Therapist Driven Protocols in the PF lab“Did the Doctor really

order a complete PFT”

Katrina M. Hynes, MHA RRT RPFT Clinical Education Manager

Chair – AARC Diagnostic SectionAdjunct Faculty – University of Minnesota, Mayo Clinic

Conflict of Interest

I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is

not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of

emphasis.

Objectives

• Discuss the drivers for therapist driven protocols (TDPs) in the PFT Lab

• Understand the applications of TDPs in PF testing

• Apply TDPs using case-based scenarios

Therapist Driven Protocols in Respiratory Care

Respiratory Care 1981; 26(5):430-436

Respiratory Care 1989; 34(3):185-90

Respiratory Care and Sleep Medicine 2002 Vol. 11 •Issue 3 • Page 45

Therapist Driven Protocols in Respiratory Care

• Conclusion

• Most would agree that it simply makes no sense to invest in resources to perform a service that is not needed

• Departments are short-staffed with increasing work loads that may reduce the ability to provide quality care while at the same time using valued resources to perform unnecessary care that will make no difference

Mayo Clinic’s Pulmonary Function TDPs

• Premise/goals

• “Right tests” at the “right time”

• Reduce the number of unnecessary procedures

• Lower costs for the patients

• Increase access

Mayo Clinic’s Pulmonary Function TDPs

• Patient safety!

• If undocumented low

SpO2 notify ordering MD

Mayo Clinic’s Pulmonary Function TDPs

• System allows for MD override

Normal Spirometry and DLCO VA – No TLC

Normal Spirometry and DLCO VA – No TLC

• 51-year-old gentleman who came to Mayo for health assessment in the executive health program

• PMH

• Asthma

• Patient developed asthma as a child. He relates it to exposure to agricultural dusts

• Allergy shots ages 16-19 with good results. After that he noted his symptoms had diminished.

• Currently does not take medication.

• Assessment completed

Restrictive Protocol – No BD following non-responsive previous test

Restrictive Protocol – No BD following non-responsive previous test

• 23 y.o. with a history of Granulomatous-lymphocytic interstitial lung disease (GLILD) associated with common variable immune deficiency.

• GLILD is a lung complication of common variable immunodeficiency disorders (CVID). It is seen in approximately 15% of patients with CVID. It has been defined histologically as the presence of (non-caseating) granuloma and lymphoproliferation in the lung.[

• No airway hyperreactivity associated with the disease

Restrictive Protocol – No BD following non-responsive previous test

• This is an 82-year-old male with known asbestosis and chronic lung disease

• Asbestosis is long term inflammation and scarring of the lungs due to asbestos exposure.

• No wheezing or hyperreactivity noted in hx

IMPRESSION:

1. Indeterminate pulmonary nodules.

2. Right pleural effusion with associated rounded

atelectasis in the right lower lung.

3. Calcified pleural plaques.

4. Scattered areas of sub-pleural fibrosis.

Neuromuscular disease protocol

Neuromuscular disease protocol

• ALS, Multiple Sclerosis

• Chronic Fatigue Syndrome

• Dermatomyositis

• Fibromyalgia

• Guillain Barre

• Muscular Dystrophy

• Paralyzed Diaphragm

• Myasthenia Gravis

• Parkinson’s

• Polymyalgia Rheumatica

• Polymyositis

• Post Polio

• Stroke

• MVV < 30 times FEV1

Neuromuscular disease protocol

• 62 y.o. female with current and past medical history

• Fibromyalgia and fatigue.

• Obstructive sleep apnea, on BiPAP and supplemental oxygen

• Right hemidiaphragmaticdysfunction.

• Truncal obesity.

Neuromuscular disease protocol

• History of present illness

• Possible neurological deficit

• Best description of the problem or concern: numbness, tingling, weakness or paralysis

• numbness right leg

• PMH

• Coronary artery disease s/p CABG

• S/P diaphragm elevation

• Vertigo with exertion

• Generalized weakness and exhaustion

Non-specific Pattern protocol

• Reduction in FVC, FEV1

• Normal ratio

• Normal TLC

• Characterize using sRaw or sGaw

CHEST 2009; 135:419–424

Non-specific Pattern Protocol

• 60 y.o. with tonsillar cancer, post chemotherapy and radiotherapy without any surgery

• Aspergillus pneumonia post therapy

• Bronchiectasis and nodules

Non-Specific Pattern Protocol

• 66-year-old who carries a diagnosis of limited scleroderma and asthma-type reactive airway disease syndrome

• Current Meds

• Symbicort and as needed albuterol

IMPRESSION: Similar CT findings

consistent with fibrosing interstitial

pneumonia, inconsistent with UIP

DLCO VA Abnormal Protocol

Rest and Exercise Oximetry TDPs

Rest and Exercise Protocol

• Severe emphysema. Persistent diffuse bronchiectasis with increased mucous plugging, predominantly within the left lower lobe.

Next Slide

Rest and Exercise Protocol

Rest and Exercise Protocol

• 67-year-old man from Arkansas returns for evaluation and reassessment of interstitial lung disease

IMPRESSION:

1. Positive for acute pulmonary

embolism. Multiple bilateral

segmental and subsegmental

pulmonary emboli without CT

evidence of right heart strain.

2. Stable findings of lower lung

predominant fibrotic interstitial

lung disease

Rest and Exercise Protocol

Therapist Driven Protocols in the PF Lab

• Summary

• They can be implemented with consensus of the medical/laboratory leadership

• Reduce clinically unwarranted tests

• Allow resources to be allocated efficiently and provide the right tests when needed

Questions?