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Adherence to Established Guidelines for

Preoperative Pulmonary Function Testing
Oleh W. Hnatiuk, Thomas A. Dillard and Kenneth G. Torrington

Chest 1995;107;1294-1297
DOI 10.1378/chest.107.5.1294

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lines.. FCCP.2 modify further management of the patient in the light of test results. Fifty-two (39%) requests did not meet ACP guidelines. 25 occurred in asymptomatic. easy to do. Requests for either set of guidelines. observation and believe that the ACP guidelines and partment of Medicine. Of the 31 studies that did not meet the American College of Physicians (ACP). To our knowledge. 39% of preoperative institution and utilize significant man-hours of techni. or possible upper airway WRAMC=Walter Reed Army Medical Center obstruction were found in the group of requests in which spirometry was not indicated. Orlando. MC. Washington DC 20307-5001 indications for preoperative spirometry. Most of these requests were found exclusively in preoperative care Requests for preoperative spirometry represent a The reasons for the popularity of preoperative significant portion of all screening spirometries spirometry are many. Ltc Thomas A. the literature does not We sampled 441 screening spirometries performed by support obtaining preoperative spirometry in such pa- the Walter Reed Pulmonary Function Laboratory over tients except for those undergoing only lung resection.chestjournal. "the percep- done at Walter Reed Army Medical Center tion that pulmonary function tests. tory of smoking. 107:1294-97) 20 to 84 years of age. preoperative spirometries represent a significant por. a 4-week period. Hayhurst3 states. FVC=forced vital capacity. Our hypo- 1294 Clinical Investigations Downloaded from www. 1993 at the annual meeting of the is supported by several recent articles questioning the American College of Physicians US Army Region. tion. "in many hospitals this request is made almost on Guidelines for ordering preoperative spirometry have reflex. ranging from (Chest 1995. Manuscript received May 16. how to interpret the results. Most of these requests were asso. 1994. Dillard.5'6 the Department of Defense or the Department of the Army.org by guest on August 21. FCCP." We agree with Hayhurst's *From the Pulmonary and Critical Care Medicine Service..Adherence to Established Guidelines for Preoperative Pulmonary Function Testing* Maj Oleh W. this is the first study designed Reprint requests: Maj. Spirometry re. De.5=forced mild spirometric abnormalities (n=14). USA. ACP=American College of Physicians. or how to American College of Physicians (ACP). Of the requests that did not meet ACP guidelines. PFT=pulmonary function test.are informa- (WRAMC). spirometry requests did not meet ACP guidelines. The ACP notes. in 1 s. contributes to the already high cost of medical care. morbid obesity. revision accepted October 6. Walter Reed Army Medical Center. had a mean age of 59 years (± 14 years). The opinions contained herein represent solely the views of the utility of preoperative spirometry in predicting post- authors and are not to be construed as representing the views of operative complications. In conclusion. with little regard for why the tests are been proposed by Tisil and more recently by the indicated. guidelines. Bethesda. and Col Kenneth G. surgery. Patients in the analyzed group unnecessary spirometries being performed.. FEF50%=forced ciated with either normal spirometry (n=34) or only expiratory flow at 50% vital capacity. current. USA. and a current/prior his- characterized why these requests were being generated. Hnatiuk. Md. USA. This viewpoint Presented on November 20. One hundred thirty-eight (31%) of these We recommend stricter adherence to the ACP guide- were done preoperatively and complete data were lines as a means of decreasing the number and cost of available in 135 cases. No cases of moderate obstruc. Hnatiuk. The large number of these requests tive. 21 met Tisi's broader guide. the accompanying review4 both suggest that preop- Washington DC.5 s. FIF50%=forced inspiratory flow at 50% vital quest was not indicated. Walter Reed Army Medical Center. Fla. Most cian time. Pulmonary Critical Care Med. and well accepted by the patient has consumes many man-hours of technician time and led to their liberal use"2 However. MC. Torrington. FEVO. capacity. MC. PEFR=peak expira- tory flow rate. surgery not involving lung resection. expiratory volume in 0. 2009 Copyright 1995 by the American College of Chest Physicians . during a 4-week tion of all requests for screening spirometry at our study period at our institution. severe restrictive pattern. FCCP Guidelines for ordering preoperative spirometry have patients older than 70 years of age (n=13) and the mor- been proposed by GM Tisi (1979) and more recently by bidly obese (n=4). However. Key words: respiratory function test. to determine compliance with guidelines regarding icine Service. DCI Protocol 1761. We determined the percentage of these of the patients had been referred because of age greater requests that did not meet the ACP guidelines and than 70 years. or prior smokers. and the Uniformed Services University of the erative spirometry is an overutilized modality in Health Sciences. FEVI=forced expiratory volume vealed severe obstruction in only one case when the re.

the reason for the request or any of the other patient data. Conduct of this study was approved by the mately.'3 Ideal body weight was determined by using the maximum recommended weight from the "medium frame" col- ACP guidelines. (n=13) or the patient was morbidly obese (n=4). abnormal flow-volume current or former smokers. 1995 1295 Downloaded from www.'2 The purpose of evaluating pulmonary function The questionnaire. and FEVI/FVC were derived from Morris et al. mixed Thirty-one requests did not meet either guideline. FVC -<80% predicted and FEV. patients in the analyzed group had a mean age of 59±14 underwent routine spirometry consisting of forced expiratory and years. All requests identifying patients as being preoperative were indicated. eight (31%) of these were done preoperatively. severe included in the study for further analysis.org by guest on August 21. we hope our findings will assist in reducing WRAMC Department of Clinical Investigation. along with data regarding the patient's preoperatively is to identify individuals at increased CHEST / 107 / 5 / MAY. all patients completed a brief ques- tionnaire (Appendix). 50 to 64% DISCUSSION predicted. The questionnaire. with permission. Values for forced expiratory flows were (Table 3). < 50% predicted. rehabilitation programs *Uncharacterized pulmonary disease defined by authors as pulmo- nary symptoms or history of pulmonary disease and no PFTs within 60 days. Colo). ranging from 20 to 84 years of age. Heights and Weights for Men and Women. One hundred thirty- nary function testing by their primary care physicians were in. Boulder. who was blinded to the results of spirometry. Of this inspiratory spirometry.Table 1-ACP Guidelines for Preoperative Spirometry Table 2-Tisi's' Guidelines for Preoperative Spirometry* Lung resection Coronary artery bypass graft and (smoking history or dyspnea) Age >70 years old Upper abdominal surgery and (smoking history or dyspnea) Obese patients Lower abdominal surgery and uncharacterized pulmonary Thoracic surgery disease.5 s (FEVI/FEVo5) (Table 4). 2009 Copyright 1995 by the American College of Chest Physicians . No cases of moderate obstruction. or upper airway obstruction were The spirometry was separated from the questionnaire. In this group. It was found in the group of requests in which spirometry then interpreted by one of the investigators. height. After completing the questionnaire. who was blinded to was not indicated. weight. Patients monary function laboratory.'4 recognized guidelines. and age were separately reviewed by one of the investigators.5.1. Testing followed ther normal spirometry (n=34).11 Severity scoring was accomplished using the following criteria: mild. The Twenty-one requests that failed to meet ACP following standardized criteria were used to interpret the spirom. moderate restrictive patterns and one had a mixed pacity (FVC) plus forced expiratory volume in ls (FEVy). seated position. cluded in the data collection. FVC >80% predicted and FEVI/ FVC>90% predicted. 441 screening During a 4-week period from March 15 to April 8. peripheral loop and FEV1/peak expiratory flow rate (FEVI/PEFR) >0. restrictive pattern. 52 patients (39%) did not meet ACP guide- using a heated pneumotachograph (Cybermedic screener.7 L/s or FEVI/forced expiratory flow in 0. (STATISTIX 4. umn of the 1983 Metropolitan Life Insurance Company Table of quests based on previously published and well. Spirometric measurements were made group. Upon arrival in the WRAMC pul. 1993.6 or forced expiratory flow at 50% vital capacity/forced inspiratory vascular surgery (n=7) and joint or extremity surgery flow at 50% vital capacity (FEF50%/FIF50%) > 1 or FIF50% < (n=6) were the most commonly planned procedures 1. mild obstructive published guidelines for performance of pulmonary function tests (PFT)7-10 and all tests were accomplished with patients in the defects (n=4). In defect. we attempt to identify reasons Data analysis was accomplished using a software package why unnecessary tests are being generated. XL lines. guidelines met Tisi's broader guidelines either be- etry: normal spirometry. flattened. Three other cases were associated with obtained from the effort with the largest sum of forced vital ca.* particularly if the surgical procedure will be prolonged Upper abdominal surgery or extensive Smoking history and cough Other surgery and uncharacterized pulmonary disease. was then collected and coded. 65 to 80% predicted. along with a copy reveal severe obstruction when the request was not of the patient's spirometry results. 25 of these 31 cases. By characterizing this group of re.0). to determine if the request met either ACP or other published guidelines for preoperative pulmonary function testing (Tables 1 and 2). 1993. or mild restrictive patterns (n=9) upright. all spirometries were performed by the WRAMC Pul- ambulatory patients 18 years of age or older referred for pulmo. Complete data were available in 135 cases. FVC -< 80% predicted and FEVI/FVC < 90% predicted. Normal values for FEVy. Morbid obesity was defined as 45 kg or 100% over ideal thesis is that many of these requests do not meet the body weight. .* Any pulmonary disease particularly in those who might require strenuous postoperative *From reference 1. In only one case did spirometry minimum of three efforts. restrictive pattern. Ulti.90% predicted. obstructive ventilatory defect.chestjournal. monary Function Laboratory. pos. >. moderate. FVC>80% cause the patient's age was greater than 70 years old predicted and FEV1/FVC<90% predicted. on a ventilatory defect. patients were asymptomatic sible upper airway obstruction. RESULTS METHODS From March 15 to April 8. Most of these requests were associated with ei- and CM5-Cybermedic Inc. the number of needless preoperative spirometries. FVC. and severe.

2009 Copyright 1995 by the American College of Chest Physicians . and that morbid obesity has been 2 Preoperative pulmonary function testing: American College of Physicians position statement. studied. in another recent review article on the same topic.2 Our study showed these guidelines are policy will miss very few patients with significant not being followed in over one third of cases. Indications for pulmonary 1 296 Clinical Investigations Downloaded from www. tuberculosis. should result in fewer inappropriate requests for nary function testing exists in the recent pulmonary preoperative spirometry in the future. 4 Zibrak JD. the authors state 1."2 To our knowledge. defect leg vein stripping) Moderate restrictive pattern 3 (2) 5 (4) Gynecologic surgery (hysterectomy [2].." Obesity and age are not included in their rec. Have you ever smoked? How old when started? How old when "be recommended when patients being prepared for stopped? On the average. no study has ever attempt to alter that risk or to plan a different oper. many ob. what type of surgery is planned? 2. how many packs per day do (did) you abdominal surgery are found to be cigarette smok. Our methods also allowed us to identify the phy- gists may be unaware of these guidelines. spirometric abnormalities. mastectomy. **One each: hernia. that "it may be reasonable to perform this test pre. No. Our study demonstrates that such a icine journal. This cumstances in which these tests assist in clinical de- allows the referring physician either to intervene to cision making. any disease requiring removal of part of the proposes that heavy smokers should have preopera. Guidelines for obtaining preoperative spirom. ACP guidelines. At our institution. In recent extensive review article by Zibrak and O'Donnelll5 on indications for preopera. Table 3-Spirometric Interpretations (n=135) Table 4-Planned Surgical Procedures in Patients Not Meeting Either ACP or Tisi's Guidelines (n=31)* Not Indicated. 4 Severe obstructive defect 1 (1) 1 (1) ovarian cancer. emphysema. In his 1993 editorial. APPENDIX tive pulmonary function testing. Indicated.. herniated disk. Celli16 pointed out that studies address. Hayhurst3 also cancer. Support for Ongoing utilization review and physician education this more liberal approach to preoperative pulmo.org by guest on August 21. Marton K. extensive If yes. Preoperative evaluation of pulmonary function. Normal spirometry 34 (25) 40 (29) Peripheral vascular surgery 7 Mild obstructive defect 4 (3) 5 (4) Joint or extremity surgery (hip or 6 Mild restrictive pattern 9 (7) 13 (9) knee surgery [3]. O'Donnell CR. and target our educational efforts at these groups. (%) No. has your breathing changed since then? tobacco use" in patients undergoing coronary artery 3. (%o) Procedure No. 87:161-63 guidelines "until further studies better define cir. Have you ever been diagnosed as having any of the following? ers. or current/former asymptomatic smokers de. lung. most preoperative clinical factors in predicting postoperative pulmo- requests are generated by anesthesiologists and sur. sicians or surgical services ordering most preopera- tain routine spirometry in the elderly. Ann Intern Med 1990. none of the above? tive pulmonary function testing. 119:293-310 are conflicting. neurofibroma. Have you had a breathing test at WRAMC in the last 60 days? operatively if there is a history of . Clinic or service of requesting doctor? bypass grafting. chronic bronchitis. 112:793-94 poorly studied. smoke? 5. Is this test being done in preparation for surgery? Yes or No. transurethral prostatectomy. lower extremity Mixed/mild obstructive 1(1) 1(1) amputation. Until these areas are further geons. none of the above? However.chestjournal. Do you currently have any of the following? Shortness of and age over 70 years on his list of indications. lung ommendations. pelvic mass) Moderate obstructive defect 0 1 (1) Exploratory laparotomy (intestinal 3 Mixed/moderate 0 5 (4) fistula. Preoperative pulmonary function testing. hoarseness. spite the existence of the ACP guidelines. Although some of our surgeons and anesthesiolo. REFERENCES ing whether smoking and age are independent risk 1 Tisi GM. cough. literature. morbidly tive spirometries that did not meet ACP guidelines obese. These conflicting data undoubtedly 3 Hayhurst MD. nephrolithiasis) obstructive defect Hemorrhoidectomy 3 Mixed/severe obstruction 0 7 (5) Head and neck malignancy 3 Severe restrictive pattern 0 3 (2) Other 5* Possible upper airway 0 2 (1) Total 31 obstruction Total 52 (39) 83 (61) *From reference 1. wheezing. Am factors for perioperative pulmonary complications Rev Respir Dis 1979. sarcoidosis. risk for perioperative pulmonary complications. He includes obesity 6. Asthma. Respir led the ACP to recommend a more rigid set of Med 1993. colectomy. nary complications. They also state that spirometry can 4. breath. If yes. shoulder arthroplasty. we recommend stricter adherence to the etry were published by the ACP in an internal med. interstitial fibrosis. shown that spirometry adds to any of these three ative strategy.

Harris GD. 682 9 Ferris BG. 112:763-71 1987 update. Page CP. eds. Standardization of spirometry: a summary of 16 Celli BR. Standardization of spirometry. Ann Intern Med 1986. Weg JG. The risks of surgery 1987 update. 104:540-46 8 American Thoracic Society. Clin Chest Med 1993. 118(pt 2):1-120 nary function testing. 2009 Copyright 1995 by the American College of Chest Physicians . 1995 1297 Downloaded from www. Diagnosis of upper airway ob- ing postoperative pulmonary complications: is it a real prob. et al. Liss HP. Crapo RO. ATS Statement-Snowbird work. In: Mor- 6 Lawrence VA. et al. 14 1983 Metropolitan Life Insurance Table of Heights and Weights shop on standardization of spirometry. Clinical pulmonary before abdominal operations: a critical appraisal of its predic. 1986. 108:217-20 5 Williams-Russo P. struction by pulmonary function testing. What is the value of preoperative pulmonary func- recommendations from the American Thoracic Society: the tion testing? Med Clin North Am 1993 77:309-25 CHEST / 107/ 5/ MAY. Crapo RO. function testing. Benotti PN. function testing. Ann Intern Med 1990.chestjournal. Salt Lake City. 136:1285-98 in obese patients. Bistrian BR. 152:1209-13 12 Morris AH. ed. Indications for preoperative pulmo- Respir Dis 1978. et al. 11 Rotman HH. 1984. Spirometry. New York: Macmillan. Am Rev Respir Dis 1979. 9-27 7 American Thoracic Society. O'Donnell CR. 13 Pasulka PS. Am Rev Respir Dis 1987. Arch Intern Med 1989. Chest 1975. Kanner RE. Normal and ther- 119:831-38 apeutic nutrition. Preoperative spirometry ris AH. Charlson ME. 17th ed. 68:796-99 lem? Arch Intern Med 1992. Am Rev 15 Zibrak JD. Predict. 149:280-85 Society. 14:227-36 10 Gardner RM. Utah: Intermountain Thoracic tive value. MacKenzie R. Ann Intern Med 1988. for Men and Women. In: Robinson CH. Kanner RE. et al. Epidemiology standardization project.org by guest on August 21.

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