2014 First PAPP Proceedings on Pediatric Pulmonary Function Testing

PAPP Task Force in Pediatric Pulmonary Function Testing

2014 PAPP Board of Directors.

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 President. Clara R. Rivera, MD FPPS FPAPP
Vice-president. Mary Therese M. Leopando, MD FPPS FPAPP
Secretary. Mary Ann F. Aison, MD FPPS FPAPP
Treasurer. Regina M. Canonizado, MD FPPS FPAPP
Director. Nepthalie R. Ordonez, MD FPPS FPAPP
Anna Marie S. Putulin, MD FPPS FPAPP
Lydia K. Chang, MD FPPS FPAPP

2014 Task Force on Pediatric Pulmonary Function Testing.

Chair. Cristan Q. Cabanilla, MD FPPS FPAPP
Secretary. Jonijohn R. Jimenez, MD DPPS DPAPP
Members. Kevin L. Bautista, MD DPPS DPAPP
Angeli T. Espiritu, MD DPPS DPAPP
Olivia C. Go, MD FPPS FPAPP
Joseph Dale R. Guiterrez, MD DPPS DPAPP
Vicente Carlomagno D. Mendoza, MD FPPS DPAPP
Emily G. Resurreccion, MD FPPS FPAPP
Dulce E. Requiron-Sy, MD FPPS FPAPP
Vincent Michael R. Reyes, MD DPPS DPAPP
Marion O. Sanchez, MD FPPS FPAPP
Kristine H. Tanega-Aliling, MD DPPS DPAPP
Jemaila B. Valles, MD DPPS DPAPP
Josy Naty M. Venturina, MD DPPS DPAPP

Table of contents.

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 Section 1. Background.

Section 2. Methodology.

Section 3. General considerations.

Section 4. Pulmonary function testing among subjects 8 years of age and above.

Section 5. Pulmonary function testing among subjects below 8 years of age.

Appendix.

Bibliography.

SECTION 1. BACKGROUND.

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 1.1. Rationale.
Pulmonary function testing is a diagnostic tool employed in the specialty of pediatric pulmonology.
1.2. Objective.
The objective of this document is to establish standards of care in the performance and reporting of
pulmonary function testing among subjects below 19 years of age in a hospital test facility.
1.3. Scope.
This manuscript includes the following:
1.3.1. Performance, reporting and interpretation of results of spirometry and peak expiratory
flow rate measurement; and
1.3.2. Performance and reporting of results of tidal breathing analysis, impulse oscillometry, and
raised volume rapid thoracoabdominal compression technique.

SECTION 2. METHODOLOGY.
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 2.1. 2014 Task Force on Pediatric Pulmonary Function Testing.
2.1.1. Membership.
The current members include pediatric pulmonologists who are active members of
Philippine Academy of Pediatric Pulmonologists [PAPP].
2.1.2. Technical Working Group.
The Technical Working Group involved in the development of the 2014 First PAPP
Proceedings on Pediatric Pulmonary Function Testing included all members of the
Task Force.
2.2. Preparation of the manuscript.
2.2.1. Initial draft.
After reviewing relevant and published local and foreign literature, the Technical
Working Group formulated the initial draft.
2.2.2. Peer Review.
The initial draft shall be presented to an external peer review composed of_____
__________________________________________________________________
2.2.3. Final draft.
The final draft shall be submitted to the current PAPP Board of Directors for review,
approval, publication and dissemination.
2.3. Periodic review.
2.3.1. The Task Force on Pediatric Pulmonary Function Testing shall make a periodic evaluation
and revision of the document, subject to the approval by the PAPP Board of Directors.
2.3.2. Periodic evaluation, and revision if necessary, shall be done every 2 years.
2.4. Disclosure.
2.4.1. Review of relevant literature.
For purpose of standardization, a greater part of the content of the document was based on
the following documents: the Philippine College of Chest Physicians Council of Diagnostics
and Therapeutics: Consensus Statement on the Performance and Reporting of Spirometry
Testing 2012; American Thoracic Society/ European Respiratory Society [ATS/ERS] Statement:
Pulmonary Function Testing in Preschool Children Am J Respir Crit Care Med 2007; 175:1304-
1345; ATS/ERS Task Force: Standardisation of lung function testing. General considerations Eur
Respir J 2005:26:153–161; ATS/ERS Task Force: Standardisation of lung function testing.
Interpretative strategies for lung function tests Eur Respir J 2005;26:948–968; ATS/ ERS Task
Force: Standardisation of lung function testing. Standardisation of spirometry Eur Respir J
2005;26:319–338; and American Thoracic Society Guidelines for Methacholine and Exercise
Challenge Testing Am J Respir Crit Care Med 2000;161:309-329.1-6 Significant differences in the
performance, reporting and interpretation of lung function studies recommended in the
above documents shall be mentioned accordingly.
The Task Force recognizes the pitfall arising from the use of predominantly Caucasian
reference equations as basis for spirometric interpretations in the local setting, as was raised
by the Global Lung Function Initiative Task Force [GLI].7 To address this concern, it has been
agreed upon by the members of the Task Force that multicenter studies determining values
among normal Filipino children be done to establish lower limit of normal in this age group. In
addition, the Task Force recommends that the GLI reference equations for spirometry be
implemented and correspondingly installed in the software of all spirometers being used in
the Philippines.
2.4.2. Funding.
The development of the 2014 First PAPP Proceedings on Pediatric Pulmonary Function Testing
has been solely funded by the Philippine Academy of Pediatric Pulmonologists.
2.4.3. Competing interest.
No competing interest has been declared by the members of the Task Force.
SECTION 3. GENERAL CONSIDERATIONS.
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3.1. Test considerations.
3.1.1. Indication.
3.1.1.1. Evaluation tool.
a. To establish dysfunction in an individual at risk of having abnormality resulting from
a.1. a primary pulmonary disease; or
a.2. as a secondary event, such as pulmonary manifestations of a systemic illness,
drug toxicity, radiation and injurious inhalational agents.
b. To be a part of a predictive tool in assessing
b.1. perioperative risk; or
b.2 disability at home or school.
c. To monitor course of a pulmonary abnormality.
d. To assess the impact of therapy in an individual with pulmonary abnormality.
3.1.1.2. Epidemiological tool.
a. To establish normative data in a normal population.
b. To determine the impact of disease or environment in a general population.
3.1.2. Relative contraindication.
3.1.2.1. Conditions where suboptimal lung function results are likely.1
a. Chest or abdominal pain of any cause.

b. Oral or facial pain exacerbated by a mouthpiece.
c. Stress incontinence.
d. Dementia or confusional state.
3.1.2.2. Conditions where performance of lung function test may aggravate current disease.
a. Acute respiratory failure.
b. Acute heart failure.
3.1.2.3. Condition where failure to perform lung function test is most likely.
a. Uncooperativeness.
b. Psychiatric disorders.
3.2. Patient preparation.
3.2.1. Preliminary consultation and appropriate instruction as provided by the hospital test
facility personnel to the referring physician and patient [or patient’s guardian].
3.2.2. Consent/assent.
Securing informed consent/assent shall be in accordance to the general policies of the
hospital test facility. In the absence of such policies, it shall be the direct responsibility
of the test facility manager to secure informed consent/assent.
3.2.3. Vital signs and anthropometric measurements.
3.2.3.1. Vital signs.
a. Blood pressure.
b. Cardiac rate in full minute.
c. Respiratory rate in full minute.
d. Body temperature per axilla.
3.2.3.2. Anthropometric measurements [in the nearest tenths].
a. For subjects less than 2 years old.
a.1. Recumbent length [or standing height + 0.7 cm]2
[in meter measured using stadiometer].
a.2. Weight [in kilogram].
b. For subjects 2 years old and older.
b.1. Standing height [or recumbent length-0.7 cm] 2, or arm span if with thoracic
deformity [in meter measured using stadiometer].
b.2. Weight [in kilogram].
3.2.4. Other provisions as deemed appropriate by the hospital test facility.
3.3. Hospital test facility.
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 3.3.1. Personnel.
3.3.1.1.Test performer.
a. Qualification [any of the following].
a.1. Philippine respiratory therapy board and Basic Life Support [BLS] provider
certified respiratory therapist; or
a.2. Philippine Subspecialty Board in Pediatric Pulmonology [PSBPP] and BLS provider
certified pediatric pulmonologist; or
a.3. BLS provider certified medical personnel directly under the supervision of a
PSBPP certified pediatric pulmonologist.
b. Function.
b.1. Patient preparation. Please see Section 3.2.
b.2. Test performance including test quality of pulmonary function testing.
Please see Section 4 and Section 5.
b.3. Quality control of the equipment used in pulmonary function testing, including
its daily calibration.
3.3.1.2. Test result interpreter.
a. Qualification.
PSBPP certified pediatric pulmonologist.
b. Function.
Test result interpretation.
3.3.1.3. Test facility manager.
a. Qualification.
Administrative officer.
b. Function.
b.1. Oversee test facility operations.
b.2. Implement quality control measures.
3.3.2. Equipment quality control.
For spirometry, quality control shall conform to the recommendations as provided by
the ATS/ERS Task Force in Pulmonary Function Testing: Standardisation of spirometry
Eur Respir J 2005;26:319-338.1 Discrepancies shall be reported.
For nonspirometry pulmonary function testing, quality control shall be subject to the policies
of the test facility. In the absence of such policies, it shall be the direct responsibility of the
test facility manager to formulate and implement equipment quality control measures.
3.3.3. Infection control.
Infection control shall be subject to the policies of the test facility. In the absence of such
policies, it shall be the direct responsibility of the test facility manager to formulate and
implement infection control measures.
3.3.4. Patient safety.
3.3.4.1. Availability of the following monitoring devices at the test facility.
a. Pulse oximeter.
b. Sphygmomanometer.
c. Capnograph.
d. Thermometer.
3.2.4.2. Availability of the following airway management equipment at the test facility.
a. Oxygen source and administration equipment.
b. Suction machine with suction catheters.
c. Laryngoscope with blades for all ages.
d. Endotracheal tubes for all ages.
e. Self-inflating ventilation bags for all ages.
f. Drugs for resuscitation.
3.4. Reporting of results.
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 3.4.1. Patient data sheet. For recommended patient data sheet, please see Appendix A.
3.4.1.1. Name of patient.
3.4.1.2. Age as of last birthday, gender, and race.
3.4.1.3. Standing height [or length] or arm span in meters, and weight in kilograms.
3.4.1.4. Current diagnosis.
3.4.1.5. Name of referring physician and medical institution.
3.4.2. Pulmonary function test data sheet.
3.4.2.1. Procedure requested.
3.4.2.2. Date and time of procedure.
3.4.2.3. Date, time and result of equipment calibration.
3.4.2.4 Ambient room temperature and atmospheric pressure at time of testing.
3.4.2.5. Name and phone number of the hospital test facility.
3.4.2.6. Name, signature and comments of test performer.
3.4.2.7. Name, signature, interpretation and comments of test result.
3.4.3. Reference values in interpretation of results.
3.4.3.1. Lower limit of normal values for spirometric interpretation.
The 2014 Task Force recognizes the need for a transition from the use of the
traditional percent predicted in determining lower limit of normal as basis for
spirometric interpretation to using z-score as recommended by the Global Lung
Function Initiative Task Force.3
3.4.3.2. Lower limit of normal values for nonspirometric pulmonary function testing.
Although normal values of tidal breathing analysis and impulse oscillometry in
Filipino children have been reported [See Appendix D], the 2014 Task Force
cannot yet make recommendations as to the utility of these tests in
assessing pulmonary disease.

SECTION 4. PULMONARY FUNCTION TESTING AMONG SUBJECTS EIGHT [8] YEARS OF AGE AND ABOVE.
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4.1. SPIROMETRY.
4.1.1. Description.
Spirometry is a physiological test measuring how an individual inhales or exhales
volume of air as function of time. Primary signal measured may be flow or volume.
4.1.2. Equipment.
4.1.2.1. Basic equipment.
Flow-sensing spirometer which directly measures airflow rate, with volume
calculated from flow signal.
4.1.2.2. Requirement.
Equipment requirements, display, validation and quality control applicable for
flow-measuring devices shall conform to the recommendations as described
by the ATS/ERS Task Force in Pulmonary Function Testing: Standardisation of
spirometry Eur Respir J 2005;26:319-338.1
4.1.3. Test.
4.1.3.1. Identification of test to be requested.2
a. Baseline spirometry.
b. Baseline spirometry with bronchodilator challenge test if baseline result is abnormal.
c. Baseline spirometry with bronchodilator challenge test.
d. Baseline spirometry with exercise challenge test.
4.1.3.2. Basic parameters that should be measured and reported.
a. Baseline spirometry.
a.1. FEV1/FVC.
a.2. FEV1.
a.3. FVC.
a.4. FEF25-75%.
b. Baseline spirometry with bronchodilator challenge test.
b.1. FEV1 and percent change pre- and postbronchodilator.
b.2. FVC and percent change pre- and postbronchodilator.
b.3. FEF25-75% and percent change pre- and postbronchodilator.
c. Baseline spirometry with exercise challenge test.
FEV1 and percent change pre- and postbronchodilator.
4.1.3.3. Additional parameters that may be measured and reported.
a. FEF25.
b. FEF75.
c. MVV.
4.1.3.4. Test protocol for FVC, FEV1 and FEF25-75% determination.
a. Test protocol shall conform to the recommendations as provided by ATS/ERS Task Force in
Pulmonary Function Testing: Standardisation of spirometry Eur Respir J 2005;26:319-338.1
b. Patient preparation to be done by the test performer prior to test.
b.1. Information as to patient’s abstinence of the following:1
b.1.1. Short-acting beta-agonist and anticholinergic.
Salbutamol or ipratropium bromide within 4 hours.
b.1.2. Long-acting b-agonist and oral aminophylline.
Salmeterol, formoterol or aminophylline within 12 hours.
b.1.3. Exposure to cigarette smoke.
b.1.4. Exercise.
b.1.5. Meal.

b.2. Patient’s vital signs and anthropometric measurements.

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 Please see Section 3.2.3.
b.3. Demonstration to the patient of the following.
b.3.1. Correct posture: upright posture with head slightly tilted backward.
b.3.2. Rapid and complete inhalation.
b.3.3. Correct mouthpiece position: closed lips around mouthpiece past teeth.
b.3.4. Maximal forced exhalation.
b.4. Spirometer calibration and documentation including date, time
and result of calibration.
c. Procedure.1
c.1. Correct posture instruction.
c.2. Nose clip attachment.
c.3. For closed circuit method:
c.3.1. Place mouthpiece in mouth.
c.3.2. Inhale completely and rapidly with a pause of <1 second
at total lung capacity [TLC].
For open circuit method:
c.3.3. Inhale completely and rapidly with a pause of <1 second
at TLC.
c.4.4. Place mouthpiece in mouth.
c.4. Exhale maximally until no more air can be expelled while maintaining an
upright posture.
c.5. Repeat instructions as necessary, coaching vigorously.
c.6. Repeat for a minimum of three maneuvers.
c.7. Check if criteria for acceptability/end of test have been fulfilled.
d. Acceptability criteria for spirogram.11
d.1. Within maneuver criteria.
d.1.1.The following should be avoided:
d.1.1.1. Cough during the first second of exhalation.
d.1.1.2. Glottic closure.
d.1.1.3. Early termination or cut-off.
d.1.1.4. Effort that is not maximal throughout.
d.1.1.5. Leak.
d.1.1.6. Obstructed mouthpiece.
d.1.2. Good start.
d.1.3. Extrapolated volume <5% of FVC or 0.15 L, whichever is greater.
d.1.4. Satisfactory exhalation.
d.1.5. Duration of >6 s or a plateau in the volume–time curve.
d.2. Between maneuver criteria for 3 acceptable individual spirograms.
d.2.1. Two largest values of FVC within 150 mL of each other; and
d.2.2. Two largest values of FEV1 within 150 mL of each other.
e. End of test criteria.1
e.1. Criteria stated in Section 4.1.3.4.d. are met.
e.2. If criteria stated in Section 4.1.3.4.d. are not met, continue testing until criteria
are met with analysis of additional spirograms [maximum of 8 tests];
or until subject is unable to continue.

4.1.3.5. Protocol for bronchodilator challenge test.1

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 a. Patient preparation.
Please see Section 3.2 and Section 4.1.3.4.b.
b. Procedure.
b.1. Perform baseline spirometry. Please see Section 4.1.3.4.
b.2. Administer salbutamol 100 ug in two successive doses through a spacer at 30
seconds interval as recommended by the 2014 Task Force. An option is
administering salbutamol 2.5 mg as single dose through a jet type nebulizer.3
c. Repeat spirometry 10-15 minutes after administration of salbutamol.
4.1.3.6. Protocol for exercise challenge test [ECT].5
a. Patient preparation.
a.1. Please see Section 3.2 and Section 4.1.3.4.b.
a.2. Patient in comfortable clothes and running or gym shoes.
a.3. Patient having consumed no more than a light meal.
a.4. The following should be avoided prior to test:
a.4.1. Short-acting inhaled bronchodilators 8 hours [h]
a.4.2. Medium-acting bronchodilators [ipratropium] 24 h
a.4.3. Long-acting inhaled bronchodilators 48 h
a.4.4. Oral bronchodilators
Liquid theophylline 12 h
Intermediate-acting theophylline 24 h
Long-acting theophylline 48 h
Standard beta 2-agonist 12 h
Long acting beta 2-agonist 24 h
a.4.5. Cromolyn sodium 8h
a.4.6. Nedocromil 48 h
a.4.7. Leukotriene modifiers tablets 24 h
a.4.8.Hydroxyzine, cetirizine 3 days
a.4.9. Coffee, tea, cola drinks, chocolate Day of study
a.4.10.Exercise Day of study
b. Procedure.
b.1. Test protocol.
Test protocol shall conform to the recommendations as provided by the
American Thoracic Society Guidelines for Methacholine and Exercise
Challenge Testing Am J Respir Crit Care Med 2000;161:309-329.
b.2. Supervision.
BLS certified physician shall supervise the performance of the procedure.
b.3. Inhalate.
b.3.1. Dry air with nose clip in place.
b.3.2. Air-conditioned room [ambient temperature of 20-25c and relative
humidity of <50%].
b.4. Monitoring index.
Heart rate monitoring using a 3-lead electrocardiographic configuration,
or a pulse oximeter, or any device determining heart rate.
b.5. Outcome spirometric parameter.
FEV1. See Section 4.1.3.4. for test protocol.
b.6. Testing schedule.
b.6.1. Immediately before exercise.
b.6.2. 5, 10, 15, 20, and 30 minutes after cessation of exercise.

b.7. Total exercise duration.

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 b.7.1. 6 minutes <12 yr of age.
b.7.2. 8 minutes for older age group.
b.8 Target exercise parameter.
b.8.1. Heart rate 80-90% of predicted maximum
(calculated as 220-age in years); or
b.8.2. Ventilation 40-60% of predicted maximum voluntary ventilation
(calculated as FEV1X 35).
b.9. Protocol.
b.9.1. Motor-driven treadmill with adjustable speed/grade.
. Speed and grade chosen to produce 4-6 minutes of exercise at near-
maximum targets [recommended speed: >4.5 km/h, and
gradient: >15%].
Start at low speed and grade then progressively advanced during the
first 2-3 minutes until target exercise parameter is reached.
b.9.2. Electromagnetically braked cycle ergometer.
Work rate [watts=(53.76 x measured FEV1)-11.07] chosen to produce
4-6 min of exercise at near-maximum targets.
Start work rate set to 60% of target in the 1st minute, 75% in the 2nd,
90% in the 3rd, and 100% in the 4th minute until target exercise
parameter is reached.
b.10. End of test
Target heart rate or ventilation maintained for at least 4 minutes.
4.1.4. Reporting of results.
4.1.4.1. Algorithm.5
Interpretation shall be based on the algorithm suggested by the ATS/ERS Task
Force in Pulmonary Function Testing: Interpretative strategies for lung
function tests Eur Respir J 2005;26:948-968.

a. For purpose of standardization, the 2014 Task Force has set the lower limit of
normal [LLN] as 80 percent of predicted. Please see Section 3.4.3.1. for
consideration in defining normative data as recommended by the Global
Lung Function Initiative Task Force.
b. For an interpretation consistent with “Obstruction”, the 2014 Task Force has
included FEF25-75 as an additional index to report..
c. For an interpretation consistent with “Restriction”, lung volume study is needed
to determine total lung capacity [TLC].

4.1.4.2. Content.
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 a. Test result selection and reporting of acceptable and reproducible spirogram
shall conform to the ATS/ERS Task Force in Pulmonary Function Testing:
Standardisation of spirometry Eur Respir J 2005;26:319-338.
b. Acceptable spirogram containing largest FVC and largest FEV1 as defined in
Section 4.1.3.4.d., and FEF25-75% derived from the curve with the largest
sum of FEV1 and FVC.
c. Indices to report.
c.1. Tabular display of the following parameters, with corresponding
actual and predicted values, percent predicted, percent change
from baseline to post-bronchodilator and postexcercise
measurement, and 95% CI limit [if available]:
c.1.1. Baseline spirometry: FEV1/FVC, FVC, FEV1, FEF25-75%.
c.1.2. Bronchodilator challenge test: FEV1, FEF25-75%.
c.1.3. Exercise challenge test: FEV1 plotted as percentage of
preexercise FEV1, at each postexercise interval.
c.2. Graphic display of the following showing the best trial flow volume loop.
c.2.1. Baseline spirometry.
c.2.2. Pre- and postbronchodilator.
d. Test Performer’s Section.
d.1. Report pertaining to:
d.1.1. Result of previous spirometry testing[s], if available.
d.1.2. Test performance described in Section 4.1.3.4. including
number of trials.
d.1.3. Conditions that may alter the results, including poor effort.
d.2. Printed name and signature of performer/s.
e. Test Result Interpreter’s Section.
e.1. Assessment of the presence or absence of obstructive and/or restrictive
ventilatory defect, including grading of severity. [See Appendices B for
nomenclature and C for grading of severity].
e.2. Suggestion for additional test [bronchodilator or exercise challenge test to
determine reversibility, or lung volume study to determine total lung
capacity].
e.3. Assessment of the presence or absence of reversibility in bronchodilator
challenge test, as follows:
e.3.1. Significant response to bronchodilator [defined as >12% change
from baseline FEV1 or FVC; or >30% from baseline FEF25-75%6].
e.3.2. No significant response to bronchodilator.
e.4. Assessment of the presence or absence of response in ECT, as follows:
e.4.1. Significant response to exercise challenge test [defined as 10%
decrease below preexercise baseline FEV1 at each
postexercise interval].
e.4.2. No significant response to exercise challenge test.
e.5. A reminder that result should be correlated with clinical data.
e.6. Printed name and signature of interpreter/s.

4.2. PEAK EXPIRATORY FLOW.

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 4.2.1. Description.
Peak expiratory flow [PEF] is the highest flow achieved from a maximum forced
expiratory maneuver from a position of maximal lung inflation.
4.2.2. Equipment.1
PEF can be obtained from a flow–volume curve or portable instrument that records
flow. Equipment requirements applicable for flow-measuring devices shall conform to
the recommendations described by the ATS/ERS Task Force in Pulmonary Function
Testing: Standardisation of spirometry Eur Respir J 2005;26:319-338.
4.2.3. Test.
4.2.3.1. Patient’s preparation.
a. Please refer to 4.1.3.4.b.1. and 4.3.4.b.2.
b. Demonstration to the patient of the following:
b.1. Correct neck position: neutral position.
b.2. Correct mouthpiece position: closed lips around mouthpiece past teeth.
b.3. Delivery of blow.
4.2.3.2. Protocol.1
a. Nose clip attachment.
b. Subject must be encouraged to blow as vigorously as possible.
b. Neck should be in a neutral position.
c. After point of full lung inflation, subject must deliver the blow without any delay.
d. Tonguing, spitting or coughing at the start of the blow not allowed.
e. Subject must perform a minimum of three maneuvers.
4.2.3.3. Parameter.
Peak expiratory flow rate.
4.2.3.4. Acceptability criteria.1
a. Within maneuver evaluation.
Subject must be observed
a.1. to ensure a good seal at the mouth,
a.2. no hesitation has occurred, and
a.3. there was no abnormal start.
b. Between maneuver evaluation.
b.1. Largest 2 out of 3 acceptable blows within 0.67 L/s-1 (40 L/min-1).
b.2. PEF values and their order must be recorded to detect
maneuver-induced bronchospasm.
1
4.2.3.5. End of test.
Up to five attempts.
4.2.3.6. Protocol for bronchodilator challenge test.
Please see Section 4.1.3.5.
4.2.3.7. Reporting of results.
a. Test result selection.
The largest value from at least three acceptable blows is recorded.1
b. Content of the report.
The 2014 Task Force recommends assessment for bronchodilator
challenge test as provided by the Global Initiative for Asthma 20147:
b.1. Significant response to bronchodilator [defined as >20% change from
baseline].
b.2. No significant response to bronchodilator.

SECTION 5. PULMONARY FUNCTION TESTING BELOW 8 YEARS OF AGE

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5.1. SPIROMETRY.
Joseph Dale R. Guiterrez, MD DPPS DPAPP
5.1.1. Description.
Spirometry is a physiological test measuring how an individual inhales or exhales
volume of air as a function of time. The signal measured may be flow or volume.
Although test performance has been reported among subjects 5 to 8 years old,
concerns1 have been raised as to its adherence to the recommendations provided
by the ATS/ERS Task Force in Pulmonary Function Testing: Standardisation of
spirometry Eur Respir J 2005;26:319-338,2.
5.1.2. Equipment.
5.1.2.1. Basic equipment.
Flow-sensing spirometer which directly measures airflow rate, with volume
calculated from flow signal.
5.1.2.2. Requirements.
Equipment requirements, display, validation, and quality control applicable
for flow-measuring devices shall conform to the recommendations provided
by the ATS/ERS Task Force in Pulmonary Function Testing: Standardisation of
spirometry Eur Respir J 2005;26:319-3382 and ATS/ERS Statement: Pulmonary
Function Testing in Preschool Children Am J Respir Crit Care Med
2007;175:1304–1345.3
If used in preschool subjects, equipment should measure instantaneous flows
with an accuracy of at least +5%, and should contain a software that includes
animated incentives designed to encourage rapid and prolonged expiration.3
5.1.3. Test.
5.1.3.1. Identification of test to be requested.
a. Baseline spirometry.
b. Baseline spirometry with post bronchodilator challenge test if baseline result is
abnormal.
c. Baseline spirometry with post bronchodilator challenge test.
5.1.3.2. Basic parameters that should be measured and reported.
a. Baseline spirometry.
a.1. FEV1/FVC.
a.2. FEV1.
a.3. FVC.
a.4. FEF25-75%.
b. Baseline spirometry with post bronchodilator challenge test.
b.1. FEV1 and percent change pre- and postbronchodilator.
b.2. FVC1 and percent change pre- and postbronchodilator.
b.3. FEF25-75% and percent change pre- and postbronchodilator.
5.1.3.2. Test protocol for baseline spirometry.
a. Test protocol shall conform to the recommendations provided by the
ATS/ERS Task Force in Pulmonary Function Testing: Standardisation of
spirometry Eur Respir J 2005;26:319-338, and ATS/ERS Statement: Pulmonary
Function Testing in Preschool Children Am J Respir Crit Care Med
2007;175:1304–1345.

b. Protocol for FVC, FEV1 and FEF25-75% determination.

15
 a.1. Patient preparation.
Please see Section 3.2.3 and Section 4.1.3.4.b.
a.2. Procedure.
a.2.1. Open circuit method.
Exhale Inhale completely and rapidly with a pause of <1 sec at TLC.
Correct mouthpiece position.
a.2.2. Aided by animated incentives, exhale maximally until no more
air can be expelled while maintaining an upright posture.
b.3. Repeat instructions as necessary, coaching vigorously.
b.4. Repeat for a minimum of 3 maneuvers.
b.5. Check test repeatability [please see Section c below];
perform more maneuvers as necessary.
c. Acceptable spirogram.
c.1. Within maneuver criteria.
c.1.1. Free from the following:
Cough during the first second of exhalation.
Glottic closure.
Early termination or cut-off.
Effort that is not maximal throughout.
Leak.
Obstructed mouthpiece.
c.1.2. Good start.
c.1.3. Extrapolated volume <5% of FVC or 150 mL, whichever is
greater.
c.1.4. Satisfactory exhalation.
c.1.5.Duration of 3 seconds, or plateau in the volume–time curve.
c.2. Between maneuver criteria for 3 acceptable individual spirograms.
c.2.1. At least 2 acceptable curves, where second highest FVC and
FEVt are within 100 mL, or 10% of the highest value, whichever is
greater.
d. End of test.
d.1. If criteria in Section c. are met, test session may be concluded.
d.2. If criteria are not met, continue testing until
d.2.1. criteria are met with analysis of additional acceptable
spirograms; or
d.2.2. a maximum of 10 tests has been performed; or
d.2.3. subject is unable to continue.
5.1.3.3. Test protocol for bronchodilator challenge test.
a. Patient preparation.
Please see Section 3.2.3. and Section 4.1.3.4.2.
b. Procedure.
Please see Section 4.1.3.5.2.
. 5.1.4 Reporting of results.
The 2014 Task Force recommends that the reporting of results be similar to spirometry being
done for children above eight years old. See Section 4.1.4.

5.2. TIDAL BREATHING ANALYSIS.1,2,5

16
Josy Naty M. Venturina, MD DPPS DPAPP
Emily G. Resurreccion, MD FPPS FPAPP
5.2.1. Description.
Tidal breathing analysis is a non–invasive pulmonary function test that measures changes
in the flow and volume at the airway opening.
This test is intended for subjects below 6 years old.
5.2.2. Equipment.
5.2.2.1. Basic equipment.
Tidal breathing flow volume [TBFV] loop is measured using Masterscreen Paed Jaeger
Pediatric [VIASYS Healthcare GmbH Leibnizstr. 7,D-97204 Hoechberg Germany]. The
measurements required are flow (V ) and volume (V), measured over time (t). Flow or
volume is measured and integrated or differentiated with respect to time to calculate
the other. The flow is measured at the airway opening using a pneumotachometer
[or other flow meter] via a mask or a mouthpiece.
Technical requirements for equipment and software have been described.1
5.2.2.2. Face mask.
For standardization, the following should be reported:
a. Brand and size of mask.
b. Presence of an air-filled cuff.
c. Measures to improve airtight placement such as silicon putty or Vaseline.
d. Measures to reduce mask volume such as shortening of the mask port or putting
silicon putty in the mask.
e. Estimation of effective dead space.
5.2.2.3. Flow meter.
Combination of pneumotachometer (PNT) and differential pressure transducer.
5.2.3. Test procedure.
5.2.3.1. Patient preparation.
a. Vital signs and anthropometric measurements.
Please see Section 3.2.3.
b. Patients should be rested for at least 10 minutes prior to the procedure.
5.2.3.2. Protocol.
a. Measurements should be done in a quiet awake state, and in a sitting position.
b. Patient breathes via a facemask [or mouthpiece] attached to the PNT.
c. Flow and volume are displayed on the screen. Both signals are shown versus time
and simultaneously the flow/volume curve appears.
d. After each breath, the key parameters are evaluated and displayed in a diagram
versus breath. It is essential to visualize the signal in real time to ensure that
the respiratory pattern is stable and regular before starting data recording.
Ideally, both types of plot should be available [1] V –V to ensure repeatability
of shape, and [2] V –t to ensure stable respiratory rate and volume.
e. Once a stable pattern is observed [steady end-expiratory level, respiratory rate,
and tidal volume], a minimum of 30 seconds of tidal breathing should be
recorded to obtain a stable epoch of 10 tidal breaths.
f. Indices to be obtained shall be calculated for 20 consecutive individual breaths per
trial.

5.2.3.3. Acceptability criteria.

17
 a. 10 breaths are adequate to yield a reliable mean value.
b. As the shape of the tidal flow/volume loops and the two key parameters may
show a large variability, it is necessary to average several breaths. The
average value can easily be spoiled by one single disturbed value (outlier).
To avoid this, an outlier-rejection procedure is used.
All values of the last 20 breaths are sorted by size. The upper and lower
quarter of values are deleted and only the middle 50% of values are declared
valid. The average values reported by the program are calculated from these
valid values, only. If both parameters are valid for one breath, then this whole
breath is labeled “valid” and is used in the curve averaging. To complete the
representative flow/volume curve, all valid curves are average in time for
expiration and inspiration separately.
c. Breaths should not be included for analysis if they are obviously different in shape
or size from the surrounding breaths, if there are doubtful points of zero flow
(e.g. pause between inspiration and expiration), or if there is more than one
peak of expiratory flow.
5.2.3.4. End of test.
a. Acceptability criteria have been fulfilled.
b. Incomplete test.
b.1. Refusal: refusal to cooperate during measurement.
b.2. Failure: when measurement had begun but stopped halfway or fewer
than 3 reliable results.
5.2.4. Reporting of results.
5.2.4.1. Reference data and predictive equation.
a. There are currently no satisfactory normative data in preschool children. Although
"reference data" have been published, the values are highly specific
for software that was used and the ethnicity studied. It therefore cannot
be recommended for general use. In the local setting, two studies were done
to determine the normal values of pulmonary function using tidal breathing
analysis3,4
Please see Appendix D.
b. Predictive equation.
The predictive equations below were derived from the software using
Masterscreen Paed Jaeger Pediatric [VIASYS Healthcare GmbH Leibnizstr. 7,D-
97204 Hoechberg Germany] among Filipino children aged 1 month to 5 years
old. 3
Peak tidal expiratory
flow measurements Regression equation
tPTEF/tE tPTEF/tE = 10.277 x exp(0.012) x (ht in cm)
VPTEF/VE VPTEF/VE = 13.283 x exp(0.010) x (ht in cm)

5.2.4.2. Content
a. The final report should contain the following:
a.1. Total number of breaths recorded and the number of those selected for
analysis;
a.2. Table of individual trials and a statistical summary showing indices.
Please Section C below.
a.3. Mean and SD [or coefficient of variation] for all parameters;

b. Graphic display.
18
 Representative loops showing measured flow and volume signals
plotted against time and against each other, as shown.

Fig. 1. Computer display during tidal breathing analysis. a) Flow-time curve; b) Flow-volume display;
c) Trend-display, which shows the calculated tPTEF/tE ratios. The blocks represent the ratios
which are taken into the averaging.

Fig. 2. – Computer screen during result phase of tidal breathing analysis (after ending the recording).
a) Mean expiratory flow-time curve; b) mean flow-volume curve; c) box-plots representing mean values,
standard deviations and range of tPTEF/tE (left) and VPTEF/VE (right) ratios, after standard computer
selection. tPTEF/tE: time taken to achieve peak tidal expiratory flow as proportion total expiratory time;
VPTEF/ VE: volume taken to achieve peak tidal expiratory flow as proportion of total expiratory volume.

c. Indices.
c.1. Time to peak tidal expiratory flow (t PTEF) (s).
c.2. Total expiratory time (tE) (s).
c.3. Ratio of time to peak tidal expiratory flow to total expiratory time
(tPTEF/tE).
c.4. Volume at peak tidal expiratory flow (Vptef) (ml).
c.5. Expired tidal volume (Ve) (ml).
c.6. Ratio of volume at peak tidal expiratory flow to expired tidal volume
(Ve) (Vptef/Ve).
5.2.5. Interpretation.
The 2014 Task Force has no recommendation for interpreting results outside of normal values.

5.3. IMPULSE OSCILLOMETRY.

19
Jemaila B. Valles, MD DPPS DPAPP
Emily G. Resurreccion, MD FPPS FPAPP
5.3.1. Description.
Impulse oscillometry measures impedance over a range of frequencies (5–20 Hz). Resistance
(Rrs) and reactance (Xrs) measured at 5 Hz are designated as Rrs5 and Xrs5, respectively.
Lower-frequency oscillation at 5Hz, generally travel farther to the lung periphery and provide
indices of the entire pulmonary system. Therefore, when either proximal or distal airway
obstruction occurs, Rrs5 and Xrs5 may be increased. Higher-frequency oscillations, such as 20
Hz, transmit signals more proximally and provide information primarily concerning the central
airways.1
This test is intended for subjects 3 to 5 years old.
5.3.2. Equipment.
Measurement of respiratory impedance is carried out using Impulse Oscillometry (VIASYS
Healthcare GmbH Leibnizstr.7,D-97204 Hoechberg Germany). The device includes an impulse-
generator (loudspeaker) connected by a Y-adapter at one upper arm, an exit for flow with
terminating resistor at the second upper arm and a lower arm connected to the
pneumotachograph. A mouthpiece is connected to the pneumotacograph, and transducer
connected to a computer.1,2
5.3.3. Test procedure.
5.3.3.1. Patient preparation.
Vital signs and anthropometric measurements.
Please see Section 3.2.3.
5.3.3.2. Protocol.1,2.3.4
a. Subject shall be seated comfortably in upright position with the head in neutral
position or slight extension.
b. Nose should be occluded with a nose clip.
c. Cheeks should be supported by the test performer from behind to avoid pressure
loss and upper airway vibration.
d. Mouthpiece should be tightly placed between the teeth with the tongue beneath
the mouthpiece and the lips firmly closed around it.
d. Instruction shall be given to have regular spontaneous breathing.
e. During the recording, respiratory impedance (Zrs) shall be partitioned into
resistance and reactance.
f. Measurements shall be repeated in order to obtain three acceptable data sets
to calculate the mean.
5.3.3.3. Acceptability criteria.
Tidal breathing curve should not be disturbed by a respiratory pause, swallowing,
speaking, moving or coughing. If such disturbance occurs, data acquisition should be
either stopped and repeated, or continued until 20 seconds of undisturbed tracing
shall be seen.
5.3.3.4. Repeatability criteria.
The Coefficient of Variation shall be calculated from standard deviation to mean ratio
and should be <10% in young children for intra-measurement and between test
repeatability.
5.3.3.5. End of test.
a. Acceptability and repeatability criteria have been fulfilled.
b. Incomplete test.
b.1. Refusal: refusal to cooperate during measurement.
b.2. Failure: when measurement had begun but stopped halfway or
fewer than 3 reliable results
5.3.4. Reporting of results.
20
 5.3.4.1. Reference data and predictive equation.
a. To date, there are 5 published studies on reference values for preschool
children, with 1 reported among Korean population. There are two
unpublished studies done among Filipinos. Please see Appendix D.
b. Predictive equation.
Valles JB, Jiao AJ. Philippine Children’s Medical Center9
Resistance: Rrs5Hz =2.206 – 0.012 (ht in cm);
Rrs20Hz =1.268 – 0.005 (ht in cm)
Reactance: Xrs5Hz = -0.856 + 0.005(ht in cm)
Monzon SL, Espinoza HM, Bautista N, Go OC. University of Santo Tomas
Faculty of Medicine and Surgery10
Y=B0 + (B1 x ht in cm) + (B2 x wt in kg) + (B3 x age in yrs) + (B4 x sex
where f=1, m=2) [where Y=ios parameter, B0=y intercept or the value of y
when all the independent variables are zero, B1= change in y per unit increase
in height controlling for weight, age and sex, B2=change in y per unit increase
in weight controlling for height, age and sex, B3= change in y per unit increase
in age controlling for height, weight and sex, B4=difference in y between
males and females, f=female, m=male]
5.3.4.2. Content
a. Graphic display.
Flow and impedance versus time loop.

b. Indices.
b.1. Rrs 5Hz
b.2. Rrs 20Hz
b.3. Xrs 5Hz
5.3.5. Interpretation.
The 2014 Task Force has no recommendation for interpreting results outside of the
normal values.

5.4. RAISED VOLUME RAPID THORACOABDOMINAL COMPRESSION.

21
Vicente Carlomagno D. Mendoza II, MD DPPS DPAPP
5.4.1. Description.
Raised volume rapid thoracoabdominal compression [RVRTC] is a maneuver used to study
forced expiratory flow by rapid compression consisting of applying positive pressure to the
thoracoabdominal region at end of inspiration. Volumes used range from functional residual
capacity to close to total lung capacity.
This test is intended for subjects less than 2 years old.
5.4.2. Equipment.1,2
5.4.2.1. Jacket.
The jacket used for producing the rapid compression consists of an inflatable
component that is positioned against the infant's anterior chest wall and upper
abdomen, and an outer nonexpansile component that wraps around the infant.
5.4.2.2. Pressure source.
A drum of 50-100 L capacity is used to inflate the jacket. The jacket should be
connected to the pressure source through a wide bore tubing to ensure rapid
inflation. To ensure that the jacket pressure is maintained during the maneuver,
the recommended minimum size for the reservoir should be at least 50 L. Essential
features include the following. [1] The material the drum must withstand pressures
of up to 45 kPa without rupture; [2] The drum is usually filled from a pressurized wall
source or other suitable compression source (pressures up to 400 kPa). A pressure
regulation system is necessary to ensure that the drum is not exposed to these
pressures; [3] A pressure relief valve is required to ensure that pressure in the drum is
not accidentally increased too much; it is set to blow off at pressures above the
maximum pressure required to inflate the jacket [~12±15 kPa].
5.4.2.3. Valves.
a. A valve to occlude the airway opening if jacket transmission pressure is being
assessed statically during brief airway occlusions.
b. A valve to fill the jacket from pressure source.
c. A valve to empty the jacket to atmosphere.
d. A valve to isolate the drum from the filling pressure source.
e. A valve to control mask flushing flow of air or oxygen.
5.4.2.4. Face mask.
For purpose of standardization, the following are recommended.
a. Reporting of brand and size of mask [Rendell Baker size 0, 1, 2 or 3].
b. Reporting of measures to reduce mask volume such as silicon putty.
c. Estimation of effective dead space.
5.4.2.5. Flowmeter.
This should be a low-resistance, low-dead space device with linear range appropriate
to the age of infant studied. It is recognized that the pneumotachometer [PNT] is
currently the most commonly used device. PNT should be a low-resistance, low dead
space device with linear range appropriate for the age and should be maintained
when heated.
5.4.2.6. Pressure transducers.
a. A transducer for airway opening pressure.
b. A transducer for applied jacket pressure.

5.4.3. Test procedure.

22
 5.4.3.1. RVRTC maneuvers are performed based on the procedure as described in Frey U,
Stocks J, Coates A, Sly PD, Bates J, on behalf of the ERS/ATS Task Force on Standards
for Infant Respiratory Function Testing: Specifications for equipment used for infants
pulmonary function testing. Eur Respir J 2000;16:729-738.2
5.4.3.2. Patient preparation.
a. Vital signs and anthropometric measurements.
Please see Section 3.2.3.
b. Sedation with chloral hydrate (70-100 mg/kg), if available, is recommended.
5.4.3.3. Protocol.2
a. Posture
a.1. Infant should be supine position
a.2. Neck and/or shoulders supported in the midline in slight extension
using a neck roll or head ring.
b. Procedure
b.1. An inflatable device is placed around the anterior part of the trunk from
the sternal manubrium to the pubic symphysis.
b.2. Trunk is then covered loosely (about 3-4 adult fingers’ breadth) by a
suitably sized jacket.
b.3. The measuring equipment is connected via mask attached to a
pneumotachograph.
b.3.1. The mask should be attached on the face leak free.
b.3.2. An automatic device applies a pressure of 30 cmH2O to the
infant’s lungs, in phase with spontaneous inspiration (V30).
b.3.3.The pressure is then released allowing passive expiration.
b.3.4. Such inflation and expiration maneuver should be repeated
several times (from 1 to 10 times) until apnea occurs.
b.3.5. Once with apnea, the infant’s lungs are again inflated to V30.
b.3.6. Once V30 is reached, the valve connecting the inflatable jacket
to the pressure source is opened to inflate the jacket and
to produce a forced expiration that ends when residual
volume is reached.
b.3.7. When the expiratory flow reaches zero, compression is
removed and spontaneous breathing resumes.
b.3.8. The jacket pressure is increased progressively in intervals
of 5 to 20 cmH2O until no further increase in flow is achieved
at higher jacket pressures.
5.4.3.3. Acceptability criteria.2
a. Forced expiration proceeds smoothly without signs of early inspiration, marked flow
transients or glottis closure.
b. Peak expiratory flow is achieved before 10% volume is expired.
5.4.3.4. Repeatability criteria.
a. A minimum of two technically acceptable maneuvers are required, provided that
the FVC, FEF25-75, and FEV0.4 or FEV0.5 are within 10% of each other.
b. The “best” trial is defined as the one with the highest sum of FVC and FEV0.4-0.5 ,
or highest sum of FVC and FEF25-75.
5.4.3.5. End of test.
a. Acceptability and repeatability criteria have been fulfilled.
b. Failure is considered if there is only one good curve produced during the maneuver
or the variability is greater than 10% between maneuvers.

5.4.4. Reporting of results

23
 5.4.4.1. Reference data and predictive equation.
a. There are no local normative values.
b. Predictive equations based among infants 3 to 149 weeks of age have been
published4, as follows:
b.1. FVC = - 5.804 + 2.614 x length + 0.144 x length (age)
b.2. FEV0.5 = -3.880 + 2.113 x length + 0.139 x Iength (age)
b.3. FEV0.5/FVC = 1.965 – 0.515 x length
b.4. FEF25-75% = -2.128 + 1.995 x length - 0.108 x 1 if mother is smoker
[0 if mother is non smoker].
2
5.4.4.2. Content.
a. Graphic display.
In order to achieve the acceptable criteria for each maneuver a graphical
representation should be made. Figure below shows an acceptable RVRTC
flow volume loop.

b. Indices.
b.1. FEV0.4,
b.2. FEV0.5, or FEV0.75,,
b.3. FEF as a percentage of FVC (FEF25, 50, 75%).
Values for these indices are similar to those of spirometric curves in adults. 2,3
5.4.5.Interpretation.
The 2014 Task Force has no recommendation for interpreting results outside of the
normal values.

24
APPENDIX A. PAPP Pulmonary Function Testing Information Sheet

1. Name _________________________________ Age__________ Gender___________ Ethnicity___________

2. Height/length/arm span [m]________Weight [kg]________ CR______ RR______ BP______ Temp________

3. Date and time of procedure ___________

4. Room temperature ______________Atmospheric pressure _______________ Humidity_________________

5. Referring physician/medical facility: ___________________________________________________________

6. Current diagnosis___________________________________________________________________________

7. Pulmonary function test_____________________________________________________________________

8. Indication for pulmonary function testing_______________________________________________________

9. Previous pulmonary function testing. Type______________________________________________________

Date ____________________________ __________________________
Place______________________________________________________
Result_____________________________________________________
Note: Previous official pulmonary function testing results can be attached.
10. Conditions that may influence the results [Place a check if present]
__Chest or abdominal pain of any cause
__Non standing position of the patient while performing the test
__Alcohol or caffeinated drink intake within 4 hours prior to testing
__Vigorous exercise within 30 minutes prior to testing
__Eating large meals within 2 hours prior to testing
__Intake of any of following drugs prior to testing. Please state route, dose and hours prior to test.
Salbutamol________________________________________________________
Terbutaline________________________________________________________
Procaterol_________________________________________________________
Clenbuterol________________________________________________________
Formoterol________________________________________________________
Salmeterol________________________________________________________
Ipratropium bromide________________________________________________
Methylxanthine____________________________________________________
Formoterol/budesonide______________________________________________
Salmeterol/fluticasone_______________________________________________
Oral Steroid________________________________________________________
Other drugs________________________________________________________
_________________________________________________________
__Other conditions__________________________________________________________________

10. Remarks________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Accomplished by:
_______________________________________________

25
APPENDIX B. Spirometric nomenclature

1. The report must use the phrase “Ventilatory Defect” (not lung defect or ventilatory pattern)

2. Slowing down of the terminal portion of spirogram must be described as “exaggerated concavity in distal
portion of the expiratory limb of the flow volume loop”. The term “scooping” is discouraged.

3. In cases where in the interpretation uses flow volume loop’s configuration, FEF25-75 and “other
spirometry parameters”, it must be stated that these parameters are suggestive but not definitive.
Use of the term “compatible” is discouraged.

4. Response to bronchodilator must be labeled as “significant or no significant response to bronchodilator”.

The use of “poor or good response to bronchodilator” are discouraged.

26
APPENDIX C. Grading of severity of ventilatory defect.

Degree of severity FEV1 % predicted (pre- or post-bronchodilator) values

Lower limit of normal 80%

Mild > 70%

Moderate 60-69%

Moderately Severe 50-59%

Severe 35-49%

Very Severe <35%

27
APPENDIX D. Normal reference values.

1. Tidal breathing analysis.

Reyes-De Leon A, De Leon N, Estepar E Venturina JN, Jiao AG, Dela Cruz JR, Dygico R
Philippine Heart Center 2006 Philippine Children’s Medical Center 2013

Group I Group II Group III Group I Group II All Ages

Age group 0-29 days 30d-1yr11 2-6 yrs 1 mo- <2 2-5 years
mo. yrs
tPTEF/tE 33.26±11.12 32.85 ± 9.52 32.74±10.08 23.45 ± 36.95± 2.45 31.77±12.38
Mean±SD
6.25
25th %ile 24.72 25.35 25.50 18.90 26.00 21.90
75th %ile 39.48 36.85 38.85 26.70 46.70 40.20
VPTEF/VE 31.48± 3.06 31.38 ± 31.66± 2.28 25.82 ± 37.35±11.09 32.93± 0.86
Mean±SD
11.36 5.29
25th %ile 21.25 22.15 21.40 22.60 27.10 24.65
75th %ile 39.42 36.50 39.35 27.55 46.00 39.78

2. Impulse oscillation.

Valles JB, Jiao AJ. Philippine Children’s Medical Center 2016*

Outcome Male Female All p-value
Measure Mean (sd) Mean (sd) Mean (sd)
[N=54] [N=56] [N=110]
Rrs5Hz 0.99 (0.08) 1.00 (0.09) 1.00 (0.08) 0.494 (NS)
Rrs20Hz 0.75 (0.04) 0.76 (0.05) 0.76 (0.05) 0.973 (NS)
Xrs5Hz -0.36 (0.04) -0.37 (0.04) -0.37 (0.04) 0.309 (NS)
*Age group: 3-5 years old.

28
BIBLIOGRAPHY.

Section 2.
1 Philippine College of Chest Physicians Council of Diagnostics and Therapeutics: Consensus Statement on the
Performance and Reporting of Spirometry Testing 2012.
2 American Thoracic Society/European Respiratory Society [ATS/ESR] Statement: Pulmonary Function Testing in
Preschool Children Am J Respir Crit Care Med 2007;175:1304-1345.
3 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function
testing. General considerations Eur Respir J 2005: 26:153–161.
4 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function
testing. Interpretative strategies for lung function tests Eur Respir J 2005:26: 948–968.
5 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function
testing. Standardisation of spirometry Eur Respir J 2005; 26: 319–338.
6 American Thoracic Society Guidelines for Methacholine and Exercise Challenge Testing Am J Respir Crit Care Med
2000;161:309-329.
7 Global lung function initiative www.lungfunction.org.

Section 3.
1 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function testing.
Standardisation of spirometry Eur Respir J 2005; 26: 319–338.2012;6.
2 Philippine Pediatric Society: Preventive Health Care Handbook
3 Global lung function initiative www.lungfunction.org.

Section 4.
1 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function testing.
Standardisation of spirometry Eur Respir J 2005; 26: 319–338.
2 Philippine College of Chest Physicians Council of Diagnostics and Therapeutics: Consensus Statement on the
Performance and Reporting of Spirometry Testing 2012.
3 Deerojanawong J, Manuyakorn W, Prapphal N, Harnruthakorn C, Sritippayawan S, Samransamruajkit R.: Randomized
controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young
children with wheezing. Pediatr Pulmonol 2005;39:466-72.
4 American Thoracic Society Guidelines for Methacholine and Exercise Challenge Testing Am J Respir Crit Care Med
2000;161:309-329.
5 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function
testing. Interpretative strategies for lung function tests Eur Respir J 2005:26: 948–968.
6 Rao DR, Gaffin JM, Baxi SN, Sheehan WJ, Hoffman EB, Phipatanakul W.: The utility of forced expiratory flow between
25% and 75% of vital capacity in predicting childhood asthma morbidity and severity J Asthma. 2012;49:586–592
7 Global Strategy for Asthma Management and Prevention 2014.

Section 5.1.
1 Arets HGM, Brackel HJL, van der Ent CK: Forced expiratory manoeuvres in children: do they meet ATS and ERS criteria
for spirometry? Eur Respir J 2001; 18: 655–660.
2 American Thoracic Society/European Respiratory Society [ATS/ESR] Task Force: Standardisation of lung function
testing. Standardisation of spirometry Eur Respir J 2005; 26: 319–338.
3 Beydon N, Davis S, Lomabardi E, Allen J, Arets G, Aurora P.: An Official American Thoracic Society/European Respiratory
Society Statement: Pulmonary Function Testing in Preschool Children. Am J Resp Crit Care Med. 2007;175:1304–
1345.

29
Section 5.2.
1 Beydon N, Davis S, Lomabardi E, Allen J, Arets G, Aurora P.: An Official American Thoracic Society/European Respiratory
Society Statement: Pulmonary Function Testing in Preschool Children. Am J Resp Crit Care Med. 2007;175:1304–
1345.
2 Bates JHT, Schmalisch G, Filbrun D, Stocks J.: Tidal breath analysis for pulmonary function testing. Eur Resp J
2000;16:1180-1192.
3 Reyes-De Leon A, De Leon N, Estepar E.: Values of tidal breathing analysis in Filipino infants and children aged 0-6 years
old in 5 areas around Philippine Heart Center. Philippine Heart Center Journal. 2006;12:27-35
4 Venturina JN, Jiao AG, Dela Cruz JR, Dygico R.: Reference values of pulmonary function testing using tidal breathing
analysis among healthy Filipino children aged 1 month to 5 years from the National Capital Region. Unpublished.
5 Van der Ent CK, Brackel, HJL, Mulder P, Bogaard.: Improvement of tidal breathing pattern analysis in children with
asthma by on-line automatic data processing Eur Resp J 1996.9:1306-1313

Section 5.3.
1 H.J.Smith, P. Reinhold, M.D. Goldman. Forced oscillation technique and impulse oscillometry. Eur Respir Mon . 2005
2 Nielsen K. Lung function and bronchial responsiveness in young children.Danish Medical Bulletin. February 2006.
3 Beydon N, Davis S,Lombardi E,Bisgaard H. American Thoracic Society/European Respiratory Society Statement:
Pulmonary Function Testing in Preschool Children. Am J Respir Crit Care Med, 2007;175:1304-1345.
4 Komarow H, Myles I, Uzzaman A,Metcalfe D. Impulse oscillometry in the evaluation of diseases of the airways in
children. Ann Allergy Asthma Immunol.March 2011.
5 Beydon N. Pulmonary function testing in young children. Pediatric Respiratory Reviews. 2009.
6 Hellinckx J, De Boeck K,Bande-Knops J, van der Poel M,Demedts M. Bronchodilator Response in 3-6.5 years Old
Healthy and Stable Asthmatic Children. Eur Respir J,1998;12:438-443.
7 Klug B,Bisgaard H. Specific Airway Resistance, Interrupter Resistance and Respiratory Impedance in Healthy
Children Aged 2-7 years. Pediatr Pulmonol, 1998;25:322-331.
8 FreiJ,Jutla J,Kramer G,Hatzakis G, Ducharme F,Davis M. Impulse Oscillometry. Reference Values in Children 100 to
150cm in Height and 3 to 10 years of Age. Chest, 2005;128:1266-1273.
9 Valles JB, Jiao AJ. Philippine Children’s Medical Center 2016. Unpublished.
10 Monzon SL, Espinoza HM, Bautista N, Go OC. University of Santo Tomas Faculty of Medicine and Surgery : Impulse
oscillometry values among normal schoolchildren. Unpublished.

Section 5.4.
1. Sly PD, Tepper R, Henschen M, Gappa M, Stocks J: ERS/ATS Task Force on Standards for Infant Respiratory Function
Testing. Tidal Forced Expirations Eur Respir J 2000; 16: 741-748.
2. Frey U, Stocks J, Coates A, Sly PD, Bates J, on behalf of the ERS/ATS Task Force on Standards for Infant Respiratory
Function Testing: Specifications for equipment used for infants pulmonary function testing. Eur Respir J 2000;16:
729-738.
3. ATS/ERS Statement on Raised Volume Forced Expirations in Infants. Guidelines for Current Practice. Am J Respir Crit
Care Med 2005;172:1463–1471.
4. Jones M, Castile R, Davis S, Kisling J, FIlbrun D, Flucke R, Goldstein A, Emsley C, Ambrosius W, Tepper RS.: Forced
Expiratory Flows and Volumes in Infants. Normative data and lung growth Am J Respir Crit Care Med 2000;
161:353-359.

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