to performing the forced deflation attached to a circuit containing a technique; (c) temporary loss of distending pneumotachograph, and placed pressure; around the infant’s nose and 6.6 Bradycardia secondary to the sedation, mouth. 35, 68, 73 122,123 7.1.1.1.3 The infant’s lung volume 6.7 Cough, is increased to an airway pressure 6.8 Hypocapnia or dizziness (during the raised of 30 cm H2O (V30) using a pop- off in the circuit attached to the volume technique), 121 facemask. 35, 68, 73 6.9 Paradoxical excitement from the chloral hy- 7.1.1.1.4 Cricoid pressure could be 121 drate (common sedative used), applied during the inflation maneu- 6.10 Gastrointestinal side effects such as nau- ver to limit gas entry into the stom- sea, vomiting, diarrhea from chloral hydrate, ach.
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