Disc lo sure o f F ina nc ia l I nte re st F unde d b y the - - PDF document

What lung func tion study should I or der and why?

Unive r sity of Califor nia, San F r anc isc o – Division of OE M

Mar c h 5, 2020

R

• be r

t Cohe n, MD, F CCP

Clinic a l Pro fe sso r - E OHS, Unive rsity o f Illino is Sc ho o l o f Pub lic He a lth Chic a g o , Illino is Pro fe sso r o f Me dic ine No rthwe ste rn Unive rsity F e inb e rg Sc ho o l o f Me dic ine

Ca rdio pulmo na ry E xe rc ise T e sting the Chic a g o Bla c kha wks Pre -Se a so n 2009

Disc lo sure o f F ina nc ia l I nte re st

 F unde d b y the Alpha F

• unda tio n fo r the I

mpro ve me nt

• f Mine Sa fe ty a nd He a lth

 F unde d b y HHS/ HRSA/ ORHP/ BL CP & BL CE  E mplo ye e o f NI OSH/ RHD  F unde d b y USDOL / OWCP & MSHA  F unde d b y Que e nsla nd Go ve rnme nt, Austra lia  Pro vide I ME ’ s fo r Oc c upa tio na l L ung Dise a se

Go a l fo r T

• da y’ s T

a lk

 Disc uss the indic a tio ns fo r lung func tio n te sting in

• c c upa tio na l me dic ine

 Disc uss the whic h te sts sho uld use d, a nd the ir stre ng ths a nd limita tio ns

I ndic a tio ns fo r lung func tio n te sting in

• c c upa tio na l me dic ine

Pre -e mplo yme nt Me dic a l Sc re e ning a nd Surve illa nc e Dia g no sis o f spe c ific o c c upa tio na l lung dise a se Re turn to wo rk Disa b ility E va lua tio n

Co mmo nly Use d Pulmo na ry F unc tio n T e sts

 Spiro me try  L ung Vo lume Me a sure me nts  Diffusing Ca pa c ity  Arte ria l Blo o d Ga se s  Airwa y Re sista nc e , I mpulse Osc illo me try  L ung Me c ha nic s MI P, ME P, PV Curve s  Airwa y Re a c tivity/ Cha lle ng e  Ca rdio pulmo na ry e xe rc ise te sting

I ndic a tio ns fo r Pre -E mplo yme nt Spiro me try

 I ndustrie s whic h re q uire c a pa b ility to pe rfo rm he a vy e xe rtio n F

ire fig hte rs, Po lic e , Milita ry

 I ndustrie s with e xpo sure to re spira to ry ha za rds  I ndustrie s whic h re q uire a re spira to ry pro te c tio n pro g ra m

(ma y a pply o nly to a sub se t o f wo rke rs de pe nding o n re spo nse to re spira to ry q ue stio nna ire ).

I ndic a tio ns fo r Me dic a l Sc re e ning a nd Surve illa nc e - Spiro me try

Asb e sto s Be nze ne – e ve ry 3 ye a rs if re spira to r re q uire d Ca dmium Co a l mine rs o n hire – vo lunta ry e ve ry 5 ye a rs Co ke Ove n E missio ns

I ndic a tio ns fo r Me dic a l Sc re e ning a nd Surve illa nc e - Spiro me try

Co tto n Dust F

• rma lde hyde – if re sp pro te c tio n is use d

Silic a e xpo se d wo rke rs a s o f 2016 ne w OSHA Silic a sta nda rd.

> 25 ug / m3 fo r a t le a st 6 mo nths

HAZWOPE R

 (Ha za rd o us Wa ste Ope ra tio ns a nd E me rg e nc y Re spo nse )

Optima l Co nditio ns F

• r PF

T s

E xc e lle nt e q uipme nt we ll c a lib ra te d Pa tie nt a nd te c h spe a k sa me la ng ua g e , ha ve g o o d ra ppo rt, a nd a re b o th hig hly mo tiva te d Pre vio us study b e fo re pa tie nt wa s e xpo se d o r b e c a me ill fo r c o mpa riso n Appro pria te re fe re nc e va lue s

L imita tio ns o f Pulmo na ry F unc tio n T e sts

Me a sure me nts a re Hig hly Va ria b le Bio lo g ic / individua l va ria b ility Me a sure me nt va ria b ility T e mpo ra l va ria b ility

Critic a l e le me nts o f a spiro me try pro g ra m

40 yo , Cauc asian , male , pr e -e mployme nt physic al

Spiro me te r Ac c ura c y Pe rfo rma nc e AT S 2019 Sta te me nt – Gra ha m e t. a l. 2019

 Upda te s the 2005 AT S/ E RS Sta te me nt  Instrume nts must me e t ne w ISO 26782:2009 Sta nda rds

 Ma ximum pe rmissib le a c c ura c y e rro r o f ± 2.5%

 Ope ra to r tra ining a nd c o mpe te nc y sta nd a rd s  Ro le o f inspira to ry ma ne uve rs – c o ntro ve rsia l fo r Oc c Me d  (T

• wnse nd – AJRCCM 2020)

 Ac c e pta b ility a nd re pe a ta b ility a nd E OF E upd a te d  Ind e pe nd e nt la b o ra to ry va lid a tio n te sting fo r pro to type spiro me te rs a nd so ftwa re  NIOSH Re c o mme nd s c e rta in spiro me te rs https:/ / www.c d c .g o v/ nio sh/ to pic s/ c whsp/ ma nuf_ta b le 06-04-18.html

NI OSH-Appro ve d Spiro me try T ra ining Pro g ra m

Cre a te d b y 1978 OSHA Co tto n Dust Sta nda rd NI OSH a dministe rs pro g ra m Spo nso rs te a c h c o urse E ndo rse d a s a mo de l tra ining pro g ra m b y

AT S ACOE M

Co urse De sig n

 Minimum o f 16 ho urs: 8 ho urs o f ha nds o n use o f e q uipme nt

E q uipme nt c a lib ra tio n c he c ks E mplo ye e instruc tio n a nd te sting Ide ntifying a nd c o rre c ting te st pro b le ms

4 ho urs o f le c ture s (the o ry a nd te sting pro c e dure s) 2 ho urs o f sta nda rdize d te sting

Writte n e xa mina tio n Pra c tic a l e xa mina tio n

NI OSH Re so urc e s

http:/ / www.c dc .gov/ niosh/ doc s/ 2004-154c /

19

Pre dic tio n E q ua tio ns

1. Glo b a l L ung Initia tive 2012 – re c o mme nde d b y ne w AT S/ E RS sta nda rd 2019 2. Na tio na l He a lth a nd Nutritio n E xa mina tio n Surve y* (NHANE S II I ) – Ha nkinso n 1999

• Re c o mme nde d by OS

HA (2013), ACOE M (2011), AT S / E RS (2005)

2. K nudso n 1983 – Bla c k L ung Disa b ility USDOL 3. K nudso n 1976 – (OSHA Co tto n Dust Sta nda rd) 4. Cra po 1981 - (AMA g uide s)

Glo b a l L ung I nitia tive

Spiro me try 2012 a nd DL CO 2017 E thnic ity

White (E uro pe a n a nc e stry) Afric a n Ame ric a n No rthe a st Asia n So uthe a st Asia n Othe r/ Mixe d

Re fe re nc e E q ua tio ns NHANE S I I I – fo r Oc c upa tio na l Me dic ine

 Re fe re nc e E q ua tio ns – NHANE S II I – Ha nkinso n 1999

 White (E uro pe a n a nc e stry)  Afric a n Ame ric a n  Me xic a n Ame ric a n  Othe r – ma y use c o rre c tio n fa c to rs

 Pa tie nt Pre p - re mo ve de nture s - OK  No se c lip in pla c e – e xc e pt fo r e xpira to ry lo o ps o nly  Re a ltime displa y with dig ita l fe e db a c k to pa tie nts during fo rc e d e xpira tio n impro ve s pa tie nt e xpe rie nc e a nd E OF E  Displa y vo lume time a nd flo w vo lume fo r QA  Sa fe ty o f spiro me try - 5/ 10,000 e piso de s in te rtia ry c a re ho spita l – a ll we re sync o pe

Re la tive c o ntra indic a tio ns to spiro me try Re la tive c o ntra indic a tio ns to spiro me try

Re la tive c o ntra indic a tio ns to spiro me try Pe rfo rma nc e o f F VC Ma ne uve r

 Cha ng e s fro m 2005 Sta te me nt

 Ra pid inha le to T L C – he sita tio n < 2 se c  E OF E 15 se c o nds o r pla te a u, < 25 ml in la st se c o nd  No minimum F E T b ut must ha ve re pe a ta b le F VC  F IVC-F VC must b e le ss tha n 0.1 lite r o r < 5% o f F VC whic he ve r is g re a te r  F IVC is impo rta nt c he c k o n ma xima l inspira tio n prio r to F VC  Ba c k E xtra po la te d Vo lume (BE V) e rro r is no w 0.100 lite r no t 0.15 a nd still <5% F VC whic he ve r is g re a te r

 F VC Ma ne uve r – re pe a ta b ility

 0.15 ML > 6  0.1 ml 6 o r yo ung e r o r 10% o f la rg e st F VC  8 ma ne uve rs

 Bro nc ho d ila to r re spo nsive ne ss – te ste d e ve n with no rma l pre -b ro nc ho dila to r te sting – fo r dia g no stic studie s  Cha ng e in b ro nc ho d ila to r a s c ha ng e in % re fe re nc e no t % c ha ng e

Pe rfo rma nc e o f F VC Ma ne uve r

T e st Re po rt – Minimum Gra phic Size s Also re q uire s re a l time g ra phic s

T

• wnse nd, MC e t. a l. JOE
• M. 2011;53:569-584

AT S/ E RS Spiro me te r Pe rfo rma nc e - sta nda rdize d e le c tro nic o utput

Co mple te te st re sults a re sa ve d F ull da ta fro m flo w vo lume lo o ps re ta ine d T ra c ing s c a n b e re c o nstruc te d a t a la te r da te , if ne e de d

ACOE M – De dic a te d c a lib ra tio n c he c k ro utine Ove rsig ht b y E xpe rie nc e d Pe rso nne l

Re vie we r sho uld b e kno wle dg e a b le a b o ut spiro me try a c c ura c y a nd te st va lidity F e e db a c k me c ha nism a nd fre q ue nc y Pe rfo rma nc e a c c o unta b ility

Upda te T ra ining a nd F e e db a c k I mpro ve T e st Qua lity

I nte rpre ta tio n o f Re sults

Co mpa ring re sults to re fe re nc e va lue s L

• ng itudina l a sse ssme nt

L

• ng itudina l I

nte rpre ta tio n

ACOE M a nd AT S a do pte d the 15% de c line in %re fe re nc e fro m b a se line a s a re c o mme nde d “lo ng itudina l no rma l limit” (a llo ws fo r a ve ra g e lo ss due to no rma l a g ing )

L

• ng itudina l I

nte rpre ta tio n

I n 2003, NI OSH de ve lo pe d “Spiro me try L

• ng itudina l Da ta Ana lysis (SPI

ROL A)” so ftwa re to o l to a ssist with inte rpre ta tio n o f lo ng itudina l spiro me try da ta (c re a te s “lo ng itudina l limit o f de c line ” b a se d o n da ta pre c isio n)

SPI ROL A T e c hnic a l So urc e s o f Va ria tio n

 Obse r

ve r

 T ra ining , fe e db a c k, a nd suppo rt  T e st a dministra tio n: pre pa ra tio n o f sub je c t a nd c o a c hing  T ria l se le c tio n a nd a na lysis  Subje c t  Co mpre he nsio n, c o lla b o ra tio n, mo tiva tio n  Bo dy a nd ne c k po sitio n, No se c lips, Re c e nt e xpo sure s/ a c tivitie s o f sub je c t  Inte r

ac tions

 Ob se rve r-sub je c t, o b se rve r-instrume nt  Sub je c t-instrume nt

Disa b ility E va lua tio n

Spiro me try Diffusio n Ca pa c ity CPE

T

Disa b ility E va lua tio n

Spiro me try Diffusio n Ca pa c ity Ca rdio pulmo na ry E

xe rc ise T e sting

AMA Guide – 6th E ditio n 2008

PFT Class1 (0-9%) Class2 (10-25%) Class 3 (26-50%) Class4 (51-100%) FVC >=LLN and >=60% and < LLN or >=51% and <+59% or <=50% or FEV1 >= LLN and >=60% and < LLN >=41% and <=59% or <=40% or FEV1/FVC >= LLN DLCO >= LLN >=60% and < LLN >=41% and < 59% or <=40% or VO2 Max >=25 ml/kg >=20 and < 25 ml/kg or 5.7- 7.1METS >=15 and < 20 ml or 4.3-5.7 METS <15 ml/kg or <1.05 L/min or <4.3 METS

I ndic a tio ns fo r DL CO

E a rlie st Indic a to r o f Inte rstitia l L ung Dise a se Ma y pre dic t De sa tura tio n With E xe rc ise T rue Indic a to r o f L ung F unc tio n Me a sure s Inte g rity o f Alve o la r Ca pilla ry Units Ma y De te c t Pulmo na ry Va sc ula r Pro b le ms

Pulmo na ry Va sc ulitis PE , T umo r I nvo lve me nt o f Pulmo na ry Circ ula tio n

Sc he ma tic Of Diffusio n T e st Diffusio n Ma ne uve r

Qua lity Co ntro l

Me a n o f te sts use d T e sts sho uld b e within 10% o f e a c h o the r Sta b le Ca lc ula te d Bre a th Ho ld 8-12 Se c o nds (No Va lsa lva o r Mue lle r Ma ne uve rs) E xha la tio n < 4 se c (sa mple < 3 se c ) sho uld b e o n a lve o la r pla te a u

Disa b ility E va lua tio n Spiro me try Diffusio n Ca pa c ity

CPE

T

Unexplained dyspnea Pre-op assessment Fitness, impairment, disability Cardiopulmonary rehabilitation Cardiac vs. pulmonary exercise limitation

CPET

Indications for Exercise Testing

Prognosis

Whe n to Orde r E xe rc ise PF T s

 Whe n re sting PF T s do no t sho w se ve re impa irme nt (> 40% pre d.)  Re sting PF T s inc o nc lusive  Any wo rke r with une xpla ine d dyspne a e ve n with no rma l PF T s  Whe n the re is a ne e d to e va lua te whic h o rg a n syste m is c a using disa b ility

L e ve l Of Wo rk E ne rg y E xpe nditure

Bro nc hia l c ha lle ng e te sting to a sse ss a irwa y hype r-re spo nsive ne ss - indic a tio ns

Sympto ms sug g e st a sthma a nd sub je c t ha s no rma l o r ne a r no rma l PF T s

Whe e zing , dyspne a , c he st tig htne ss, c o ug h Sympto ms whe n e xpo se d to c o ld a ir, e xe rc ise , o r with re spira to ry infe c tio ns Sympto ms re la te d to wo rkpla c e e xpo sure s, a lle rg e ns

Mo re use ful e xc luding dia g no sis Use ful in c o nfirming o c c upa tio na l a sthma

Bro nc hia l c ha lle ng e te sting to a sse ss a irwa y hype r-re spo nsive ne ss - indic a tio ns

Use ful in sc re e ning hig h risk o c c upa tio ns

Sub ma rine rs Dive rs

Bro nc hia l c ha lle ng e te sting – type s

 Dire c t BCT

 Me tha c ho line , Hista mine  Dire c t a c tio n o n musc a rinic re c e pto rs

 I ndire c t

 E xe rc ise , c o ld a ir, e uc a pnic hype rve ntila tio n  Hype rto nic sa line , ma nnito l po wd e r  Ad e no sine mo no pho spha te

 Spe c ific I nha la tio n c ha lle ng e s

Dire c t b ro nc hia l c ha lle ng e te sting to a sse ss a irwa y hype r-re spo nsive ne ss

Ne g a tive te st in pre se nc e o f a c tive sympto ms use ful in rulling o ut the dia g no sis o f OA – g o o d NPV Po sitive MCT unle ss ve ry lo w do se re a c tivity is do c ume nte d is no n-spe c ific with lo w PPV

I ndire c t b ro nc hia l c ha lle ng e te sting to a sse ss a irwa y hype r-re spo nsive ne ss Use ful in c o nfirming the dia g no sis a sso c ia te d with spe c ific e xpo sure s. Ma y b e use ful in a sse ssing re spo nse to the ra py.

Co a te s e t. a l. E ur Re spir J . 2017

Bro nc hia l Cha lle ng e T e sting Ne we r Co nside ra tio ns

 PD20, no t PC 20  Allo ws lo ng itud ina l inte rpre ta tio n o f re sults  Inha la tio n o f pro vo c a tive a g e nt a t tida l b re a thing  Use b re a th a c tua te d o r c o ntinuo us ne b uliza tio n a s lo ng a s d e live ry c ha ra c te ristic s o f d e vic e a re kno wn.  No lo ng e r using ma xima l inha la tio ns to T L C  Sta rt a t 1-3 µg a nd the n d o ub le o r q ua d ruple d o se in ste ps  Ma in o utc o me me a sure is F E V1 (o the r o utc o me s inc luding b o dy b o x a nd fo rc e d o sc illa tio n

Me tha c ho line Bro nc ho Pro vo c a tio n

Me tha c ho line Bro nc ho pro vo c a tio n E xe rc ise Cha lle ng e

 R/ O E xe rc ise I nduc e d Bro nc ho spa sm E I B  F

• r Athle tic Oc c upa tio ns

 Milita ry, Po lic e , F ire fig hte rs

 De te rmine o ptima l tre a tme nt fo r E I B  Co ntra indic a tio ns sa me a s MT C, e xc e pt I HD, Ag e > 60 g e t E K G  No e xe rc ise within 4 ho urs.

E xe rc ise Cha lle ng e

Inha le a ir 20-25 de g re e s C Dry < 50% re la tive Humidity VE sho uld b e 40-60% MVV Ma x HR – 80-90% ta rg e t Ac hie ve ta rg e t VE

• r HR within 4-6 minute s

T e st spiro me try a t 5,10,15,20,a nd 30 min

E xe rc ise Cha lle ng e I nte rp

10% to 15% de c re a se is a b no rma l F

• llo w pa tie nt until Na dir is se e n

Give b ro nc ho dila to r if pa tie nt is no t b a c k to b a se line Do n’ t fo rg e t vo c a l c ho rd dysfunc tio n – lo o k a t F V lo o ps.

E xe rc ise Cha lle ng e E xa mple Spe c ific I nha la tio n c ha lle ng e s

Use ful in c o nfirming the dia g no sis o f

• c c upa tio na l a sthma a sso c ia te d with spe c ific

e xpo sure s. Only do ne in spe c ia lize d c e nte rs F a ll in F E V1 > 15% o ve r b a se line is the o utc o me Re q uire s o b se rva tio n fo r a t le a st 6 ho urs a fte r the c ha lle ng e

Spe c ific I nha la tio n c ha lle ng e s

 F irst line fo r OA in E uro pe , Ca na da Re se rve d fo r c a se s whe re the re is diffic ulty in ma king a dia g no sis Use ful fo r ne w c he mic a l e xpo sure s no t pre vio usly re po rte d a s huma n se nsitize rs

E va lua te hig h a nd lo w mo le c ula r we ig ht c o mpo unds

Co nside re d the “Re fe re nc e Sta nda rd”

Va nde npla s e t. a l. E ur Re spir J . 2014

Co nside ra tio ns fo r SI C

 Outc o me is % c ha ng e F E V1

 Mo nito r b o dy te mp a nd DL CO if HP a lso c o nside re d

 NSBHR me a sure d b e fo re the SIC a nd a t the e nd o f a ne g a tive SIC  A sig nific a nt inc re a se in po st-c ha lle ng e NSBHR pro vide s e vide nc e fo r a po sitive re spo nse whe n c ha ng e s in F E V1 a re inde te rmina te  Sputum e o sino phils a nd F e NO ma y he lp  E xpo sure s sho uld simula te wo rkpla c e c o nc e ntra tio ns a nd no t e xc e e d PE L / OE L

Re fe re nc e s

 1. Bo ra k J, L e fko witz RY, L inde B. Bro nc hia l hype r-re spo nsive ne ss: a te c hnic a l upda te . Oc c up Me d. Se pte mb e r 2018. do i:10.1093/ o c c me d/ kq y122  2. Ha llstra nd T S, L e uppi JD, Jo o s G, e t a l. E RS te c hnic a l sta nd a rd o n b ro nc hia l c ha lle ng e te sting : pa tho physio lo g y a nd me tho do lo g y o f indire c t a irwa y c ha lle ng e te sting . E urRe spirJ . 2018;52(5):1801033. do i:10.1183/ 13993003.01033-2018  3. Re dlic h CA, T a rlo SM, Ha nkinso n JL , e t a l. Offic ia l Ame ric a n T ho ra c ic So c ie ty T e c hnic a l Sta nd a rds: Spiro me try in the Oc c upa tio na l Se tting . Am J Re spirCrit Care Me d. 2014;189(8):983-

• 993. do i:10.1164/ rc c m.201402-0337ST

 4. Co a te s AL , Wa ng e r J, Co c kc ro ft DW, e t a l. E RS te c hnic a l sta nd a rd o n b ro nc hia l c ha lle ng e te sting : g e ne ra l c o nside ra tio ns a nd pe rfo rma nc e o f me tha c ho line c ha lle ng e te sts. E ur Re spirJ . 2017;49(5):1601526. do i:10.1183/ 13993003.01526-2016  5. Va nde npla s O, Suo ja le hto H, Aa se n T B, e t a l. Spe c ific inha la tio n c ha lle ng e in the d ia g no sis

• f o c c upa tio na l a sthma : c o nse nsus sta te me nt. E

urRe spirJ . 2014;43(6):1573-1587. do i:10.1183/ 09031936.00180313  6. T a n JHY, Che w WM, L a ppe rre T S, T a n GL , L

• o CM, K
• h MS. Ro le o f b ro nc ho pro vo c a tio n

te sts in ide ntifying e xe rc ise -induc e d b ro nc ho c o nstric tio n in a no n-a thle tic po pula tio n: a pilo t

• study. J T

ho rac Dis. 2017;9(3):537-542. do i:10.21037/ jtd.2017.02.70

All of the following te sts ar e use d in me dic al sur ve illanc e / sc r e e ning for

• c c upational lung

dise ase e xc e pt whic h one ?

• A. Spiro me try
• B. Bo dy ple thysmo g ra phy
• C. F

E V1

• D. F
• rc e d vita l c a pa c ity

E . E xe rc ise T e sting

Whic h one of the following is the most r e c e nt r e c omme nde d r e fe r e nc e value s for inte r pr e tation of spir

• me tr

y:

A.Glo b a l L ung I nitia tive

• B. NHANE

S I I I Ha nkinso n e t. a l. C.K nudse n e t. a l. D.Cra po e t. a l. E . Co a te s e t. a l.

Whic h o f the fo llo wing is c o nside re d a dire c t te st o f a irwa y re a c tivity

• A. Co ld a ir c ha lle ng e
• B. E

xe rc ise c ha lle ng e

• C. Me tha c ho line c ha lle ng e
• D. Ma nnito l c ha lle ng e

E . Spe c ific inha la tio n c ha lle ng e