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.