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Body Plethysmography: 2001 Revision & Update AARC GUIDELINE: BODY PLETHYSMOGRAPHY: 2001 REVISION & UPDATE AARC Clinical Practice Guideline Body Plethysmography: 2001 Revision & Update BP 1.0 PROCEDURE: 4.1 for diagnosis of restrictive lung disease; Body plethysmography for determination of thoracic 4.2 for measurement of lung volumes to distin- gas volume (VTG) and airways resistance (Raw). guish between restrictive and obstructive pro- cesses; BP 2.0 DESCRIPTION/DEFINITION: 4.3 for evaluation of obstructive lung diseases, During body plethysmography, the subject is en- such as bullous emphysema and cystic fibrosis, closed in a chamber equipped to measure pressure, which may produce artifactually low results if 7 flow, or volume changes. The most common mea- measured by helium dilution or N2 washout. surements made using the body plethysmograph are With simultaneously determined volumes, an 1,2 VTG and Raw. Airways conductance (Gaw) is also index of trapped gas (ie, FRCplethysmograph/ 8 commonly calculated as the reciprocal of Raw. Spe- FRCHe dilution) can be established. cific airways conductance (ie, conductance/unit of 4.4 for measurement of lung volumes when lung volume) is routinely reported as sGaw. Other multiple repeated trials are required or when tests that can be administered in the body plethys- the subject is unable to perform multibreath mograph include spirometry, bronchial challenge, tests;9 10 diffusing capacity (DLCO), single-breath nitrogen 4.5 for evaluation of resistance to airflow; (N2), multiple-breath N2 washout, pulmonary com- 4.6 for determination of the response to bron- pliance, and occlusion pressure. These will not be chodilators, as reflected by changes in Raw, 11 discussed as part of this guideline. Some have been sGaw, and VTG; previously addressed.3-6 4.7 for determination of bronchial hyperreac- 2.1 VTG is expressed in liters (BTPS, or body tivity in response to methacholine, histamine, temperature and pressure saturated) and is the or isocapnic hyperventilation as reflected by 12,13 volume of gas in the lung when the mouth shut- changes in VTG, Raw, and sGaw; ter is closed. In plethysmographic studies, it is 4.8 for following the course of disease and re- commonly used to represent the functional sponse to treatment. residual capacity (FRC). 2.2 Raw is reported in cm H2O/L/s (ie, cm H2O t BP 5.0 CONTRAINDICATIONS: L-1 t s-1). RETIREDRelative contraindications to body plethysmogra- -1 2.3 sGaw is reported in L/s/cm H2O (ie, L t s t phy are: -1 cm H2O ) and is the reciprocal of the Raw 5.1 mental confusion, muscular incoordination, (1/Raw) divided by the lung volume at which body casts, or other conditions that prevent the the resistance measurement is made. subject from entering the plethysmograph cabi- net or adequately performing the required ma- BP 3.0 SETTINGS: neuvers (ie, panting against a closed shutter); 3.1 Pulmonary function laboratories 5.2 claustrophobia that may be aggravated by 3.2 Cardiopulmonary laboratories entering the plethysmograph cabinet; 3.3 Clinics and physician’s offices 5.3 presence of devices or other conditions, such as continuous intravenous infusions with BP 4.0 INDICATIONS: pumps or other equipment that will not fit into Body plethysmographic determination of VTG, the plethysmograph, that should not be discon- Raw, and sGaw may be indicated: tinued, or that might interfere with pressure 506 RESPIRATORY CARE • MAY 2001 VOL 46 NO 5 AARC GUIDELINE: BODY PLETHYSMOGRAPHY: 2001 REVISION & UPDATE changes (eg, chest tube, transtracheal O2 lished laboratory procedure.22,23 catheter, or ruptured eardrum); 7.5 Excessive abdominal gas or panting tech- 5.4 continuous oxygen therapy that should not niques that employ accessory muscles may in- be temporarily discontinued. crease the measured VTG, due to compression effects.24 BP 6.0 HAZARDS/COMPLICATIONS: 7.6 Plethysmography is a complex test. Careful 6.1 VTG and Raw measurements require the calibration of multiple transducers is required. subject to pant against a closed shutter; improp- Attention to frequency response, thermal stabil- er panting technique may result in excessive in- ity, and leaks is necessary.25 trathoracic pressures. 7.7 Choice and application of reference values 6.2 Prolonged confinement in the plethysmo- affect interpretation. Reference values for VTG graph chamber could result in hypercapnia or using plethysmographically determined lung hypoxia; however, because of the limited volumes are not widely available. length of the test and the fact that the plethys- 7.7.1 Make a tentative selection from mograph must be vented periodically, this is an whatever published reference values are uncommon occurrence. available. The characteristics of the 6.3 Transmission of infection is possible via healthy reference population should improperly cleaned equipment (ie, mouth- match the study group with respect to age, pieces) or as a consequence of the inadvertent body size, gender, and race. The equip- spread of droplet nuclei or body fluids (patient- ment, techniques, and measurement con- to-patient or patient-to-technologist). ditions should be similar. 7.7.2 Following selection of seemingly BP 7.0 LIMITATIONS OF METHODOLOGY/ appropriate reference values, compare VALIDATION OF RESULTS: measurements obtained from a represen- Limitations of the body plethysmograph in mea- tative sample of healthy individuals (10- surement of VTG, Raw, and sGaw include but are 20 subjects, over an appropriate age not limited to: range) to the predicted values obtained 7.1 overestimation of VTG in subjects with se- from the selected reference values. If an vere obstruction or induced bronchospasm un- appreciable number of the sample fall out- less a slow ‘panting’ speed (ie, approximately 1 side of the normal range, more appropri- 14-17 cycle/s) is maintained. ate reference values should be sought. 7.2 Erroneous measurement of VTG, Raw, or This procedure detects only relatively sGaw due to improper panting technique. Ex- gross differences between sample and ref- cessive pressure fluctuations or signal drift dur- erence populations.26 ing panting may invalidate VTG, Raw, or 18 sGaw. BP 8.0 ASSESSMENT OF NEED: 7.3 Nonpanting measurements RETIREDhave been sug- 8.1 See Section 4.0 Indications. gested for use in children or others who have 8.2 Protocols may define the need for measure- difficulty mastering the panting maneuver.19,20 ment of lung volumes and airway resistance Nonpanting maneuvers in plethysmographs measurements based on the results of previous- with built-in thermal leaks may invalidate VTG ly performed tests (ie, spirometry, diffusing ca- 2,21 or Raw measurements. pacity) and the clinical question to be an- 7.4 Computer-determined slopes of either VTG swered. or Raw tangents may be inaccurate. Many sys- tems calculate the slopes using a best-fit regres- BP 9.0 ASSESSMENT OF QUALITY & VALI- sion analysis. This technique may produce DATION OF RESULTS: widely varying results if extraneous data points The consensus of the Committee is that all diagnos- are included (due to improper panting or exces- tic procedures should follow the quality model de- sive signal drift). All slopes should be visually scribed in the NCCLS GP26-A A Quality System inspected and adjusted according to an estab- Model for Health Care.27 (Fig. 1) The document de- RESPIRATORY CARE • MAY 2001 VOL 46 NO 5 507 AARC GUIDELINE: BODY PLETHYSMOGRAPHY: 2001 REVISION & UPDATE scribes a laboratory path of workflow model that in- 9.1.3 Documentation of results, therapeutic corporates all the steps of the procedure. This pro- intervention (or lack of) and/or clinical de- cess begins with patient assessment and the genera- cisions based on the testing should be tion of a clinical indication for testing through the placed in the patient’s medical record. application of the test results to patient care. The 9.1.4 The type of medications, dose, and quality system essentials defined for all health care time taken prior to testing and the results services provide the framework for managing the of the pretest assessment should be docu- path of workflow. A continuation of this model for mented. respiratory care services is further described in 9.1.5 Report of test results should contain NCCLS HS4-A A Quality System Model for Res- a statement by the technician performing piratory Care.28 In both quality models the patient is the test regarding test quality (including the central focus. patient understanding of directions and ef- Pulmonary Diagnostics Path of Workflow Pretest Testing Session Post-test Quality Patient Assessment Patient Training Results Report Test Request Test Performance Interpretation System Patient Preparation Results Review and Selection Clinical Consult Essentials Equipment Preparation Patient Assessment for Further Testing Organization Personnel Information Management Equipment Information System Purchasing/ Inventory Process control Documents/ Records Occurence management Quality system essentials Internal apply to all operations assessment in the path of workflow Process improvement Service and Satisfaction Fig. 1. Structure for a Quality SystemRETIRED Model for a Pulmonary Diagnostics Service (From Reference 27, with permission) 9.1 General consideration include: 9.1.1 As part of any quality assurance pro- fort expended) and, if appropriate, which 29-31 gram, indicators must be developed to recommendations were not met. monitor areas addressed in the path of 9.1.6 Test results should be interpreted by workflow. a physician, taking into consideration the 9.1.2 Each laboratory should standardize clinical question to be answered. procedures and demonstrate intertechnol- 9.1.7 Personnel who do not meet annual ogist reliability. Test results can be con- competency requirements or whose com- sidered valid only if they are derived ac- petency is deemed unacceptable as docu- cording to and conform to established lab- mented in an occurrence report should not oratory quality control, quality assurance, be allowed to participate, until they have and monitoring protocols. received remedial instruction and have 508 RESPIRATORY CARE • MAY 2001 VOL 46 NO 5 AARC GUIDELINE: BODY PLETHYSMOGRAPHY: 2001 REVISION & UPDATE been re-evaluated.
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