2006 OPEN FORUM Abstracts
Flow-Volume Loop (FVL) in the 3-6 Year-old Patient at Arkansas Children's Hospital
Pamela K. Leisenring, RRT,
CPFT; Robert H. Warren, M.D.;
Arkansas Children's Hospital Pulmonary Lab at Little Rock, Arkansas.
Background: Successful introduction of FVL in children
less than 6 years of age has been reported in recent years, but data remains
limited and spirometry testing in this group is still not common practice.
Objective: Retrospective evaluation of the level of success in obtaining
clinically reliable FVL data in children at our institution beginning at 3
years of age and up to the day of the 6th birthday (the term
"preschool" will be used to describe this group of children).
Method: All
therapists that worked with this group in our Pulmonary Lab had the minimum
credential of Registered Respiratory Therapist. FVL testing was accomplished
using a standard FVL program on Collins brand pulmonary function equipment. For
clinical testing in this group, issues that might affect successful FVL
performance in young children were addressed. Examples included therapist
proficiency with FVL data, ways to reassure patients and parents, and methods
to increase patient focus on performing the task. Solutions included: 1) only
therapists with at least two years experience in pediatric FVL performed
testing with this group, 2) a child-focused educational video about the test
was developed for patients and parents to watch prior to testing, 3) patient
focus on the task was improved by having only the therapist and patient in the
testing room, and 4) therapist-patient interaction included a short play time
to gain the patient's trust before proceeding to practice and performance of
FVL technique. During the collection of clinical data a scale of 1 to 5, with 5
being the best, was used to rate the patient's level of success with the FVL
maneuver. The scale incorporated both the therapist's subjective assessment of
the patient's technique and objective goals for each level of success. Each
level addressed varying patient ability with level 3 yielding the lowest amount
of data accepted for interpretation. Level 5 required at least 3 good efforts
based on ATS criteria, level 4 required at least 2 good efforts, and both
included a goal of a minimum 3-second exhalation time. Level 3 required one
good effort (with other efforts generally consistent with the best one) and
included a goal of a minimum 2-second exhalation time. A respiratory therapist
evaluated data prior to submitting them to a pediatric pulmonologist who
verified whether results were acceptable prior to interpretation for clinical
use.
Results: Over the 26-month period
retrospectively evaluated, 459 FVL studies had been performed by preschool
patients. Some of these children performed the test more than once over this time
frame. The youngest was 2 years and 11 months (2y11m) of age and the oldest was
tested the day before his 6th birthday. Interpretable studies were
performed by 51% of patients with 29% of those at success level 3 and 22% of
them achieving success levels of 4 and 5 combined. The remaining 49% of
patients were unable to obtain even one acceptable FVL effort or were unwilling
to attempt the test. Of the 25 patients who achieved level 5, all were at least
4y9m old and 88% of those were 5y5m or older. Of the 74 patients
achieving level 4 success, 68% were 5y5m or older. There were 135 patients
who achieved level 3 and 4% of these were 3 years old. No 3 year old
achieved greater than a level 3 success rate and only 5 of them (16%) achieved
level 3 (reportable).
Conclusions: Of the clinical records examined, nearly
half of the 459 preschool studies did not meet the criteria expected of older
children. More flexible criteria for preschoolers apparently allowed some
success in obtaining clinically useful FVL data. The retrospective review also
revealed that factors such as attention to therapist experience, an educational
video for patients and parents, improving patient focus, creating a relaxed and
fun environment, praising children regardless of test performance, and
evaluation of data by a pediatric pulmonologist contributed to obtaining
successful clinical data in the preschool patient.