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Manual of Pulmonary Function Testing, 8th ed.

This venerable book has been around for as long as I can remember. This is the 8th edition already and, although it came out in 2003, we would be remiss in not reviewing it now, especially as we welcome Gregg Ruppel MEd RRT RPFT FAARC on board the Focus writing staff.

First, what more could we say about Gregg Ruppel, other than "he wrote the book?" Indeed, he did write the book. His first edition of Manual of Pulmonary Function Testing came out in 1975 and it immediately filled a void that many of us in the field at the time subconsciously knew existed, but couldn't quite articulate. I ran a pulmonary physiology lab in a New York City teaching hospital in 1975 and had a responsibility for teaching pulmonary function testing to pulmonary fellows on their PFT rotations. We had a number of fine pulmonary physiology texts available to us in those days as well as some device specific pamphlets from the manufacturers of the era. But a clear, concise, practical, informative and non-commercial text about how to perform the various pulmonary function tests on a variety of equipment simply did not exist. Until Gregg Ruppel came along.


In retrospect, the first book was a thin flimsy little paperback that could fit in my rear pants pockets. But its impact was enormous. My only complaint about the current edition is that it is a flimsy large paperback. It is much larger, thicker and more comprehensive that its early predecessor, but it is still paperbound and that annoys me. In the 2 weeks or so that I have been carrying the 8th edition around with me to read frequently in the preparation of this review, I have not intentionally abused it, but it is now dog-eared and worn. The durability of a hardcover for a reference text such as this would be appreciated. That said; do not let the lack of a hard cover detract from the excellent content and organization.


The book has 523 pages organized into 11 chapters. The chapter layout is pretty much what you would expect from a pulmonary function manual. So it will be useful for new students moving logically through the subject, as well as for seasoned practitioners who need a concise reference. Chapter 1 is titled Indications for Pulmonary Function Testing and is actually a bit more broad-based than that. It provides a brief overview of each major class of test and describes the lung disease for which it would be appropriate. As the chapter progresses, it further elucidates obstructive and obstructive impairments and provides examples of those patterns in a number of diseases. This potpourri introductory chapter also includes a section on properly preparing the patient for PFTs as well as a useful decision tree for logically determining which PF testing protocol(s) to conduct.

Chapter 2 is a tour de force about Spirometry and Related Tests. It very comprehensively covers a great deal of physics and physiology relating to the forced expiratory spirogram and the related tests of airway obstruction such as the flow/volume loop and specific conductance (SGaw) as obtained from body plethysmography. Chapter 3 is about Lung Volumes and Gas Distributions Tests. It begins with an excellent description of the multiple breath nitrogen washout technique, the multi-breath helium dilution technique and goes on to discuss single breath techniques and body plethysmography for thoracic gas volume.

Ventilation and Ventilatory Control Tests are the subject of Chapter 4. Techniques are described for measuring ventilation, calculating dead space and alveolar ventilation and determining the ventilator response to O2 and CO2. Chapter 5 is dedicated to Diffusing Capacity Tests and does an excellent job at clearly illuminating an otherwise confusing subject. In describing the test procedure, it starts with the classic methodology for the DLCO using a water-sealed spirometer and collecting the end-tidal sample after a 10 second breath hold. The extensive mathematics is broken down into simple steps and the DLCO maneuver is represented graphically by an excellent drawing. Elsewhere in the chapter the classic methodology is contrasted with contemporary methodology built in to currently available testing devices that rely upon computer controlled continuous gas analysis and gas chromatography. This chapter concludes with a detailed overview of the significance and pathophysiology of the diffusing capacity tests.

Blood Gases and Related Tests are covered in Chapter 6. Because most of this information is available in a number of comprehensive texts dedicated to blood gas and acid-base balance, this chapter is relatively sparse and does not pretend to be more than just a brief overview. However, the key parts of this chapter are the sections where various blood gas test results are assessed in conjunction with other PFTs such as spirometry, lung volumes and diffusing capacity.

Chapter 7, co-written with the assistance of Carl Mottram, is a very comprehensive 60+ page overview of Cardiopulmonary Exercise Testing. It covers equipment, protocols, and a variety of techniques. However, the real value of this chapter lies in the excellent synthesis concerning expected physiologic changes to exercise and the interpretation of test results to determine the various causes of exercise limitation in cardiorespiratory disease. This chapter is also replete with 30+ excellent graphics and tables providing illustration of the intricacies of exercise testing.

Pediatric Pulmonary Function Testing is covered in Chapter 8, written exclusively by Deborah White. A fair amount of attention is paid to the issue of effort and cooperation in the pediatric population, inasmuch as that is the primary limiting factor for the young child undergoing PFTs. The author relates many tip and tricks for eliciting reliable test results from young children and further covers the gamut of pediatric testing ranging from spirometry to lung volumes, diffusing capacity and even plethysmography. The chapter includes an interesting section of infants and toddlers and even discusses some of the techniques that can be applied in newborn infants with contemporary devices.

Chapter 9 is titled Specialized Test Regimens and describes less common testing procedures. Chief among these is bronchial challenge testing, a topic covered well and in sufficient detail to guide a lab in establishing this additional testing protocol if they are not already doing it. Most of what I have seen in print heretofore about bronchial challenge testing is merely a rehash, or even direct quotation of the ATS and/or AARC guidelines for methacholine challenge testing. This chapter is refreshing in that it includes well-written conversational stepwise instructions that don't read as though they are lifted from a protocol. For example, one of the "PFTips" offered indicates that patients who truly have asthma will display at 20% decrease in FEV1 regardless of the technique for administering methacholine.

The book concludes with two chapters of support material. Chapter 10 describes a large variety of Pulmonary Function Testing Equipment ranging from spirometers of every ilk to peak flow meters to valves and gas analyzers. I find it helpful for the understanding of how some PFTs have evolved over the years to be able to see and understand the legacy equipment that was first used when the original tests were being developed. The difference between flow and pressure plethysmographs is explored and a section on computerized PFT instruments discuss data acquisition, sampling techniques, analog to digital conversion, plus data storage and analysis. The 11th and final chapter pertains to Quality Assurance in the Pulmonary Function Laboratory and describes calibration and QC of a wide range of PF instrumentation and blood gas analyzers.

This is an excellent book for the beginning student as well as the experienced therapist/technologist. I would recommend the book for all labs to be used in teaching and training of both technologists and house officers. It provides a comprehensive overview of the entire spectrum of pulmonary function testing and also an excellent bibliography at the end of each chapter to aid those who wish to delve more deeply into a specific area of interest. And now, we can look forward to additional contributions from Gregg Ruppel as we welcome him aboard Focus as a regularly appearing columnist in Pulmonary Function testing.

Reviewed by Michael McPeck BS RRT FAARC
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Author:McPeck, Michael
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Article Type:Book review
Date:Jan 1, 2006
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