Adherence to Established Guidelines for

Preoperative Pulmonary Function Testing

Oleh W. Hnatiuk, Thomas A. Dillard and Kenneth G. Torrington

Chest 1995;107;1294-1297
DOI 10.1378/chest.107.5.1294

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Adherence to Established Guidelines for
Preoperative Pulmonary Function
Testing*
Maj Oleh W. Hnatiuk, MC, USA, FCCP;
Ltc Thomas A. Dillard, MC, USA, FCCP; and
Col Kenneth G. Torrington, MC, USA, FCCP
Guidelines for ordering preoperative spirometry have
been proposed by GM Tisi (1979) and more recently by
the American College of Physicians (ACP). Requests for
preoperative spirometries represent a significant por-
tion of all requests for screening spirometry at our
institution and utilize significant man-hours of techni-
cian time. We determined the percentage of these
requests that did not meet the ACP guidelines and
characterized why these requests were being generated.
We sampled 441 screening spirometries performed by
the Walter Reed Pulmonary Function Laboratory over
a 4-week period. One hundred thirty-eight (31%) of these
were done preoperatively and complete data were
available in 135 cases. Patients in the analyzed group
had a mean age of 59 years (± 14 years), ranging from
20 to 84 years of age. Fifty-two (39%) requests did not
meet ACP guidelines. Most of these requests were asso-
ciated with either normal spirometry (n=34) or only
mild spirometric abnormalities (n=14). Spirometry re-
vealed severe obstruction in only one case when the re-
quest was not indicated. No cases of moderate obstruc-
tion, severe restrictive pattern, or possible upper airway
obstruction were found in the group of requests in which
spirometry was not indicated. Of the requests that did
not meet ACP guidelines, 21 met Tisi's broader guide-
lines. Most of these requests were found exclusively in
Requests for preoperative spirometry represent a The reasons for the popularity of preoperative
significant portion of all screening spirometries
done at Walter Reed Army Medical Center
(WRAMC). The large number of these requests
consumes many man-hours of technician time and
contributes to the already high cost of medical care.
Guidelines for ordering preoperative spirometry have
been proposed by Tisil and more recently by the
American College of Physicians (ACP).2
*From the Pulmonary and Critical Care Medicine Service, De-
partment of Medicine, Walter Reed Army Medical Center,
Washington DC; and the Uniformed Services University of the
Health Sciences, Bethesda, Md.
DCI Protocol 1761.
Presented on November 20, 1993 at the annual meeting of the
American College of Physicians US Army Region, Orlando, Fla.
The opinions contained herein represent solely the views of the
authors and are not to be construed as representing the views of
the Department of Defense or the Department of the Army.
Manuscript received May 16, 1994; revision accepted October 6.
Reprint requests: Maj. Hnatiuk, Pulmonary Critical Care Med-
icine Service, Walter Reed Army Medical Center, Washington
DC 20307-5001
1294
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Copyright 1995 by the American College of Chest Physicians
patients older than 70 years of age (n=13) and the mor-
bidly obese (n=4). Of the 31 studies that did not meet
either set of guidelines, 25 occurred in asymptomatic,
current, or prior smokers. In conclusion, during a 4-week
study period at our institution, 39% of preoperative
spirometry requests did not meet ACP guidelines. Most
of the patients had been referred because of age greater
than 70 years, morbid obesity, and a current/prior his-
tory of smoking. However, the literature does not
support obtaining preoperative spirometry in such pa-
tients except for those undergoing only lung resection.
We recommend stricter adherence to the ACP guide-
lines as a means of decreasing the number and cost of
unnecessary spirometries being performed.
(Chest 1995; 107:1294-97)
ACP=American College of Physicians; FEF50%=forced
expiratory flow at 50% vital capacity; FEVO.5=forced
expiratory volume in 0.5 s; FEVI=forced expiratory volume
in 1 s; FIF50%=forced inspiratory flow at 50% vital
capacity; FVC=forced vital capacity; PEFR=peak expira-
tory flow rate; PFT=pulmonary function test;
WRAMC=Walter Reed Army Medical Center
Key words: respiratory function test, guidelines; surgery,
preoperative care
spirometry are many. The ACP notes, "the percep-
tion that pulmonary function tests....are informa-
tive, easy to do, and well accepted by the patient has
led to their liberal use"2 However, Hayhurst3 states,
"in many hospitals this request is made almost on
reflex, with little regard for why the tests are
indicated, how to interpret the results, or how to
modify further management of the patient in the
light of test results." We agree with Hayhurst's
observation and believe that the ACP guidelines and
the accompanying review4 both suggest that preop-
erative spirometry is an overutilized modality in
surgery not involving lung resection. This viewpoint
is supported by several recent articles questioning the
utility of preoperative spirometry in predicting post-
operative complications.5'6
To our knowledge, this is the first study designed
to determine compliance with guidelines regarding
indications for preoperative spirometry. Our hypo-
Clinical Investigations
Table 1-ACP Guidelines for Preoperative Spirometry
Lung resection
Coronary artery bypass graft and (smoking history or dyspnea)
Upper abdominal surgery and (smoking history or dyspnea)
Lower abdominal surgery and uncharacterized pulmonary
disease,* particularly if the surgical procedure will be prolonged
or extensive
Other surgery and uncharacterized pulmonary disease,*
particularly in those who might require strenuous postoperative
rehabilitation programs
*Uncharacterized pulmonary disease defined by authors as pulmo-
nary symptoms or history of pulmonary disease and no PFTs within
60 days.
thesis is that many of these requests do not meet the
ACP guidelines. By characterizing this group of re-
quests based on previously published and well-
recognized guidelines, we attempt to identify reasons
why unnecessary tests are being generated. Ulti-
mately, we hope our findings will assist in reducing
the number of needless preoperative spirometries.
METHODS
During a 4-week period from March 15 to April 8, 1993, all
ambulatory patients 18 years of age or older referred for pulmo-
nary function testing by their primary care physicians were in-
cluded in the data collection. Upon arrival in the WRAMC pul-
monary function laboratory, all patients completed a brief ques-
tionnaire (Appendix). After completing the questionnaire, patients
underwent routine spirometry consisting of forced expiratory and
inspiratory spirometry. Spirometric measurements were made
using a heated pneumotachograph (Cybermedic screener, XL
and CM5-Cybermedic Inc, Boulder, Colo). Testing followed
published guidelines for performance of pulmonary function tests
(PFT)7-10 and all tests were accomplished with patients in the
upright, seated position. Values for forced expiratory flows were
obtained from the effort with the largest sum of forced vital ca-
pacity (FVC) plus forced expiratory volume in ls (FEVy), on a
minimum of three efforts. The questionnaire, along with a copy
of the patient's spirometry results, was then collected and coded.
All requests identifying patients as being preoperative were
included in the study for further analysis.
The spirometry was separated from the questionnaire. It was
then interpreted by one of the investigators, who was blinded to
the reason for the request or any of the other patient data. The
following standardized criteria were used to interpret the spirom-
etry: normal spirometry, FVC >80% predicted and FEVI/
FVC>90% predicted; obstructive ventilatory defect, FVC>80%
predicted and FEV1/FVC<90% predicted; restrictive pattern,
FVC -< 80% predicted and FEVI/FVC < 90% predicted; mixed
defect, FVC -<80% predicted and FEV, .90% predicted; pos-
sible upper airway obstruction, flattened, abnormal flow-volume
loop and FEV1/peak expiratory flow rate (FEVI/PEFR) >0.6 or
forced expiratory flow at 50% vital capacity/forced inspiratory
flow at 50% vital capacity (FEF50%/FIF50%) > 1 or FIF50% <
1.7 L/s or FEVI/forced expiratory flow in 0.5 s (FEVI/FEVo5)
>- 1.5.11 Severity scoring was accomplished using the following
criteria: mild, 65 to 80% predicted; moderate, 50 to 64%
predicted; and severe, < 50% predicted. Normal values for FEVy,
FVC, and FEVI/FVC were derived from Morris et al.'2
The questionnaire, along with data regarding the patient's
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Copyright 1995 by the American College of Chest Physicians
Table 2-Tisi's' Guidelines for Preoperative
Spirometry*
Age >70 years old
Obese patients
Thoracic surgery
Upper abdominal surgery
Smoking history and cough
Any pulmonary disease
*From reference 1, with permission.
height, weight, and age were separately reviewed by one of the
investigators, who was blinded to the results of spirometry, to
determine if the request met either ACP or other published
guidelines for preoperative pulmonary function testing (Tables 1
and 2). Morbid obesity was defined as 45 kg or 100% over ideal
body weight.'3 Ideal body weight was determined by using the
maximum recommended weight from the "medium frame" col-
umn of the 1983 Metropolitan Life Insurance Company Table of
Heights and Weights for Men and Women.'4
Data analysis was accomplished using a software package
(STATISTIX 4.0). Conduct of this study was approved by the
WRAMC Department of Clinical Investigation.
RESULTS
From March 15 to April 8, 1993, 441 screening
spirometries were performed by the WRAMC Pul-
monary Function Laboratory. One hundred thirty-
eight (31%) of these were done preoperatively.
Complete data were available in 135 cases. Patients
in the analyzed group had a mean age of 59±14
years, ranging from 20 to 84 years of age. Of this
group, 52 patients (39%) did not meet ACP guide-
lines. Most of these requests were associated with ei-
ther normal spirometry (n=34), mild obstructive
defects (n=4), or mild restrictive patterns (n=9)
(Table 3). Three other cases were associated with
moderate restrictive patterns and one had a mixed
ventilatory defect. In only one case did spirometry
reveal severe obstruction when the request was not
indicated. No cases of moderate obstruction, severe
restrictive pattern, or upper airway obstruction were
found in the group of requests in which spirometry
was not indicated.
Twenty-one requests that failed to meet ACP
guidelines met Tisi's broader guidelines either be-
cause the patient's age was greater than 70 years old
(n=13) or the patient was morbidly obese (n=4).
Thirty-one requests did not meet either guideline. In
25 of these 31 cases, patients were asymptomatic
current or former smokers. In this group, peripheral
vascular surgery (n=7) and joint or extremity surgery
(n=6) were the most commonly planned procedures
(Table 4).
DISCUSSION
The purpose of evaluating pulmonary function
preoperatively is to identify individuals at increased
CHEST / 107 / 5 / MAY, 1995 1295
 Table 3-Spirometric Interpretations (n=135)
Not Indicated, Indicated,
No. (%) No. (%o)
Normal spirometry 34 (25) 40 (29)
Mild obstructive defect 4 (3) 5 (4)
Mild restrictive pattern 9 (7) 13 (9)
Mixed/mild obstructive 1(1) 1(1)
defect
Moderate restrictive pattern 3 (2) 5 (4)
Severe obstructive defect 1 (1) 1 (1)
Moderate obstructive defect 0 1 (1)
Mixed/moderate 0 5 (4)
obstructive defect
Mixed/severe obstruction 0 7 (5)
Severe restrictive pattern 0 3 (2)
Possible upper airway 0 2 (1)
obstruction
Total 52 (39) 83 (61)
risk for perioperative pulmonary complications. This
allows the referring physician either to intervene to
attempt to alter that risk or to plan a different oper-
ative strategy. At our institution, most preoperative
requests are generated by anesthesiologists and sur-
geons. Guidelines for obtaining preoperative spirom-
etry were published by the ACP in an internal med-
icine journal.2 Our study showed these guidelines are
not being followed in over one third of cases.
Although some of our surgeons and anesthesiolo-
gists may be unaware of these guidelines, many ob-
tain routine spirometry in the elderly, morbidly
obese, or current/former asymptomatic smokers de-
spite the existence of the ACP guidelines. Support for
this more liberal approach to preoperative pulmo-
nary function testing exists in the recent pulmonary
literature. In recent extensive review article by
Zibrak and O'Donnelll5 on indications for preopera-
tive pulmonary function testing, the authors state
that "it may be reasonable to perform this test pre-
operatively if there is a history of ... extensive
tobacco use" in patients undergoing coronary artery
bypass grafting. They also state that spirometry can
"be recommended when patients being prepared for
abdominal surgery are found to be cigarette smok-
ers." Obesity and age are not included in their rec-
ommendations. In his 1993 editorial, Hayhurst3 also
proposes that heavy smokers should have preopera-
tive pulmonary function testing. He includes obesity
and age over 70 years on his list of indications.
However, in another recent review article on the
same topic, Celli16 pointed out that studies address-
ing whether smoking and age are independent risk
factors for perioperative pulmonary complications
are conflicting, and that morbid obesity has been
poorly studied. These conflicting data undoubtedly
led the ACP to recommend a more rigid set of
guidelines "until further studies better define cir-
1 296
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Copyright 1995 by the American College of Chest Physicians
Table 4-Planned Surgical Procedures in Patients Not
Meeting Either ACP or Tisi's Guidelines (n=31)*
Procedure No.
Peripheral vascular surgery 7
Joint or extremity surgery (hip or 6
knee surgery [3], lower extremity
amputation, shoulder arthroplasty,
leg vein stripping)
Gynecologic surgery (hysterectomy [2], 4
ovarian cancer, pelvic mass)
Exploratory laparotomy (intestinal 3
fistula, colectomy, nephrolithiasis)
Hemorrhoidectomy 3
Head and neck malignancy 3
Other 5*
Total 31
*From reference 1.
**One each: hernia, herniated disk, mastectomy, neurofibroma,
transurethral prostatectomy.
cumstances in which these tests assist in clinical de-
cision making."2 To our knowledge, no study has ever
shown that spirometry adds to any of these three
clinical factors in predicting postoperative pulmo-
nary complications. Until these areas are further
studied, we recommend stricter adherence to the
ACP guidelines. Our study demonstrates that such a
policy will miss very few patients with significant
spirometric abnormalities.
Our methods also allowed us to identify the phy-
sicians or surgical services ordering most preopera-
tive spirometries that did not meet ACP guidelines
and target our educational efforts at these groups.
Ongoing utilization review and physician education
should result in fewer inappropriate requests for
preoperative spirometry in the future.
APPENDIX
1. Is this test being done in preparation for surgery? Yes or No.
If yes, what type of surgery is planned?
2. Have you had a breathing test at WRAMC in the last 60 days?
If yes, has your breathing changed since then?
3. Clinic or service of requesting doctor?
4. Have you ever smoked? How old when started? How old when
stopped? On the average, how many packs per day do (did) you
smoke?
5. Have you ever been diagnosed as having any of the following?
Asthma, chronic bronchitis, emphysema, tuberculosis, lung
cancer, sarcoidosis, any disease requiring removal of part of the
lung, interstitial fibrosis, none of the above?
6. Do you currently have any of the following? Shortness of
breath, cough, wheezing, hoarseness, none of the above?
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CHEST / 107/ 5/ MAY, 1995 1297

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Adherence to Established Guidelines for Preoperative Pulmonary
Function Testing
Oleh W. Hnatiuk, Thomas A. Dillard and Kenneth G. Torrington
Chest 1995;107; 1294-1297
DOI 10.1378/chest.107.5.1294
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