The issue of PFT staff licensure or certification has recently been a topic of discussion on the LinkedIn Pulmonary Function Studies group and the Diagnostics section of the AARConnect discussion board. The overwhelming majority of those posting comments have been in favor of some form of licensure or certification. CPFT (Certified Pulmonary Function Technician) and RPFT (Registered Pulmonary Function Technician) certification is discussed most often but not surprisingly on the AARConnect board most posters feel that RRT (Registered Respiratory Therapist) certification should be required as well.

I don’t think there is any argument that pulmonary function tests should be performed by qualified personnel. I will also stipulate that possession of CPFT or RPFT certification is a reasonable step in that direction. I will disagree that RRT credentials should be a requirement. The ATS-ERS recommends:

“…that completion of secondary education and at least 2 yrs of college education would be required to understand and fulfill the complete range of tasks undertaken by a pulmonary function technician.

“For pulmonary function testing, an emphasis on health-related sciences (nursing, medical assistant, respiratory therapy, etc.) is desirable. Formal classroom-style training alone does not, however, establish competency in pulmonary function testing. Technicians who conduct pulmonary function testing need to be familiar with the theory and practical aspects of all commonly applied techniques, measurements, calibrations, hygiene, quality control and other aspects of testing, as well as having a basic background knowledge in lung physiology and pathology.”

However, despite the ATS-ERS recommendations what incentive is there to become a CPFT or RPFT? At the present time (with the exception of one state) there is no legal requirement for any form of licensure or certification in order to be able to perform pulmonary function tests anywhere in the USA. Even if you don’t include those performing office spirometry, it’s been estimated that over half the staff in all pulmonary function labs lack any kind of certification.

There is also no incentive from insurers. Although Medicare requires a physician to be “at the bedside” for infant pulmonary function testing for all other pulmonary function tests they merely state that testing be “furnished by qualified personnel”. The presumption on the part of all insurers is that the staff performing pulmonary function tests are supervised and monitored by a physician who is responsible for assuring that testing is being performed correctly. I understand the logic but for most PFT Labs the reality is probably different. I’ve had close to a dozen medical directors over the years and I have liked all of them and they have all been competent and knowledgeable pulmonary physicians but at the same time all of them were far too busy to be involved in day-to-day operations.

So what can or should be done? Without incentives of some kind not much is likely to happen. Some of those posting in the forums have advocated for state licensure of Pulmonary Function labs. To them I would say be careful what you wish for. Not only do we not need another layer of bureaucracy but the only state (New Jersey) that mandates that only credentialed staff be allowed to perform pulmonary function tests requires that they be a RRT. Strange as it may seem CPFT or RPFT certification alone is not sufficient to be able to perform any test other than spirometry in New Jersey.

It is more likely that insurers will eventually act to require PFT Lab accreditation and staff credentialing. This would probably occur as part of an overall program to decrease costs by improving diagnostic testing quality. I am not aware of any specific programs in this area, but the quality of medical care continues to be subjected to more and more sophisticated analyses and PFT lab accreditation could easily become part of an overall crusade to improve the care for patients with COPD or asthma.

A critical factor that seems to be overlooked in these discussions is the distinct lack of college-level courses in pulmonary function testing. What pulmonary function testing classes I am aware of are one-semester lecture courses that are part of a respiratory therapy or exercise physiology course. They may be adequate to orient students to some of the basic issues but they do not and cannot devote the time needed for many of the esoteric yet critically important issues involved in patient testing. One reason that adequate pulmonary function classes don’t exist is probably that pulmonary function testing is a niche field. It’s difficult to make a career out of pulmonary function testing. Many small and medium sized hospital don’t even have a pulmonary function lab and there are probably over ten times as many respiratory therapists as there are pulmonary function technicians.

Since there is no incentive for credentialing those hospitals and pulmonary function labs that do require that staff be credentialed have done so through a personal decision on the part of the hospital administration, lab administrator or medical director. A good question though, is if you make this a policy in your lab, will you be able to find enough (any!) credentialed staff to meet your needs? I was a PFT Lab manager in a large teaching hospital in Boston for over 20 years yet whenever a job opening was posted I rarely had any candidates with prior experience apply and only one candidate with a CPFT (and she decided not to leave her current job despite being offered an increase in pay). The only solution I had was to hire individuals with a degree in the life sciences and then train them.

The elephant in the room in this discussion is office spirometry. My experience is that those tasked with performing office spirometry (most often medical assistants or the equivalent) are most often woefully undertrained, inexperienced and lacking any knowledge about anatomy, physiology or testing systems. They are most often trained by another medical assistant and more time is usually spent learning how to enter patient information than in how to perform the test. Many of the posters on AARConnect and LinkedIn have advocated quite strongly that all pulmonary function testing, including office spirometry, should only be performed by credentialed staff but for office spirometry this just isn’t going to happen. Even the busiest physician office is never going to perform enough spirometry to justify the expense of hiring a specialist. The best we can hope for is that the office staff get some form of professional training. For lack of anything better, the AARC offers an office spirometry certificate that requires applicants to at least pass an exam.

It takes hard work to manage a quality pulmonary function lab. Requiring the lab staff to be credentialed may simplify this but does not change the fact that there will need to be ongoing education for existing staff and that new staff will need to be trained to the lab’s and hospital’s requirements. How many resources a lab decides it has to devote to training and education will to a large extent be determined by the availability of qualified staff, however the term “qualified” is determined.

One final point is that no matter how qualified a lab’s staff, qualifications alone do not ensure test quality. Regardless of who performs a test, test quality must always monitored continually.

Update: 

Most states now require RRT, CRT, CPFT or RPFT credentials in order to work in a Pulmonary Function Lab.  For a listing of what each state requires please see State Licensure Requirements for PFT Testing.

Links:

NBRC (CPFT and RPFT credentialing)

AARC Office Spirometry Certificate program

References:

Brusasco V, Crapo R, Viegi G. Standardisation of Lung Function testing: General considerations for lung function testing. Eur Respir J 2005; 26: 153-161

PFT Blog by Richard Johnston is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.