Eye was fooled

A couple of days ago I was reviewing (triaging, actually) the spirometry portion of a full panel of PFTs performed with pretty terrible test quality and was trying to decide if the technician responsible for performing the tests had made the right selections from the patient’s test results. I noticed that the FEV1 that had been selected was actually the lowest FEV1 from the all the spirometry efforts the patient made, and was trying to decide whether this was really the correct choice. We use peak flow to help determine which FEV1 to select and that particular spirometry effort appeared to have the highest and sharpest peak flow by a large margin:

particularly when compared to the other spirometry efforts:

But this was hard to reconcile given how low the FEV1 was relative to the others:

Test #1 Test #2 Test #3
Observed: %Predicted: Observed: %Predicted: Observed: %Predicted:
FVC (L): 1.71 41% 2.46 59% 2.39 58%
FEV1 (L): 1.24 39% 1.81 57% 1.77 55%
FEV1/FVC: 73 95% 74 96% 74 97%

Continue reading

Social Security Disability Evaluations

I was contacted recently by an individual with some questions about the pulmonary function testing needed for a Social Security Disability evaluation. With a small amount of research I was able to answer their questions but this brought up an interesting point and that is that despite the number of patients we see every year my lab only rarely performs any pulmonary function testing for disability evaluations. The reason I know this is because the Social Security Administration (SSA) has very specific requirements for the content and form of pulmonary function reports and we are very rarely asked for these reports.

The pulmonary function tests the SSA uses as part of a disability evaluation are:

  • Spirometry
  • Diffusing Capacity (DLCO)
  • ABG
  • Pulse Oximetry

Interestingly, lung volume measurements are not included. This is not specifically explained but it appears to be because evaluation for restriction is covered by the criteria for FVC and FEV1.

For all pulmonary function tests the SSA requires that the individual be medically stable, which they define as not:

  • Within 2 weeks of a change in prescribed respiratory medication.
  • Experiencing, or within 30 days of completion of treatment for, a lower respiratory tract infection.
  • Experiencing, or within 30 days of completion of treatment for, an acute exacerbation of a chronic respiratory disorder.
  • Hospitalized, or within 30 days of a hospital discharge, for an acute myocardial infarction (heart attack).

Continue reading

When is a change in FVC significant?

Most of the COPD patients that are seen in my lab tend to have little change in their FEV1 from visit to visit but their FVC often changes significantly. A change in FVC is usually related to how long a patient is able to exhale and this in turn is usually related to how well they are feeling at the time. This would seem to imply that a significant change in FVC, particularly for a patient with COPD, is, if not clinically significant, at least clinically important even when the FEV1 hasn’t changed.

The problem with this is that expiratory time can be affected by things other than how the patient is feeling. Dyspnea and fatigue, of course. As importantly some technicians are better at motivating patients than other technicians so it can also be related to which technician is performing their tests. Even when the same technician is involved however, there is no guarantee that the level of motivation or a patient’s response to that motivation will be the same.

So how do you know if a change in FVC clinically significant or not?

Recently a spirometry report from a patient with very severe COPD came across my desk. When comparing the results to those of the last visit I could see that there had been a small (but not significant) increase in FEV1 but at the same time there had been a large (and significant) increase in FVC.

Visit 1: Observed: %Predicted:
FVC (L): 1.28 36%
FEV1(L): 0.53 19%
FEV1/FVC: 41 53%
Visit 2: Observed: %Predicted:
FVC (L): 1.93 55%
FEV1(L): 0.60 22%
FEV1/FVC: 31 40%

Continue reading