Pulmonary function testing in young children

doi:10.1016/j.prrv.2009.03.001

Paediatric Respiratory Reviews

Volume 10, Issue 4, December 2009, Pages 208-213

https://doi.org/10.1016/j.prrv.2009.03.001 Get rights and content

Summary

Specific knowledge on paediatric physiology and adapted material are necessary to perform pulmonary function testing (PFT) with reliable results in young children (2–6 years). During this age period, although co-operation is minimal, successful testing data can greatly be enhanced because of team experience and motivation. A range of equipment able to measure resistance and spirometry is now widely available, but technical issues have to be considered before its use in young children. In this review, we detail equipment, data collection, reference values and clinical applications for resistance measurements (forced oscillation technique, interrupter technique and plethysmography) and spirometry. All these non-invasive techniques can be easily repeated in order to monitor treatment and lung development in congenital and early-acquired respiratory diseases.

Section snippets

General considerations

Young children are known to be emotionally vulnerable and have a short attention span. Therefore, in order to perform accurate PFT on such young children, it is essential for laboratory staff to be aware of the age-related challenges. Time and patience are a necessity, as well as enthusiastic rewards for the child's efforts. To make the child feel comfortable, adapted seats and games to play between measurements are essential. The parents’ presence can be warranted depending on the laboratory

Resistance measurement

Respiratory resistance (Rrs) reflects the relationship between changes in airway pressure and the corresponding airflow. In non-invasive airway-resistance measurements, the change in airflow is recorded at the airway opening, and alveolar pressure has to equilibrate mouth pressure at the time of measurement. For all resistance techniques, freedom of the upper airways is required. In young children, enlarged tonsils are frequently present, which makes inspection of the child's throat prior to

The forced oscillation technique (FOT)

An extensive methodological article has been published on this technique² and a specific chapter on the FOT is included in the ATS/ERS statement.¹ Briefly, an external pressure wave is applied to the respiratory system, usually at the mouth, and the resulting pressure–flow relationship is analysed in terms of respiratory impedance (Zrs). Zrs encompasses the Rrs and its reactance (Xrs). The measured Rrs is calculated from the pressure change in phase with flow, while the Xrs is derived from the

The interrupter resistance technique (Rint)

In the Rint technique, the change in mouth pressure during a brief airflow interruption is divided by the airflow measured immediately before the interruption to calculate the airway resistance. To reliably measure the pressure change that corresponds to the measured airflow, instantaneous interruption and assessment of pressure are required. Further details on the background of the Rint technique can be found in the ATS/ERS statement.¹

Specific airway resistance

In the classical plethysmographic technique, airway resistance (Raw) is calculated from ‘Δ volume (V)’/’Δ gas flow (V′)’ and ‘Δ alveolar pressure (Palv)’/ΔV relationships, which are recorded during normal breathing or panting (ΔV/ΔV′), and ventilation against a closed shutter (ΔPalv/ΔV). It has been suggested that direct measurement of sRaw (Raw × thoracic gas volume (TGV)) is possible from the slope of the ΔV′/V relationship, omitting the TGV (ΔPalv/ΔV) measurement, which is difficult to

Spirometry

Spirometry is probably the most widely performed PFT in school children, adolescents and adults. The possibility of obtaining a reproducible flow–volume curve in young children has recently been reported, and despite relatively few data in this age group, knowledge is sufficient to give advice on the way to perform spirometry in young children.¹ Young children may be unable to blow for 1 s, but this does not preclude reliable and reproducible measurement. In that case, forced expiratory volume

Conclusion

A number of PFTs are easy to perform in young children and are now commercially available. Some of these techniques are convenient for field studies or outpatient measurement, whereas others are better suited to the physiology department. It is essential to know the practical aspects and limitations of the techniques. Further studies will increase our knowledge to make better use of these techniques in clinical practice.

Conflict of interest statement

The author declares no conflict of interest.

Educational aims

•
To perform an overview of easily available techniques for pulmonary function testing (PFT) in young, awake children.
•
To explain the basic physiological principles that PFT in young children rely upon.
•
To describe the data collection procedures for the different techniques used.
•
To give references for normative values for resistance measurements and spirometry in young children.
•
To discuss the clinical applications of the different techniques according to the current knowledge.

Practice points

•
Resistance and spirometry are feasible in young children with a success that increases with age, from 3 to 6 years of age.
•
Most of the technical issues have been clarified and recommendations are available for most of the described techniques.
•
Baseline value might not be the sensitive enough to discriminate between healthy and sick young children, and bronchial responsiveness might be a better way to detect lung function impairment.

Research directions

•
Some technical aspects as well as data collection issues have to be addressed. These include: the best algorithm for Rint technique, which FEVt is the more relevant parameter, how to express bronchial changes, absolute value and percentage predicted ranges for different populations.
•
An international reference database could allow for the establishment of reference values from a large number of young children.
•
More studies on bronchial responsiveness in healthy individuals are needed to validate

CME Section

This article has been accredited for CME learning by the European Board for Accreditation in Pneumology (EBAP). You can receive 1 CME credit by successfully answering these questions online.

(A)
Visit the journal CME site at http://www.prrjournal.com.
(B)
Complete the answers online, and receive your final score upon completion of the test.
(C)
Should you successfully complete the test, you may download your accreditation certificate (subject to an administrative charge).

Acknowledgements

This review was first published in the ERS Buyer's Guide 2008/2009 and is reproduced with the permission of the ERS.

References (25)

N. Beydon et al.
Interrupter resistance short-term repeatability and bronchodilator response in preschool children
Respir Med
(2007)
H. Bisgaard et al.
Plethysmographic measurements of specific airway resistance in young children
Chest
(2005)
D. Vilozni et al.
The role of computer games in measuring spirometry in healthy and “asthmatic” preschool children
Chest
(2005)
D. Vilozni et al.
Spirometry in early childhood in cystic fibrosis patients
Chest
(2007)
N. Beydon et al.
An official American Thoracic Society/European Respiratory Society statement: pulmonary function testing in preschool children
Am J Respir Crit Care Med
(2007)
E. Oostveen et al.
The forced oscillation technique in clinical practice: methodology, recommendations and future developments
Eur Respir J
(2003)
G.L. Hall et al.
Respiratory function in healthy young children using forced oscillations
Thorax
(2007)
K. Udomittipong et al.
Forced oscillations in the clinical setting in young children with neonatal lung disease
Eur Respir J
(2008)
C.L. Gangell et al.
Respiratory impedance in children with cystic fibrosis using forced oscillations in clinic
Eur Respir J
(2007)
C. Thamrin et al.
Assessment of bronchodilator responsiveness in preschool children using forced oscillations
Thorax
(2007)

I. Dab et al.

A simplified approach to the measurement of specific airway resistance

Pediatr Res

(1976)

I. Dab et al.

Lung function measured with a whole body plethysmograph: standard values for children and young adults

Acta Paediatr Belg

(1979)

Cited by (26)

The role of parental psychological flexibility in childhood asthma management: An analysis of cross-lagged panel models
2020, Journal of Psychosomatic Research
Citation Excerpt :
This study relied on parental reports of childhood asthma, which may have been subject to recall bias and social desirability response bias. It should be noted that over one-third of the children (61/168 = 36.3%) in this study were aged five years or below, they might have had a short attention span and have been unable to follow instructions to perform an accurate measurement of lung function in the test to verify that their asthma symptoms had improved [57]. Meanwhile, the parental reports may even more closely reflect the actual status of the disease of the child at the time that the data were collected [58,59].
This is a secondary analysis of a previously reported randomized controlled trial, aimed at examining the mediating role of parental psychological flexibility (PF) in an Acceptance and Commitment Therapy (ACT)-based childhood asthma management program for parents.
The participants were 168 parents (mean age (SD) = 38.40 (5.90) years; 88.1% mothers) and their children who had been diagnosed with asthma (mean age (SD) = 6.81 (2.50) years; 62% boys). They were randomly allocated to either the program composed of a four-session, group-based ACT plus asthma education (ACT Group) or to a group-based asthma education talk plus three telephone follow-ups (Control Group). The parents underwent assessments at baseline, and immediately, 3-months, and 6-months after the intervention for the following outcomes: PF (Acceptance and Action Questionnaire-II), psychological distress of the parents (Depression Anxiety Stress Scale-21); and the asthma symptoms and use of inhaled bronchodilators of their children.
Cross-lagged panel models showed that the improvement in parental PF at post-intervention mediated the effect of ACT on reducing parental psychological distress (all beta coefficients (βs) ranged from −2.20 to - 2.30, all Ps < 0.01) and childhood asthma symptoms in terms of daytime symptoms (β = −0.22, 95% CI [−0.52, −0.02], P = 0.04), nighttime symptoms (β = −0.17, 95% CI [−0.33, −0.02], P = 0.04), and the use of bronchodilators (β = −0.22, 95% CI [−0.48, −0.02], P = 0.03) at 6-months post-intervention.
ACT makes a unique contribution to improving the health outcomes of parents and their children diagnosed with asthma through fostering parental PF.
Respiratory pathology at the patients with cerebral palsy (CP) and severe disabilities
2016, Motricite Cerebrale
La pathologie respiratoire chez les personnes infirmes moteurs cérébraux (IMC) et polyhandicapées, reste la première cause de mortalité (Reddihough et al., 2011). L’échographie pulmonaire, par tous ses bénéfices que nous allons décrire, constituerait un nouvel outil pertinent et cohérent tant dans l’évaluation de la démarche diagnostique que dans l’analyse de l’efficacité de nos techniques kinésithérapiques manuelles et instrumentales. Ce nouvel appareil d’évaluation des troubles respiratoires offre de nombreux avantages afin d’obtenir une meilleure information diagnostique, un allégement du dossier médical et d’autres avantages que nous allons décrire plus tard sans avoir recours à une prescription médicale. D’où la facilité et la nécessité pour les kinésithérapeutes d’y avoir recours lors de leur examen et leur pratique respiratoire sans aucun risque vital, ni même de complications secondaires ! Longtemps considérée comme inutile dans l’exploration du thorax, l’échographie est devenue ces dernières années un outil incontournable dans la pratique clinique des professionnels dans le domaine respiratoire. Elle permettrait aux kinésithérapeutes d’explorer des éléments cohérents aux techniques kinésithérapiques manuelles et instrumentales avec des signes prédictifs de diagnostic kinésithérapique, domaine récent et même nouveau à explorer mais on ne pourra le faire que si on pratique l’échographie pulmonaire en notant des observations cliniques et cela demande beaucoup de formations (notamment un projet de recherche clinique afin de construire des tableaux comparatifs des signes d’encombrement bronchique à l’aide d’auscultation et leurs analyses observées sur l’écran de l’échographie pulmonaire avant et après une séance de kinésithérapie), un domaine de recherche clinique en kinésithérapie respiratoire qui pourrait être valorisé dans les prochaines années afin d’améliorer notre pratique quotidienne et même prouver l’efficacité de nos techniques de rééducation respiratoire pour le bien de nos sujets IMC et polyhandicapés. Cet article a pour objectif de mettre, aux mains des chercheurs, une gamme de références bibliographiques et de sensibiliser surtout les kinésithérapeutes qui travaillent dans le domaine de neurologie respiratoire d’avoir recours à l’échographie pulmonaire dans une nouvelle perspective de la démarche thérapeutique.
Respiratory pathology at the patients with cerebral palsy (CP) and severe disabilities remains the leading cause of death (Reddihough et al., 2011). Lung ultrasound, for all its benefits to be described, would be a new tool both relevant and coherent in the evaluation of the diagnostic process in the analysis of the effectiveness of our manual and instrumental physical therapy technics. This new device for evaluating respiratory disorders offers many advantages to provide better diagnostic information, relief of medical records and other advantages, which will be described later without requiring a prescription. Hence, the ease and the need for physiotherapists to have recourse during their examination and respiratory practice without any risk to life, or even secondary complications! The practice of lung ultrasound in the medical field, allows us, as physiotherapists, explore coherent elements in our manual and instrumental physical therapy techniques with predictive signs of physiotherapy diagnosis, new area to explore and even new but can only do that if we practice lung ultrasound noting clinical observations and its demand many trainings (clinical research project to construct comparative tables of bronchial obstruction signs in auscultation and analysis using observed on the screen of lung ultrasound before and after a session of physiotherapy), a clinical research field in physiotherapy respiratory which could be upgraded in the coming decades in order to improve our daily practice and even prove the effectiveness of our pulmonary rehabilitation techniques for BMI good of our subjects and multiple disabilities. This article aims to put, in the hands of researchers, a range of references and educate especially the physiotherapists working in the neurological respiratory field to use lung ultrasound in a new perspective of their therapeutic approach.
Prediction equations for spirometry in four- to six-year-old children
2016, Jornal de Pediatria
Citation Excerpt :
Before the test, each child received age-appropriate instructions and then performed the maneuvers. The measurements were collected with the subject seated using a disposable well-adjusted mouthpiece (to prevent leaks), a nose clip, and computer-animation programs that provided instructions and stimuli to the participants.2 The subjects were asked to breathe in the tidal volume and then instructed to fill their lungs as much as possible and blow as strongly, rapidly and long as possible.
To generate prediction equations for spirometry in 4- to 6-year-old children.
Forced vital capacity, forced expiratory volume in 0.5 s, forced expiratory volume in one second, peak expiratory flow, and forced expiratory flow at 25–75% of the forced vital capacity were assessed in 195 healthy children residing in the town of Sete Lagoas, state of Minas Gerais, Southeastern Brazil. The least mean squares method was used to derive the prediction equations. The level of significance was established as p < 0.05.
Overall, 85% of the children succeeded in performing the spirometric maneuvers. In the prediction equation, height was the single predictor of the spirometric variables as follows: forced vital capacity = exponential [(−2.255) + (0.022 × height)], forced expiratory volume in 0.5 s = exponential [(−2.288) + (0.019 × height)], forced expiratory volume in one second = exponential [(−2.767) + (0.026 × height)], peak expiratory flow = exponential [(−2.908) + (0.019 × height)], and forced expiratory flow at 25–75% of the forced vital capacity = exponential [(−1.404) + (0.016 × height)]. Neither age nor weight influenced the regression equations. No significant differences in the predicted values for boys and girls were observed.
The predicted values obtained in the present study are comparable to those reported for preschoolers from both Brazil and other countries.
Gerar equações de predição da espirometria em crianças de quatro a seis anos.
Capacidade vital forçada, volume expiratório forçado em 0,5 segundo, volume expiratório forçado em 1 segundo, pico de fluxo expiratório e fluxo expiratório forçado com 25-75% da capacidade vital forçada foram avaliados em 195 crianças saudáveis que residem na cidade de Sete Lagoas, Estado de Minas Gerais, Sudeste do Brasil. O método dos mínimos quadrados foi usado para derivar as equações de predição. O nível de significância foi estabelecido como p < 0,05.
No geral, 85% das crianças foram bem-sucedidas ao fazer as manobras espirométricas. Na equação de predição, a estatura foi a única variável preditora das variáveis espirométricas, da seguinte forma: capacidade vital forçada = exponencial [(-2,255) + (0,022 x estatura)], volume expiratório forçado em 0,5 segundo = exponencial [(-2,288) + (0,019 x estatura)], volume expiratório forçado em 1 segundo = exponencial [(-2,767) + (0,026 x estatura)], pico do fluxo expiratório = exponencial [(-2,908) + (0,019 x estatura)] e fluxo expiratório forçado com 25-75% da capacidade vital forçada = exponencial [(-1,404) + (0,016 x estatura)]. Nem a idade nem o peso influenciaram as equações de regressão. Não foi observada diferença significativa nos valores previstos em meninos e meninas.
Os valores previstos obtidos neste estudo são comparáveis àqueles relatados em crianças em idade pré-escolar tanto do Brasil quanto de outros países.
Increased day-to-day variability of forced oscillatory resistance in poorly controlled or persistent pediatric asthma
2014, Chest
Pediatric asthma lacks sensitive objective measures for asthma monitoring. The forced oscillation technique (FOT) offers strong feasibility across the pediatric age range, but relationships between FOT parameter day-to-day variability and pediatric asthma severity and control are unknown.
Day-to-day variability in FOT respiratory system resistance (Rrs) and respiratory system reactance (Xrs) compared with peak expiratory flow (PEF) were defined in 22 children with asthma (mean ± SD age, 10.4 ± 1.1 years) during a 5-day asthma camp. FOT was performed at 6 Hz in triplicate on each test occasion. Relationships between day-to-day FOT variability (expressed as within-subject SD [SDW] and asthma control and severity (defined according to GINA [Global Initiative for Asthma] recommendations) were explored. For comparison, normal baseline FOT values and variability, measured on two occasions, were defined in a separate cohort of 38 healthy children (age, 9.5 ± 1.0 years).
Day-to-day Rrs variability was greater in persistent (n = 16) vs intermittent (n = 6) asthma (mean SDW, 0.69 cm H₂O/L/s vs 0.39 cm H₂O/L/s; P ≤ .01). Day-to-day Rrs variability was increased in uncontrolled (n = 13) vs partly controlled asthma (n = 9) (mean SDW, 0.75 cm H₂O/L/s vs 0.42 cm H₂O/L/s; P ≤ .05). PEF variability did not differentiate the groups. Day-to-day variability of Rrs and Xrs but not baseline values were increased in children with asthma vs control children (Rrs mean SDW, 0.61 cm H₂O/L/s vs 0.33 cm H₂O/L/s [P ≤ .05]; Xrs mean SDW, 0.24 cm H₂O/L/s vs 0.15 cm H₂O/L/s [P ≤ .05]).
Increased day-to-day FOT variability exists in school-aged children with asthma. Day-to-day Rrs variability was associated with asthma severity and asthma control. FOT may be a useful objective monitoring tool in pediatric asthma and warrants further study.
Australian and New Zealand Clinical Trials Registry; No.: ACTRN12614000885695; URL: www.anzctr.org.au
Office-based exhaled nitric oxide measurement in children 4 years of age and older
2013, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
In young children, objective evaluation of asthma can be challenging. Difficulty with reliable performance of spirometry and mismatch between symptoms and lung function have been reported.16–18 The 2007 National Heart, Lung, and Blood Institute (NHLBI) guidelines state that spirometry is generally valuable in children older than 5 years, although some children may not adequately conduct the maneuver until 7 years of age.19
Fractional exhaled nitric oxide (FENO) is increasingly being used in the office-based management of asthma, but data in children are limited.
To report FENO values in 4- to 7-year-old children with suspected asthma and characterize their relation to clinical variables and describe the relation among FENO levels, age, and sex in 4- to 18-year-old children with suspected asthma.
Retrospective data in 4- to 18-year-old children (n = 825) who underwent FENO testing using the NIOX MINO device were collected and analyzed. Chart reviews were performed for the 4- to 7-year-old children (n = 75).
FENO values ranged from less than or equal to 5 to 89 ppb in 75 4- to 7-year-old children and less than or equal to 5 to 300 ppb in 750 > 7 to 18-year-old children. Approximately one tenth of 4- to 7-year-old children and one third of > 7 to 18-year-old children had FENO values indicative of eosinophilic/allergic inflammation (>35 ppb). In regression analysis of the 4- to 7-year-old children, increasing age (P = .03) and asthma severity (P = .01) were associated with higher FENO levels. Atopic dermatitis was significantly associated (P = .03), whereas allergic rhinitis was marginally associated (P = .06), with higher FENO levels. Inhaled corticosteroid use was associated with lower FENO levels (P = .02).
This study characterizes the largest cohort of 4- to 7-year-old children to undergo FENO testing in ambulatory asthma management. Correlations between FENO levels and clinical variables were consistent with established findings in older children. This preliminary real-world study suggests that FENO assessment may be feasible and useful in the office-based asthma management of children as young as 4 years.
Exhaled nitric oxide in asthma management
2012, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
The level of accuracy is higher than for traditional measurements, such as peak flows and spirometry, and similar to that associated with bronchial challenge tests.3,4 It can be challenging to perform spirometry reliably in younger children,5 and there can be a mismatch between symptoms and lung functions.6 In contrast, FeNO testing using currently available devices can be performed in school-aged children relatively easily.

View all citing articles on Scopus

View full text

CME articlePulmonary function testing in young children

Summary

Section snippets

General considerations

Resistance measurement

The forced oscillation technique (FOT)

The interrupter resistance technique (Rint)

Specific airway resistance

Spirometry

Conclusion

Conflict of interest statement

Educational aims

Practice points

Research directions

CME Section

Acknowledgements

Respir Med

Chest

Chest

Chest

An official American Thoracic Society/European Respiratory Society statement: pulmonary function testing in preschool children

Am J Respir Crit Care Med

The forced oscillation technique in clinical practice: methodology, recommendations and future developments

Eur Respir J

Respiratory function in healthy young children using forced oscillations

Thorax

Forced oscillations in the clinical setting in young children with neonatal lung disease

Eur Respir J

Respiratory impedance in children with cystic fibrosis using forced oscillations in clinic

Eur Respir J

Assessment of bronchodilator responsiveness in preschool children using forced oscillations

Thorax

A simplified approach to the measurement of specific airway resistance

Pediatr Res

Lung function measured with a whole body plethysmograph: standard values for children and young adults

Acta Paediatr Belg

CME article
Pulmonary function testing in young children