1.3 Professional Standards, Ethics, and Patient Safety in Diagnostic Testing

1.3 Professional Standards, Ethics, and Patient Safety in Diagnostic Testing

Pulmonary function testing requires technologists to perform strenuous, maximal diagnostic maneuvers on vulnerable patients who may present with severe cardiopulmonary impairment. Consequently, adherence to strict professional ethics, rigorous pre-test patient screening, robust emergency safety protocols, stringent infection control, and patient privacy regulations is essential to prevent adverse clinical events and maintain public trust.

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NBRC Code of Ethics and Judicial Committee Enforcement

All CPFT credential holders and examination candidates are bound by the NBRC Code of Conduct. This ethical framework establishes mandatory principles governing professional practice, patient interactions, and data integrity.

Enforceable Ethical Principles

• Integrity of Diagnostic Data: Technologists must record and report pulmonary diagnostic data truthfully, accurately, and without falsification or selective omission. Modifying calibration factors to force failing tests into "acceptable" ranges constitutes severe ethical misconduct.
• Maintenance of Competence: Technologists must maintain clinical and technical currency, refusing to perform complex diagnostic procedures (e.g., methacholine challenge or arterial line placement) unless properly trained and qualified.
• Patient Advocacy & Respect: Technologists must treat all patients with dignity, avoiding discrimination based on race, age, gender, religion, national origin, or disability status.
• Avoidance of Conflicts of Interest: Technologists must decline financial kickbacks, unauthorized equipment endorsements, or unapproved referral fees that compromise objective clinical judgment.

Role of the NBRC Judicial Committee

The NBRC Judicial Committee is empowered to investigate allegations of ethical misconduct, examination subversion, credential fraud, substance abuse impairment, and state licensing disciplinary actions.

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Pre-Test Patient Screening & Contraindication Assessment

Before initiating forced exhalation maneuvers, plethysmographic body box testing, or exercise stress testing, the technologist must conduct a comprehensive pre-test screening to identify contraindications that present unacceptable patient risks.

The 2019 ATS/ERS Contraindication Framework

Forced expiratory maneuvers raise intrathoracic, intra-abdominal, intracranial, intraocular, and sinus/middle-ear pressures, increase myocardial demand, and swing systemic blood pressure. The 2019 ATS/ERS Standardization of Spirometry made a change that older textbooks have not caught up with: there are no absolute contraindications to spirometry. Every listed condition is a relative contraindication. Spirometry is not precluded; the ordering clinician performs a risk–benefit assessment for that specific patient, and potential contraindications should be flagged on the request form so the technologist knows what to watch for. Testing stops immediately if the patient experiences pain during the maneuver.

The 2019 statement also shortened several timeframes. The pre-2019 "no testing within one month of a myocardial infarction" rule became within one week.

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|      RELATIVE CONTRAINDICATIONS TO SPIROMETRY (ATS/ERS 2019) - GROUPED BY RISK    |
+-----------------------------------------------------------------------------------+
| INCREASED MYOCARDIAL DEMAND OR BLOOD PRESSURE CHANGE                              |
| - Acute myocardial infarction within 1 WEEK                                       |
| - Systemic hypotension or severe hypertension                                     |
| - Significant atrial or ventricular arrhythmia                                    |
| - Noncompensated heart failure                                                    |
| - Uncontrolled pulmonary hypertension; acute cor pulmonale                        |
| - Clinically unstable pulmonary embolism                                          |
| - History of syncope related to forced expiration or cough                        |
+-----------------------------------------------------------------------------------+
| INCREASED INTRACRANIAL / INTRAOCULAR PRESSURE                                     |
| - Cerebral aneurysm                                                               |
| - Brain surgery within 4 WEEKS                                                    |
| - Recent concussion with continuing symptoms                                      |
| - Eye surgery within 1 WEEK                                                       |
+-----------------------------------------------------------------------------------+
| INCREASED SINUS / MIDDLE EAR PRESSURE                                             |
| - Sinus surgery, middle ear surgery, or middle ear infection within 1 WEEK        |
+-----------------------------------------------------------------------------------+
| INCREASED INTRATHORACIC / INTRA-ABDOMINAL PRESSURE                                |
| - Presence of pneumothorax                                                        |
| - Thoracic surgery within 4 WEEKS                                                 |
| - Abdominal surgery within 4 WEEKS                                                |
| - Late-term pregnancy                                                             |
+-----------------------------------------------------------------------------------+
| INFECTION CONTROL                                                                 |
| - Active or suspected transmissible respiratory or systemic infection,            |
|   including tuberculosis                                                          |
| - Physical conditions predisposing to transmission (e.g., hemoptysis, open        |
|   oral sores, significant secretions)                                             |
+-----------------------------------------------------------------------------------+

Exam nuance: Aortic aneurysm was historically listed as a contraindication. The 2019 task force reviewed the limited available data (no adverse events reported in abdominal aneurysms 5–13 cm or thoracic aneurysms 5–8 cm) and did not retain it as a listed relative contraindication. Conditions that merely prevent a valid effort — nausea, vomiting, oral or facial pain, confusion or dementia, stress incontinence — are not safety contraindications but are documented reasons a session may yield unusable data.

Pre-Test Instruction & Medication Withholding

To obtain accurate baseline diagnostic data and evaluate bronchodilator responsiveness, technologists must verify that patients have adhered to medication withholding guidelines prior to testing:

• Smoking / vaping: no smoking within 1 hour of spirometry, and avoid smoking on the day of a DLCO study (24 hours is the practical target) because carboxyhemoglobin back-pressure falsely lowers DLCO.
• Judgment call: if the clinical question is whether lung function can be improved beyond the patient's current regimen, ATS/ERS allows the patient to continue their usual medication — adherence should be checked first and the medication status documented on the report.

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Patient Safety Protocols & Emergency Preparedness

Because maximal forced exhalation and bronchial challenge testing carry inherent risks of syncope, severe bronchospasm, and dysrhythmias, pulmonary laboratories must maintain strict emergency preparedness:

1. Managing Syncope & Vasovagal Events:
   • Forced exhalation causes decreased venous return to the heart due to sustained high intrathoracic pressure (Valsalva effect), leading to cerebral hypoperfusion and cough syncope.
   • Safety Rule: Patients MUST be seated in a secure chair with armrests (wheelchair locked) during all testing. Technologists must never perform spirometry on a standing patient.
2. Emergency Resuscitation Availability:
   • The PFT laboratory must have immediate access to a fully equipped emergency crash cart, supplemental oxygen, high-flow suction, bag-valve-mask (BVM) resuscitators, an automated external defibrillator (AED), and emergency bronchodilator / anaphylaxis medications (Albuterol, Epinephrine).
3. Continuous Monitoring During Strenuous Testing:
   • During cardiopulmonary exercise testing (CPET) and bronchial challenge testing, continuous 12-lead ECG, pulse oximetry (SpO2), and non-invasive blood pressure (NIBP) monitoring are mandatory.

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Infection Control & Decontamination Standards

Pulmonary diagnostic procedures produce significant high-velocity aerosols and droplet nuclei during coughing and forced exhalation, creating substantial cross-contamination hazards.

Infection Control Hierarchy

• Single-Use Inline Bacterial/Viral Filters: Every patient MUST be tested using a dedicated, single-use, high-efficiency bacterial/viral filter placed between the patient's mouth and the flow sensor/tubing. Filters must demonstrate > 99.9% filtration efficiency for both bacteria and viruses.
• Spaulding Classification for Equipment Disinfection:
  • Semi-Critical Items: Reusable equipment contacting intact mucous membranes (e.g., non-disposable pneumotachometers, reusable mouthpieces, nose clips, body box interior handles) requires high-level disinfection (HLD) using EPA-registered liquid chemical sterilants (e.g., glutaraldehyde, peracetic acid, or hydrogen peroxide plasma) between patients.
  • Non-Critical Items: External equipment surfaces, computer keyboards, and outer plethysmograph walls require intermediate-level disinfection with hospital-grade germicidal wipes.
• Hand Hygiene: Strict hand hygiene (alcohol-based hand rub or soap and water washing for > 20 seconds) must be performed immediately before putting on gloves and after glove removal between every patient.

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Patient Confidentiality & HIPAA Compliance

Diagnostic pulmonary software systems generate extensive electronic Protected Health Information (ePHI). Technologists must adhere strictly to Health Insurance Portability and Accountability Act (HIPAA) mandates:

• Data Security: Computerized PFT workstations must utilize automatic screen lock timeouts, role-based access control, and encrypted storage for patient database records.
• Secure Transmission: Transmitting diagnostic reports over public networks requires end-to-end encryption.
• Informed Consent: Prior to testing, technologists must explain the procedure, potential risks, and diagnostic benefits to the patient, obtaining verbal or written informed consent.