D - Pulmonary Diagnostic Testing

PULMONARY DIAGNOSTIC
TESTING
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SECTION
D
PULMONARY DIAGNOSTIC TESTING
CONTENT OUTLINE:
l.
ll.
lll.
Arterial Blood Gases

Pulmonary Function Testing
Bronchoscopy
D-3

t.
Arterial Blood Gases (ABG)
A.
The exam will cover six (6) areas.
1.
ABG sampling.
2. Equipment.
3. Venous sampling.
4. ABG calculations - CaOz, PAO2, A-aDOz, C(a-v)Oz, etc.
5.
6.
B.
,r)
Interpretation and Management - Relating blood gas values to life functions.
Acid base status.
Blood Gas Sampling
1.
2.
3.
- puncture of a p54p[s1a!-g!!g]y to obtain an arterial blood sample for direct

measurement of pH, PaCOz, PaOz.
Arterial puncture
lndications.
Evaluation of the adequacy of a patient's ventilation (PaCOz), oxygenation (PaO2), and/or acid
base status (pH).
Assess
the need for therapeutic intervention (i.e. oxygen therapy, mechanical ventilation, etc.)
b.
and/or diagnostic evaluation (i.e. exercise desaturation).
c. Monitor the severity and progression of a documented disease process.
a.
There are three primary sites for obtaining an arterial blood gas:
a.
b.
c.
4.
Radial.
Brachial.
Femoral.
Capillary_,s_alples and heel sticks can also be used to obtain blood gas samples in infants.
The site must be arterialized by wrapping it in a wet, warm cloth at 45" C fol S*.-l-.nng]9,s.
a,
b.
d
e.
The heel is cleansed with alcohol and a lancet is used for the puncture and is done deep
enough to allow for free-flowing blood.
Results will show a consistent correlation with arterial pH, and PCO2.
Capllleryggps should NOT be used to monitor oxygen therapy. A9l9f olygen-leuels-meybe
in caprllary
capillary sample.
effi-erfrEher or lower than what is measured rn
dil|1gltqfrjr
pO2
correlate very well with actual a49,1_4_plgd. This is especially true when
valuesro
the arter-ial PO2 is above 60 torr.
\*
i'i.
D-4
5.
Umbilical arterial lines are used for newborn babies.

a' A catheter is inserted into the umbilical artery at the cut end of the umbilical cord. The safest
place forlhe tip of the umbilical arterial catheter is at L-3,
wrricn i{aooveln" iiiur""tion
of the
L
aorta'butlbelow the renal arteries.
*
b.
c'
U'niridii arte'vFO; ma-f6e

tSqg.1ggsFAFQ2
Differences between qre-and post ductal Po2 indicate right to left shunting
across the ductus
i'' rtt- i>.
d.
3$.erioglfs.
-)-
Advantages of umbilical artery catheter (UAC).

1) Allows continuous monitoring of blood pressure.
2) Arterial samples for ABG and other lab analysis.
3)
Blood replacement(transfusions).
6.
Obtain blood from an arterial or pulmonary artery line:

Withdraw ftuid and blood from tubing before sampling by
means of a stopcock in which a discard syringe is useO io
aspi rate the fl u id/blood m ixtu re (approxi m ately 3-__. 5
L)
.m
before obtaining the blood sample.
Then draw arteriar brood_gas sampre with pp-heparilized
a.
b.
syringe.
c.
d.
f,
'
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Catheters can be inserted into the radial, brachial, or femoral

artery to provide continuous monitoring of brood pressure ano
access for arterial blood sampling.
Procedure.
1) Catheter-over-needle is inserted into artery.

2) Position inside vesset confirmed by ogpgryllg ltgglr ql-Ul^qod in hub of needte.
3) Needle is removed, leaving catheter in place.
4) Catheter is sutured in place.
5) Continuous flush device keeps line open by providing continuous flow of heparinized
solution.
D-5
PU
f.
g.
LMONARY DIAGNOSTIC TESTING
Transducer is used to convert pressure (analog signal) to an electricalsignal (digital signal)

which is measured, displayed and recorded by a monitor.
Transducer should be level with the catheter for accurate measurement of pressure.
1)
2)
lf trangducer is above catheter, displayed pressure is lgwer than actual.

lf transducer is below catheter, displayed pressure is higher tnan Z":tual.
Sampling technique.
1) Withdraw approximately 3 - 5 mL of fluid from catheter and discard (waste solution).
2) Attach blood gas syringe to sampling port and collect blood sample.
3)
h.
Close stopcock and flush catheter and tubing.

Complications.
1) Thrombosis/Embolism.
2) Bleeding.
3) Infection.
4) Hematoma.
5) ArterialSpasm.
D-6
.i

7.
The radial artery is the first choice in most patients because of its accessibility and collateral blood
flow.
a.
b.
B.
9.
The brachial artery is an appropriate alternative site.

The femoral artery is llg,qgt Jlrggg
The Modified Allen's Test is used to assess the collateral circulation in the hand prior to drawing a
radialABG.
A positive Modified Allen's Test confirms that collateral blood flow is present.
a.
b.
c.
rhe hand should pink
up within 1_- 2
lf it does not - use another site.
sg9ol9" ?l9l l9]9T'lq
th_e_yl1ai artgry
Never attempt arterial punctures on patients with an indwelling dialysis shunt (Radial or
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10. Sampling Hazards and Problems.
a.
b.
c.
d.
e.
f.
g.
Disruption of blood flow
hematoma.
Clotting.
Bleeding - Hold pressure on site minimum 5 min.
Vessel Spasm.
Tissue trauma - muscles, bone, nerves.
Anticoagulant therapy - Apply pressure to site longer.
PaCOz decreases toward 0 torr.

PaOz increases or decreases towards 150 torr.
increases. ;1.', 4 ?ar-N,-
Air bubbles:
pH
h.
increases. T"
lmproper cootingr
(sample not
'
;;-*-(tJ
PaO2 decreases.
iced)
-PaCoz
pH decreases.
Too much heparin:
*" pH
decreases towards 7.0.
PaCOz decreases towards 0.

PaOz increases towards room air (150 torr).
D-7
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C.
Blood Gas Analyzers
1.
Directly measure only the following:
a.
PCO2 - Partial pressure of carbon dioxide in sample.
(Severinghaus electrode).
b. POz - Partial pressure of oxygen in sample.

c. pH
2.
3.
4.
(Clark electrode).
- Acid Base Status.
(Sanz Electrode).
All other values are calculated (SaO2, HCO3- etc.).

Calibration.
a.
Calibration is performed by inserting solutions or gases with known values (one low value and
one high value).
b.
c.
The machine readings are then calibrated to these known values.

Low calibration gas levels and insufficient buffer solution would affect auto-calibration.
Quality control.
a.
b.
Commercially prepared controls.

Methodology.
1) Plotting of control runs.

a) Three levels of controls are commonly
i. Acidotic (pH, PCO2, PO).
ii. Normal(pH, PCO2, PO2).
iii.
used:
Alkalotic (pH, PCO2, PO2).
b) Each level is run at least once per day and the values are plotted on a graph.
c) After 20 to 30 consecutive values are plotted for each level, the information is
2)
evaluated to assess the operation of the analyzer.

Analysis of Data (Levey - Jennings Charts).
a)
For detecting a machine that is out-of-control, the
standard deviation (SD) range is
used.
b)
c)
Values should remain within 2 standard deviations t SD of the mean 1X).

The following graphs illustrate different situations that exist based on the reported
control values:
i.
ii.
ln Control situation - all the values are within 2 standard deviations of the mean.
Random Error situation - only 1 point falls outside the t 2 standard deviation
range.
iii.
iv.
v.
Trend situation - values are progressively increasing or decreasing, but stilt in the
acceptable t 2 standard deviation range.
Shift situation - The plotted points all fall within the t 2 standard deviation range,
but the mean value has shifted from where it was at the onset of data
accumulation.
Out of Control situation - steadily increasing or decreasing trend that is moving
outside the t standard deviation range. This indicates that the electrode needs to
be replaced.
D-8
e+2
IN CONTROL
+2
Mean
-2
RANDOM ERROR
+2
TREND
OUT OF CONTROL
D-9
5.
Other Methods.
a.
ProficiencyTesting.
1) Unknown control samples
are sent to different laboratories using the same brand and
model of analyzer.
2)
b.
1)
2)
c.
Laboratories that have more than one blood gas analyzer can run patient samples on two
:.
or more machines to compare the results.
lf significant differences occur between machines, the cause of the discrepancy should be
investigated.
Gas Exchange Validation Device
1)
2)
3)
6.
The analysis of the data then allows labs to compare their results to other labs.
Multiple machine analysis.
Tonometry.
Tonometer - a device that allows precision gas mixtures to be equilibrated with whole
blood or a buffer solution. After an equilibration period, the sample is transferred to a
blood gas analyzer.
Expected gas tensions (torr) are calculated from the fractional concentration (F1O2 and
FrCO2) of the precision gas.
Method of choice for precise control of the POz electrode.
Point of Care Testing.
a.
b.
c.
d.
Any type of monitoring done at the bedside (pulse oximetry, blood glucose, arterial blood gas,
hematocrit, serum electrolytes, etc.).
Monitoring at the bedside reduces turnaround time.
Results are comparable with actual lab testing.
Point of care testing for arterial blood gas analysis.
1) Portable battery powered devices.
2) Analysis is done with a disposable cartridge that contains calibration

3) Results are ready within 90 seconds.
e.
f.
7
Can also measure chemistry, hematology, electrolytes, glucose, BUN, and clotting factors.
Are subject to same quality control procedures as lab-based measurement devices.
Venipuncture/Phlebotomy.
a.
b.
8.
solutions.
Venipuncture is performed to provide vascular access for continuous infusion or for blood
sampling for laboratory analysis.
1) The antecubital vein located anterior to the elbow is usually the largest and easiest to use.
Venous blood samples are used for most blood tests (Hb, Hct, RBC, WBC, BUN,
electrolytes, etc.).
lntravenousinfusion.
a.
b.
Used to administer medications, blood or blood products, and supplemental nutrition and fluids
continuously to the patient.
lntravenous infusion can be performed through any central vein, such as the femoral, jugular,
or subclavian vessel.
1) Peripheral vessels in the hand or arm are most commonly used.
D-10
D.
Calculations
1.
PAO2 : Alveolar Air Equation (Alveolar PO2).
a.
b.
c.
Calculates the partial pressure of oxygen (POz) in the alveoli.
FORMULA: PAO2 = (Pe
Pnzo) FrOz
- PaCOr
(R= 0.8)
Example: Calculate the PAO2 for a patient on 50% oxygen with a PaCO2 of 40 torr and a
barometric pressure of 747 torr.
Answer
PAO2 = (Pe
PHzo) FrOz
PaCOr
.8
. PAO2=947-47).50-40
.8
x.50) - 50
PAO2= 350-50
PAO2 = 300 torr
PAO2 = (700
d.
2.
Normal value varies directly with patient's
F1O2
and
PB.
A-aDO2 : The A-a Gradient.
a.
b.
c.
d.
e.
Measures the difference (gradient) between alveolar and arterial PO2.

Therapy to improve distribution of ventilation can be evaluated by the A-aDO2 (IPPB, Incentive
Spirometry, P&D, etc.).
Best done after the patient has been on 100% O2for 20 minutes or more.
FORMULA: A-aDOz = PAOz -PaOz.

Example: What would the A-a gradient be for the patient above if the PaO2 was B0 torr?
Answer:
A-aDOz=PAOz-PaOz
A-aDOz
f.
300 mm Hg
80 mm Hg =220 mm
Hg
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Interpretation:
r, l
g.
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25-65 mm Hg on 100%
Normalvalue
66 - 300 mm Hg
V/Q mismatch
> 300 mm Hg
Shunting
Normal value varies directly with patient's
D-11
F1O2.
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3.
CaO2: Arterial Oxygen Content.
a.
b.
c.
d.
Best measurement of oxygen delivered to the tissues, or the best index of oxygen transport.
Estimates the oxygen carried UV tfre fremoglo-ffis wett as that dissolved in the plasma.
FORMULA: CaO, = (Hb x 1.34 x SaO2) + (PaO2 x .003).
Oxygen in RBG Oxygen in Plasma

Example: Calculate the CaOz for a patient whose SaOz is g8%, PaO2 is 90, torr
and Hb is '14 g/100 mL blood.
Answer:
CaO2 = (Hb x1.34 x SaO2)+ (PaO2 x.003)
CaO, = (14 x 1.34 x SaO2) + (90 x .003)
CaO, = (18.76 x.98 ) + (.27)
CaO2= (18.38) + (.27)
Ir. , , ;
CaOt=18'65vol% / a j
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e. Normal value !,; 2pyol o/o.(T!/.9L):
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Cvo2 (mixed venous oxygen content).
a. Total amount of oxygen carried in the mixed venous blood.
b. Measured in mL O2l100 mL blood (vol%).
c. Calculated using the same formula as the CaO2 except for using mixed venous POz and
1:
4.
saturation. (PvO2 and SvO2).
d.
The blood is drawn from the Pulmonarv Artery via the balloontip, flow-directed (Swan-Ganz)
catheter.
e.
f.
g.
h.
5.
FORMULA:CvO2 = (Hb x 1.34 xSvO2) + (PvOz x .003).

Normal value = 14 volo/o (12 - 16 vol%).
CvO2 values will decie-aG-e wrren iJiOiac output deglqases
SvO2 values also decrease when cardiac output decreases.
C(a-v)O2 (arterial-venous oxygen content
ifference).
a.
b.
c.
d.
e.
The CvO2 is subtracted from the CaO2.
f.
C(a-v)O2 difference will increase when the CvOz is decreasing and would indicate a decreasing
Cardiac output.
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Measures the oxygen consumption of the tissues.

FORMULA: C(a-v)Oz = CaOz - CvOz.
Normalvalue = !:*?_Wl%.
Used in the Fick equation to calculate cardiac output (L/min.) or oxygen consumption
(mL/min.). See Cardjac Output Calculation.
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D-12
.t.-:

PaO2lF1O2 ratio or P/F ratio.
a.
Ratio of the partial pressure of arterial oxygen to the inspired fractional concentration of oxygen
(Pa02/F1O2).
b.
c.
d.
e.
f.
7.
Used in determination of acute lung injury (ALl) or acute respiratory distress syndrome
(ARDS).
Measures the efficiency of oxygen transfer across the

Normal value is 380 torr or greiGn
lung. '/ tt'
,+i
A ratio less than S00"1orr ffnities nll.

A ratio less than 200 torr signifies ARDS.
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Qr (cardiac output).
a.
b.
The modified Fick equation is used to calculate cardiac output when 02 consumption (VO2)
and 02 content difference are known (Ca-vO2).
I
FoRMULA: Qr
vO"c(a-v)oz (10)
'.!,''i
t.lu':
/ li-',it'",,,,r
tv
Qlu't
li.r,,
,.,
VOz
c.
= oxygen consumption in ml/min.

C(a-v)O2 = is in vol%'
Qr
= liters/min.
Example: Calculate the Qr for a patient with an 02 consumption of 250 ml/min.

and C(a-v)O2 of
Answer: d,
S*v_ol%.
VorC(a-v)Oz (10)
=
5
250
(10)
250
50
d.
e.
g Liters per min. (L/min.).
Normalvalue = L9_14ru1
Rearranging the formula will allow calculation of 02 consumption.
VOz=QrxC(a-v)O2x10.
f.
Example: What would the Oz consumption be when the Qr is 6 L/min. and the C(a-v)Oz
is 5 vol%?
Answer:
VOz
6x5x10
30
10
300 mL/min.
D-13
B. Qg/Q1
(shunt equation).
a.
The portion of the cardiac output (Qr) that is shunted (Qs).
b.
FORMULA: Qs/Qr
c.
Method: Arterial and mixed venous blood gases are drawn and analyzed to determine the
d.
A-aDOz and C(a-v)O2.

Example: Calculate the % shunt when A-aDO2 is 300 torr and the C(a-v)O2 is 3.6 vol%.
Answer: Qs/Qr
(A-aDOz) (.003)
(A-aDOz) .003 + C(a-v)O2
(A-aDOr) (.003)
(A-aDO2) .003 + C(a-v)O2
(300) (.003)
(300) .003 + 3.6
=
=
=
0.9
0.9 + 3.6
e.
9.
0.9
4,5
0.20 or 20% shunt
Normalvalue = 3-5To.
SaO2 (arterial oxygen saturation).
a.
b.
c.
d.
e.
The percentage of the hemoglobin that is bound by oxygen.

The SaOz value routinely reported by a blood gas analyzer is calculated.
Actual saturation can be measured using an oximeter or co-oximeter.
Large differences between the calculated and measured values may be due to elevated
carbon monoxide (COHb) levels.
The PaOz value can be estimated by subtracting pO from the SaOz.

1 ._,
PaOz
SaOz
40
50
60
70
80
90
-,
0. Temperature corrections.
a. Blood gases are routinely reported at 37 oC (normal body temperature).
b. lf the patient has an abnormal temperature, corrections should be made.
c. lf the qlglyzer temperature (37 "C) is Loqer than body temperature (patient has a fever),
the results displayed or measured by the ABG machine will be:
Lower PaCOz, PaO2 and Hiqher pH, than the actual (corrected) results.
d. lf the analyzer temperature (37 oC; is Hiqher than body temperature (patient is hypothermic),
the results displayed or measured by the ABG rnachine will be:
Hiqher PaCOz, PaOz and Lower pH, than the actual (corrected) results.
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fft
D-14
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r''''

11. VDNr (Deadspace to Tidal Volume Ratio).
a. The percentage of the tidal volume that is deadspace (does not participate in gas exchange)
b.
c.
Ventilation without perfusion.

Normal value = 20 - 40% (up to 60% for ventilator patients).
FORMULA: PaCOr
pECOz_x 100
PaCOz
d.
A
f.
The PECO2 is the average PCO2 of the exhaled air that can be measured by a capnograph.
An increase in the VpA/1 ratio indicates a deadspace producing disease (pulmonary embolus).
Example: Calculate the VpAft ratio for a patient who has a PaCO2 of 40 torr and a pECO2 of
30 torr.
g.
Answer: VoA/r
PaCO^
- PECOz x
100
PaC02
VoA/r=-Tx100
VoA/r=10x100
40
VoA/r
h.
= .25 or 25o/o
lf VDA/r Ratio and V1 are known, Ve can be calculated.
1)
FORMULA: VpA/1 x Vr = Vo.

a) Example: At a set V1 of 800 mL and a VoA/r ratio of 2so/o, what is the Vp?
b)
Answer: Ve
= .25 x 800 mL =
200 mLV^
12. Desired Minute Volume.

a. Used to determine what minute volume setting will deliver a desired PaCOr.
b.
c.
FORMULA: (current Vs x current Paco2) = (desired Vs x desired paco2).

Example: With a minute volume of B L/min., the patient has a PaCOz of 50 torr. What minute
volume is required to achieve a PaCO2 of 40 torr?
Answer: (current Vs x current PaCO2) = (actual
(S.0x50)=(VEx40)
(400)=(VEx40)
Ve = 400 = 10 L/min.
40
D-15
VE x
actual paCO2)
PU
13. Desired PaO2.
a.
b.
Used to determine the FrOz required to obtain a desired PaO2 level.

FORMULA: FlOz x Desired PaOu
Current PaOz
c.
Example: A patient's PaO2 value is 60 torr on 40o/o oxygen. The physician would like to
increase the patient's PaO2 level to 90 torr. What FrOz would be necessary to achieve this?
Answer: FlQ2x Desired PaOz

Current PaOz
0.40 x 90
60
36
60
.60 or 60%
D-16
PU
E.
Interpretation and Management
1.
NORMALVALUES.
Parameter
NormalArterial
NormalVenous
PC02
40 torr
35 - 45
torr
46 torr
Poz
97 torr
80 - 100
torr
40 torr
pH
7.40
7.35 -7.45
7.35
SOz
98%
95-100%
70-75%
24 mEqlL
22-26 mEqlL
24 mEqlL
BE
0 mEq/L
-2 - +2 mEq/L
0 mEq/L
Hb
14g
12-16 g
20Volo/o
17-20Vd%
HC03-
CaO2
CvO2
2.
Acceptable
Ranoe
12
16Vol%
'14g
15 Vol%
RELATING BLOOD GAS VALUES TO LIFE FUNCTIONS.

a. VENTILATION - PaCOz - Best reflects sufficient or adequate ventilation.
PaCOz VALUE
INTERPRETATION
35 - 45 torr
Normal Ventilation
ABOVE 45
Patient NOT Ventilating
BELOW 35
Patient lS Venlilating but

is ventilating too much.
b.
RESPONSE
DON'T CHANGE VENTILATION
DON'T PUT ON VENTILATOR
INITIATE VENTILATION oT
REMOVE/DECREASE DEADSPACE oT
INCREASE CURRENT VENTILATION
DON'T PUT ON MECHANICAL VENTILATION
ADD DEADSPACE (if PaO2 acceptabte), or
DECREASE VENTILATION (if PaO2 is high ),
or look for other causes of hyperventilation
(hypoxemia, metabolic acidosis, etc.)
Abnormal PCOz with normal pH: don't change ventilation (chronic patient, COPD).
D-17
c.
OXYGENATION
PaOz VALUE
B0 - 100 torr
F'O,
BELOW 80
(Hypoxemia)
.21 - .59
.21
- PaOz,FtOz.
INTERPRETATION
Normal Oxygenation
RESPONSE
MAINTAIN SETTINGS,
CHECK SaOz & Hb
HYPOXEMIA due to:

1. Poor Ventilation (high PaCOz)
2. V-Q Mismatch (normal or low
INCREASE VENTILATION
INCREASE F1O2 up to 0.60
PaCO,)
.60 +
BELOW 80
(Hypoxemia)
ABOVE
.22 - 1.0
1OO
START or increase CPAP or

PEEP.
CPAP: Patient is breathing
spontaneously
PEEP: Patient on ventilator
DECREASE FIO2,
PEEP. or CPAP.
3. Shunting
Refractory hypoxemia
Venous admixture
Over Oxygenation
(Hvperoxemia)
d.
e.
F.
Decrease the FrOz first if at or above .60. Once the FrOz is below .60, then reduce
PEEP/CPAP.
lt would also be safe to decrease the ventilation if it is excessive (low PaCO2).
ACID BASE STATUS
1.
There are three steps to acid - base interpretation.
a.
b.
ACIDOSIS vs. ALKALOSIS.
INTERPRETATION
7.35 -7,45
Below 7.35
Acceptable ranoe - compensated

ACIDOSIS - non-compensated
(due to increased COz or low HCOa-)
Above 7.45
ALKALOSIS - uncompensated
(due to increased HCO3-or low COz)
COMPENSATED vs. NON-COMPENSATED (Chronic vs. Acute).
1)
When the pH is inside the acceptable ranse (7.35 - 7.45) then
ilis
Compensated or
Chronic.
2) When lhe pH is outside the acceptable

pH
pH
<
>
7.35
7.45
=
=
D-18
ranqe then it is Non-Compensated or Acute.
Non - Compensated Acidosis.

Non- Compensated Alkalosis.
c.
RESPIRATORY vs. METABOLIC.
1)
A Respiratorv Acidosis or Alkalosis is the diagnosis when the pH is abnormal because of

a change in the PGOa.
a)
Example: A 56 year old woman in respiratory distress.
pH
(acidosis, non-compensated).
PaGO2
(increased, hypoventilation).
7.31
52torr
PaOz 58 torr
HGO3- 25 mEq/L
b)
(decreased, hypoxemia).
(normal range).
i.
Diagnosis: Non-compensated Respiratory Acidosis with hypoxemia (Acute

Ventilatory Failure).
ii.
Treatment: Assisf ventilation.
Example: An
1B year old patient with
pH
7.54
PaGO2 24torr
PaOz 61 torr
HCOs-22 mEq/L
i.
ii.
asthma in respiratory distress.
(alkalosis, non-compensated).
(decreased, hyperventilation).
(normal range).
Diagnosis: Non-compensated Respiratory Alkalosis with hypoxemia (Acute

Alveolar Hyperventilation With Hypoxemia).
Treatment: Oxygen for hypoxemia.
2) A Metabolic Acidosis or Alkalosis is the diagnosis
when the pH is abnormal because of a
change in the HCOa-.
a)
Example: A32year old patient with diabetes who is tachypneic and hyperpneic.
pH
7.28
PaCOz 35 torr
PaOz 88 torr
HCO3- 16 mEq/L
i.
ii.
b)
(acidosis, non-compensated).
(normal range).
(normal range).
(low, acidosis).
Diagnosis: Non-compensated MetabolicAcrdosls (Diabetic Ketoacidosis).

Treatment: Sodium bicarbonate for acidosis. lnsulin to control diabetes.
Example: A 30 year old man who has been sick and vomiting for the past 2 days.
pH
7.54
PaGOz 44torr
PaOz 71torr
HCO3- 41 mEq/L
(alkalosis, non-compensated).
(normalrange).
(high, alkalosis).
i.
Diagnosls: Non - compensated Metabolic Alkalosis (Loss of metabolic acids,
ii.
dehydration, electrolyte imbalance).

Treatment: Administer potassium chloride (KCI) and oxygen.
D-19
d.
PARTIALLY COMPENSATED AND MIXED BLOOD GASES.

1. A partial compensation occurs when the pH is out of normal range and both CO2 and
HCO3-are changing in the same direction.
a)
Example:
pH
7.30
(acidotic).
(high).
(high).
PaCO2 60 torr
HCO3- 29 mEq/L
i.
b)
Partially Compensated RespiratoryAcrdosls.
Example:
pH
7.50
PaGO2 50 torr
HGO3- 40 mEq/L
i.
(alkalosis).
(high).
(high).
Paftially Compensated Metabolic Alkalosis.
2) A mixed (combined)
respiratory and metabolic imbalance occurs when both CO2 and

HCO3-contribute to the problem.
a)
Example:
pH
(alkalotic).
7.54
(low).
PCO2 31 torr
HCO3- 29 mEq/L (high).
i. Respiratory and Metabolic Alkalosis.
e.
ADDITIONALCONSIDERATIONS.
1) Normal room air ABG can be evaluated by adding the PaOz and PaCOz. The total should
be between 1 10 - 140 torr.
2) Lower values may indicate V/Q mismatch, diffusion defect, shunting or venous blood.
3) Higher values (> 140) would indicate supplemental oxygen in use, bubble in sample, or
4)
technical error.
Normal ABG values for a newborn are slightly acidotic:
a) pH should be > 7.30.
b) PaCOz should be < 50 torr.
c)
PaO2 should be > 60 torr.
D-20
f.
SPECIAL PATHOLOGIES (Exceptions to the rule).

1. Some patients will have ABG results that do not match their clinical appearance. There
are two different types.
a) Type #1 - ABG looks good / Patient looks & feels bac.
b)
Type#2 - ABG looks bad / Patient looks & feels fine.
2.
CO Poisoning - Saturation of Hb with carbon monoxide (Type #1).

a) Normal looking ABG is misleading since SaOz is calculated.
b) Must first suspect carbon monoxide poisoning, then measure CO Hb with
CO-oximeter.
c) Suspect smoke inhalation victims. (firemen, people pulled from burning buildings or
running cars, etc.).
d) TREATMENT is 100% oxygen and Hyperbaric oxygen therapy.
3)
Anemia - Low hemoglobin content (Type #1).

a) NormalABG can be misleading if PaO2 and SaO2 are normal. Watch for low Hb (<12 g).
b) Occurs in post-op patients, trauma victims.
c) Patient may be hypoxic (PVC, tachycardia, distress), but not cyanotic.
d) TREATMENT is to restore normal Hb levels. Give oxygen to support patient until
transfusion is completed.
4)
Pulmonary Embolus - Increased deadspace (Type #1).

a) Suspect pulmonary embolus in:
i. Post-op patients.
ii. Bedridden patients.
iii. History of deep vein thrombosis (DVT).
iv. Woman in advanced sfages of pregnancy.
v. Venous sfasis (srffing for long periods of time).
vi.
Obesity.
vii.
Varicose veins.
viii. Trauma.
ix. Atrial fibrillation.
b)
c)
d)
e)
Diagnosis is made by bedside assessment and an ABG (VDA/r is increased).

Bedside assessment shows hyperpnea (increased rate and depth of ventilation).
Patient appears to be hyperventilating but is not (dyspneic, diaphoretic, chest pain,
occurs all of a sudden).
Blood gas reveals normalvalue (no hyperventilation).
TREATMENT is: Prevention. Support ventilation, prevent further emboli with
anticoagulant therapy.
D-21
5)
COPD - Chronic Obstructive Lung Disease. (Type #2).

a) ABG shows Compensated (CHRONIC) respiratory acidosis with hypoxemia (low
PaOz).
pH
7.36
PaOz
62torr HCOs-
58 torr
36 m
b) Oxygen induced hypoventilation
can result when COPD patients are given too much

oxygen. Patients will become tired, sleepy, lethargic, and then unresponsive.
EXAMPLE: A patient on 40% Venturi mask has the following arterial blood gas results:
pH
PaCOz
7.30
PaOz
B0 torr
HCO"-
ventilating?
ls the patient oxygenating?
ls the pH normal?
ls the HCO3- low, normalor high?
ls the patient
B0 tor
38 m
YES_
YES X
YES_
NO X
NO_
NO X
LOW_ NORMAL_
HIGH X
Can a patient raise their PCO2

in a matter of
seconds?
YES
NO
Can a patient raise their HCO3in a matter of
c)
d)
e)
0
seconds?
YES_
NO X
At first glance this blood gas looks like acute respiratory failure, ( T CO, and J pH).
However, closer examination shows some oddities, mainly the high PO2
Most patients that hypoventilate will not oxygenate either. Also, a patient with a PCO2 of B0
would have a pH much lower than 7.30 unless it had been compensated with an increased
HCO3- (indicating CHRONIC).
So what we have here is a COPD patient in acute respiratory failure due to too much
oxygen (loss of Hypoxic drive).
The solution is not mechanical ventilation but instead you should turn down or decrease
the
F1O2.
D-22

g.
02 - Hb Dissociation Curve.
1) Shift to the left (increased oxygen affinity) means there will be a higher oxygen content for
any given PO2.
2)
Shift to the right (decreased oxygen affinity) means there will be a lower oxygen content at
any given PO2.
s
o
E
N
U)
20 30 40 50 60 70 80 90 100
P"O, (mmHg)
SHIFT TO LEFT
(increased affinitv)
H*(T pH)
+ Pco2
'l'
+
SHIFT TO RIGHT
(decreased affinitv)
H*
(J pH)
T pco,
feUPennTURE
2-3 DPG
T z-s opc
3) P - 50 is the method of expressing

Normal
Riqht shift
Left shift
rrvpeRRTURE
the position of the curve.
27 torr
> 27 torr
< 27 torr
D-23
Decreased affinitv
Increased affinitv
ll.
Pulmonary Function Testing

A.
The exam will cover three (3) areas of pulmonary function
tegtlng:
I
1. Pulmonary Function Equipment.

2. Testing: Methods and Procedures.
3. Evaluation: Interpretation and Assessment.
B.
specific questions will deal
1.
with:
When to recommend Pulmonary Function Testing"
I
I
,,
'' h l" If
!
,*
,..
I
I
\,: !r"-L' 'i'tr

2. How to instruct the patient and evaluate his/her performance \ tr ' , ':-'i
:.; '- *
'-; \'J
i
3. Whatthe differenttests are (SVC, FVC, MW, DL6e, etc.).
I
4. What each test measures (volumes, flows, diffusion, etc').
I
5. How to interpret the results (restrictive or obstructive).
I
6. The type of pulmonary function disorder (pathology).
I
Uses
and
Indications
Testing:
Function
Pulmonary
I
1. pulmonary function testing is indicated any time that an assessment of the respiratory system is
I
required or desired.
I
the:
evaluate
2. Specifically, PFT will
a)
c.
:.
ilffir:$M::"':",*r:;F51
II
I
I
I
I
I
I
I
I
I
I
I
I
D-24
|
I
D.
PULMONARY D|AGNOSTIC TESTING

"'t 'i ' i
Pulmonary Function Equipment ?o' ]-'ri lE '-1r
1.
Spirometers (Positive displacement -
a.
i
I
i ir ' -
volume).
Several types of spirometers are used to measure volumes and flow

1) D_ry-pll!rc seal (horizontal piston) - measures volume and time.
._\,,L
rates. \ i, ,.._ ," ,,
2)
Water-seal (Collins, Stead-Wells) - measures volume and time.

a) Water-sealed spirometers (Collins) still remain the most accurate.---and are the best
machine to use to check the accuracy of other PFT equi[rnent.
3)
Electronic Spirometer.
Used with permission of CareFusion
D-25

Pneumotachometers (Flow).
z.
I
ia.
Turbine device (Wright respirometer) - measures flow, and may display volume.
ilr<o,..,
b.
Pressure Differential (Fleisch) pneumotachometer
measures flow.
1) Can be used to continuously measure (V s) minute ventilation.

Pneumotachs are not accurate at very low flows or very high flows.
3.
Peak Flow
a.
b.
c.
d.
Meters.
{,,
'i
,, ,
Device used to measure Peak Expiratory Flowrate (PEFR) at the bedside.

Patient exhales forcefully through a device which incorporates a resistor and a moveable
indicator.
Resistance is provided by utilizing a narrow orifice.
The moveable indicator is deflected in proportion to the velocity of air flowing through the
device.
e.
f.
g.
h.
PEFR is read directly from the scale.
.Low range
Available in two flowrate ranges.
measures PEFR between 300 - 400 L/min., and
the High range measures PEFR between 600 800 L/min.
Accuracy is affected by patient effort.
Moisture and debris can affect accuracv.
D-26
4.
Finding Personal Best Peak Flow Number.
a.
To identify the patient's personal best peak flow measurement instruct them to record their
peak flow every day, morning and afternoon, for two to three weeks during a period when their
b.
A peak flow measurement should also be recorded after quick relief (SABA) medication is
taken and any other time the physician/asthma specialist has instructed them to record it.
The single highest measurement recorded during this lrmejrernq jg
llglt.
lhg p
This process should be repeated occasionally to identify changes in the personal best peak
flow number.
ast!.Tlq!1!g
c.
d.
5.
gqUlot.
How To Measure Peak Flow.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Move the indicator/arrow to the bottom of the scale.

Stand up or sit up straight.
Take a deep breath filling up lungs (to TLC) and hold your breath.
Place mouthpiece in mouth, close lips around mouthpiece.
Blow out as hard and as fast as possible.
The indicator/arrow will move up the scale according to how much air was blown out.
Record the peak flow reading.
Repeat the process two more times.
Record the highest of the three numbers as the peak flow measurement.
Check to see what zone the peak flow measurement is in and follow the appropriate action
plan.
6.
Typical Peak Flow Value (for a healthy adult).
a.
10 L/sec or 600
l0
L tr r
lc L I ?(
L/min.
D-27
cl
t
ltro >' d /ili./r
7.
Plethysmograph (Body
a.
'' . i''-{!
-..
rr
; f
,','
tYt
it
.
l'
\u'''
tju.;
:..,..
&i'
t,
;-
Based on Boyle's Law which states that pressure and volume vary inversely if temperature is
constant.
1) Measures thoraci.c gas volume (TGV), which is the same as functional residual capacity
2)
i(r, "': ;;
Box). V 'i ,
3)
4)
Lr ::":l'l.
(FRC). f
i; :"
. -.i.!.
f.
?,, ," "..r, ". i'
..
Measures airway resistance (Raw) which is the difference in pressure between the mouth
(atmospheric) and the alveoli, related to gas flow at the mouth.
l'
Raw is the ratio of alveolar pressure (P) to Airflow (V ).
Patient pants with the shutter open and the flow is plotte9.qgqins! box pressure that
*produces an S-shaped curve on the oscilloscope.
;
, 5) At the end of a normal expiration, the shutter momentarily closes and a second curve is
'
p
t-'t., produced that plots mo!4b-pJqgg_q1e agains! box pressure
6) Raw is then calculated from these two curyes. t I ,- l'l' 't' c1"i '"' i"'
r':
" b.
it' r:r:"
c.
'.r,ti
The advantage of the body box is that it will more accurately measure FRC in patients with
o-lgfugtive lung disease.
Disadvantages of the body box include:
1) Patient may be unable to enter box due to pbt_sjqal

2) Claustrophobia prohibits patient from entering box.
3) Patient may be unable to pant acceptably.
D-28
liprlita-tions.

8.
Recording Devices.
a. Kymograph. ii '!.'
1) Rotating drum on which maneuver is recorded on graph paper.
2) Plots volume (Y - axis) against time (X - axis).
3) Inspiration will cause an upward deflection of the pen and expiration will cause a downwaro
deflection of the oen.
4)
Displacement of the spirometer bell causes an equivalent movement of the pen that
records the movement on the paper.
:
: i':
::'r;'r'i
5) RequirescorrectionsforBTPS." '"i '' ii
i.,
X-YRecorder.
1) Plots volume (X - axis) against flow (Y - axis).
2) Advantage over kymograph - allows for recording of flow-volume loops.
"'
),
h;
I
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i
I.{
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I
F$,t
D-29
PU
9.
Calibration and Quality Control of Equipment.
a.
b.
c.
All equipment must meet ATS - ERS standards.

Volume calibration and leak tests are done by using a large volume syringe (Super Syringe).
Standard syringe volume is 3.0 Liters.
Daily calibration with a 3.0 L syringe.
1) Accuracy ! 3.5% (Range 2.895 L - 3.105 L).
2)
Calibrate with flows between 2 and
;.i+ii
. ''
:;
o.
e.
f.
n
- 10.
''t.
,i
12Llsec.
:-
l;. -,r,**,*. j
Flow calibration is done using a rotameter.

Gas analyzers are calibrated to zero by running a gas through it that is free of that particular
gas. (i.e. - 100o/o 02 gas would read 0% on a He or N2 analyzer). A known concentration of
the gas is used to set the second or third point of calibration.
Timing devices (kymograph, X - Y r""orOerijJr".i,".ktO with a stopwatch.
The plethysmograph is calibrated by using a rotameter for flows and a barometer for
pressures.
,'" #**r{i
Gas Analyzers.
a.
Galvanic fuel cell.
1)
Creates electron flow as a result of the

oxidation/reduction of 02 (produces a current).
2) Measures partialpressure, displays F1O2 as %.

3) Accuracy can be affected by water on the sensor,
4)
b.
%s"
'"',
i"'**:1
high system pressures and changes in altitude.

lf unable to calibrate, change fuel cell.
Polarographic.
1)
fu'W.r
ii
,,,.,
':
'; ',: :
Operation is similar to a galvanic fuel cell except for

the presence of a battery used to polarize the
electrodes.
This type of device is analogous to the Clark electrode.
Measures partial pressure, displays FlO2 as %.
2)
3)
4) Accuracy
can be affected by altitude, water and high
DTESSUTE.
5)
c.
lf unable to calibrate, change the battery and check

electrolyte level (refill if low).
Troubleshootino.
1)
2\
lf after setup of a ventilator, blender or Venturi system the Oz analyzer reads higher or
lower - recalibrate analyzer and then recheck equipment.
Must be accurate within 2% of the kn.rwn value.
D-30
d.
Gas

t) 'fi.) 1i': ;r i il'e v '
Chromatography (absorption
type).
lows
"i
r m eas u re m e n t of s eve ra I d ifle19[O aggs_fytll_o.qgSlgtp r.

r,.$Advantage:
2)
can analyze many gases at one time and is very accurate.
1
3)
4)
5)
Al
fo
Disadvantages: requires more time for analysis tnan some otf'er types of analyzers such
as infrared.
Affected by water and CO2,
Can measurethefollowing gases:
$ e, Aq ) t\q. I {il .
a) Ne. Yri o n
b) C2.
c) N2. $ itro $"4t
d) CO. f6riJer' '
e.
Mass Spectrometry.
1)
Pru1r'r1'Yi1!{
tl't''l'''t'-
\*t
Ft *o''*.'u;
f.
al or,r.e '
Sample is drawn by a vacuum into an ionization chamber. The individual gases are
separated and analyzed.
2) Advantages:
3)
4)
Pl*
rapid response time (can be affected by condensatjgn), capable of breAth-bybreath analysis, allpyslgt ny!!p!_g_qas.-elAty,gis (He, NzlG,
t
f
J
Disadvantage: very expensive, large in size, and requires high degree of maintenance.
Most suitable for analysis of several patients at once rather than for individual testing.
e6f, rod f l"
Carbon dioxide/Carbon monoxide.
1) !!!r.qged absorption analyzer.

Z) Quick response for diffusion (DLco) measurement.
3) Calibrate to room air (0%) and known oncentralion, or serial measurements of different
gases containing differeni levels 5?tq:ifi$l;zero. Then use "gain" to match readout to
4)
g.
Helium.
1)
2)
3)
4)
5)
h.
known concentration or measuremeht levels.

CgdensAtion in the tubing would cause a slow response time.
Thermal conductivity (Wheatstone bridge).

Measures psllq.rytage.
Calibrate to room ar (0%) and a known amount (10%), then re-zero. Use gain to adjust to
known amount.
Do not use with flamTaPl,gges.
Used in Helium dilution.
Nitrogen.
1)
2)
Geisler tube ionizer.

Sample is pumped into an ionzlationghamber where a light is emitted and monitored by a
p l"rqlglube. I nte n s ity ol_l g ht/j
rectl vJ o qo oo rti o I gt tg
r
3)
4)
5)
Measures
percentage.
{o
1*V
fr
f-e
llpjg
llo
Provides breath-by-breath analysis.

Calibrate to zero with 100% 02 (0%N2) and a known concentration.
D-31
PU
11. Barometers or Manometers.
a.
Mercury.
1) Measures barometric pressure.

2) A column is completely filled with mercury and erected with its open
3)
4)
5)
6)
end below the surface of the mercury reservoir.

Mercury in the column attempts to return to the reservoir as a result
of gravity, but the reservoir has submitted on it the force of gas
molecules hitting the surface.
Force of the gas molecules pushes the mercury up the column from
the reservoir.
When the force of gravity on the weight of mercury in the column
equals the gas pressure force, equilibrium exists and the gas
pressure can be measured.
Needle indicator in barometer is set flush with mercury allowing the
mercury in the column to rise or fall. Read from the top of the
meniscus.
7) Water can be substituted

B)
b.
for mercury.
lf barometer contains water - read from the bottom of the meniscus.
Aneroid.
1)
Consists of a sealed metal container with a gear or spring mechanism that responds to
changes in pressure.
2)
Changes in the container's dimensions are recorded by the spring or gear mechanism that
changes the needle indicator on the dial or scale.
A decrease in the gas force surrounding the container will allow the container to re-expand
back to its normal shaoe.
Less precise than a mercury instrument.
Used in blood pressure cuffs and in ventilators to record pressures.
3)
4)
5)
D-32

12. MIP/MEP Device (Pressure Manometer).
a.
Measurement of maximum pressures, and are more accurate than vital capacity
measurements in neuromuscular disease patients.
1. Maximum Inspiratory Pressure (MlP).
a) Used to monitor and assess the readiness to wean in ventilator patients.
b)
Assesses the degree of respiratory muscle impairment in Guillain-Barre'and

Myasthenia Gravis.
c)
Procedure:
i.
ii.
Have patient exhale to residualvolume (RV).

Then have patient breathe in as quickly anQ as hay! 99 po-ssible for 15-20
seconds).
iii.
Take measurement on manometer and repeat maneuver and measurements 3

times.
Measurements of < -20 cmH20 pressure indicates inspiratory muscle weakness.
iv.
2.
Maximum Expiratory Pressure (MEP).

Helpful in evaluating a patient's ability to maintain an airway and clear secretions (their
a)
ability to cough effectively).
b)
Procedure:
i. Patient inhales to total lung capacity (TLC).

ii. Then have patient blast out air as quickly and as forcefully as posslb/e.
iii. Take measurement on manometer and repeat maneuver and measurements
3 times.
iv.
Measurements of < + 40 cmH2O pressure indicates poor ability to clear ainuay

secretions.
D-33
E.
Testing and
1.
,/..
i 1"
\Aell'' r '
Patient is instructed to take a maximal inspiration followed by a maximal exhalation without

force.
The SVG will provide the important Volumes used to identify Restrictive Disease.
b.
c. The following Volumes and Gapacities will be measured:
, c -!.
t,':t)}.1)Vr-tida|volume,norma|breathing.$r:T{i''1{|'f7!;|.-)."
2) IRV - inspiratory reserve volume.
tI
3) ERV - expiratory reserve volume.
4) lC - inspiratory capacity (lRV + Vr).
5) VC - vital capacity (lRV + V1 + ERV).
.l-r I z'
"'-.
+.
,j
.!/
lIir7r,rl.:"i
\ ,' , t.".t',,i"
,l(
I
i.
' '':'
.
1
//
ti
I
:
t '
,."
',
tt.l,rf )
,-I
( i '/k(lA
{:';
IRV
tc
"t
VC
VT
TLC
ERV
FRC
d.
A
Decreased volumes indicate Restrictive Disease.

Decreased Vital Capacitv is the BEST indicator of RES'IEIQIjVE lung disease.
),
;
/ n w't:r'
.t ;
a\'"*"uo
Vital Capacity (VC), Slow Vital Capacity (SVC).'
a.
'",
J'I
Procedures
to:i,.' i' "
..- i
jiji.; it '
t"
i'l
':i
l,r,r.,,rt',
ti;:'1
D-34
'i{,r'tt.t
.'-.|
t-',.,
nr
!t,'.
2.
Forced Vital Capacity (FVC).
a.
Description: The volume that can be expired as forcefully and as rapidlv as possible after a
maximum insoiration.
The patient is instructed to take a maximal inspiration followed by a maximal expiration as
forcefully and rapidly as possible.
The FVC maneuver/procedure will provide the important Flow Rates used to identify
Obstructive Disease.
The following flows can be measured:
1) FEV 1 0 - Forced Expiratory Vqlg1g. in 1 sec.
:
2) FEF zoo-.rzoo- Forced Expiratory flow-ZOO-tZOO. .. '
b.
c.
d.
3)
4)
tl
:'":'
- Forced Expiratory Flow 25-75. 1 n-E t! ai r ,.r,':;

PEFR - Peak Expiratory Flow Rate. -=-7 ?t
r:..'i ,, L
FEF
25-75
'
Example graph:
-\'
,I-
* ---\
a
o
5
c)
E
f
123456
Time (seconds)
e.
f.
t'
* l&if i:
tv.
1-1,4r, 4,ri
Forced Expiratory Volumes (FEV 1 0).

1) Volume of gas expired in the first second of th-e-FVC.
2) Most individuats can exhate ail of their air in 1q_qlllasqqefids.
3) A decreased FEVI is a good indicator of obstructive disease.
"L
*7r
1lor"
"
FEV/FVC ratio or FEVI %.

1) FEV for a given interval expressed as a oh of FVC.
2\ Values of FEV/FVC x 100 = FEV/FVC ratio.
3)
4\
5)
6)
Measurement
FEV N^ / FVC
Minimum Acceotable
60%
FEVlO/FVC
FEV,"/FVC
FEV 3O / FVC
7jYo
Decreased FEV
94o/o
97o/o
10
/ FVC is the BEST indicator of OBSTRUCTIVE DISEASE.
= obstructive disease.
Normal values = not obstructive disease (may still be restrictive).
Decreased values
lf the FEVl is decreased but the FEVl/FVC ratio is normal, then the patient has restrictive
disease only.
D-35
! tlt it.....t 1:
J :. !':
-j +'o .r
,,i
(lr
PULMONARYDIAGNOSTTCTESTTNG,.
l- ''r
:-
[,"' i / n', f'
1)
1
12oo (FEF 2ee-1266).
"t
Average flow during the first 1000 mL after 200 mL expired.
Decreased values are associated with l"gqg,rryqy 9p*"._trup"tion.
Forced Expiratory Flow 200
i'-'
! "''n
2)
3) TypicalValue:
n.
i.
8 L/sec (480 L/min).

Forced Expiratory Flow 25o/o -75% (FEF 25-7).
1) Average flow rate during the mid portion of the FVC.
2) Decreased in the early stages of obstructive disease.

3) Decreased values are associated with small airway obstruction.
,' '-r r
4) TypicalValue: 6 L/sec (360 L/min).
Peak Expiratory Flow Rate (PEFR).
1) Effort dependent.
2) May appear normal in abnormal patients.
/1
3) Sometimes used to evaluate asthmatic patients, pre & post bronchodilation.
4) TypicalValue: 10 L/sec (600 L/min).
q,11,it',
j. FVC - this is not a flow, it is a VOLUME and should be equalto the SVC.
' lr'
/' '
1) May be used as a substitute for the SVC. -- -r
/ | t,"\i\,
2) lf the FVC is smaller than the SVC, indicates obstructive disease (air trapping).
3) lf the FVC cannot be completed in 3 seconds, indicates obstruction.
3.
Maximum Voluntary Ventilation (MW).
a.
b.
The largest volume and rate that can be breathed per minute OyfglglQrygffpqt The patient is
told to breathe in and out as fas_t as posgrble uli!!-g!9.to_gtop.
Performed for 12 - 15 seconds.
ft r.rl".
'10
8
Volume
(liters)
60
Total
Volume
(liters)
20
80
40
"15101215
0
Time (seconds)
c.
d.
r{
,ii
Measures the muscular mechanics of
breathing
d:l
Decreased with o;;tr;;ti"&;;"r",-r"i""."0 ,irway resistance (Raw), muscle weakness,

"decreased compliance, and poor patient effort.
.
l,,r-,4
; r ir)
Pre and Post Bronchodilator Testing.
f
; ;ro{'
a. U:gllg:S.*ure the reversibility of qn.obstructive p-attgn

b. Minimum increase of 12% and 200 mL in the FEV.r post study is considered
therapy should be held B hours prior tp testing.
c. All pro4chodilator
?";'l- I' :
:
....*'iF,l(l'(1{i....:k1,,.r
D-36
significant.
5.
FRC Measurement (RV, TLC).
a.
t 11"'li o
; 17i !'r ':-
i.ril',
_,
li;
l,
[;
-";
i+
He dilution (Closed Method) - a known o/o of He is diluted by the patient's FRC. The change in
the He% is used to determine the FRC.
r-s r
-
, Tr4- 'iln1;, i'
Ir
-L-,)
C\(
,*.{\
'
,i,;"1'
'i'i,l
;'':''r'':'
ir
1l
'r'r t i
jij
't ll iu
L:
l;,|,
b.
N2 wash out (Open Method) - the FRC is washed out of the lung by having the patient inspire
1OO% Ozto replace the N2 from the FRC. The-amounlof
reiroveO@rlGAflt-o cabutate
,trtz
FRC.
,l
1:
r..1-
,n-,
J'!
jo
,"
at'
fY'4t
., {iF,
tf
,E
"1^ L
t
z
.r
.^)S
rt"
a
^L Fl,(
ut
CIl t!i;\!&!:t:'Y' L' i
r
aL
fr<<.
I
i'
r !"'[r
.$i.
'
,:;
c.
- \\
li z iit,*-.*
.-i
rn
h"
,rr
:i
flPtf
-9
-J
llll1Trr,
1;grr! 1.1,;s. Volume (L)
f :.i
{' lr
L/f , -fir'r
,;
,..':
tr-6
1*''
rr i-rr;
''{"j
ii.\
ali l
I
I
f l" r
:.,,".,
Plethysmograph/Body Box - uses Boyle's Law to determine total thoracic gas volume at FRC.
Patient pQlts at FRC while pressures and volumes are4gtgllgd
1) Measures gases trapped inside the lung and otherwise excluded from the FRC with the
other procedures (He dilution and N2 Washout).
2) Airway resistance (Raw) can be determined by measuring the changes in Pressure vs.
Flow (normal airway resistance
6- 2 a cn\71!4r*""Q: i), i * ',. '
i-."
3)
10
Compliance can be determined by measuring the volume change per unit pressure change
in liters/cmHzO or milliliters/cmH2O (normalcompliance = 60 - 100 mL/cmH2O)
{.4!{ i//rjrgr'r ,
'i'.r,f'',
I. ",,t
fi'
l/t Inr l('yt"l)
V *i.$;,,;
t';'ill n t'.u'\r'(- r
{y:i p'r;itr"
')
4',';';'1;'i"':i
D-37
PU
6.
Flow-Volume
a.
b.
c.
d.
e.
A {t:t "l
Loops. , frot@
1f't?'
Displays the volumes {ndflow rates of thdFVC)//

Patient performs a rdV followed by aFlV.Y
The flow rates are displayed directly on the vertical axis. Expiratory flows are above the base
line. lnspiration is below the line.
Volume is displayed directly on the horizontal axis.
Special measurements include:
1) Vmax 5s - flow at 50% of the VC - similar to the FEF 25-75 (small airways).
t'r:f.'*a
I
7
=
-9
II
Ylu'
e.
i:
x
,:: 2
o,
al
'o-
="
x.2
=
-e
uJ
tL
z"
6
7
'yo,),}h
utc'
{or*+"
n &r"
pl
Volume (Liters)
'
1) Restrictive
= skinny and tall loop.
sllq 2; oor,rr",'u" = sr'ort and wide loop.

3)
Flow-volume loops can evaluate partial vocal cord paralysis (large airway obstruction).
4
3
^2
o1
^2
o1
,,
ai"
i.
ol
tr^
L^
'CN
4
3
^2
o1
^2
o1
3.
o2
tr"
3
LARGE AIRWAY
OBSTRUCTION
\rra{
?oc'a{eJi
012345678910
012345678910
012345678910
012345678910
Volume (Liters)
Volume (Litets)
Volume (Liters)
Volume (Liters)
D-38
{A " Q}e',|at
7.
'/';l'u''
Gas Diffusion (DLco, Dco).
a.
DLco - Carbon monoxide diffusion capacity.
1)
b.
Measures all the factors that affect the diffusion of a gas across the A-C membrane.
DLco - Single breath (SB).
1) Patient inhales a vital capacity of gas containing a known amount of CO, He and air.
2) They hold their breath 10 seconds, and then exhale the gas into the machine where the
gas concentrations are analyzed.
3) The amount of CO that diffuses across the A-C membrane is equal to the total amount of
Cg_Uggd, m[Uslbe amount returned plus the amount remaiffig-rn1heTesldlelfitlum*e:'
CO/min/mm Hg (STPD).
Normal DLco
,."/--d
(o ){i,s.* Al, .,
=,3-Tl!J
d.
Factors that affect the DLs6.
1) Hb, Hct. ( an{'-ie '; ' , !)

\,",\';{"rl*rx q' {
2) PCO2.
t,*"1
3) Bodyposition. -il fnicvr"'Sl , 0l
di)f; tpc';"
4) Breath holding time. :
5) Blood volume",- \
'
Decreased DL"o (decreasdd diffusion) occurs in:
1)
2\
Pulmonary fibrosis.
4)
5)
Edema.
Sarcoidosis.
;; il;; ;; tb r"n? \turh*
r
Emphysema (the only obstructive disease).
D-39
d-r">
I r,
oi'
F-1
r'a.Le"r"Q
i,,5p;*.A tN'\'
{ry'1
[rr'+ rr'r"i
F.
Evaluation of Pulmonary Function Tests
1.
2.
Predicted Normal Values.
a.
b.
All measured values are compared with the predicted normal values for that individual.
The relationship is expressed as a percent.
Actualvalue / predicted value = % of predicted.
c.
Predicted values are primarily based on:
1)
Age.
2)
3)
Sex/gender.
Height.
Classification of lnterpretation.
80-100% of predicted
60-79Yo of oredicted
40-59% of predicted
< 40% of predicted
NormalPFT
Mild disorder
Moderate disorder
Severe disorder
Example: The following results are obtained from a 58-year-old woman.
,f,
ijr'*
*8',*l
r''0t
'
Interpretation: The volume measurement (FVC) is decreased (65%) so there is a

mild restrictive problem. The flows (FEVr and FEVI/FVC) are normal (83% of
predicted) so there is no obstructive problem.
Diagnosis: Mild Restrictive only.
Example:The following results are obtained from a 47 year old
FVC (L)
FEVI (L)
FEV./FVC (%)
Predicted
Observed
6.10
4.58
4.99
2,04
70
41
man.
% Predicted
81.8
44.6
.,
Interpretation: The volume measurement (FVC) is normal (80+%) so there is 4

restrictive problem. The flows (FEV1 and FEVI/FVC) are
decreased so there is a moderate obstructive problem.
Diagnosis: Moderate Obstructive onlv. Recommend a post bronchodilator study to see if the
obstruction is reversible.
D40
3.
Remember: Patients can have any of the following:
a.
b.
c.
d.
4.
Restrictive only
(t
Obstructive only
(J
volumes: VC or FVC).
flows: FEV1, FEVI/FVC).
Both Obstructive & Restrictive 1.L nows &

'l' volumes).
Neither Obstructive nor Restrictive (normalvolumes & flows).
Obstructive and restrictive disease.
a.
Decreased flows indicate obstructive disease.

1) Cystic fibrosis.
2) Bronchitis.
3) Asthma.
4) Bronchiectasis.
5) Emphysema.
b.
Decreased volumes indicate restrictive disease.

1) Inflammatory diseases.
2\ Cardiac disease.
3) Neurological/neuromuscular.
4\ Pleural disease.
5) Thoracic deformities.
6) Post-surgical patients.
7) Fibrotic diseases.
B)
Anybody else you can think of....
D41
PU
G.
Quality Assurance
1.
Patient performance standards (ATS
a.
- ERS).
SVC maneuver.
1) All patients should be carefully instructed in the procedure.
2) The therapist should demonstrate the procedure for the patient.
3)
A minimum of three (3) acceptable procedures should be recorded that are:

a) Free from artifacts.
b) Have good starts.

c) Show satisfactory exhalation for a minimum
b.
of 6 seconds.
FVC maneuver.
1) All patients should be carefully instructed in the procedure.
2) The therapist should demonstrate the procedure for the patient.
3)
4)
A minimum of three (3) acceptable procedures should be recorded.

a) No false starts.
b) Tests should not differ by more than 5% or 200 Ml.
The best test should be determined and used for reporting results.
a) Best test is the trial that results in the largest sum of (FVC + FEVl).
Example:
Trial#2
Trial#1
FVC (L)
PEFR (L/s)
6.0
FEV1 (L)
4.6
FEF25-75"7"
(L/s)
8.2
"
5.8
5.9-1 ro,'fr
8.1 ,/".
4.9.,'
5.5
Trial#3
5.1
"
6.7
4.3
3.4
Question:
a.
b.
c.
2.
Which of the above is the best test?

Which of the above shows a poor effort?
Should the patient repeat the FVC?
(Trial #2).
(Trial #3).
(yes).
Equipmentperformancestandards.
Volume measuring devices (spirometers) must be capable of:
1) Measuring volumes up to B liters.
2) Recording expiratory maneuver for a minimum of 30 seconds.
b. Flow measuring devices (pneumotachometers) must be capable of recording expiratory
maneuver for specified time depending upon test performed.
a.
1) SVC - 30 sec.
2) FVC - 14 sec.
3) FEVI-1sec.
c.
d.
e.
f.
Volume calibration is performed using a 3 Liter calibrating syringe.

Flow calibration is performed using a roiameter.
Timing device (kymograph, X -Y recorder) calibration is performed using a stopwatch.
Gas analyzers are calibrated to zero by running a gas through it that is free of that particular
gas (i.e. - 1O0Yo 02 gas would read 0% on a He or N2 analyzer). A known concentration of the
gas is used to set the second or third point of calibration.
D-42
PU
ilt.
Bron
A.
A bronchoscopy is a procedure that allows the therapist to visualize the trachea and bronchi.
B.
A bronchoscope contains several separate lumina that:

"i
1. Provide light source for visualizing structures . 't L' ; r ifl
'
; i t'
2. Aflow suctioning of lower airway
,' i ,, :. .
3. Allow insertion of biopsy forceps and bt1t9!gt
+ rF.fgliQle_lf-o1ch-ogcopei for use in adult patients are available in 5.0 mm OD and 6.0 mm OD sizes
that can be inserted via the mouth, nose, endotracheal or tracheostomy tube.
5.
C.
Pediatric patients may benefit from bronchoscopy and most manufacturers provide scopes in a
size (3.5 mm OD.) appropriate for children.
A bronchoscopy can be performed for both Diagnostic and Therapeutic reasons.
{$ Diaqnostic
Iherapeqtie
Foreion-bodv Obstruction
Secretion removal
Bronchial Lavage
Stenosis
Atelectasis
Suspected foreiqn-bodv
Suspected maliqnancV
Bronchial washinqs
Hemoptvsis
Persistent oroblems
D.
E.
.--...
i-
.,1.
i,
\ ;i;,:..,' ii'
fr
4' i'i,,
i.'., i
Recommend flexible bronchoscopy for intubating in patients with suspected neck fracture.
i
:),: i': ;"ri ''

{,-,,,'1"'.
,c,
;""#::ril:TonchoscoRl
2.
3.
4.
5.
F.
Bleeding
disorders. '.\c'','
\,1
"i'''"'
il ' ' -
Cardiovascular instability.
asthmaticus
i
Marked h_yp_ercapnea.
Status
"
ii!'
i''' t"''
{'
Hazards and Complications
1.
2.
3.
The most common complication is mild epistaxis (nasal bleeding) when the nasal route
Internal hemorrhage common following tissue biopsy. Most cases can be controlled with saline
lavageanoilme.
t" ri
lf serious bleeding occurs, on-e_9f mq!9,9-f
a.
b.
c.
4.
is_us,ed.
t!',tq,fo-llo1,1tlng
qlqps illould
!e taken:
Instill epinephrine.
Compress the site with the scope.
Insert a Fogarty catheter.
Bronchospasm/Laryngosp?s1 are possible and are prevented/treated with bronchodilators and

i'i'' l:''6'1 1'r "; o f' ir1':l' i't :''
anesthetics. 1't',
5.
Hypoxemia would be a serious hazard and is monitored by pulse oximetry and ECG and
prevented/ treated ut1! _o_1ygen.
6.
Pneumothorax is possible when taking tissue
D-43
gitpf"!'
'
'{'
.'
G. Procedure.. i \(
1. Topidal anesthetic
,,
... \,
,-)
yr.:"
r'
:- i.
(lidocaine) is administered to control the gag/cough reflex and prevent

laryngospasm (benzocaine, Novmain, cetafaine)
i a j . i. , .:. I
ti,
\
l.linlri''
rl:i'. ,i
2.
Intubation is preferred but not required. Intubation will not allow visualization of the true vocal
coros.
3.
The scope is inserted and the airurays are viewed.
4.
Oxygen should be provided to the patient via mask or by removing one prong of the nasal cannula
from the nose to allow for insertion of the scooe.
f*.
i'r"i"'
"j{l'r';
5.
o.
: ''
':'
'
Patients receiving co,n!i1.u9u-9 ye4!il_ation will need a special adapter (Bodaii@ adapter)for
introduction of the scope.
a.
This adapter should fit tightly and pre_vent loss of:
1) Ventilatingpressure. - l',.''''
''.
2) PEEP.
3) Tidalvolume.
b.
d.
e.
1,.';
" ,:
Further precautions should be taken for patients on

mechanical ventilator that include:
1) A topical anesthetic should be administered
through the endotracheal tube or tracheostomy
tube frior to' F1O2 insertion of the bronchoscope.
2)
3)
c.
:.
rlgeags-t!9JQal9j.-q.
Increase high pressure alarm setting.

Using a high-fTelu#met;v-entiiator may be
preferred during a bronchoscopy qroce9ure.
Continuous monitoring of the electrocardiogram and
oxygen saturation by pulse oximetryis re_commended.
Decontamination is best done with alkaline
gluteraldehyde (Cidex).
Used with oermission of CareFusion
7.
Therapist Responsibilities.
a.
Check equipment.
1) Patency of scope lumen.

2) Opticalfibers.
b.
Assemble equipment.
1)
2)
Oxygen.
Suction regulator, canister and tubing.
a) Occlude end of scope to check suction.
D-44

D - Pulmonary Diagnostic Testing

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D - Pulmonary Diagnostic Testing

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PULMONARY DIAGNOSTIC

PULMONARY DIAGNOSTIC TESTING

Arterial Blood Gases

PULMONARY DIAGNOSTIC TESTING

Arterial Blood Gases (ABG)

The exam will cover six (6) areas.

Interpretation and Management - Relating blood gas values to life functions.

Acid base status.

Blood Gas Sampling

- puncture of a p54p[s1a!-g!!g]y to obtain an arterial blood sample for direct

the arter-ial PO2 is above 60 torr.

PULMONARY DIAGNOSTIC TESTING

Umbilical arterial lines are used for newborn babies.

U'niridii arte'vFO; ma-f6e

Advantages of umbilical artery catheter (UAC).

Obtain blood from an arterial or pulmonary artery line:

Catheters can be inserted into the radial, brachial, or femoral

1) Catheter-over-needle is inserted into artery.

LMONARY DIAGNOSTIC TESTING

Transducer is used to convert pressure (analog signal) to an electricalsignal (digital signal)

lf trangducer is above catheter, displayed pressure is lgwer than actual.

Close stopcock and flush catheter and tubing.

PULMONARY DIAGNOSTIC TESTING

The brachial artery is an appropriate alternative site.

rhe hand should pink

lf it does not - use another site.

sg9ol9" ?l9l l9]9T'lq

10. Sampling Hazards and Problems.

Disruption of blood flow

PaCOz decreases toward 0 torr.

Too much heparin:

decreases towards 7.0.

PaCOz decreases towards 0.

PULMONARY DIAGNOSTIC TESTING

Blood Gas Analyzers

Directly measure only the following:

PCO2 - Partial pressure of carbon dioxide in sample.

b. POz - Partial pressure of oxygen in sample.

All other values are calculated (SaO2, HCO3- etc.).

The machine readings are then calibrated to these known values.

Commercially prepared controls.

1) Plotting of control runs.

Alkalotic (pH, PCO2, PO2).

evaluated to assess the operation of the analyzer.

For detecting a machine that is out-of-control, the

standard deviation (SD) range is

Values should remain within 2 standard deviations t SD of the mean 1X).

PULMONARY DIAGNOSTIC TESTING

PULMONARY DIAGNOSTIC TESTING

1) Unknown control samples

are sent to different laboratories using the same brand and

Gas Exchange Validation Device

Multiple machine analysis.

Point of Care Testing.

2) Analysis is done with a disposable cartridge that contains calibration

PULMONARY DIAGNOSTIC TESTING

PAO2 : Alveolar Air Equation (Alveolar PO2).

Calculates the partial pressure of oxygen (POz) in the alveoli.

FORMULA: PAO2 = (Pe

Normal value varies directly with patient's

A-aDO2 : The A-a Gradient.

Measures the difference (gradient) between alveolar and arterial PO2.

FORMULA: A-aDOz = PAOz -PaOz.