MedStore Medical Supplies YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Enhance your learning with Evolve Student Resources. These online study tools and exercises can help deepen your understanding of textbook content so you can be more prepared for class, perform better on exams, and succeed in your course. Activate the complete learning experience that comes with each http://evolve.com/Mottram/Ruppel/ If your school uses its own Learning Management System, your resources may be delivered on that platform. Consult with your instructor.
has already been revealed, the code may have been used and cannot be re-used for registration. To purchase a new code to access these Place valuable study resources, simply follow the link above. Sticker Here REGISTER TODAY! You can now purchase Elsevier products on Evolve! Go to evolve.com/shop to search and browse for products. Ruppel’s Manual of Pulmonary Function Testing Ruppel’s Manual of Pulmonary Function Testing T WELF TH EDITION Carl D.
Mottram, RRT, RPFT, FAARC Associate Professor of Medicine President – PFWConsulting LLC Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 RUPPEL'S MANUAL OF PULMONARY FUNCTION TESTING, TWELFTH EDITION ISBN: 978-0-323-76261-8 Copyright © 2023 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher.
Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2017, 2013, 2009, 2003, 1998, 1994, 1991, 1986, 1982, 1979, 1975. Senior Content Strategist: Yvonne Alexopoulos Content Development Specialist: Andrae Akeh Publishing Services Manager: Shereen Jameel Senior Project Manager: Manikandan Chandrasekaran Design Direction: Julia Dummitt Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 List of Contributors The editor(s) would like to acknowledge and Katrina M. Hynes, MHA, RRT, RPFT offer grateful thanks for the input of all previous Sr.
Manager, Customer Education editions’ contributors, without whom this new People and Culture edition would not have been possible. Vyaire Medical Inc. Mettawa, IL Susan Blonshine, BS, RRT, RPFT, FAARC, AE-C CEO and President David A. Kaminsky, MD Management Professor of Medicine TechEd Consultants, INC.
Pulmonary and Critical Care Medicine Mason, MI University of Vermont; Attending Physician Jeffrey M. Haynes, RRT, RPFT, FAARC Pulmonary and Critical Care Medicine Clinical Coordinator University of Vermont Medical Center Pulmonary Function Laboratory Burlington, VT Elliot Health System Manchester, NH v Preface The primary functions of the lung are oxygenation • Each test section includes criteria for accept- of mixed venous blood and removal of carbon diox- ability and repeatability, as well as interpretive ide. Gas exchange depends on the integrity of the strategies with criteria that are organized to help entire cardiopulmonary system, including airways, those who perform pulmonary function tests pulmonary blood vessels, alveoli, respiratory mus- adhere to recognized standards. cles, and respiratory control mechanisms.
A few • Most of the testing criteria are based on the pulmonary function tests assess individual parts of American Thoracic Society and European the cardiopulmonary system. However, most lung Respiratory Society (ATS-ERS) statements, function tests measure the status of the lungs’ com- with a few based on the clinical practice ponents in an overlapping way. guidelines of the American Association for This twelfth edition describes the most common Respiratory Care. pulmonary function tests, their techniques, and • The interpretive strategies are presented as a se- the pathophysiology that may be evaluated by each ries of questions that can be used as a starting test.
Topics covered include the following: point for test interpretation. In this edition, we • Basic tests of lung function, including spirometry, include a flowchart process for systematically in- lung volume measurements (i., body plethys- terpreting the basic lung function tests. mography, nitrogen washout, and helium dilu- • Case Studies with real-life patient scenarios, tion), diffusing capacity, and blood gas analysis questions, and discussion topics are included at • Ventilation and ventilatory control, cardiopul- the end of the chapters. monary exercise tests, and pediatric and infant • How To boxes populate specific testing chapters.
pulmonary function testing These are step-by-step guides for performing • Specialized test regimens that focus on exhaled function tests. When possible, we provide illus- nitric oxide measurements, forced oscillation trations. These procedures take the guesswork techniques, metabolic studies, disability deter- out of performing an accurate test. mination, and preoperative evaluation • The Evolve Learning Resources feature updated • Bronchial challenge tests that assist the clinician Case Studies in PowerPoint format so that in- in characterizing the hyperreactivity of the airways structors can utilize them during class discus- • Pulmonary function testing equipment, sions.
Clinical Scenario slides, organized by quality assurance, and reference values and disease process, provide an in-depth case anal- interpretation ysis, with figures and charts noting lab values and treatment options. Instructors and student DISTINCTIVE FEATURES study groups can use these to supplement their own clinical experiences. The twelfth edition includes many of the features from the previous editions: TEXT UPDATES • Learning objectives for entry-level and advanced practitioners are again included at the beginning • Chapter 1 includes updates related to the 2019 of each chapter. ATS-ERS technical standard.
vi Preface vii • Chapter 2 is updated per the 2019 ATS-ERS r eference for technologists and physicians. Because Technical Standard published in 2019. of the wide variety of methods and equipment used • Chapter 3 is now aligned with the 2017 ATS-ERS in pulmonary function evaluation, some tests are technical standard for the Global Lung Initiative discussed in general terms. For this reason, read- (GLI).
ers are encouraged to use the selected bibliogra- • The ERS published their methacholine technical phies provided. The presentation of indications, standard in late 2017 and their indirect testing pathophysiology, and the clinical significance of (e., mannitol, exercise, hyperventilation, cold various tests presumes a basic understanding of air) technical standard in 2018. Both have been cardiopulmonary anatomy and physiology. Again, incorporated into Chapter 9.
readers are urged to refer to the General References • Updates to several sections are included in included in the selected bibliographies to refresh Chapter 10: their background knowledge of lung function. The ○ Respiratory muscle strength testing— terminology used is that of the American College of Respiratory Muscle Strength testing section Chest Physicians (ACCP)-ATS Joint Committee on has been updated to include the 2019 ERS Pulmonary Nomenclature. In some instances, test Testing Standard and the 2017 reference set names reflect common usage that does not follow for children the ACCP-ATS recommendations. ○ Exhaled nitric oxide—Exhaled nitirc oxide test- ing has been updated to include the 2017 ERS EVOLVE ANCILLARIES Technical Standard on Exhaled Biomarkers and the 2021 ATS Clinical Practice Guideline • Evolve is an interactive learning environment on the Use of FENO to Guide Treatment designed to work in coordination with Ruppel’s ○ Spirometry sections modified based on new Manual of Pulmonary Function Testing, twelfth 2019 ATS-ERS technical standard edition.
• Chapter 11 has been updated to reflect new For the student, our Evolve Learning Resources equipment and vendors. include: • Chapter 12 covers the new version of QMS01, • Practice tests to help students apply the knowl- the quality management system document. The edge learned within the text components of the ATS Pulmonary Function • Conversion and correction factors Laboratory (PFL) Accreditation Program are • Helpful equations included. • Reference tables • Chapter 13 includes the new GLI diffusion of • Sample calculations lung capacity for carbon monoxide reference, • Electronic image collection consisting of images published in 2019 and the 2020 GLI Lung from the textbook Volume reference set.
For the instructor, our Evolve Learning Resources As in previous editions, each chapter includes include: self-assessment questions. The questions in this edi- • PowerPoint presentations of Case Studies and tion are divided into entry-level and advanced cat- Clinical Scenarios egories. The answers may be found in Appendix A. • Test Bank containing approximately 600 A selected bibliography at the end of each chapter questions is arranged according to topics within the chapter, • Electronic image collection consisting of images including standards and guidelines.
from the textbook Instructors may use Evolve to provide an USING THIS BOOK Internet-based course component that reinforces and expands the concepts presented in class. Evolve This manual is intended to serve as a text for stu- may be used to publish the class syllabus, out- dents of pulmonary function testing and as a lines, and lecture notes; set up virtual office hours viii Preface and e-mail communication; share important dates instructors to post examinations and manage their and information through the online class calen- grade books online. For more information, visit dar; and encourage student participation through http://evolve.com or contact an Elsevier chat rooms and discussion boards. Evolve allows sales representative.
A u t h o r ’s C o m m e n t a r y I would like to ac- stages of his career, and I learned so much about knowledge a few his passion for pulmonary physiology testing. key colleagues and Paul Scanlon, David Driscoll, Bruce Staats, and friends who have Ken Beck treated me as they would a pulmonary contributed to my fellow in training and later as a colleague. These professional suc- individuals were tremendously instrumental in my cess. First, I had understanding of pulmonary physiology and my the honor of be- professional development.
Jeff Ward, MEd, RRT, ing educated and FAARC, Mayo Clinic’s former respiratory therapy mentored by Drs. program director, started me on my professional Fred Helmholtz journey with the mindset of inquiry and yearning and Robert (Bob) for knowledge. I would not be the professional I am Hyatt, both giants today without all of their guidance and tutelage. in their field.
I would personally like to thank the contributors Helmholtz, along with colleagues, assisted in the to this edition, Susan Blonshine, Dr. David Kaminsky, development of the G-suit during World War II and Jeffrey Haynes, and Katrina Hynes, for their excel- the nitrogen washout test. After his retirement, he lent subject review. I would also like to thank the continued to have a significant impact on the field staff members and leadership of the Mayo Clinic through his contributions to the National Board Pulmonary Function Laboratories, especially Drs.
for Respiratory Care’s credentialing system and Alex Niven and Kaiser Lim. They continue to carry specifically the initiation of the pulmonary func- forward the incredible work the laboratory has been tion credentialing exam. Hyatt was the first to renown for since its inception by championing Mayo’s describe the flow-volume curve and tests for evalu- primary value of “the needs of the patient come first.” ating respiratory muscle strength. I had the privi- lege of sharing an office with Dr.
Hyatt in the later Carl D. Mottram, RRT, RPFT, FAARC ix MedStore Medical Supplies Contents CHAPTER 1 Indications for Pulmonary Function Testing, 1 CHAPTER 2 Spirometry, 41 CHAPTER 3 Diffusing Capacity Tests, 84 CHAPTER 4 Lung Volumes, Airway Resistance, and Gas Distribution Tests, 109 Jeffrey M.